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Presentation Notes in PDF Format
Pharmacy Services Administration Organization ‐ PSAO today, tomorrow and beyond Subspecialty pharmacy opportunity The Hemophilia Alliance Member Meeting Washington D.C. April 26, 2015 Today’s HTC challenges in a changing healthcare environment • Specialty drugs are targeted by payers as the most rapidly increasing cost • Payers, providers, insurers and PBMs are all consolidating and pushing vertical integration of their services to steer business and control margins • Payers don’t understand the HTC integrated clinical and factor distribution model leading to better outcomes and cost control • HTC access to payer networks • Threatened HTC sustainability www.hemoalliance.org [email protected] What a potential solution may look like • The HTCs could work together to market their services • Directly to payers • Indirectly to payers through PBMs or insurers • The service offering should provide a unified consistent benefit and pricing • It would be desirable to provide products and services as a sub-specialty network • Easily defined and limited to area of specific expertise with a correlation of the service benefit to outcomes www.hemoalliance.org [email protected] A PSAO may be the vehicle of choice • PSAO – Pharmacy Services Administration Organization • Created in the late 1980’s as an organization of like minded providers of pharmacy services and benefits that join together with their peers to provide a defined group of services (benefit design) that are targeted at a select population (patients with hemophilia and perhaps other limited health issues) and marketing those products and services collectively to payers (directly and indirectly) while avoiding anti‐trust issues. * Today there are approximately two dozen PSAOs primarily in the retail pharmacy space www.hemoalliance.org [email protected] Components of the PSAO www.hemoalliance.org [email protected] PSAOs require infrastructure to effectively market their network • Basic network services • Recruit, educate and communicate with network members (HTCs) • Develop a benefit design and pricing that is supported by the network members and flexible enough to be nimble in the marketplace www.hemoalliance.org [email protected] PSAOs require infrastructure to effectively market their network • Basic network services (cont.) • Develop and support a marketing plan • Develop contracts consistent with service offering • Direct payers • Self insured employers • Carve-outs from larger benefit • Indirect payers • PBMs • General specialty pharmacy www.hemoalliance.org [email protected] Network Benefit Design Define the services and products that will be part of the sub-specialty benefit • Factor and other medications as agreed upon (HIV, Pain, etc) • Services that are consistent with the mission of the PSAO and the HTC coordinated care model • available at all network members • administered in substantially the same way with consistent standards www.hemoalliance.org [email protected] Quality Issues and Quality Assurance • PSAO network member credentialing • Provide network quality assurance standards • Support and/or conduct patient satisfaction surveys www.hemoalliance.org [email protected] PSAO back end service • Maintenance of and adherence to payer contract terms • Claims processing/clearing house (direct contracts) • Reporting on quality, outcomes and other payer needs • Assay management • Cost data www.hemoalliance.org [email protected] How would network access happen? • HTCs through Hemophilia Alliance agree to form a PSAO • PSAO develops a third party offering (benefit design, quality assurance, etc.) • Benefit design is marketed to payers by PSAO (fully insured and self insured payers) • Offering accepted by payer as a subspecialty pharmacy network • Hemophilia patients can access subspecialty pharmacy network through their insurance benefit www.hemoalliance.org [email protected] How does an HTC participate in PSAO? • HTC signs a participation agreement with PSAO giving you access to review contracts • HTC reviews individual PSAO contract offerings and key terms and requirements • Pricing • Services • Reporting • HTC chooses which contracts to participate in • HTC executes and agrees to terms of chosen contract(s) with the PSAO. • HTC communicates participation in contract to its patients and other stakeholders www.hemoalliance.org [email protected] The overall HTC member PSAO process HTC receives payment for factor/drug from PSAO and uses funding to support patient services START HA forms PSAO PSAO bills payer under contract terms and receives payment PSAO governance establish benefit parameters HTC bills for factor/drug to PSAO Benefit is offered to payers for patient benefit Patient receives HTC pharmacy services www.hemoalliance.org Patient chooses sub‐specialty HTC network through exchange or from employer [email protected] The HTC owned PSAO Indirect process HTC receives payment for factor/drug from PBM/insurer START HA forms network through PSAO HTC bills payer under HA PSAO contract terms and receives payment from PBM/insurer PSAO governance establish benefit parameters Benefit is marketed to payers to be a part of their patient benefit HTC bills for factor/drug to the PBM/insurer Patient receives HTC pharmacy services through the PBM included benefit www.hemoalliance.org Payer contracts with HC PSAO for their network and benefit to be a part of the overall contracted benefit [email protected] Questions and Panel Discussion www.hemoalliance.org [email protected] Key Definitions • Fully Insured healthcare is where the employer contracts with an insurance company to cover the employees and dependents. The insurance company underwrites the risk. Fully insured plans are subject to State law insurance regulations. • Self‐funded Healthcare is a self insurance arrangement whereby an employer provides health or disability benefits to employees with its own funds. Thus, the employer is acting as an “insurance company” and underwrites the risk. Self funded health plans, under the provisions of Section 514 of ERISA, are exempt from state insurance regulations. www.hemoalliance.org [email protected] Key Definitions • Third Party Administrator (TPA) – a TPA handles the claims processing for an employer that self‐insures its employees. The risk of loss remains with the employer, and not with the TPA. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, prescription drug card programs, or membership functions. www.hemoalliance.org [email protected] Key Definitions • Pharmacy Benefit Manager (PBM)‐ An administrator of prescription drug programs. PBMs are responsible for processing and paying prescription drug claims, and often developing and maintaining a formulary of drugs. PBMs also may contract with pharmacies and negotiate discounts and rebates with drug manufacturers. www.hemoalliance.org [email protected]
