Managed Care - January 2008 - (Page 32) Now Is the Time for Pharmacy Performance Incentives We’ve made strides in increasing the transparency of pricing in the pharmacy supply chain, and now we need to change dispensing behavior more for Medicaid than for primary and secondary education. Pay-for-performance programs require agreeay for performance in medicine is a topic ment on measurements, including their integrity of wide discussion among managed care and repeatability, so that a fee structure can be executives for its supposed ability to connegotiated that offers both parties a reasonable tain costs, to improve health outcomes, opportunity for gain as well as the potential for and to raise the overall quality of health services. risk of loss of revenue. One goal is to enhance provider satisfaction by Retail pharmacies use standardized increasing provider participation. A comcomputer software for prescription claim mon method is to raise payment levels since, processing. These systems comply with the as we all know, high pay is more satisfying National Council for Prescription Drug than low pay. It’s simple, and it’s why the Programs (NCPDP 5.1) format. The pay-for-performance movement is so atDeficit Reduction Act of 2005 mandates tractive. particular software edits — features to be In community pharmacy, pay for perimplemented for e-prescribing and for formance is developing because of the comelectronic medical records. plexity of the prescription benefit programs The NCPDP 5.1 software standard and because members and prescribers are transmits details of claims but is also a increasingly frustrated. When something Busy stores operstandard storage format for over 100 data goes wrong at the pharmacy counter, they ate on the idea that call their insurer’s member-services line to time and volume are elements. These data fields give the opporcomplain. Maybe the pharmacy didn’t call what matters, which tunity to report or validate edits and is why prescriptions actions taken. Edits in the pharmacy softthe prescriber for a refill when it discovered often go unfilled, or that one was needed, or the prescriber was members are told to ware allow for robotic actions to take place, such as comparing the dose to what is preasking for a non-preferred medication or go elsewhere, says scribed vs. what the FDA has approved for one that requires prior authorization, or the the author. safe administration, or evaluating the drug was found to be on a higher copayment numbers of tablets dispensed per 30-day period, tier. There are many reasons why the requests for allowing the benefit to be managed according to a medication filing fails. expected cost estimates. Electronic edits are nanoseconds fast and ordinarily in a yes-or-no Critical benefit format, and are based on a predefined decision Pharmacy is a critical benefit: Approximately 20 tree. percent of health plan expenses can be attributed Reports are always historical, providing a powto pharmacy, up significantly over the past 15 erful tool for evaluating the results of the edits in years. a summary display. They allow the insurer, plan Outpatient pharmacy costs now approach those pharmacist, and other stakeholders to evaluate of inpatient services, and states are now spending and reliably estimate the market results for the benefit. Edits as well as reporting can also be used Thomas Kaye, RPh, MBA, is the senior pharmacy to determine patient compliance with taking director at Passport Health plan, which is medications. Robust data elements allow for creadministered by AmeriHealthMercy. By Thomas Kaye, RPh, MBA P 32 MANAGED CARE / JANUARY 2008
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