Managed Care - January 2008 - (Page 33) ative reporting and for development of an auditable pay-for-performance pharmacy program. Because the data fields are available to the claim processor, payments for services are easy to sort by dispensing pharmacy, by prescriber, by brand or generic status, or by formulary status. Easily captured The data are easily captured, analyzed, and reported to the contract holders, such as commercial insurance companies or pharmacy benefit managers. In fact, a pay-for-performance pharmacy program is easily implemented within the contract for services. Often the data elements or edits that are important to measurement of service levels or actions can be, and are, designed and implemented to address specific needs for the reporting task, such as the use of refill activities for diabetic members. This reporting element can indicate the member’s compliance. Data elements are aligned with continuous quality improvement and quality attainment efforts by the insurance plan to provide enhanced rankings by an accrediting or credentialing body. The NCQA (National Committee for Quality Assurance), JCAHO (now the Joint Commission — previously the Joint Commission on Accreditation of Healthcare Organizations), and URAC (originally the Utilization Review Accreditation Commission) are all very important organizations setting quality attainment standards so consumers may evaluate the services provided by the insurance or hospital providers. Medicare Part D has also brought efforts to improve quality and, ultimately, health status. Many specialty pharmacy providers of high-cost selfinjectables and some pharmacy mail service vendors do acknowledge the very positive approach to quality improvement based on measured performance. Vendors like PerformRx and Caremark (both PBMs) and Accredo and OptionCare (specialty injectable providers) all have active programs to improve health outcomes for members and customers using many of these tools. Pharmacy based pay for performance is simplistic at present, usually a review for member compliance with medications. It is well known that in retail pharmacy an area of high growth is that of biological medications re- quiring injection. These are typically much more costly than oral agents, and the numbers of these agents on the market is growing rapidly. Moreover, self-injectables need special handling, refrigeration and storage. Specialty pharmacy services for self-administered injectables is an example of performance pay in contracting. The contract can be written to have the speciality pharmacy take over the responsibility of authorizing a medication for the insurance plan with the promise of better health outcomes, greater provider and member satisfaction, and lower cost from reducing waste and increasing operational efficiencies. The specialty provider evaluates medical necessity based on the plan’s requirements and uses the recorded experience to prevent inappropriate utilization. PerformRx, Caremark, Accredo, OptionCare, and others have contracts with insurance plans to do certain quality-related duties and do have financial risk for nonperformance. Some may ask why there is a need for such programs in retail pharmacy when the fees that are usually offered by payers and plans have been accepted for services provided. Historically, the answer is simply that many offered the bare minimum in payment to allow for claim filing. Often, the low dispensing fees and deep discounts for ingredients were offset by the provider’s ability to control costs in various purchase programs including volume discounts, free goods, extended dating programs, and other nonrebate subsidies. But the business model of the high-volume retail pharmacy is mismatched with that of other providers and with insurers. Service expected As an example, the member’s prescription may require the pharmacist to call the pharmacy benefit manager or the prescriber for additional information or prior authorization. The member may not understand the process, but he does expect the pharmacist to do whatever it takes to dispense the drug. In pharmacy, the payment system in many contracts is unsophisticated and is based on average wholesale price. But AWP has been subjected to a great degree of criticism as being unreliable, if not dishonest, and easily manipulated to increase revenue for manufacturers and wholesalers. JANUARY 2008 / MANAGED CARE 33
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