Managed Care - November 2008 - (Page 18)

Is Care Coordination Making Carve-outs Less Desirable? By Martin Sipkoff Contributing Editor G iven emerging technology — and a contracting economy — health plans are looking hard at whether carve-outs for pharmacy benefits, disease management, specialty pharmacy, and behavioral health care are worth the money. Affordable software for managing even the most esoteric of services — expensive long-term drug therapies for cancer, for example — is becoming available. Most important, plans are increasingly aware that a comprehensive integrated approach to managing a continuum of care is a powerful marketing strategy. They say their ability to merge drug data with lab results and diagnostic history is the future of high quality medicine. Why, they ask themselves, should they subsidize the bottom lines of PBMs, managed behavioral health care companies, and disease management vendors? Couldn’t they earn the revenue going to these vendors from purchasers? “Several very large plans, such as Aetna, are bringing these services back in-house, especially disease management,” says Peter Kongstvedt, MD, a leading health care consultant. “The theory is that they themselves can use the sophisticated information technology needed to manage care upstream, identifying cases early that will cost more money later. Handling these services in-house allows them to tightly integrate case management.” A carve-out is just what the phrase implies: health care programs focused on a specific disease (like diabetes) or service (like prescription coverage) that are “carved-out” of a benefit design. A vendor is paid to provide them, usually for a flat fee. The care provided is usually highly managed and generally the vendor assumes financial risk. The value of a carve-out — whether it is for managing prescriptions, chronic diseases, mental health and substance abuse treatment, or expensive injectables — is to provide the expertise that would be prohibitively expensive for plans to develop and sustain. But health plans are developing the technology needed to successfully manage those areas, say some experts, and offering an integration of care that stand-alone vendors can never provide. Plans refer to the technology that allows for service integration as informatics, and they view their claims databases as chronic disease management tools. Kongstvedt says that predictive modeling — a sophisticated and expensive technology used to predict individual member risk for specific diseases — is an example of what deep-pocketed national plans might be able to implement that is beyond the reach of regional plans, which makes them more reliant on carve-outs. “But even that is changing as sophisticated technology becomes less expensive and therefore more available to more plans,” he says. “That could be what will affect the future, especially for disease management vendors.” DISEASE MANAGEMENT One carve-out industry undergoing significant transformation is disease management. Plans are bringing these programs in-house for several reasons — the single biggest reason being that new technology is allowing the integration of databases, including prescription records, medical claims, and laboratory data. A survey by Health Industry Research Companies (HIRC), a consultant, found that in 2006, health plans purchased 169 such programs from DM vendors. Last year, that number had fallen to 80. A marketing push by a couple of vendors brought that number back up to 112, as of last spring. Plans are increasingly aggressive in marketing their ability to manage chronic diseases, and they position themselves as competitors to stand-alone DM vendors — in fact, they use informatics to push their book of business. Aetna, for example, 18 MANAGED CARE / NOVEMBER 2008

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

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