Pharmacoeconomics & Health Outcomes
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Pharmacoeconomics & Health Outcomes
Applied Pharmacoeconomics Research Community Rx & Managed Care Quality Leon E. Cosler, R.Ph., Ph.D. Associate Professor of Pharmacoeconomics Albany College of Pharmacy
Road Map
• •
PE in Community Pharmacy PE in Managed Care • MC Characteristics • Role of PBM’s • Rx benefit applications • Performance Measures • Report Cards
•
Where’s he getting this? • Text Chs. 13 + 14
PE in Community Rx
• • •
Conducting studies? Participating in studies Pharmaceutical Care – emphasis on Pt. outcomes • R.Ph. – quality care to cost – conscious Pts.
•
Who cares? • Governments • Payers • Patients
PE in Community Rx
•
Future trends
- Increased use of technology - Information / www / and consumerism - Consolidation of large hospitals / systems • Seemless care / no redundancy • Merging drug formularies…
• •
Drug Utilization review Modifying prescribing behavior “… all of these skills require training in pharmacoeconomics…”
PE in Community Rx Pharma #1
Pharma #2
Pharma #3
Wholesaler or Warehouse PBMs
Chain #1
Chain #2 Rx Alliance #1
Chain #3
PE in Community Rx Rx Alliance #1
Large Health System will select from…
•
Decision based on:
Rx Alliance #2
Rx Alliance #3
- Increased use of technology - cost / quality of Rx services • superior formulary ? • lowest acquisition costs
PE in Community Rx
•
Future trends
- Patient health monitoring as routine care? • Monitor changes & coordinate with MD?
- Evaluating their services • Evaluate cognitive services
- Post-marketing surveillance studies - Critically evaluate PE literature •
Pharmacist = “Pharmaceutical Outcomes Manager” ?
Pharmacy Quality Alliance
Pharmacoeconomics in Managed Care
PE in Managed Care
•
Ch.14 excellent review of Managed Care • Business Models • Unique strategies for controlling costs &
utilization - Shift financial risk to providers
• Leaders in quality of health care & Pt.
outcomes - NCQA / HEDIS measures
Managed Care Characteristics: 1. Negotiated pricing, discounts, & salaries 2. Patient Co-payments 3. Bundling services into one price 4. Peer review 5. Utilization review 6. Capitation payments 7. Channel Pts. to “preferred” providers 8. Quality criteria accountability 9. Health promotion & prevention efforts
Managed Care Rx Benefit Characteristics:
•
Accomplished by using a PBM 1. P&T committee 2. Drug formulary 3. Generic / Tx interchanges 4. Treatment guidelines 5. DUR 6. Disease management 7. Academic detailing
Role of PE in Managed Care 1. Formulary Policies •
Been there / done that…
3. Appropriate use (MDs & RPh) 5. Drug Benefit design
Managed Care 1. Appropriate Rx
Usage • Prescribing • Optimize quality / cost • Use of treatment guidelines / algorithms
• •
Dispensing Adherence
Role of PE in Managed Care 1. Drug Benefit design • • • • •
•
Prior authorizations Category inclusion / exclusions Step – therapies Rx outlets (mail order, etc.) Benefit caps
PE needed to measure ‘big picture’ effects
Why measure performance?
•
In response to criticism • Employers / payers demanding quality
•
Consumers “vote with their feet”
•
Measure the quality of providers in plan
•
All utilization is not excessive • ↑ spending does ↑ satisfaction & outcomes
•
Reduce variation in $$$ procedures
Managed Care Accreditation National Committee for Quality Assurance (NCQA):
- formulates performance measures called: - Health Plan Employer Data Information Set (HEDIS)
- partial list of measures - care effectiveness - access to care - satisfaction - MCO stability
– use of services – cost of care – education – MCO information
HEDIS Data HCFA #
Plan Name
H3351 Excellus Health Plan, Inc. dba Univera Healthcare H3356 Excellus Health Plan, Inc. - Rochester Area Division Rochester Area Health Maintenance Organization H3305 d.b.a. Preferred Care H3362 Independent Health H3388 Capital District Physicians Health Plan, Inc. HealthNow New York, Inc. dba BlueCross BlueShield H3384 of Western New York H3370 Empire BlueCross BlueShield H3330 HIP Health Plan of New York H3307 Oxford Health Plans - New York H3366 Health Net of New York, Inc. H3379 United HealthCare of New York, Inc. H3312 Aetna Health Inc. H3361 WellCare of New York, Inc. H3359 Managed Health, Inc.
EOC020-0010 EOC020-0070 EOC020-0100 HbA1c testing Eye Exams Lipid Panels 91.97 91
71.05 82
94.65 91.73
90.75 89.78 89.29
77.13 62.04 71.53
91.73 91.73 91.97
88.81 86.62 86.37 84.98 83.77 80.05 78.91 77.98 77.62
70.32 72.51 74.45 66.59 68.26 53.04 70.38 55.96 39.9
92.21 94.16 91.24 93.5 92.12 86.86 87.2 77.06 78.59
HEDIS Data HCFA ID No. Plan Name H3351 H3362 H3305 H3356 H3379 H3384
H3359 H3388 H3307 H3330 H3361 H3370 H3366 H3312
Excellus Health Plan, Inc. dba Univera Healthcare Independent Health Rochester Area Health Maintenance Organization d.b.a. Preferred Care Excellus Health Plan, Inc. - Rochester Area Division United HealthCare of New York, Inc. HealthNow New York, Inc. dba BlueCross BlueShield of Western New York Managed Health, Inc. Capital District Physicians Health Plan, Inc. Oxford Health Plans - New York HIP Health Plan of New York WellCare of New York, Inc. Empire BlueCross BlueShield Health Net of New York, Inc. Aetna Health Inc.
Rx Cost PMPM No. Rxs PMPY 102.22
29.25
109.64 111.2
36.49 26.31
116.88
37.38
24.87 36.49
10.1 24.88
46.45 53.49
12.81 22.78
54.45 62.13 63.81 70.97 81.94 NR
17.83 18.43 13.47 23.06 26.18 23.15
Managed Care Accreditation: NYS NYS has its our own performance measures...
- Quality Assurance Reporting Requirements (QARR)
- MCO performance measures • “commercial” and “Medicaid” measures
- Report available on the www • www.health.state.ny.us
Quality Assurance Reporting Requirements
Uses for this information:
•
developing practice guidelines
•
provider report cards
- give providers a score and compare them - encourage providers to improve - potential financial implications - no Rx report cards (yet) - e.g. new NYS Hospital Profiles - http://hospitals.nyhealth.gov/
NCQA Report Cards:
NCQA Report Cards:
That’s all for today! THURSDAY:
• • •
Post – assessment quiz Complete individually Incentive
-
BOTH done = 100% ONE done = 90% NONE done = 65%
Applied Pharmacoeconomics Research Community Rx & Managed Care Quality Leon E. Cosler, R.Ph., Ph.D. Associate Professor of Pharmacoeconomics Albany College of Pharmacy
Road Map
• •
PE in Community Pharmacy PE in Managed Care • MC Characteristics • Role of PBM’s • Rx benefit applications • Performance Measures • Report Cards
•
Where’s he getting this? • Text Chs. 13 + 14
PE in Community Rx
• • •
Conducting studies? Participating in studies Pharmaceutical Care – emphasis on Pt. outcomes • R.Ph. – quality care to cost – conscious Pts.
•
Who cares? • Governments • Payers • Patients
PE in Community Rx
•
Future trends
- Increased use of technology - Information / www / and consumerism - Consolidation of large hospitals / systems • Seemless care / no redundancy • Merging drug formularies…
• •
Drug Utilization review Modifying prescribing behavior “… all of these skills require training in pharmacoeconomics…”
PE in Community Rx Pharma #1
Pharma #2
Pharma #3
Wholesaler or Warehouse PBMs
Chain #1
Chain #2 Rx Alliance #1
Chain #3
PE in Community Rx Rx Alliance #1
Large Health System will select from…
•
Decision based on:
Rx Alliance #2
Rx Alliance #3
- Increased use of technology - cost / quality of Rx services • superior formulary ? • lowest acquisition costs
PE in Community Rx
•
Future trends
- Patient health monitoring as routine care? • Monitor changes & coordinate with MD?
- Evaluating their services • Evaluate cognitive services
- Post-marketing surveillance studies - Critically evaluate PE literature •
Pharmacist = “Pharmaceutical Outcomes Manager” ?
Pharmacy Quality Alliance
Pharmacoeconomics in Managed Care
PE in Managed Care
•
Ch.14 excellent review of Managed Care • Business Models • Unique strategies for controlling costs &
utilization - Shift financial risk to providers
• Leaders in quality of health care & Pt.
outcomes - NCQA / HEDIS measures
Managed Care Characteristics: 1. Negotiated pricing, discounts, & salaries 2. Patient Co-payments 3. Bundling services into one price 4. Peer review 5. Utilization review 6. Capitation payments 7. Channel Pts. to “preferred” providers 8. Quality criteria accountability 9. Health promotion & prevention efforts
Managed Care Rx Benefit Characteristics:
•
Accomplished by using a PBM 1. P&T committee 2. Drug formulary 3. Generic / Tx interchanges 4. Treatment guidelines 5. DUR 6. Disease management 7. Academic detailing
Role of PE in Managed Care 1. Formulary Policies •
Been there / done that…
3. Appropriate use (MDs & RPh) 5. Drug Benefit design
Managed Care 1. Appropriate Rx
Usage • Prescribing • Optimize quality / cost • Use of treatment guidelines / algorithms
• •
Dispensing Adherence
Role of PE in Managed Care 1. Drug Benefit design • • • • •
•
Prior authorizations Category inclusion / exclusions Step – therapies Rx outlets (mail order, etc.) Benefit caps
PE needed to measure ‘big picture’ effects
Why measure performance?
•
In response to criticism • Employers / payers demanding quality
•
Consumers “vote with their feet”
•
Measure the quality of providers in plan
•
All utilization is not excessive • ↑ spending does ↑ satisfaction & outcomes
•
Reduce variation in $$$ procedures
Managed Care Accreditation National Committee for Quality Assurance (NCQA):
- formulates performance measures called: - Health Plan Employer Data Information Set (HEDIS)
- partial list of measures - care effectiveness - access to care - satisfaction - MCO stability
– use of services – cost of care – education – MCO information
HEDIS Data HCFA #
Plan Name
H3351 Excellus Health Plan, Inc. dba Univera Healthcare H3356 Excellus Health Plan, Inc. - Rochester Area Division Rochester Area Health Maintenance Organization H3305 d.b.a. Preferred Care H3362 Independent Health H3388 Capital District Physicians Health Plan, Inc. HealthNow New York, Inc. dba BlueCross BlueShield H3384 of Western New York H3370 Empire BlueCross BlueShield H3330 HIP Health Plan of New York H3307 Oxford Health Plans - New York H3366 Health Net of New York, Inc. H3379 United HealthCare of New York, Inc. H3312 Aetna Health Inc. H3361 WellCare of New York, Inc. H3359 Managed Health, Inc.
EOC020-0010 EOC020-0070 EOC020-0100 HbA1c testing Eye Exams Lipid Panels 91.97 91
71.05 82
94.65 91.73
90.75 89.78 89.29
77.13 62.04 71.53
91.73 91.73 91.97
88.81 86.62 86.37 84.98 83.77 80.05 78.91 77.98 77.62
70.32 72.51 74.45 66.59 68.26 53.04 70.38 55.96 39.9
92.21 94.16 91.24 93.5 92.12 86.86 87.2 77.06 78.59
HEDIS Data HCFA ID No. Plan Name H3351 H3362 H3305 H3356 H3379 H3384
H3359 H3388 H3307 H3330 H3361 H3370 H3366 H3312
Excellus Health Plan, Inc. dba Univera Healthcare Independent Health Rochester Area Health Maintenance Organization d.b.a. Preferred Care Excellus Health Plan, Inc. - Rochester Area Division United HealthCare of New York, Inc. HealthNow New York, Inc. dba BlueCross BlueShield of Western New York Managed Health, Inc. Capital District Physicians Health Plan, Inc. Oxford Health Plans - New York HIP Health Plan of New York WellCare of New York, Inc. Empire BlueCross BlueShield Health Net of New York, Inc. Aetna Health Inc.
Rx Cost PMPM No. Rxs PMPY 102.22
29.25
109.64 111.2
36.49 26.31
116.88
37.38
24.87 36.49
10.1 24.88
46.45 53.49
12.81 22.78
54.45 62.13 63.81 70.97 81.94 NR
17.83 18.43 13.47 23.06 26.18 23.15
Managed Care Accreditation: NYS NYS has its our own performance measures...
- Quality Assurance Reporting Requirements (QARR)
- MCO performance measures • “commercial” and “Medicaid” measures
- Report available on the www • www.health.state.ny.us
Quality Assurance Reporting Requirements
Uses for this information:
•
developing practice guidelines
•
provider report cards
- give providers a score and compare them - encourage providers to improve - potential financial implications - no Rx report cards (yet) - e.g. new NYS Hospital Profiles - http://hospitals.nyhealth.gov/
NCQA Report Cards:
NCQA Report Cards:
That’s all for today! THURSDAY:
• • •
Post – assessment quiz Complete individually Incentive
-
BOTH done = 100% ONE done = 90% NONE done = 65%
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