Payer Update, February 2021

Payer Update

Update on the Disease Management Program
by George Oestreich

Over the last couple years, the Payer Team has been working on a bleeding disorders Disease Management Program (DMP). The goal of the DMP is to develop and implement a payer reimbursement model that supports the integrated comprehensive care Hemophilia Treatment Centers (HTCs) provide to their patients. In addition to receiving reimbursement for the dispensation of bleeding disorder products, HTCs would also receive a DMP fee from the payer for the integrated care and care coordination provided to patients. To effectively roll out a DMP model, we must first capture cost data for pharmacy and clinical services. The DMP model should fit well in Medicaid and with private insurance payers.

To begin our data collection efforts, we have contracted with Mercer, a multinational firm that is very involved in data collection for state Medicaid Agencies and is respected by the Centers for Medicare and Medicaid Services (CMS). The data collection will occur in two (2) phases, which are highlighted below.

  • Phase 1 – Cost of Dispensing (COD) Survey:

    HTC pharmacies have been involved in traditional COD surveys with their state Medicaid Agencies for several years. Unfortunately, by being included in traditional cost of dispensing surveys HTC pharmacies COD came back as “outliers” and their COD was excluded from the results. The goal of our HTC COD survey is to obtain a statistically valid sample to support a more reasonable COD that represents the true cost of providing bleeding disorder products through an HTC. This will provide us with data to support HTCs’ higher cost of dispensing and we will be able to use that information to support higher Medicaid dispensing fees for our members. In addition, we have strengthened this effort by working with Mercer to also integrate an advisory group of Medicaid pharmacy directors into the project, giving our study even greater viability and support.

    We are very close to finalizing the Survey questionnaire to collect the COD data. Our goal is to distribute the survey to our member HTC pharmacies during March and Mercer will be having a webinar explaining the most expedient way to complete the Survey. The Hemophilia Alliance Team will also be available to support your efforts. Please look forward to the announcements of the information and the webinar. This is a great opportunity to support our position with data.

  • Phase 2 – Cost Data for Clinical Care & Care Coordination:

    This phase of the Survey will gather data on the clinical and care coordination services that HTCs provide that are typically not reimbursed by payers. This data will be analyzed and grouped so we may be able to bill for these imperative but non-dispensing services in the future. As dispensing fees erode and exclude the other adjuvant data that is critical to patient outcomes, we must find a way to support the provision of these services by the HTC. This is important financially, for patient outcomes, and to fulfill our mission of providing comprehensive and coordinated care for our patients that also recognizes the impact of social determinants of care.

  • We are excited about this opportunity to obtain data to support our dispensing fee and the overall value of the HTC model of care. We are equally excited to identify those other services that HTC do on a regular basis that is often unreimbursed by the payers.

    We look forward to working with you on this program.

Also in this Issue…

Notes from Joe
· Interesting

Legal Update
· State Laws Regulating Pharmacy Reimbursement, ERISA, and the Supreme Court – What Could Rutledge Mean for 340B Covered Entities?

Washington Update
· What’s new in Washington?

Alliance Update
· Introducing our new Board Member
· Harmony in Hemophilia Update
· Membership Dues and Benefits
· 2021 Meeting Schedule

Notes from the Community
· Reminder about the Patient Notification System