Payer Trends: What You Need to Know
By Jeff Blake

Over the last few years, the Payer Team has established strong relationships with several national insurance brokers and consultants, stop-loss/reinsurance carriers, insurance companies/third party claims administrators and mid-tier pharmacy benefit managers. These payers and advisors work with employers, many offer self-insured health plans, to manage their health plan expenditures and design.

So, what have we learned over the last few years and what are some of the trends?

1. Employers continue to focus on enhanced management of high cost complex claims – including bleeding disorders. All eyes are on HTCs, products prescribed and dispensing pharmacy practices.
    
2. Many manufacturers are providing rebates for clotting factor to health plans and PBMs and commercial specialty pharmacies are able to lower their reimbursement rates with payers to be more competitive with HTC pharmacies. If this trend continues HTC pharmacies may need to reduce their reimbursement rates with payers.
    
3. Payers are now requiring performance guarantees with penalties in their contracts with HTCs. Guarantees include Assay Management and avoidable emergency department visits. We were recently asked to include an Assay Management guarantee in an individual Letter of Agreement (LOA).
    
4. Bleeding disorders product pricing and reimbursement rates are getting more competitive. Our competitors want to grow their business just like our member HTC pharmacies. The rates our competitors are charging payers continues to decrease, so HTC pharmacies must continue to review their bleeding disorders reimbursement rates to remain competitive.
    
5. Self-insured employers and their brokers/consultants are very willing to work with HTCs and their pharmacy programs to reduce the cost of the bleeding disorder medication. Many times, this requires an individual Letter of Agreement (LOA) between the employer’s health plan and the HTC.
    
6. The Hemophilia Alliance Team typically receives 3 – 5 broker/consultant requests each week to evaluate potential savings by moving the bleeding disorders medication from a commercial specialty pharmacy to a member HTC pharmacy. Below are additional items we have determined in our work with these brokers/consultants:
    
   1. 5% – 10% of the time the HTC and their pharmacy program are already providing the clinical and pharmacy services. No changes are necessary – the employer has the best deal.
       
   2. The remaining 90% – 95% of the time there is an opportunity for the HTC and their pharmacy program to get new business.
       
      1. When the Hemophilia Alliance and the HTCs can respond to these opportunities quickly (within 5 – 10 business days) and with competitive pricing for the bleeding disorders medication, we are more likely to win the business for the HTC pharmacy.
          
      2. When it takes us longer than 2 weeks to respond, their interest in our response has significantly declined and they have moved on to other hot items. Often, we cannot get them re-engaged in our proposal.
          
      3. If your HTC is operating its pharmacy program exclusively through contract pharmacy arrangements with pre-determined pricing, consider signing a contract pharmacy arrangement with The Alliance Pharmacy (TAP). This provides a low-cost option for administrative services but more importantly creates an opportunity to offer flexibility in product pricing as the payer team helps your HTC acquire business.
          

7. The payer community has gained an enhanced understanding of the HTC model of care and how integrating the medical care with the HTC pharmacy can improve outcomes and save money.
    
8. Payers continue to gain interest in contracting with Hemophilia Alliance Network Services (HANS). We now have 4 payer contracts – CareSource, ArchimedesRx, AscellaHealth and Security Health Plan and we are working with several other payers on potential HANS contracts. If your HTC has not signed the HANS PPO agreement to participate in HANS payer contracts, now is an excellent time to sign up.

If you would like additional information about the HANS PPO Agreement and our payer relations activities, please contact a member of the Hemophilia Alliance Team. We Work for You!!