Payer Relations Update
15 Key Points From Your Payer Team
The Hemophilia Alliance Fall meeting in Portland was a huge success. We had a record number of member attendees and a wide array of timely topics were discussed. The Payer Team’s five members have each summarized their presentations into 3 key points to remember as we continue to seek access to payer networks and expand your business.
Jeff Blake, Senior VP of Payer Relations:
- The HANS PPO Agreement is a contract between the HTC and HANS that allows the Hemophilia Alliance Team to negotiate regional and national payer contracts on behalf of HTCs.
- One of the goals of the PPO Agreement is to work together with HTCs to solve insurance issues so more patients can use the HTC pharmacy programs and grow your business.
- There is no additional cost to participate in the PPO Agreement. This service is included in your annual membership dues.
Roland Lamy, VP of Payer Relations:
- Anthem’s new PBM, Ingenio Rx, will transition all business served by ESI/Accredo by 1/1/20.
- IngenioRx is supported in the "back office functions" by CVS/Caremark, but Ingenio is calling all the shots on decisions, including those with respect to the network
- IngenioRx has told us there is no intention to move patients away from HTCs. But member communication could be messy if HTC patients currently receive other medications from Accredo, since they will be told those other prescriptions must transition. That fact should not impact an HTC’s ability to continue to dispense clotting factor under its prevailing Anthem agreement.
George Oestreich, Pharm D, MPA, Senior Medicaid Consultant:
- Each Medicaid agency in each state is different. It is important to know the differences and how they affect your practice. It is also important to maintain a relationship with your state Medicaid agency.
- You can impact reimbursement for products and services separately. It is important to separate the products and clinical services to increase your reimbursement and to assure that patients are well supported in caring for their disease.
- Managed care is continuing to grow as a delivery system. You may work with your state to assure your reimbursement has a “floor” set and may not be reduced below the state direct reimbursement. You may also negotiate your MCO contract. It is not a “take-it-or-leave-it” opportunity.
Jeff Amond, Director, Payer Relations, Midwestern States:
SUCCESS – Based on the last few years of experience, the Payer Team has found a successful approach to winning back the clotting factor business to your HTC. The approach consists of 3 parts:
- Establish a relationship with your Hemophilia Alliance Payer Team and complete the insurance questionnaire and clotting factor utilization spreadsheet.
- Get a Business Associates Agreement signed between the HTC and the Hemophilia Alliance. Once this is signed, an in-person meeting is arranged. The in-person meeting will focus on using the clotting factor utilization spreadsheet and insurance questionnaire to develop the strategic plan to win back the clotting factor business.
- Identify the key people at your HTC and/or hospital that will be needed when a clotting factor opportunity is brought to you. Then work with them to develop a process to be ready for any opportunity that comes your way. For example, figure out who are the decision makers for pricing and who has signatory authority for signing a Letter of Agreement. Having a well-defined process is essential since the window of opportunity for clotting factor opportunities is about 3 weeks. If a decision is not made within that time, the opportunity is lost, and the broker moves on to other business.
Mark Plencner, Director, Payer Relations, Western States:
- Our Specialty Pharmacy competitors at national conferences continue to say that they can manage clotting factor assays better than HTCs and everyone should be able to manage to assays to within 0.5% of the prescribed dose. An assay management best practice model that includes timely and robust reporting capabilities would be a useful addition to our integrated care model.
- Bleed log use, management, and reporting is picking up steam as well. There are several mobile apps, such as Audaire and MicroHealth, and some HTCs use home-grown apps. Regardless of which app you use, the data is relevant to excellence in patient care and can prove to be of benefit when seeking access to a payer network.
- Payers and PBMs continue to focus on accreditation, though there is variety across the marketplace for what payers require. As payers, PBMs and pharmacies continue to vertically integrate, it may be in the best interest of your HTC pharmacy practice to take a closer look at seeking accreditation.
Also in this Issue…
Notes from Joe
· Celebrating 20 Years of the Alliance!
· Alliance Seeking Board Member Nominations
· Portland Didn’t Disappoint
· Linda Gammage Social worker conference – Register for one of the spots
· Keeping and Getting Back What’s Yours
Notes from the Community
· HTC Patients Highly Satisfied with HTC 340B Programs Nationwide
Team Alliance Contact Information
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