Thursday, October 31, 2013

Session Spotlight: Redefining the Paradigm of Care: Use Clinical Initiatives to Create Healthier, Happier Members member experience begins when the member goes to enroll in your plan, and lasts throughout their time with you. Improving their experience can not only increase retention rates, but can help to create a happier, healthier member pool. So what are the clinical initiatives you should be taking for creating an ideal member experience and implementing the best practices?  

Session: Redefining the Paradigm of Care: Use Clinical Initiatives to Create Healthier, Happier Members

Moderator: Alexandra Schweitzer, Executive Director, Senior Care Options, Tufts Health Plan

Linda Hines, RN, MS, MBA, Vice President of Medical Management, Virginia Premier Health Plan, Inc.
Jeffrey E. Epstein, MD, President, National Association of Physician Advisors (NAPA); President and CEO, Epstein Healthcare Consulting Group (eHCG)
Romilla A. Batra, MD, MBA, Corporate Medical Director, Scan Health Group
Kristin Neal, Vice President, Stars Part C & Clinical, Cigna-HealthSpring

When members are confident in their treatment and their ability to manage their diseases, they’re healthier, and therefore happier with their experience. Want to learn more about using medical management as a tool that helps drive engagement? Join us for IIR's Medicare Congress 2014 taking place February 10-12 in New Orleans, LA. To learn more, download the brochure.

As a reader of the this blog, you’ll receive 15% off of the standard rate when you use priority code XP1907BLOG to register. We hope to see you this February!

Wednesday, October 23, 2013

Attend IIR’s expanded 2014 Medicare Congress

With these sweeping changes facing us, attending IIR's Medicare Congress in New Orleans on February 10-12 will be your roadmap to success, as it's positioned early in Q1, giving you and your team ample time to get ahead of the market and become change agents!

For 2014, the Congress will expand to provide you with all of the overarching trends that affect your bottom line, from sales and marketing, clinical, financial, and product development perspectives, making it the "one and done" event. IIR's Medicare Congress is the one place where team members from across your organization can meet to learn from one another and network with peers.

The Medicare Congress includes: 

• The integration of the D.U.A.L.S. Forum, providing Medicaid plans an exclusive opportunity to network with Medicare plans for an ultimate peer learning experience to improve health outcomes and minimize spend

• The reenergized Stars University, focused on health plan all-stars and rising stars that have significantly improved their star ratings so you can duplicate their winning strategy and grow reimbursement

• An increased focus on creating the ideal customer experience to help you boost quality scores and member retention, with of-industry and out-of-industry examples

To learn more, download our agenda.

As a reader of the this blog, you’ll receive 15% off of the standard rate when you use priority code XP1907BLOG to register. If you have any questions about the agenda or event, feel free to email Kate Devery at or visit the homepage.

We hope to see you, February 10-12 in New Orleans!

The Medicare Congress Team

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Friday, October 18, 2013

Call for papers for MMCC

We are pleased to announce 22nd annual Medicaid Managed Care Congress, taking place on May 20-22 in Baltimore. After dozens of conversations with industry experts, we’re ready to start recruiting speakers for the event! The agenda is currently under development, and we are currently looking for health plan and state government speakers who can speak to the following topics:

• Best practices for LTC
• Who is enrolling in exchanges and what their needs are, based on the services being used once coverage begins
• Examples of payment reform
• New care delivery models, including ACOs and PCMH
• Medicaid expansion
• Lessons learned from duals demonstrations
• Strategies to improve quality measurements

If you are interested in speaking on any of these topics, or would like to suggest another topic, please email,, the Program Director for the event. If you would like to get in front of our audience of health plan executives working on exchanges, please contact Sarah Scarry at for sponsorship and exhibition opportunities.

We look forward to hearing from you soon!

The MMCC Team

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Tuesday, October 15, 2013

How does the ACA affect health care professionals?

It's no secret that some government officials don't exactly agree with the new Affordable Care Act. All political views aside, how will this new law impact actual health care professionals, particularly Nurse Practitioners? And what is their role in the health care reform?

This infographic provides a snapshot of what has happened in the years since the Affordable Care Act was conceptualized and enacted, in addition to showing how nurse practitioners are contributing to primary care. 

Friday, October 11, 2013

Download the Brochure for IIR's Medicare Congress

Inquiries about IIR’s Medicare Congress 2014 event have been pouring in daily, so we are pleased to announce – the website and registration are now live!

You’ll see that we’ve expanded the program for 2014, and are excited to introduce the only event allowing you and your team to be "one and done” at the Medicare Congress, providing you with everything you need to excel in the upcoming year.

One of the ways that we’ve created your all-in-one event experience is by joining the Medicare Congress with IIR's D.U.A.L.S. Forum, providing Medicare and Medicaid executives an exclusive opportunity to network and learn from one another, creating the ultimate peer learning experience to maximize opportunities to serve this lucrative and complex population.

Additionally, the Medicare Congress has expanded to include:

• The re-energized Stars University
• An increased focus on networking with ACOs
• A full track dedicated to Increasing Membership & Creating the Ideal Customer Experience
• Another track devoted to Medical Management and Care Coordination for Medicare and Dually Eligible Members

The broader perspective at the Medicare Congress 2014 ensures your entire team will find something relevant and excel in your quest to provide higher quality, cost-efficient care to current and potential members. Your learning and networking experience will be the most productive one yet!

Want to learn more? Download our agenda!

Use code XP1907BLOG to register for the conference that helps drive next generation Healthcare through improved Clinical Care Management & Customer Centricity. If you have any questions about the agenda or event, feel free to email Kate Devery at or visit the homepage.

We hope to see you, February 10-12 in New Orleans!

The Medicare Congress Team

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Monday, October 7, 2013

A Message from MDRP Sponsor IMS Health

As always it was wonderful to see many of you at the 18th Annual Medicaid Drug Rebate Program Summit! For those of you who did not attend, we hope to see you soon. To download the presentations from MDRP, please click here.

This year's conference was relevant and interesting thanks to all of the great speakers at the event. As we reflect back on the various topics covered at the conference and synthesize the information presented, we want to highlight for you the key themes, future trends, and takeaways that we observed. Hopefully you will find this helpful as you discuss enhancements to the GP compliance program with upper management and other key stakeholders in your organization.

Future Impacts on the GP Compliance Program
A lot of this year's themes seemed to entail future or forward thinking.

Health Insurance Exchanges (HIX): HIXs are set to take effect in 2014 and most of the contracting has already been set with October as the sign up date. While contracting has not seen any dramatic changes (parallels other managed care contracts), some MCOs have aggressively sought the manufacturer Best Price. While this area will continue to evolve, we are awaiting more information on whether these plans will receive an exemption status and whether these plans will attempt the ever elusive risk sharing contracts. Key areas to watch out for are the bundling of the arrangements between the plans (e.g., Gold, Silver, Bronze) or potentially between your other commercial contracts with the same MCO. (See attached presentation)

Gross to Net (Evolution of the GP Function): Many of you in the GP arena are beginning to take on broader roles in the area of Gross-to-Net. With Medicaid expansion and the expected growth of the 340B program, incorporating GP into the strategic decision making process is becoming increasingly more important. Additionally, making sure we reduce revenue leakage in those GTN reductions can not only increase our profile within our respective companies, but increase the bottom line. (See attached presentation)

Bundling: While ACA was business as usual for some companies with respect to unbundling, it was a major change for others. Looking to the future, we seen some potential problems as government agencies cannot seem to agree on a definition. Diverging definitions of bundling between the OIG and CMS can have dire future consequences as we try and comply with both. We must continue to monitor these various definitions and work with counsel to manage our risk.

Final Rule Readiness: We are currently blessed with regulatory purgatory. Which means that now is the time to get our documentation in order (e.g., Product Master - Get the information that will be relevant to the final rule). You will never look back on this time period again unless something goes wrong, and then it's too late.

Systems: From a systems perspective, work flow improvement for claims processing is a must as managed Medicaid continues to grow and Medicaid expands. Companies should look to use multi-quarter trending on key thresholds to determine when to adjust/improve automated validations

Recent Developments / Updates
As we might expect, there are still many interesting current topics.

Authorized Generics: ACA altered the definition of a wholesaler thereby permitting the sales to the secondary manufacturer of the authorized generic to be included. In order to include these sales, we need to first identify whether an AG exists (more complicated than at first blush) and how to incorporate the sales (evaluating the methodological tradeoffs). (See attached presentation)

340B: Many manufacturers are receiving checks from what we thought were covered entities. When evaluating these checks and how/whether to incorporate them into our calculations, we must first understand the reason for the refund (e.g., Program Violations vs. Program Eligibility).

Medicaid Rebates: The volume of Medicaid rebates paid for Managed Medicaid utilization will continue to increase as more and more states shift their Medicaid drug risk to their Managed Medicaid providers. Due to this shift, it is even more critical that manufacturers scrutinize their Medicaid invoices as uncertainty surrounds the validation of the Managed Medicaid claims. An anonymous state survey conducted this past month indicated that over 75% of the state respondents are uncertain if the Managed Medicaid providers are performing ANY claim validations before they are submitted to the state. (Contact Lynn Lewis for further details)

Current Enforcement: During the enforcement discussion, the US Attorney discussed a settlement with Amgen for $24.9 million on allegations that that Amgen made available and paid to long-term care pharmacy providers (e.g., Omnicare, Inc., PharMerica Corporation, and Kindred Healthcare Inc.) market-share and volume-based rebates, as well as grants, honoraria, speaker fees, consulting services, dinners, travel and purchase of unnecessary data, all related to Aranesp, and that these payments amounted to "kickbacks" under the False Claims Act. The government also asserted that Amgen's therapeutic interchange programs improperly encouraged the "switching" of patients using competitor drugs to Aranesp. The matter was settled to compromise disputed claims and with the express acknowledgement that Amgen was not admitting liability and the government was not admitting that its claims were not well-founded. Based on the settlement, it is unclear whether this was considered a success by the DOJ or a failure, but based on the fact that many manufacturers use market-share rebates/discounts in their typical contracting, it may be prudent to review these agreements in light of the settlement.

Please do not hesitate to contact any of us at IMS Health should you have any questions or like to discuss these or any other topics further.

Kind Regards,

David S. Chan Senior Principal, Managed Markets Services IMS Health ®
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