Q&A with Miree Lee of M. Lee Consulting, LLC - A Speaker at IIR's Gross-To-Net Accounting Forum

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At the 2nd Annual Gross-To-Net Accounting Forum, Miree Lee will be leading a workshop on the Impact of the MDRP AMP Final Rule on Accruals. With the CMS AMP Final Rule scheduled to be released in May, attendees of this workshop will learn about the many variables within the rule that alter government payer forecasting, gross-to-net and accrual calculations. Different types of manufacturers must also consider how their products and their distribution model are specifically impacted.

Key considerations of the final rule, impact for each:

• Pharmaceutical Price Points (AMP, BP, ASP, NFAMP, 340B, etc.)
• Overview of Various Government Programs
• Requirements under Medicaid Drug Rebate Program
• What is AMP?
• What are the inclusion and exclusion filters?
• How is AMP used?
• What is BP?
• What are the inclusion and exclusion filters?
• How is BP used?
• What is the URA?
• What are some potential changes in AMP, BP and URA?
• How do companies accrue?
• How does Medicaid expansion impact accruals?
• Managed Care Medicaid and Duplicate Discounts
• Other changes in Medicaid that may impact accruals

Q&A:

1. How feasible is collaboration between managed markets, commercial, government programs and Finance?  

Collaboration takes on different forms for different companies.  There isn't a "one size fits all" methodology except that the core principle of collaboration is a critical necessity for government pricing/program compliance.  Some companies identify and memorialize the collaboration process via formal process methodology document which outlines the tactical activities of collaboration (e.g. roles, responsibilities, timelines, specific reports and data, meeting schedule, etc.).  Other companies may adopt a less formal process whereby key persons of each department are involved in providing the proper information to the pricing department or responsible individual to ensure government pricing/program compliance.  Depending upon the size, structure, product mix, complexity of business and various other factors, cross functional collaboration may look different company-to-company. 

2. Key questions to ask before investing and building an automated GTN or GP system? 

Number of products, number of NDCs, annual sales, number of direct and indirect customers, classes of trade for direct and indirect customers, number and types of discount contracts, rebate or chargeback, tiered or market share based contracts, volume based contracts, formulary status requirements, bundles, stacked discounts, types of fees - bona fide or not. 

3. How to accrue and forecast patient/ payer related items? What critical/ essential information is required and what aspects you can’t afford to overlook.

• Intimate knowledge of the competitive market
• Shifts in market share and causes for the shifts (pricing, special contracts, supply, reimbursement)
• Thorough understanding of payers and changes in payor reimbursement
• Changes in payor coverage and patient population (e.g. Medicaid expansion, shifts in payor mix)
• Changes in mandatory discount/rebate liability (e.g. Medicaid URA increases substantially or 340B or FSS price decreases substantially)
• Price protection and how price protection is calculated

To hear more from Miree, please join us at the Gross-To-Net Accounting Forum, June 17-18 in Philadelphia, PA. 

Register now and save an additional $100 off the current rate when using the code: XP1911BLOG

State plans for dual-eligibles face tough challenges

Via Modern Healthcare

On a bone-chilling day in January, Jennifer Turpin visited a wheelchair-bound patient named Olivia Richard at her small apartment in Boston. Turpin, a care coordinator, was conducting a home inspection for Richard, who had just joined One Care, a state program for low-income, chronically ill people who are dually eligible for Medicare and Medicaid.

Looking around the apartment, Turpin, who performs independent living assessments for the not-for-profit plan Commonwealth Care Alliance, was horrified at what she saw. Richard's sheets and dishes hadn't been washed in months, and her floor was black with dirt. Before she joined One Care, Richard did not receive consistent visits from home health aides.

“I didn't realize how bad the level of care I was getting was until that visit,” said Richard, who is 30. “If I were to get a sore on one of my legs and am lying on filthy sheets, I could get a life-threatening infection.”

Since late last year, 10 states have launched or are about to launch dual-eligible initiatives under the CMS' Financial Alignment Initiative to improve care for more than 9 million dual-eligibles by integrating Medicaid and Medicare benefits. They hope better care coordination will reduce costs for this very expensive population, currently totaling about $350 billion a year. It's estimated that about 2 million are eligible for the program in those 10 states.

But some experts question how many dual-eligible beneficiaries will voluntarily enroll in the newmanaged-care programs and whether private health plans participating in the demonstrations will get enough physicians and other providers to serve these challenging and time-consuming patients. In addition, there are questions about the quality of the plans themselves, and whether the demonstrations will produce cost savings.

While most dual-eligibles are 65 or older, around 40% are younger. Many duals under age 65 have multiple chronic health conditions, including mental-health and substance-abuse issues, or physical or developmental disabilities. Some are homeless, while others live in residential care facilities. Often the healthcare and other support services that they receive are fragmented because duals fall through the cracks of the two programs. Many duals need home- and community-based support in addition to medical and behavioral care.

While 26 states applied to participate, so far only California, Colorado, Illinois, Massachusetts, Minnesota, New York, Ohio, South Carolina, Virginia and Washington have received federal approval to start their programs. Massachusetts and Minnesota are the farthest along, having launched their programs last year. Illinois began enrollment in March, and the rest of the states are starting enrollment between April and October. Some states are targeting all their duals, while others are focusing on a subset, such as those under 65 or those needing long-term care.

“I'm glad they're moving slowly,” said Judy Feder, a Georgetown University professor of healthcare policy who has closely followed the duals demonstration. “Taking a large, fragile population and moving them into an untried new system is a gamble. Slow is better.”

To continue reading this Modern Healthcare article, please click here.

And to learn more about dual eligibles please join us at the 22nd Annual Medicaid Managed Care Congress, May 19-21 in Baltimore, MD.

Save 15% off your registration rate when using the code: XP1926BLOG 

Register Now!

MMCC Podcast Series with Dr. Tomas Gonzalez of STAR+PLUS & Cigna-HealthSpring

 Medicaid Managed Care Congress Podcast Series

Here is a teaser from our podcast series with Dr. Tomas Gonzalez

Dr. Tomas Gonzalez, Senior Medical Director, STAR+PLUS, Cigna-HealthSpring

Download the complete podcast and transcript now.

I know you’ll be speaking at the 2014 Medicaid Managed Care Congress. So, hopefully this will give folks a little bit of a preview of what your talk is going to be like in Baltimore in May.
 
Tell us a little bit about the program itself, just the “who” in terms of the care providers, the patient profile, the “what” – the care model – and the “where” in terms of the care setting.

Dr. Gonzalez: Back when Medicaid Managed Care arrived in South Texas in March of 2012, we immediately saw a challenge with our most intense and high acuity psychiatric patients. When we did a financial analysis of those patients, we saw many readmissions to the same hospitals and a high utilization rate. In fact, out of our 20 most expensive and high-utilizing members, we found that more than half of them were psychiatric patients. Nevertheless, we decided that we had to do something about these high utilizers – very, very critical – so that they could live more independently in the community.

In South Texas, there is a group called: “The Psych Nurse”. That’s the name of the company – The Psych Nurse Incorporated. They were traditionally a home-health psychiatric nurse provider for the Medicare product because in Texas, home health for psychiatry is not a covered benefit under Medicaid. So, it was a challenge and, internally at Cigna-HealthSpring, we needed to figure out how to engage the Psych Nurse because they have a very good reputation in the community and because they have a history of doing good work with the utilizing psychiatric patients.

We felt we needed to take the opportunity to engage with the Psych Nurse to be partners and help us manage this population. So, what we did was engage the Psych Nurse and say: “I think you all have what it takes. Your model of looking at the entire person, looking at the health and looking at the well-being and the independence of the psychiatric patient instead of looking at a finite number of visits per patient is going to be the right approach.” So, it took several planning sessions and we finally came to an agreement with the Psych Nurse that we would send them our sickest and our highest utilizing, highest cost members.

The framework of the program was kind of open. It was an open approach in that I would send them the name of a patient with a prior authorization for an extended amount of time – 99 visits. The Psych Nurse was then given free range to see those high-utilizing psychiatric patients as often as they thought they needed to see them – daily, every other day, seven times a week, ten times a week – whatever it took to help the patients live independently.

Now, keep this in mind. This was not a hospitalization avoidance program. Many people like to slot this program into that kind of peg. That’s not what it was designed to do at all. The program is designed to help the patients to live independently out of jails, hospitals, nursing homes and live in their home or choice of homes out in the community. So, when the Psych Nurse engages one of these members, of course, like many psychiatric patients – and these are the sickest of the sick. These are the refractory schizophrenics, the non-compliant bipolar patients, the dual diagnosis patients with polysubstance abuse and other Axis I disorders. These are the patients who many, many have discarded, many have considered un-helpable and many have considered the drain on the system that no one can really fix. Well, as we engaged these members through the Psych Nurse and we had weekly rounds with me, the Medical Director and a Psychiatrist – I am a psychiatrist – we brainstormed plans, strategized how we’re going to help these members understand 1) their medication compliance, 2) their desire and hope and need for sobriety and 3) getting families involved as much as possible. I think the Psych Nurse is extremely skilled in getting these patients to understand their own health, their own need for continued and improved mental clarity and their families.

South Texas, as you probably know, is heavily Hispanic. Mostly Mexican American. About 90% of the population is Mexican American and many of our patients only speak Spanish. The Psych Nurse is homegrown, pretty much. They are RNs – and that is the only type of nurse that we allow to see the patient. RNs – Registered nurses – who will bond with these patients in their culturally appropriate and culturally sensitive way. Some only speak Spanish. Well, our nurses only speak Spanish. 


Dr. Gonzalez will be speaking at the 22nd Annual Medicaid Managed Care Congress, May 19-21 in Baltimore, MD. To learn more about the event, click here. Save 15% off the standard registration rate when you use the code: XP1926BLOG

Register here.

Get the Complete GTN Perspective | Last Chance to Save $400 is This Friday, May 2nd

 

The 2nd Annual Gross-to-Net Accounting Forum is less than 2 months away, and I couldn't be more excited about the enthusiasm and excitement surrounding the event. Join the growing list of attendees to see why timely and imperative GTN content is and how crucial it is to your business.

We've got a packed agenda including in-depth coverage on chargebacks and the impacts of healthcare reform on Medicaid accruals and liability to ensure you leave with the complete GTN perspective. You will hear directly from experts at big and small pharma, and branded and generic companies on key areas such as:

• Automation
• Pipeline Strategy
• Medicaid Liability
• Chargebacks
• Returns
• Managed Care
• Loss of Exclusivity   

   
Click here to download the updated brochure.

Seats are filling up rapidly, so hurry and register today! This Friday, 5/2 will be your last chance to save up to $400! Be sure to use code: XP1911BLOG

Click here to register.

I look forward to meeting you in Philadelphia this June.

Decode Big Data to Drive Decisions | Register for HDI by Friday to Save $500!

 According to PricewaterhouseCoopers, big data and predictive analytics help companies better understand their audiences and how to engage them.

We're not talking to the "data guy". We're talking to YOU-the person making informed decisions based on data that is material to your business (claims data, member feedback, clinical data, etc.) By translating this information into actionable insights, you have the power to make more efficient and effective business decisions.

Don't fall behind as more and more companies grow increasingly data-driven and are more willing to apply analytics-derived insights to key business operations. Join us in Chicago this June 23-25 at IIR's all-new Healthcare Data Insights, where you will hear from speakers who successful implement big data analytics into their business strategy.

Discover how to make the best data-driven decisions for your company with speakers including:
•    Elizabeth Benz, Associate VP of Community Outreach & Engagement, Molina Healthcare of Wisconsin   
•    Greg Poulsen, Senior Vice President, Chief Strategy Officer, Intermountain Healthcare   
•    Bob Gladden, Vice President of Decision, Support & Informatics, CareSource   
•    Dan Munro, Contributor of Healthcare IT, Innovation and Policy, Forbes

Register by Friday 4/25 to save $400! Plus take an extra $100 off when registering with the code: XP1902BLOG

That is $500 in total savings, register today!

Learn more about Healthcare Data Insights here.

Summit for Oncology Management Podcast Series with Dr. Ronan Kelly of John Hopkins

Summit for Oncology Management Podcast Series

Below is a teaser from our podcast series with Dr. Ronan Kelly...

Director of Gastroesophageal Cancer Therapeutics Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins and the Medical Director of Global Oncology, John Hopkins International

Download the full podcast & transcript here.

To begin, the Institute of Medicine has declared that cancer care in the US is a system in crisis. Do you agree? 

Dr. Kelly: The word “crisis”, I think, may not be the best word to use. I certainly think that major changes are needed. If we, as a cancer community, do not take ownership of some of the problems that we will talk about today, then I think others will make the tough decisions for us.
What we have learned, especially in the last couple of years, is that costs will not constrain themselves and that we really are reaching a tipping point where we need to take definitive and direct action. Often, some uncomfortable actions will be required to get on back on path.

Some of the trends that are amplifying the crisis – as pointed out by the Institute of Medicine – is that we do have an aging population of, thankfully, more and more survivors. But, what we are seeing is a 30% increase in cancer survivors by 2020 as a result of many of the significant scientific treatment advances that we’ve been able to achieve in the last couple of years. But we are also seeing that the incidence of cancer is expected to go up approximately 45% by 2030. So, because of these changing or increasing patient survivors and increasing cancer numbers, we are seeing that the cost of cancer care is really, really going up. In the US we are expecting between 2010 and 2020 that there will be a 39% increase in the cost of cancer care up to $173 billion and some experts are even saying that this may be conservative estimate.

So, I think we certainly need to make changes. The current system that we have right now is not sustainable. So, some direct and often uncomfortable actions will need to be done in order to get us back on track. And to ensure that we continue to treat future generations with better and better treatments. So, some decisions are needed right now. I would agree that the system needs to be altered and, in some cases, needs to be dramatically fixed.

To hear more from Dr. Kelly, please join us July 21-23 in Philadelphia, PA for IIR's Summit for Oncology Management. 

To receive 15% off the standard registration rate, use the code: XP1914BLOG

Save 15% today, register now.

HDI Podcast Series with Steward Health Care Network

Healthcare Data Insights Podcast Series

 Below is a teaser from our podcast series. Thank you to our participants...

John Donlan, Chief Operating Officer

&

Dominique Morgan-Solomon, Vice President, Population Health
Steward Health Care Network

Download the full podcast & transcript here.

What are some of the challenges you faced when implementing data-driven strategies and how did you overcome them?

Dominique: We are a very heterogeneous network, we have over 2700 providers. With that we are on over – I want to say at least 30, but there are more than that – EMRs. They all look different and the data coming out of them is different. So, our challenge over the last two years has been about how do we integrate or aggregate the data that’s coming out of those EHRs such that we can use it and use it in a much more real-time fashion because that’s really what’s meaningful. That’s one of the larger challenges.

We also have the challenge of while we sit on the Network – and I’m glad that John described the larger system – we are part of a larger hospital-based system and so how do we integrate information that is coming out of those EMRs, along with the information that is coming from the ambulatory-based provider’s EMRs to be able to get to the clinical data that is necessary for us to be able to identify the population. As well as from a performance perspective, be able to articulate who are the people who fall into various populations, like our diabetic and our heart failure patients. A lot of that information is defined based off of clinical measures and not claims-based measures. So, getting access to that data is one of the larger challenges that we face.

One other challenge that is tied into that is getting information in a real-time manner. One of the interesting challenges of being part of a pioneering ACO is that the population turns over on an annual basis. While we retain a significant proportion of the population year-over-year, when January 1st comes along, we have either an influx of new patients or potentially an out flux of old patients based off the methodology that CMI uses to do attribution. Because of that, in order for us to effectively impact that population in a real-time manner, we have to be able to pull data out of systems and use real-time information so that we can quickly stratify, identify and engage that population within a less than 12 month period in order to make an impact in that performance year. So, timeliness of data, I would say, is a huge challenge in the integration of the heterogeneous system that we have within our Network are two of the biggest challenges that we’ve had with data.

Now, how do we go about overcoming them? We’ve engaged some partners who have helped other organizations resolve this problem and who have some background and experience in being able to access various EMR data sets and integrate and aggregate that data. Certainly, it’s a challenge that I wouldn’t say today that we’ve overcome it, but we have a plan to overcome it and we’re moving forward on it. But, I would also say the other quick and dirty, so to speak, are boots-on-the ground way of overcoming, which is what I said before which is we have to spend a lot more time engaging providers and members themselves to get to some of the information that is more actionable in a real-time basis.

As John mentioned, we have a very robust governance structure, but underlying that governance structure is an operational structure where we have field operations teams that are aligned to a local chapter and aligned to our local provider groups so that they can be much more in the practices and much more engaged with the providers so that they can glean a lot of that information, like Mrs. Jones who has financial issues and that’s why she’s not filling her medications, which won’t be apparent in an EMR or we don’t have access to that information in the EMR quickly.

So, we’ve chosen in the interim – as well as really trying to leverage the medical home kind of model – we leverage our field operations team being much more embedded in our local chapters. The folks who make up those teams are both clinical, as well as operational in nature. So, our performance improvement advisors are really working on workflow enhancement and work hand-in-hand with a nurse care manager and social workers and pharmacists who are also working with the providers to best identify and manage the populations for which they serve.


To hear more from Steward Health Care Network, join us June 23rd through 25th in Chicago for IIR’s Healthcare Data Insights Conference.

Download Gorman Health Group’s expert summary of the 2015 Final Rate Announcement from CMS

John Gorman predicted that -- if the rate announcement was enacted as outlined in the draft call letter -- it would be "just about a worst-case scenario for flabby, distracted, uncommitted health plans in Medicare."  John declared "there is no question that the 2015 call letter is an evolutionary event and some inferior species will be eliminated."

Now that the Final Rate Announcement has been released we can finally get some concrete answers. Gorman Health Group's renowned financial and policy experts Bill MacBain and Jean LeMasurier are teaming up to provide a detailed analysis and summary of the final regulation.

While Jean and Bill are finalizing the Summary of the Final Call Letter, you can request a copy and we will notify you as soon as it is ready.  But while you wait, enjoy access to some additional resources.  Request a copy of the Summary here.

As an added bonus, Bill and Jean will also be hosting a complimentary webinar today from 2:00PM – 3:30PM to offer insight on the Final Rate Announcement from CMS. You will walk away from this session with critical to-do items and issues to tackle in order to ensure your success in 2015 and beyond. Register now. 

                                                                                              

Reminder – Don’t miss IIR’s Healthcare Data Insights taking place June 23-25 in Chicago. Register by Friday 4/25 to save $400 on the standard conference rate.  For more information, click here.

Reminder - Complimentary Revenue Leakage Webinar | Register Now

Revenue Leakage:  Industry Definition, Insight and Best Practices to Mitigate Risk
Join us for a Webinar on April 14th—space is limited!
Reserve your Webinar seat here.
Mention Priority Code: XP1911WEB

Understand what ‘Revenue Leakage’ means to branded pharma, start-ups, generics, and biotechs with IIR’s 2nd Annual Gross-to-Net Accounting Forum’s discussion group chairs! 
• Collective Industry Definition
• Customer Segment and Channel impacts
• Financial Statement impacts (accruals, cash flow, forecasting)
• The industry risk between adjudication and audit —the need for continuous improvement.
• Industry best practices and next steps for mitigating risk and continuous improvement.   

MODERATOR:
Jennifer Sharpe, Revenue Analytics Gross-to-Net, daVIZta

PRESENTERS:
From Big Pharma – Courtney Callihan, Finance Director, GlaxoSmithKline
From Small to Mid-Sized Pharma – Larry Breen, Director of Financial Planning and Analysis/Revenue Analytics, Sunovion Pharmaceuticals
From Generics – Roxana Santiago, Senior Finance Director, Gross to Net, Hospira Worldwide, Inc.

After registering you will receive a confirmation email containing information about joining the Webinar.

Keep the discussion going with our Chairs at IIR's 2nd Annual Gross-To-Net Accounting Forum

2014 Conference Highlights include:
• New tailored discussion groups to collaborate across Managed Markets, Commercial, Government Programs and Finance for Big, Small to Mid-Sized Pharma, and Generics
• First opportunity to get up close and personal with the AMP Final Rule at the pre-conference workshop
• Never-before-heard case studies on GTN automation and chargeback methodology, in addition to strategic forecasting panel discussions
• Quantifying approaches for the impact of Medicaid, 340B and Healthcare Reform

Register by 5/2 and save up to $400 off standard registration rates

If you have any questions about the agenda or event, please contact Ryan Geswell at rgeswell@iirusa.com or visit our webpage.

We look forward to seeing you June 17-18 in Philadelphia!


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Post-Hospital Syndrome: The Return to the Community After Hospitalization

Our guest blogger today is David Young, Ph.D., Vice President of the Center for Clinical Excellence at Seniorlink, the parent company of Caregiver Homes
Earlier this year, Harlan Krumholz, MD, a cardiologist at the Yale New-Haven Hospital Center for Outcomes Research and Evaluation, published a provocative article in the New England Journal of Medicine titled "Post-Hospital Syndrome: An Acquired, Transient Condition of Generalized Risk". In the article, Dr. Krumholz reminds us that recently hospitalized patients are not only recovering from the illness or condition that prompted the hospitalization but are also experiencing a period of generalized risk for a range of adverse health events. He calls this an acquired "syndrome" that involves a temporary period of extreme vulnerability for other health problems.

Naturally, the post-hospital syndrome will vary from patient to patient based on a host of factors. However, care providers – notably those providing Home and Community-Based Services – should be on the lookout for changes in behavior that could include: heightened stress, sleep disturbance, medication changes, cognitive changes and deconditioning that can alter the ability to perform daily living activities. These changes often occur regardless of the original cause for hospitalization; it is a syndrome that can apply to all recent discharges in consumers – both young and old.

Home and community-based service providers, especially those assisting elders, should be comprehensively evaluating patients returning from the hospital for changes that might exacerbate the primary problem (that led to the hospitalization) as well as the syndrome of potential changes described by Krumholz. Details about the hospitalization should be gathered along with a comprehensive re-assessment of medical, functional and emotional status of the patient.

Critical-thinking questions should be asked. Here are some examples:

• Is the caregiver and family able to provide the post-hospital care needed?
• What is the potential caregiver strain (burden)?
• Does the caregiver need education about care requirements?
• Do caretakers have knowledge of the "red-flags" to look for so that decline can be identified early?

Dr. Krumholz suggests that community care providers use "risk-mitigation" strategies that go beyond the cause of the initial hospitalization to look at the potential for infection, medication adverse events, falling and confusion, just to name a few. He suggests that strategies aimed at reducing disruptions in sleep and pain be addressed. Good hydration and nutrition should be emphasized along with judicious, careful physical reactivation and re-introduction of leisure outlets.

Great care transition work in the community starts with great communication between all providers. When a consumer, especially an elder who needs help with several activities of daily living, returns from the hospital, a coordinated care team approach is advised; one that engages in a comprehensive assessment of patient requirements as well as the strengths and needs of the caregiver and family. By identifying areas of risk and then creating care plans that specifically address them in a person-centered manner, the risk of rehospitalization will be greatly reduced.

This is a "win" for all: the consumer is healthier and happier, caregivers feel more capable of providing the supports needed, and avoidable costs are eliminated.

To read more informative articles on person-first care planning, visit the Caregiver Homes blog here.

Caregiver Homes, the leader in Structured Family Caregiving, provides the training, support and financial assistance to keep around-the-clock caregiving in the home. Structured Family Caregiving (SFC) is a quality, 24/7 care alternative for consumers, caregivers, and the professionals who support them. The organization, a wholly owned subsidiary of Boston-based Seniorlink, Inc., is dedicated to helping elders with complex medical conditions and people with disabilities live with dignity and independence in their communities. Caregiver Homes employs highly-qualified professionals and specially-designed communication technology to empower family and community members to provide extremely effective, high-quality care at home while being paid for their commitment. The program was launched in 2005 and currently serves more than 2,000 consumers in Massachusetts, Rhode Island, Ohio, and Indiana, with plans to serve more states soon. For the professionals and families who collaborate with us, Caregiver Homes delivers safety, security, health, and well-being. Visit www.caregiverhomes.com for more information.