PBM Model In Health Care

PBM Model In Health Care essay assignment

PBM Model In Health Care essay assignment

Please provide a response to the attached peer discussion post as well as answering the below discussion post for week 2. Please continue to use Texas Health Resources in Texas. I have attached the response provided in Week 1. Please provide references for each.

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Week 2 Post:

Funding Your Winning Move and ROI

What is the most important financial data you intend to evaluate and interpret to support your winning move?

• What is the winning move going to cost?
• How much profit will this winning move generate?
• What are the potential financial risks of your winning move?

You must answer the discussion questions by speaking in the first person as the CEO of your organization and respond to your peers as a Board member of their organization. See Course Guide for additional details.

Cherilyn Post

Week 1 Discussion Attachment – Your Winning Move

Based on your analysis in JWI 581, as a CEO seeking to increase the competitive strength of your organization, restate the winning move you want to pursue and why. In considering your winning move think about Jack’s 5 Slides and address the following:

What does the playing field look like?

The current PBM playing field is an important role but still tricky at best.  PBM’s are creating huge networks to ensure better buying and bargaining power.  By PBM’s acting as the middlemen and processing pharmacy claims we can facilitate and negotiate pharmaceutical costs between manufacturers and retailers.  This gives us the opportunity to negotiate better contracts and rebates.

What are the current trends in your industry?

Currently some of the biggest trends in the industry and a significant amount of vertical integration with health plans and other health provider types to increase those networks.  A lot of these current trends have been facilitated due to the implementation of the ACA to move volume-based care and services to value-based care and services.  Consolidation of specialty pharmacies has been another trend which we have done ourselves.

What has the competition been up to?

Our competitors have been doing much of the same in moving towards outcomes-based contracting for seeking value.  Additionally, there have been a ton of acquisitions from the big 3 being CVS, Express Scripts, and OptumRx leading them to account for nearly 70% of all pharmacy claims processing volume. CVS has been one of the big contenders acquiring specialty pharmacies. This enables them huge bargaining power in contract negotiations with manufacturers.  These top 3 typically exclude several brand drugs from their more robust formularies giving them optimal savings opportunities.  RxParadigm has vowed to disrupt the PBM market by instituting a transparent view of how prescription drugs are priced and opening up new channels to increase competition.

How does your winning move address competitive challenges in your sector?

Some of the more pressing challenges as of late have been pricing transparency, slowing growth based on generic drugs, regulatory changes, and insufficient PBM analytics and reporting tools.  Our proposed winning move of incorporating COVID-19 vaccine information into our newly created COVID-19 drug trends dashboard will provide tools that are not currently provided.  We acted quickly to build the COVID-19 dashboard which is utilized by all our clinicians as well as our Chief Medical Officer, around media requests and responses.  This application has been beneficial early on by providing week over week drug utilization and trend, so we could prepare for shortages in COVID therapy.  Adding Covid Vaccine information will help us recover lost funds from improperly billed claims as well as review population adherence for both vaccine doses.

How will your winning move improve your company’s current performance?

Adding Covid Vaccine information will help us recover lost funds from improperly billed claims, by allowing account managers to target providers with the training necessary to submit claims correctly.  This will also allow us to track adherence and non-adherence for patients of both vaccine dosages.

What actions are you recommending for improving your company’s performance in the short term (1 year) and long term (3 years)?

Over the short term, let’s continue to collect COVID-19 vaccine data and measure performance by recovered monies on improperly submitted claims as well as sending target notifications to those members who have not received their second vaccination dosage.  This will help us identify our group adherence measures and then determine the effects of our targeted messaging.  Long term we should keep collecting this data and start to build more analytics around the effects of patients diagnosed with COVID-19 that received the vaccinations and that did not against certain clinical population groups.  This could really step our ability to provide more forecasting capabilities within our clinical insight’s programs and gauge population outcomes in the future.

References:

Content, A. (2021, February 9). Disrupting pharmacy benefit management: RxParadigm launches to restore drug industry competitiveness and reduce the costs of prescription drugs for Americans. WFMJ.Com. https://www.wfmj.com/story/43319967/disrupting-pharmacy-benefit-management-rxparadigm-launches-to-restore-drug-industry-competitiveness-and-reduce-the-costs-of-prescription-drugs-for

Decision Resources Group. (2020, January 14). Top 10 PBM Industry Macrotrends in 2019 & What to Expect in 2020. DRG. https://decisionresourcesgroup.com/blog/top-10-pbm-industry-macrotrends-2019-expect-2020/

HIRC. (n.d.). Pharmacy benefit managers: Market landscape and strategic imperatives | health industries research companies (HIRC). Hirc.Com. Retrieved February 17, 2021, from https://www.hirc.com/pharmacy-benefit-managers-market-landscape-and-strategic-imperatives-1

PBM watch. (n.d.). Pbmwatch.Com. Retrieved February 17, 2021, from http://www.pbmwatch.com/problems-in-the-market.html

Karen’s Post

Good morning everyone,

 

• What does the playing field look like? The characteristics of the environment- Technology-driven deliver system focusing on acute care. The high in cost, unequal in access, and average in outcome. Delivery of health care under imperfect market conditions.
• The most important customers- Customers external to healthcare organizations include patients, patients’ families, and visitors.  Internal customers include nurses, staff physicians and other professionals, students, trainees, employees, departments, and committees.
• Your competition- Northside Hospital System, Northeast Georgia Health System, Novant Health and Centra Care. Competition in health care markets benefits consumers because it helps contain costs, improve quality, and encourage innovation.

• What are the current trends in your industry?
  • Telehealth
  • Staffing shortages
  • Cybersecurity
  • Optimization & Ancillary Technology

• What has the competition been up to? How does your winning move address competitive challenges in your sector?
• Northside Hospital System is one of the biggest competitors to WellStar Health System.  I did not realize until doing research, that the blood and marrow transplant (BMT) program at Northside Hospital Cancer Institute (NHCI) is one of the largest and most comprehensive programs of its kind in the Southeast and has among the best survival rates in the nation for bone marrow transplants

 

• How will your winning move improve your company’s current performance? In the current state telehealth has a huge role in the future of medicine. Patients get both convenience and improved health outcomes. As a health system physician gain flexibility, there is a new revenue source, and the satisfaction of helping their patients feel better. Telemedicine represents a net positive for the health system.

 

• What actions are you recommending for improving your company’s performance in the short term (1 year) and long term (3 years)?  Some areas that our health system should look at improving on are:

 

Improves patient engagement.

Expands access to healthcare.

Decreases hospital admissions.

Providing new revenue streams.

Improves quality metrics.

Improves patient satisfaction.

 

Reference

 

Welch, J. & Welch, S. (2005). Winning. New York, NY: Harper

 

https://www.northside.com/about/news-center/articles/2021/02/08/bmt-survival-outcomes