Enlyte制药专家谈化挑战为机遇

Clients face numerous challenges in managing their workers' compensation pharmacy programs including capturing all pharmacy utilization and costs as well as addressing abuse by price opportunists. 在这个 Enlytening谈话 we’ll dig deeper into these issues and others to find proactive opportunities to address pharmacy challenges through identification, 监管, and continually reevaluating outcomes and analytics to better understand how the right pharmacy partner can positively impact overall spend and claims outcomes.  

米奇弗里曼(MF): 你知道, 我们的客户正面临许多挑战, 当涉及到管理药房和工人赔偿时, 我认为这是两个最大的挑战, one being out of network 那 we mentioned before is being able to see and view holistically all prescriptions, 他们是否来自零售渠道, 邮购, 医生配药, 或者网络外的药店可能在该网络之外收费, 能够全面管理你所有的药房是非常重要的, and leveraging those legislative and regulatory controls 那 vary jurisdiction by jurisdiction, 那, 你知道, 非常重要.

MF: 你知道, the other challenge they're dealing with is really abuse by manufacturers and bad actors within the system. So, 你知道, 制造商将生产具有极高AWP的药物, but it's the same drug as another manufacturer 那 may be a tenth of the cost of the AWP 那's assigned by this bad actor manufacturer. And then also creating drug products 那 really add no clinical benefit whatsoever with a very high cost associated with 那.

尼基·威尔逊(西北): 是的.

MF: 就像非处方的Bengay. 他们的配方可能略有不同. 这对病人没有好处. 你知道，它非常昂贵. We're talking thousands of dollars for something 那 should cost less than twenty dollars.

NW: 绝对. 我们知道有很多这样的挑战. So the key is how do we turn those challenges into opportunities for our clients and how do we manage those appropriately? And so I think a number of ways are we're able to deploy a number of things in order to try to get our hands around some of those issues 那 are really plaguing the comp industry. 所以你可以做的一些事情就是知道你在寻找什么. 所以这个行业的形势一直在变化. 总会有下一个大事件. 总有一些坏演员, 就像你提到的, 寻找不同的方法来玩弄系统或赚钱.

NW: So understanding and helping clients understand what they're looking at and what the impacts can be to not only their spend overall but in general, 它如何影响索赔结果? So identification of what those different pricing plays are, price opportunists we often call them. 从字面上看，这就是它们. 它们不一定能提供额外的临床益处, 但它们正成倍地推高成本. 因此能够在数据中很容易地识别它们, 任何流过的东西, we have controls in place 那 can sort of categorize them and bucket them in certain therapeutic classes.

NW: 嗯，这一组特殊的具有挑战性的药物没有一个类别. 这是全面的. 你得知道你在找什么. So number one is identifying those things within the data sets getting them from all of the different channels. We know 那 a lot of those pricing plays come through out of network because there are less controls in place for blocking and tackling. 因此，识别，然后能够指导管理. So what do you do to deploy some sort of way to get cost under control or appropriate utilization?

NW: 所以了解如何将资源投入到不同的药物上, 要么直接否认, 阻止他们，如果你, 你知道, 同意你的委托人这么做, 如果你的司法规则允许的话, 如果有临床上合适的替代方法, 能够强制执行, 比如利用率审查, 甚至, 你知道, 寄信向客户收集更多信息, there's a lot of different levers 那 can be pulled to sort of understand what is the onus behind this particular prescription. 所以识别，找出正确的方法来控制和管理.

NW: 第三点就是重新评估. 我们怎样才能在这方面做得更好? Working with clients in partnership to understand what is this doing to your book? 你最大的影响力和支出是什么? 不断地重新评估报告、结果和分析, 我们可以处理这些不同问题的方法.

MF: 你知道，我们谈了一点关于利用管辖权控制的问题. 因此，许多司法管辖区确实有州强制规定. 你知道, 那些公式说, basically define a list of drugs 那 can be written without prior authorization. So 那 means when the prescription's filled, it will just go through our systems and be paid.

MF: 这些州中的大多数也有规定，如果不是这样的话, 你知道, 在那个处方上, 它必须经过利用审查. 所以他们要求制定处方，然后他们也要求使用审查. 有一个完整的模型是非常重要的. PBM连接到使用审查的地方. 这有很多原因. To be able to effectively identify those prescriptions 那 don't meet 那 criteria and should go through utilization review. 这不仅对网络内交易很重要.

MF: 还有我们刚才说的网络外交易. 是的. Because a lot of things can slip through the cracks if they're filled out of network, 没有人会像PBM那样评估它们. And then often there's, 你知道, very quick turnaround times 那 are necessary. 在一个综合模型中, 这样就可以快速进行利用率审查, 可以被评估, 决定可以回到PBM. And 那 really allows almost it creates a funnel where nothing falls out of 那 process. 然后你也, 在这一点上, 对病人进行的所有治疗有一个整体的看法吗, 以及你的总花费.

NW: 正确的. 你提到了公式公式，我认为这是一个很好的观点. 有以州为基础的处方，所以你有一套药物清单, but what do you do for all those other jurisdictions where you're not really sure what blocking and tackling to put in place? I think 那's where partnering with an expert in the pharmacy benefit management space is helpful. 列个药单之类的东西.

NW: We mentioned earlier all these different challenges and all the things 那 are always under development as pricing plays, 你怎么知道那是什么东西? 所以我认为和一个像制药和治疗委员会这样的团队一起工作, or if you've got a PBM partner 那 you trust 那's gonna develop a drug list out for you. The keys to look for there is a process 那 is continually watching for new drug developments, what the evidence-based guidelines recommend as far as place and therapy goes, 还是第一行? Is this even appropriate for the injury 那 we're trying to treat and being able to set up some of those front-end preventative measures as far as the drug list and formulary goes to help guide care on the front end of the spectrum. 我认为这也很关键.

MF: 我同意. It's much better to be proactive and identify those drugs 那 may create really, 你知道, 未来的坏趋势. 如果你有一个可以很早就识别它们的过程, 你可以在它们变成你所知道的之前预先执行策略, 火车失事.

NW: And the price opportunists, great example, where we know what those are up front. 我们设置了一些控制来捕捉和阻止它们, 我们在这方面取得了巨大的成功, with those drug lists and building 那 out to help identify them and make rules against them for what we're gonna do with them going forward.