Do It Yourself Managed Care Analysis

Getting Started/How To Find Data Access Grids From Tracy Lucas Payor Data on Computer Pharmacists In-House and Retail Call Major Employers Office Billing Staff Run Dummy Prescription Drill Down Reports

Access Grids From Tracy Lucas

Payor Data on Computer

Pharmacists In-House and Retail

Call Major Employers

Office Billing Staff

Run Dummy Prescription

Drill Down Reports

Key Managed Care Terms Pharmacy Benefit Manager (PBM) Integrated Delivery System (IDS) Formulary Co-pay Preferred Provider Organization (PPO) Health Maintainence Organization (HMO) Fee For Service (FFS) Capitation

Pharmacy Benefit Manager (PBM)

Integrated Delivery System (IDS)

Formulary

Co-pay

Preferred Provider Organization (PPO)

Health Maintainence Organization (HMO)

Fee For Service (FFS)

Capitation

Key Managed Care Terms Definitions PBM – a company that provides a broad range of services to healthcare providers in an effort to control pharmacy costs and utilization IDS – the banding together of healthcare providers as a means to coordinate patient care, strengthen the range of services and be more competitive for contracts

PBM – a company that provides a broad range of services to healthcare providers in an effort to control pharmacy costs and utilization

IDS – the banding together of healthcare providers as a means to coordinate patient care, strengthen the range of services and be more competitive for contracts

Key Managed Care Terms Definitions Formulary – a list of drugs preferred by a provider Co-pay- a means used by providers to off set the cost of rising healthcare. (usually an amount paid by the patient to offset the total bill for the service) PPO – contract with an employer extending lower cost to participants as long as the participants use contracted physicians/services. Becoming more common

Formulary – a list of drugs preferred by a provider

Co-pay- a means used by providers to off set the cost of rising healthcare. (usually an amount paid by the patient to offset the total bill for the service)

PPO – contract with an employer extending lower cost to participants as long as the participants use contracted physicians/services. Becoming more common

Key Managed Care Terms Definitions HMO – contract with an employer extending benefits to participants like lower costs, but higher than PPO. May be out of network. Becoming less common and more difficult to sell in than the PPO FFS – Physician is paid on the basis of number of patients seen. The result is the patients may reimbursed for the cost of the service (becoming more common) Capitation – Physician is paid a fixed sum regardless of the number of patients seen. (becoming less common)

HMO – contract with an employer extending benefits to participants like lower costs, but higher than PPO. May be out of network. Becoming less common and more difficult to sell in than the PPO

FFS – Physician is paid on the basis of number of patients seen. The result is the patients may reimbursed for the cost of the service (becoming more common)

Capitation – Physician is paid a fixed sum regardless of the number of patients seen. (becoming less common)

The Peoria Market Population 112,936 with three hospitals (OSF, Methodist, and Proctor) Other cities Pekin, Washington, Morton, East Peoria, Bartonville, Creve Coeur, Dunlap, Chillicothe, and Metamora (combined have a larger population) Median Age = 33.8 74.3% over 18 and 30.5% over 62 TRx potential Zithromax 3 rd , Spiriva 4 th , and Zyrtec 3 rd Top three payors for all products are Cat, Cash, IDPA

Population 112,936 with three hospitals (OSF, Methodist, and Proctor)

Other cities Pekin, Washington, Morton, East Peoria, Bartonville, Creve Coeur, Dunlap, Chillicothe, and Metamora (combined have a larger population)

Median Age = 33.8

74.3% over 18 and 30.5% over 62

TRx potential Zithromax 3 rd , Spiriva 4 th , and Zyrtec 3 rd

Top three payors for all products are Cat, Cash, IDPA

The Peoria Market Top Five Employers Caterpillar OSF Hospital Methodist Hospital Keystone Steel and Wire District 150 Schools

Caterpillar

OSF Hospital

Methodist Hospital

Keystone Steel and Wire

District 150 Schools

The Peoria Market HCH HCH HCH OSF OSF Health Plan WHI WHI HCH Caremark Caremark/ Restat PBM Dist. 150 Keystone Methodist OSF Caterpillar Employers

The Peoria Market Who Pays The Bills? Zithromax – Cat, Cash, IDPA Zyrtec – Cat, Cash, IDPA Spiriva – Cat, Cash IDPA

Who Pays The Bills?

Zithromax – Cat, Cash, IDPA

Zyrtec – Cat, Cash, IDPA

Spiriva – Cat, Cash IDPA

The Peoria Market Access with PBMs 2nd 2nd 2nd 2nd 2nd Spiriva 3rd 3rd Not covered 3rd 3rd Zyrtec 2nd 2nd 2nd 2nd 2nd Zithromax Dist 150/ WHI Keystone/ WHI Meth/ HCH OSF/ Caremark Cat/ Caremark

IMPLEMENT!! You have comprehension of how to evaluate and leverage managed care opportunities in your market. (Regardless of formulary issues) You can synthesize resources available to help you tailor your messages to include access AFTER efficacy. (hand outs) You have the knowledge to tie in pull through strategies to formulary status. (examples) You can evaluate your market for an opportunity with Tracy Lucas. (Ideas)

You have comprehension of how to evaluate and leverage managed care opportunities in your market. (Regardless of formulary issues)

You can synthesize resources available to help you tailor your messages to include access AFTER efficacy. (hand outs)

You have the knowledge to tie in pull through strategies to formulary status. (examples)

You can evaluate your market for an opportunity with Tracy Lucas. (Ideas)