Do It Yourself


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This was a power point I presented to the district to simplify selling in the managed care environment.

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Do It Yourself

  1. 1. Do It Yourself Managed Care Analysis
  2. 8. Getting Started/How To Find Data <ul><li>Access Grids From Tracy Lucas </li></ul><ul><li>Payor Data on Computer </li></ul><ul><li>Pharmacists In-House and Retail </li></ul><ul><li>Call Major Employers </li></ul><ul><li>Office Billing Staff </li></ul><ul><li>Run Dummy Prescription </li></ul><ul><li>Drill Down Reports </li></ul>
  3. 9. Key Managed Care Terms <ul><li>Pharmacy Benefit Manager (PBM) </li></ul><ul><li>Integrated Delivery System (IDS) </li></ul><ul><li>Formulary </li></ul><ul><li>Co-pay </li></ul><ul><li>Preferred Provider Organization (PPO) </li></ul><ul><li>Health Maintainence Organization (HMO) </li></ul><ul><li>Fee For Service (FFS) </li></ul><ul><li>Capitation </li></ul>
  4. 10. Key Managed Care Terms Definitions <ul><li>PBM – a company that provides a broad range of services to healthcare providers in an effort to control pharmacy costs and utilization </li></ul><ul><li>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 </li></ul>
  5. 11. Key Managed Care Terms Definitions <ul><li>Formulary – a list of drugs preferred by a provider </li></ul><ul><li>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) </li></ul><ul><li>PPO – contract with an employer extending lower cost to participants as long as the participants use contracted physicians/services. Becoming more common </li></ul>
  6. 12. Key Managed Care Terms Definitions <ul><li>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 </li></ul><ul><li>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) </li></ul><ul><li>Capitation – Physician is paid a fixed sum regardless of the number of patients seen. (becoming less common) </li></ul>
  7. 13. The Peoria Market <ul><li>Population 112,936 with three hospitals (OSF, Methodist, and Proctor) </li></ul><ul><li>Other cities Pekin, Washington, Morton, East Peoria, Bartonville, Creve Coeur, Dunlap, Chillicothe, and Metamora (combined have a larger population) </li></ul><ul><li>Median Age = 33.8 </li></ul><ul><li>74.3% over 18 and 30.5% over 62 </li></ul><ul><li>TRx potential Zithromax 3 rd , Spiriva 4 th , and Zyrtec 3 rd </li></ul><ul><li>Top three payors for all products are Cat, Cash, IDPA </li></ul>
  8. 14. The Peoria Market Top Five Employers <ul><li>Caterpillar </li></ul><ul><li>OSF Hospital </li></ul><ul><li>Methodist Hospital </li></ul><ul><li>Keystone Steel and Wire </li></ul><ul><li>District 150 Schools </li></ul>
  9. 15. The Peoria Market HCH HCH HCH OSF OSF Health Plan WHI WHI HCH Caremark Caremark/ Restat PBM Dist. 150 Keystone Methodist OSF Caterpillar Employers
  10. 17. The Peoria Market <ul><li>Who Pays The Bills? </li></ul><ul><li>Zithromax – Cat, Cash, IDPA </li></ul><ul><li>Zyrtec – Cat, Cash, IDPA </li></ul><ul><li>Spiriva – Cat, Cash IDPA </li></ul>
  11. 18. 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
  12. 20. IMPLEMENT!! <ul><li>You have comprehension of how to evaluate and leverage managed care opportunities in your market. (Regardless of formulary issues) </li></ul><ul><li>You can synthesize resources available to help you tailor your messages to include access AFTER efficacy. (hand outs) </li></ul><ul><li>You have the knowledge to tie in pull through strategies to formulary status. (examples) </li></ul><ul><li>You can evaluate your market for an opportunity with Tracy Lucas. (Ideas) </li></ul>