1. What kind of risk contracting, if any, would you enter into with providers for the use of the new drug in enrolled population? Discuss reimbursement & UM review criteria you could potentially utilize, as well as strategies for risk sharing and cost-shifting (a payment function).
2. Describe how you will roll out the new patient education program related to prescription drug abuse to plan members through participating pharmacies (who expect to get paid for the service) with relevant clinical details (a clinical function).
here is the prompt/ Instruction ;Try to comprehend the nature and the scope of opioid addiction problem in America and recognize why prescription drug overdose is the leading cause of accidental deaths in the country. Then, read the scenario narrated below and respond to objectives, questions and challenges listed.You are the Director, Formulary Operations, for ACME Pharmacy Solutions. Recently you have been reading reports about how Oxycontin abuse, the #1 most abused prescription opioid drug today, has become a leading cause of many accidental deaths in the community. You have learned through your pharmacy network liaisons that pharmacists are really concerned about the number of ODs they have been seeing in their practice everyday and are wondering if a Medication Therapy Management program might help. They are curious to know if the health plan you are representing would be interested in supporting it, but are unsure how to go about setting one up, if your PBM is supportive as well. They are seeking your help in establishing one for their pharmacy and want to know what’s involved, structure- and process-wise.Your goal is to promote the adoption MTM by your pharmacy partners to achieve community health care benefits, improve quality of pain management and/or opioid-related care, while also helping cut overall health care costs for the health plan. You also want to enlist the network pharmacists who wish to volunteer their expertise and time to increase patient and physician participation in the program and educate your patients about the new MTM program. The P&T Committee last week recommended that your formulary retain Oxycontin during the phase-out period (about 6 months to a year) to ensure its continued availability to your plan members, while switching and signing up more members to receive MOUD services (see the White-house document above). Media reports, drug dossier, available literature evidence, and the newly developed monograph etc. all indicate that the new drug is very effective and not likely to cause as much addiction; it’s safer as well for the intended use.Your objectives are twofold: 1) Help your pharmacy partners set up an effective MTM program to prevent opioid ODs & addiction, and 2) deliver effective overdose education program for the plan members who use these powerful yet dangerous drugs. Initial indications are that most pharmacists who are interested in helping you roll out the new program are expecting to get compensated well for their effort as well. So your job is to develop an action plan to curb the misuse of this drug among your plan members to avoid its dangerous consequences and increase pharmacist participation rates in the program, among other things.Overall, your written report should cover the following aspects of MTM and patient education program.And the following questions:1. What kind of risk contracting, if any, would you enter into with providers for the use of the new drug in enrolled population? Discuss reimbursement & UM review criteria you could potentially utilize, as well as strategies for risk sharing and cost-shifting (a payment function). (500 words 2. Describe how you will roll out the new patient education program related to prescription drug abuse to plan members through participating pharmacies (who expect to get paid for the service) with relevant clinical details (a clinical function). (150 words )
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Howard University Use of Risk Sharing Contracts in Healthcare Questions
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Introduction:
When considering the implementation of a new drug and the need for patient education regarding prescription drug abuse, it is crucial to establish effective strategies to mitigate risks and ensure the well-being of the enrolled population. In this context, risk contracting and reimbursement become essential components to address. Additionally, the roll-out of a patient education program should be carefully planned in collaboration with participating pharmacies to optimize its clinical effectiveness and ensure proper compensation for their services. This response will discuss the approaches to risk contracting and reimbursement, as well as strategies for launching the patient education program.
Answer 1:
When it comes to risk contracting for the use of the new drug in the enrolled population, several factors should be considered. One potential approach could involve value-based contracting, where the reimbursement is linked to specific outcomes or performance measures related to the drug’s use. The criteria for utilization management (UM) review should focus on appropriate prescribing practices, patient monitoring, and overall patient safety.
To establish risk contracting, it is important to define key performance indicators (KPIs) that align with the goals of preventing opioid overdose and addiction. These KPIs could include metrics such as the reduction in opioid prescriptions, the increase in appropriate use of alternative pain management strategies, and the decline in opioid-related adverse events. By setting such criteria, providers can be incentivized to adhere to evidence-based practices and ensure patient safety.
In terms of reimbursement, a value-based approach could be employed, where providers are rewarded based on the achievement of predefined KPIs. This could involve outcome-based payments or shared savings models, depending on the agreement between the organization and the providers. By aligning financial incentives with the desired outcomes, the risk of promoting overutilization or inappropriate prescribing practices can be mitigated.
Additionally, strategies for risk-sharing and cost-shifting can be utilized to distribute the financial burden associated with the new drug’s use. This could involve negotiating contracts that include provisions for cost-sharing between the organization, providers, and even patients. By spreading the risk and cost, all stakeholders bear some responsibility and are motivated to ensure optimal outcomes while managing expenses effectively.
Answer 2:
Rolling out a patient education program related to prescription drug abuse requires collaboration with participating pharmacies to optimize clinical effectiveness while addressing the expectation for compensation. The program should focus on providing comprehensive and evidence-based education to plan members to raise awareness about the risks of prescription drug abuse and promote safe medication practices.
To begin, a collaborative approach should be adopted by working closely with participating pharmacies to develop a standardized curriculum for the education program. This curriculum should include relevant clinical details regarding the risks and consequences of prescription drug abuse, as well as strategies for prevention, early intervention, and harm reduction.
The education program should be designed to be easily implemented within participating pharmacies while respecting the time and expertise of the pharmacists. It is crucial to provide clear guidelines and resources to ensure consistent delivery of the program across different pharmacy locations. This could include providing educational materials, support from clinical experts, and access to online training modules.
To address the expectation for compensation, a reimbursement system should be established to acknowledge the pharmacies’ contribution to the education program. This may involve negotiating a fee-for-service model where pharmacies receive payment for each session conducted or a bundled payment model that covers the expenses associated with program implementation and delivery.
Moreover, it would be beneficial to explore potential partnerships with insurance providers or government agencies to secure additional financial support for the education program. By leveraging existing reimbursement mechanisms and external funding sources, the program can be sustained and expanded to reach a larger population of plan members.
Overall, by collaborating with participating pharmacies, providing comprehensive education materials, and establishing a fair reimbursement system, the roll-out of the patient education program can effectively address prescription drug abuse while meeting the expectations of participating pharmacies.
