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Relationships critical in complex marketplace.

FLINT, Mich. -- The health care market continues to change, not only with the evolution of the health insurance marketplace but also through the development of accountable care organizations, notes Susan Faust, vice president of new business development and payor strategy at Diplomat Pharmacy.

Diplomat, she adds, is a valuable partner in helping various components of the health care spectrum to adjust to those changes.

"There is a lot of opportunity for specialty pharmacies to partner with these different entities and to be able to assist in specialty spend, which has grown exponentially because of the rich pipeline of drugs," she says. "We think that accountable care organizations are going to be instrumental in really taking a look at health care in total or certainly at health care associated within their systems, and be able to implement some important initiatives that lead to better clinical outcomes while meeting the other objectives of payors."

Faust joined Diplomat's senior leadership team earlier this year. Part of her responsibilities include assisting in Diplomat's efforts to support payor partnerships that will create and implement initiatives in a cost-effective manner for the specialty market.

Under the new business development role, she works with both established payor clients and new prospects. The payor strategy responsibilities "cover pretty much what it implies--any payor, meaning health plan, employer, insurance company, accountable care organization, insurance exchange," explains Faust.

"If it pays, then it is under myself and my team. And we look to go all the way from the introduction of Diplomat's services to the payor entity to the contracting to the management of that payor, meaning that we are the one that delivers the reports, has quarterly meetings and looks at their goals and objectives and then matches Diplomat's products and services to those objectives. "

She points out that Diplomat's strategy for controlling the health care expenditures of payors takes a number of factors into consideration, particularly pertaining to inventory management and whether drugs are covered as part of the pharmacy benefit or the medical benefit as well as the site of care where the drug is administered.

Faust's expertise is especially valuable as it relates to coverage decisions for drugs under the medical benefit because their coding is more complex than that for drugs under the pharmacy benefit. She and her team also address charges related to medical billing, "and those can be equally difficult to discern, because several services could be bundled in a single charge."

Later, adds Faust, payors must decide what specific therapy or therapies it is going to consider and then perhaps change the site of service, based on what it is costing them in the site of service where it is currently being used and what it would cost in another site of service.

"If the payor takes a look at its hospital outpatient charges, the cost for administration alone is usually higher than other sites of care--other sites meaning either a physician's office or home care. And the drug could also be inflated in that hospital outpatient care setting," says Faust.

After conducting its analysis, the payor examines what strategy it has chosen to move to a less costly site of care and then looks at its benefit design and sees whether that design allows for a change for site of care.

"Communication, early and often, is the key," she says, whether such decisions are being made by a payor or a health plan, the latter of which could encounter a backlash from patients and physicians who are frustrated with benefit design changes or prior authorization requirements.

Concerning site-of-care provisions, Faust comments that there are obvious reasons for drugs being administered in different settings. "For example, oncology drugs are often administered in a clinic or in a physician's office because of their side-effects profile; they definitely need an extra layer of clinical monitoring done by a doctor, an RN, etc.," she remarks. "And there can be the need for labs either pre or post the infusion. It makes all the sense in the world to have chemo and other oncology drugs administered in an outpatient setting or a physician's office because of the need for that kind of oversight."

Other medications that don't have a side-effects profile that needs additional monitoring and that are self-administered--such as immunoglobulin and medications for Crohn's disease, rheumatoid arthritis and psoriasis--may be appropriate for the home care setting, notes Faust. "There are, again, reasons for all sites of care, but from a cost perspective for the payor and a convenience perspective for the patient, the home care site can be very attractive as well as being clinically appropriate," she says.
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Title Annotation:The Diplomat Difference; Diplomat Pharmacy
Comment:Relationships critical in complex marketplace.(The Diplomat Difference)(Diplomat Pharmacy)
Publication:Chain Drug Review
Geographic Code:1USA
Date:Aug 10, 2015
Words:773
Previous Article:Coordination of care key to controlling cost, quality.
Next Article:Diplomat makes mark with high-touch approach to service.
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