PHARMACY

DoD announces TRICARE rule changes for brand-name maintenance meds

BY David Salazar

WASHINGTON — The Department of Defense announced changes to rules for TRICARE beneficiaries on Friday. 
 
Starting Oct. 1, under the revised rules, patients who regularly take certain brand-name medication will have to get their prescriptions filled at a military treatment facility or through a mail-in program. The drugs likely affected, according to the agency, are brand-name medications used for maintenance in patients with chronic conditions. 
 
According to the Defense Health Agency’s pharmacy division chief, George Jones, the rules change are aimed at cutting costs for beneficiaries and taxpayers and are the result of the 2013 National Defense Authorization Act. 
 
“Based on estimates, the program is expected to save beneficiaries $16.5 million in reduced copays, and projected Defense Department savings is $88 million during the first year,” Jones said, adding that the change came after a successful pilot program last year. 
 
“It was very well received by beneficiaries and met reductions in beneficiary-put-of-pocket costs and reduced costs to the government,” he said.
 
Those affected by the rule change will be notified in mid-September and will also receive instructions on how to make the switch. Current active-duty military and TRICARE beneficiaries overseas will not be affected by the new rules, nor will nursing home residents or beneficiaries with other health plans with a prescription drug program. 

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Health reform, tech driving retail transformation

BY Jim Frederick

DENVER — By 2025, more general practice medicine will take place in a store than in a doctor’s office.
 
That’s just one prediction for healthcare retailing unveiled by retail consultant Bryan Gildenberg in a TSE seminar on “The New Shape of Retailing” Saturday. 
 
Gildenberg, chief knowledge officer for Kantar Retail, challenged industry leaders to stay nimble and broaden their strategic horizons as massive demographic changes, an aging and more fragmented population and dramatic advances in technology transform the health care and retail industries over the next 15 years.
 
These forces are reshaping both the delivery of care and the nature of retailing, Gildenberg said. And the health system’s search for cost efficiencies, improved patient outcomes and better access to care is lending urgency to that transformation.
 
“Outcomes-based payment is going to be the primary topic of conversation between doctors [and other health entities] over the next five years,” he predicted. What’s more, with the health system expected to face a shortage of 50,000 primary care physicians by 2020 — and hospitals struggling to spread the costs and risks of patient care — retail clinics are becoming an increasingly viable business model for retail pharmacies. “Clinics in stores are going to be a very big part of how hospitals” provide care and invest in future models of care for their patients posts-discharge, Gildenberg said.
 
“What role will pharmacies play in helping hospital networks manage value-based payment?” In large part, said Gildenberg, which will depend on how well pharmacies “quantify the economic value” of adherence programs and other health services, and in part on how effectively they evolve to serve the needs of both patients and payers.
 
“Anything that enables you to take a medical experience and bring it to [any location] is going to be an incredibly powerful tool,” Gildenberg said. Primary care, he added, is moving to a decentralized, “self-service” model as the shortage of primary doctors accelerates, health plans and payers seek new, lower-cost forms of front-line care, and patients themselves take a greater role in their own wellbeing. 
 
Given the increasingly fragmented consumer base and the challenges posed by online powerhouse retailers like Amazon, pharmacy chains also are going to have to become much better at targeting their stores neighborhood by neighborhood — and at presenting a clear, concise message to consumers about their own value as a shopping destination, Gildenberg said.

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Value, results center stage in health care

BY Jim Frederick

“A profound, and likely irreversible, impact on the business of health care.” That’s the effect the Patient Protection and Affordable Care Act already has had in the five years since its passage and enactment into law, PricewaterhouseCoopers said. And it’s altering the way doctors, hospitals, pharmacies and clinics deliver patient care; the way public and private health plans and patients, themselves, pay for that care; and the way insurers and even pharmaceutical companies market their products and services.

In a report titled “Healthcare reform: Five trends to watch as the Affordable Care Act turns five,” PwC’s Health Research Institute asserted that the reforms spawned by the ACA have left “an indelible mark on the $2.9 trillion health sector.” Those reforms are forcing industry leaders to “rethink strategies to remain relevant in a post-ACA world” as they roil every facet of health care and drive a gradual but sweeping transformation of the way health services are provided and paid for in America.

“By energizing five fundamental shifts … the law has given rise to a new health economy predicated on value,” PwC’s institute declared in its report. “Not since the Telecommunications Act of 1996 has a piece of legislation sparked such significant changes in a leading sector of the economy.”

The HRI cited five powerful trends that “have ignited this transformation.” Among them:

  • A massive shifting of risk among different health provider sectors as the ACA drives “new payment models that reward outcomes and penalize poor performance.” With federal and state governments now pushing such new concepts as shared savings and pay-for-performance onto hospitals, physician groups, pharmacies and other health stakeholders, HRI said, “the ACA has accelerated a shift in risk away from traditional insurers and onto providers, pharmaceutical companies and even consumers;”
  • A “back to basics” movement that’s “making primary care once again the critical touchpoint.” Besides elevating the role of primary care physicians, that movement also is elevating the critical importance of pharmacists, retail clinicians and other health professionals who extend and supplement the role played by family practice doctors in a team-based, more collaborative network of front-line care;
  • A surge of new, innovative companies that are rushing “to meet the demand for lower-cost, consumer-oriented care options in the post-ACA era,” according to HRI;
  • A shift in the health insurance industry “from wholesale to retail” as insurers adapt to the demands of consumers, federal and state health administrators and employer-sponsored health plans for a more transparent, menu-driven and market-style approach to the dizzying array of insurance options offered through the public and private health exchanges spawned by the ACA; and
  • The emergence of states “as key players in the reconfigured healthcare landscape.” Given wide latitude by the ACA in how they implement health reform and coverage plans for those seeking insurance, the states have influenced everything “from the design of exchanges to the decision over whether to expand Medicaid,” the HRI report said.

For all health providers in the new continuum of care, innovation will be key. “Paramount to remaining relevant in a post-ACA system is the willingness to innovate: to develop strategies that meet the demands of new healthcare consumers, to pursue alternative business models, to adapt new technologies and to take on new roles and activities,” HRI admonished.

In this special report, DSN takes a closer look at PwC’s research, the changes sweeping the nation’s massive healthcare system, and the impact those changes are having on pharmacies, physicians, health systems, insurers, pharmaceutical manufacturers and consumers themselves.

Click on the following links for more information:

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