Government or commercial health plan? The pharmacist’s challenge of uncertainty
While an insurance card contains a lot of information and is an important part of the pharmacy transaction, there are times when it doesn’t tell the whole story.
The insurance card indicates only the current plan covering the patient. What it cannot tell the pharmacist is whether or not there is additional coverage, or what specific type of coverage the patient has. Even when the pharmacy sends the claim to be adjudicated by the plan, the messaging returned does not indicate if the coverage is for a commercial or government plan, such as Managed Medicaid.
Helping patients, preventing problems
When a pharmacist knows the available coverage, he or she may be able to reduce a patient’s financial obligation and prevent improper or inadvertent incentives.
The former is important because a patient’s financial situation may significantly impact medication adherence. A recent report, “Adherence and Health Care Cost,” characterized it as “an important public health consideration, affecting health outcomes and overall healthcare costs.” The report estimated between 20% and 50% of patients are noncompliant with drug therapy, and stated that “reducing out-of-pocket costs leads to better medication adherence across many diagnoses.” A recent report in Annals of Internal Medicine estimated that a lack of adherence causes nearly 125,000 deaths, 10% of hospitalizations and costs between $100 billion–$289 billion per year.
Knowing the full extent of a patient’s insurance coverage helps reduce out-of-pocket costs and can lead to better medication adherence and better overall health/outcomes. If a patient only has commercial coverage, a pharmacist can offer any available manufacturer coupons or incentives, such as a promotional gift card.
Moreover, as stories of recent lawsuits have demonstrated, failing to properly determine coverage can result in inadvertent incentives and may lead to financial penalties. According to news reports, within the last five years, two pharmacy store chains had to pay $1.4 million and $7.9 million to resolve allegations that they violated the False Claims Act. Real-life examples of inadvertent incentives can be as simple as improperly using such in-store or company incentives as gasoline discounts and/or drug manufacturer coupons to reduce costs for Medicare patients. Federal law prohibits influencing a Medicare patient’s choice of provider with this type of offer.
Finding a solution to identifying complete coverage could improve healthcare outcomes and reduce costs, while allowing patients to take advantage of available incentives to save them money, when appropriate.
LexisNexis Risk Solutions Health Care is exploring the use of socioeconomic and claims data for determining if the patient is on a government plan. Additionally, we welcome collaboration with industry stakeholders to develop solutions that would allow pharmacies to identify the plan type in real time, simultaneously with prescriber verification. We invite state governments, pharmacy benefit managers, health plans and data and analytics vendors to join efforts to ensure pharmacies have full and accurate insight into the patient coverage.
Until a viable solution is identified and implemented, there are best practices pharmacies employ to determine a patient’s coverage, including:
- Knowing and engaging the patient to better understand any coverage that patient may have, including commercial, Medicare, Medicaid/Managed Medicaid;
- Working with the pharmacy’s system vendor to use the BIN/PCN/group designations in the industry to help determine if the coverage is commercial or government when assisting with coupons; and
- Reporting suspected cases of fraud to the proper authorities.
Bobbie Riley, RPh, is the vertical market lead, pharmacy, at LexisNexis Risk Solutions – Health Care
Latest efficacy studies support use of Amgen’s Repatha in conjunction with statin
THOUSAND OAKS, Calif. — Amgen on Monday announced a new analysis from the Repatha (evolocumab) cardiovascular outcomes study (FOURIER) that showed a statistically significant relationship between lower achieved low-density lipoprotein cholesterol (LDL-C) levels and lower cardiovascular event rates in patients with established atherosclerotic cardiovascular disease.
There was no evidence of a leveling off of effect and no new safety concerns were identified in this analysis. The results were presented in a Late-Breaking Clinical Trials session at the European Society of Cardiology Congress 2017 in Barcelona, Spain and simultaneously published in The Lancet.
"With this analysis, we've further demonstrated the safety and efficacy of achieving an LDL-C well below current targets," stated Robert Giugliano, Brigham and Women's Hospital and Harvard Medical School, Boston and lead author on the analysis. "These findings from the first analysis of a large cohort of patients to achieve such ultra-low LDL-C levels support the use of intensive lipid-lowering therapies, such as the combination of evolocumab and statin therapy, in high-risk patients to safely reduce the risk of another cardiovascular event."
Approximately 26,000 patients from the Repatha cardiovascular outcomes study were followed for a median of 2.2 years. Rates for the primary and secondary composite endpoints and cognitive function testing, as well as safety events, including cancer, hemorrhagic stroke, new onset diabetes, cataract, neurocognitive dysfunction and non-cardiovascular death were compared across five groups.
"Scientific evidence demonstrating the strong progressive association between lowering LDL-C and the risk reduction of cardiovascular events in patients with established atherosclerotic cardiovascular disease continues to grow," said Sean Harper, EVP research and development at Amgen. "For patients who have already experienced an event, such as a heart attack or stroke, this analysis reinforces that the intensive LDL-C lowering provided with Repatha helps patients reduce their risk of another cardiovascular event."
Rx Drug Mart receives influx of capital from BDC in its bid for 27 Rexall pharmacies
MONTRÉAL — BDC Capital, the investment arm of BDC, on Monday announced that it has completed a $10-million minority equity investment in Rx Drug Mart, alongside Persistence Capital Partners and RxDM's other existing shareholders. The investment was made in support of RxDM's growth strategy and in part enables the company to continue to look at acquisition opportunities.
"We are excited to support RxDM's platform as they execute on their growth strategy to expand across the country," stated Claude Miron, VP growth equity with BDC Capital. "The investment showcases BDC's commitment to help Canadian businesses with high-growth potential scale to the next level."
"We are building a national network of pharmacies in Canadian communities that puts the focus on the needs of patients, pharmacists, staff and communities," said Brian Dawson, CEO RxDM. "As we achieve our goal, we have become one of the fastest growing businesses in Canada and we are excited to have BDC Capital's Growth Equity team join our partnership with PCP. This investment helps further our vision of expanding pharmacy services and coverage in Canadian communities."
The equity investment was used to finance RxDM's acquisition of 27 former Rexall pharmacies from McKesson in Alberta, British Columbia, the Northwest Territories, Ontario and Saskatchewan. With the completion of the acquisition, RxDM will have a network of more than 40 pharmacies across the country.
"We are delighted to continue to support a high-growth company focused on high quality patient care across the country," commented Stuart Elman, managing partner of PCP.
BDC Capital's investment in RxDM is part of the Bank's initiative announced in June to invest $250 million of growth equity over the next five years into mid-sized, high-growth businesses with a strong track record of positive cash flow. The initiative aims to fill a financing gap in the market, as smaller companies scale in size.