CVS Caremark Corp. is going to be the last pharmacy benefit manager (PBM) company which will be managing benefits under 2012 medical benefits. The main struggle of health care providers now is to understand what is the best way to structure their specialty drugs benefits in order to understand their members and how do they use specialty medications. The issue occurred because almost half of all the specialty medications fall under pharmacy benefits, while another half was on the medical side.
CVS Caremark spokesperson said that their service is a management solution and doesn’t include medications distribution. Also, Caremark provides their customers with the comprehensive solution in management for customers with buy-and-bill. This will help physicians to do their job without distraction on drug management. Plus, Caremark will use retro- and prospective strategies to achieve the best result and drugs billed under the benefit. Caremark is going to launch several PBM pilot programs with new services offered on January 1, 2012. The spokesperson also added that they expected to expand on other conditions, not only oncolytic supportive care therapies or oncology medications but for now those initiatives are not final and could be changed until the end of this year.
The reason why Caremark is focused on oncology issues is explained by Randy Vogenberg, Ph.D., a principal with the Institute for Integrated Healthcare and strategic pharmacy advisor to the Business Group Pharmacy Collaborative. He said that oncology was the biggest category which allows saving money in the easiest way and that is also the reason why most pharmacy benefit managers have management is that area.
The way to decrease expenses
Elan Rubinstein, Pharm.D., founder and principal of consulting firm EB Rubinstein Associates told that if the system works, healthcare professionals and their patients go along it and savings are benefit which could be saved in cash or be the reduced medication trend over time, but after release it is clear that Caremark are not going further than percentage estimate and will take a special fee for using their program. However, there is no guarantee of return of investment if program fees are higher than net claims cost.
On the other hand, Vogenberg specified, that the fee will be depending on the scope of services provided by CVS Caremark and this service is typical of any services provided by PBM.
Bill Sullivan, the principal consultant for Specialty Pharmacy Solutions LLC, said that there were tools that can use like speed control in oncology. Those tools are using of preferred medications, generics, and other preferred supplies; following pathways and PBM guidelines are also good tools to make medications utilization more optimized and if someone will not achieve 15% savings by using those tactics, something is really wrong.
PBM have some new barriers on their way to medical benefits they should overcome. For last several years, they were just trying to manage medications which are covered by medical insurance.
Sullivan said that tactics used to manage benefits of patients are not something new to a Pharmacy Benefits Manager company. These tactics are active ones and they are based on best PBM practices. They can help to decrease the number of prior authorizations, instead of increasing them like in PBM model. He also added, that if (that’s still not for sure) combine pharmacy reporting with medical one, plus predictive modeling analysis and care cost analysis it would be the really appreciable benefit.
Rubinstein said that CVS Caremark program will not work unless insurance companies will provide oncology specialists with contracts or compensations to help them initiate the work with the new standards, and provide them with different benefits for using preferred therapies. Otherwise, patients and their health care specialists will not cooperate or will be resisting the program. He points out his confident about new programs will be strong enough to withstand but has some concerns if Caremark will be able to structure everything properly in perspective of prior-authorization, coverage recommendations or denials, and post-claims reviews.
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CVS Caremark program base is a collaboration between patients and health care providers (in this case- oncology specialists). Most important part of the program is providers’ engagement. Now CVS Caremark tries to understand what is their program ability to provide patients with quality of care.
Elan Rubinstein also said that a review of post claims is even harder in some cases. In future, several aspects should be considered. One of them is coverage denial by Caremark/New Century advice for expensive therapy or medication prescribed by oncology specialist. Another is would the same PBM allow such an expensive therapy or medication used by academically affiliated oncology specialist and deny it to another, less powerful specialist? And also it is not clear if Caremark will share responsibility for the quality of services provided for cancer care of patients or will just monitor it.
Spokesperson of CVS Caremark told that his company will work in collaboration with payers and their health care providers to find out, track and find the rate of adherence to indicators of quality.