Business had taken me from home one chilly evening and I was long asleep when I got a frantic 1 a.m. call -it’s my bride.
“Someone is on the roof” she exclaims with intense trepidation.
Shaking the cobwebs of my Excedrin PM induced slumber and rolling over the post-
Christmas possibilities, I asked “who would be on our roof”?
Silence, then “He’s walking” she adds and then more listening silence. “There’s more than one”.
Hmmm, a family of rooftop burglars? With no easy house entrance, I wonder about the perpetrators.
“Honey it sounds like cat burglars. Do we still have that Y2K cache of tuna”?
Click, minutes go by, ring, static filled reception that I recognize from a straining remote phone.
“I’m outside” her hushed voice filled with determined bravery, “I’m in my nightgown, with a flashlight”.
“Has that run them off”, I innocently inquired. Ignoring me, she adds “I’ve got a weapon”.
Ok, you now have my full attention. Adrenaline climbing, I’m imagining various options in our limited family arsenal
and what I should do 1,000 miles away when she adds, “I’ve got a boat paddle”.
Whew, cancel the ADT security system, the posse and the SWAT team. Lady in a nightgown with a boat paddle shining a light on the roof, hope the neighbors are getting this on video.
Phone rings, I hadn’t noticed that it was disconnected. A boisterous voice announces, “It’s a family of raccoons”.
The raccoons were trying to keep their babies warm in the wind swept evening by huddling around the still warm chimney.
“You should see them. They are really cute…but loud”.
The loud sounding rascals remind me of our latest industry neighbors, PBMs. As their habitat has become less hospitable they have searched for more promising abodes. As Medicare D PDPs, PBMs developed quite a bit of analysis on infusion providers. Entry by Medco, expansion by Walgreens and the recent retreat by Express Scripts in the infusion therapy market show their perception of opportunity as well as their challenge in providing a higher-touch product to patients.
PBMs have driven great efficiencies in the prescription drug benefit but their robotic mail-order dispensing, phone tree customer service, transparency issues and their poor image with physicians has road blocked their initial market entry into direct care for patients. But do no discount the wiles of those trying to get into the house.
PBMs are by far the largest providers in specialty infusion niches such as hemophilia. They did this by using a non-PBM service model for the bleeding disorder community and distancing themselves from the corporate headquarters. At a national hemophilia conference that I attended in May, there was great interest and riotous response as an executive dismissed his company’s ownership ties by one of the nation’s largest PBMs. Another PBM choose not to distribute a press release after acquiring an infusion company, allowing the subsidiary to assimilate while retaining its original name.
And workman’s compensation plans and health plans are beginning to listen.
I attended a PBM conference where 2 speakers encouraged the largely payor audience to open up traditional medical benefits to PBM administration to drive down costs. No surprise here but then each separately added that they estimated that health plans could save 10% off their total infusion therapy spend by eliminating false and fraudulent claims by infusion providers. No evidence of fraud by providers was produced but you could tell by looking at the audience that a subtle point had been driven home, traditional infusion providers are either sloppy or devious.
There is no discounting that PBMs generally have closer and more exclusive ties with payors. PBMs can point to claim efficiencies and some now have subsidiaries that can perform outsource claim adjudication for the health plan. Others can point to a national footprint to encourage national contracts or note your infusion company’s participation in their Medicare D network as reason why the PBM can more effectively administer an ancillary network. These features are creating some noise.
There is a course that you can take now. Your paddle and flashlight arsenal include:
1. Seeking out an independent and transparent PBM in your area and discuss comarketing to bring efficiencies to your payor customers.
2. Work closely with your largest payor customer Accounts Payable Managers to clean up claims. These loud voices within the health plans have a remarkable influence on your continued participation. A large payor in Indiana took me aside and told me that our bringing a local provider to the table with it’s A/P and Audit Team kept them from sending an already drafted termination notice that would have closed the provider’s operations in that state.
3. If those HCFA 1500s are piling up in the uncollected box, this may be a signal from the payor that they are having coding issues with one of your offices. Visit with Pete or Mandy at Rock-Pond about how your branch can be streamlined to lower A/R and avoid additional headcount.
4. Ask the health plans for risk collaboration in return for greater exclusivity or a percentage of the savings. As an example, substitute your Case Manager and ‘one-stop service model’ for one that the health plan is outsourcing.
5. Promote yourself to payors. You represent $1 of every $100 reimbursed every month for every plan patient. Show them how you impact their members and save them money. If you are challenged on developing an economic analysis then focus on developing case studies of how your company’s unique intervention, staff experience and programs kept members out of the acute care facility, reduced drug waste, returned patients back to work...summarize with real dollars saved.
Your success in a competitive market largely depends on the light that you shine on problems, your impartial assessment and the paddle you wield to win.
These proposals can be a bit challenging if your managed care team doesn’t have much experience in developing these relationships.
2020 ConsultRx has over 20 years experience building collaboration between our clients and payors. Please give me a call and let’s discuss at no obligation, how we can build your business today. Russell.gay@2020consultrx.com or call me at 501-247-1341.
Russell Gay
2020 ConsultRx, LLC
Principal
Russell.gay@2020ConsultRx.com