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Networks Seeking Partners: It’s All About the Money
Matthew Osterhaus, FAPhA, FASCPPresident CPESN IowaOsterhaus Pharmacy
Disclosure and Conflict of Interest
Matthew Osterhaus has no personal or financial conflicts of interest to disclose.
Pharmacist Objectives
At the conclusion of this program, the pharmacist will be able to:
1.Describe the concept of clinically integrated community pharmacy enhanced service networks.
2.Review the process it takes to engage a payer and implement a contract across a state-based enhanced service pharmacy network.
3.Identify the workflow and personnel strategies required to successfully incorporate CPESN opportunities into a community pharmacy practice.
Technician Objectives
At the conclusion of this program, the technician will be able to:
1. Describe the concept of clinically integrated community pharmacy enhanced service networks.
2. Identify the workflow and personnel strategies required to successfully incorporate CPESN opportunities into a community pharmacy practice.
3. Discuss which pharmacy team members are involved in efficient pharmacy workflow and the provision of enhanced services in community pharmacy.
Clinically Integrated Network Orientation
• What is a clinically integrated network (CIN)?
• What does a CIN enable us to do?
• How is it different from other provider entities?
Antitrust and CINs• Competition is the basis of the free market
• Antitrust laws are the “rules of the game” for the free market
• Actions that negatively impact the “game” or the market (consumers) are forbidden
Rules of the Game• Competitor combinations that result in concentration of market power through
acquisitions, combinations (joint ventures, collaborations, etc.) or bad behavior not allowed.
Agreements:
• Naked agreements between competitors – arrangements that always or almost always reduce output or increase prices - are per se illegal. That is such agreements have no redeeming attributes.
• Agreements that are likely to be pro-competitive- new product, higher quality, efficiencies (less costs) and have pricing agreement between competitors are analyzed under the “Rule of Reason”
Exception – Clinical Integration• Clinical Integration – interdependence and cooperation among providers
to control costs and ensure quality.
• Measuring test – Are the services being offered likely to produce the level of efficiencies that justify rule of reason treatment
• Indicia of CIN: 1. Establishing mechanisms to monitor and control utilization of health care services that are designed to control costs and assure quality of care; 2. Selectively choosing network participants who are likely to further these efficiency objectives; and 3. The significant investment of capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.
Why CPESN USA was Built Specifically to Be Clinically Integrated
• High quality, high integrity, high performing pharmacies currently have no way of organizing to express their value and clinical contribution to the rest of the care team.
• Concern that the providers themselves (the pharmacies) do not play an active role in engagement of payers and payer contracting.
• Concern that clinical programs of the future will involve other care team members that are clinically integrated (physicians, others).
• Simply put: No Clinical Integration à No Exploration or Negotiation of New Payment Models or Improvements on Existing Payment Models. You are 1 of 80,000 pharmacies and you cannot be different than the rest.
Steps to Ensure Clinical Integration• >50% of expenditures are devoted to quality assurance, quality improvement
and best practices dissemination• Standards are created and regularly updated• Minimum Service Sets• Quality Assurance Standards• Data Transmission Standards• Technology Standards• Pharmacies are required to share clinical data for the purposes of Quality
Assurance (QA), Quality Improvement (QI), and Baseline Parameter (BP) dissemination and to establish baselines for improvement
• Shared monetary investment in quality reporting and care team integration• USA and networks managed by the providers themselves• Pharmacies can be removed from the network for low performance
What does CPESN USA do to be Clinically Integrated?
• Regular monthly “check ins”
• Think – physicals in which a review is performed and a report filed that describes what has, is, and will go on to ensure clinical integration
• Training and Education (this webinar is mandatory for all Luminaries, Facilitators, and Account Managers)
• Quality Reporting
What is the purpose of the CPESN Movement?
• To aggregate pharmacy providers to express their value in an increasingly consolidated marketplace
• To catalyze a services marketplace where the sponsor/plan has a direct relationship with pharmacy providers (in aggregate)
Why is the system broken?
Source: CPESN USA
Being an Effective Salesperson
1. Attunement• Know what they want, don’t assume
2. Buoyancy• It’s going to be a roller coaster
3. Clarity• Simplicity, Problem Finding, vs. Problem Solving
Being an Effective Salesperson (cont.)4. Pitch
• Pretend its your 5 year old’s attention span
5. Improvisation• Listen and adjust
6. Serving• They are the customer, not the other way around• Make the champion better off, not worse off
(personnel)
Being an Effective Salesperson (cont.)7. Utilize Available Marketing Materials
• Digital Flyers• PowerPoint Presentations• ROI Materials – Infographics• Semi-Custom Proposals and “Leave Behinds”
8. Leads Can Come from Anywhere• You need a system to maintain your leads (Pipedrive) • Treat all leads uniquely• Be persistent in your follow-up
9. Request semi-custom materials (when needed)
10. Leverage the Experience of the USA Leadership Team
The Two Biggest Mistakes1.Somebody either says “no” or doesn’t respond• Don’t stop pushing!• T-Rex in Jurassic Park
• They are just as busy as you are• You are not selling a commodity, you are selling an idea
*Starbucks*Crazy Socks
2.Somebody says “fine, what do you want”• Be ready to tell them!• Be specific• Hold them to it (contractually if you can)
The Actors in the Play
Payer Landscape & Why it’s ”Different Strokes for Different Folks" • Medicaid Programs - FFS• Medicaid Programs - MCOs• Medicare - PDP• Medicare - MAPD• Duals - DSNP• Duals – PACE• Commercial – Group• Commercial – ERISA/Association Plan• Care Team/ACO – Government• Care Team/ACO – Non-Government• Governmental/Institution – e.g. CDC, Varies
Keep lots of “Irons in the Fire”
It’s a game of averages. Just like baseball.
Source: blogspot.attitudeandpepperspray.too-many-irons-in-fireSt. Louis Cardinals Baseball
CPESN Network(s) Payer/Partner Program Type Payment Type
Upstate NY Alliance for Better Health / Medicaid
BH-Focused Pharmacy Care Planning and Care
CoordinationMixed-PMPM, performance
bonus, and startup funds
KPCN Medicaid MCOPharmacy Care Planning
(Longitudinal + Single Encounters)
Mixed-PMPM, performance bonus, and startup funds
NYC Health System Transitional Care Fee-for-service
Iowa Commercial Pharmacy Care Planning Mixed, includes performance incentive
Iowa, NESP, South Dakota, Wyoming
Medicare Part D Enhanced MTM Custom Mixed fee-for-service and
performance incentive
KPCN, Tennessee, Mississippi, Louisiana Medicare Advantage Heart Failure Management Risk-based PMPM
Arkansas Grant Tobacco Cessation Fee-for-service
NESP Grant eCare Plan Start Up Program N/A
PPCN Medicaid MCO CMR Fee-for-service
South Carolina DHEC Diabetes Prevention Program Class group payment
Program Descriptions
Payment Models, ROI & Pay for Performance (P4P)
When they don’t believe it will work – go at risk.
• Quality and Performance Bonus• Quality and Performance Penalty• Upside Risk• Downside Risk• Fees at Risk
Contracts & Templates – Can be OverwhelmingQuestion from Payer: “Ok, how do we do this…?”
Your Response: “We can use your contracts and systems or our contracts and systems, we do not have a preference and we don’t charge for ours…”
Remember that CPESN USA is a shared services resource to the CPESN Networks – Your Participation Fees Pay for Program
Development and Administration
Closing the Deal & Keeping it Simple• Identify an Internal Champion
• Establish a Personal Relationship
• Leave the Grudges and the Politics at Home
• Pester, Persuade, Pester Again
• Be Honest and Straightforward
• Use Messaging and Talking Points
• Make it Easy to Say “Yes”!
So…. What am I supposed to do?
• Local contacts start the discussion
• Network within the network
• Elevator pitch
Source: manufacturing-operations-management.com
Implementation of a Contract
• Identify services
• Identify goals/benchmarks
Source: Osterhaus Pharmacy ArchivesCipart-library.com
Implementation of a Contract
• Establish flow of data
• Establish partners
Source: Tabula rasa Healthcare Inc. Clipart-library.com
Implementation of a Contract
• Engage sites• Training• Software• Patient Enrollment• Data Requirements• Performance Timelines/Goals for each site
Source: CPESN Iowa
Recipes for SUCCESS Efficiency in dispensing process is
ESSENTIAL
Source: Osterhaus Pharmacy Archives
Recipes for SUCCESS
•Workflow is key •Medication Synchronization• Student Pharmacists• Technicians• Resident•Management
Source: Clipart-library.com
Recipes for SUCCESS
• Staffing/Scheduling• Skill sets• Prioritization
Source: Clipart-library.com
Assessment Question #1
Clinically integrated networks are formed to increase quality of health care.
A. TrueB. False
Assessment Question #2
When in engaging a payer and they say “no” you should:
A. Walk out the door and say nothingB. Tell them they have their head in the sandC. Tell them thank you and plan your next
follow up call
Assessment Question #3Which of the following is a workflow strategy required to successfully incorporate CPESN opportunities into pharmacy practice?
A. Medication synchronizationB. TechnologyC. Increased number of cash registersD. Specialized training
Assessment Question #4
Which team members are not involved in an efficient pharmacy workflow?
A. TechniciansB. StudentsC. PharmacistsD. None of the above
Resources• CPESN USA https://www.cpesn.com
• CPESN Iowa Executive Director, Lindsey Ludwig [email protected]
Matthew Osterhaus, FAPhA, FASCPPresident CPESN IowaOwner Osterhaus Pharmacy
Email: [email protected]
Questions?
