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Stretching Program Dollars:Creative Solutions in Cost Containment
Presentation to aaa+
ADAP Crisis Summit
July 6, 2010
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Agenda
• Introductions
• Overview of HMS
• The ADAP Budget Problem
• Creative Solutions
• Questions and Contact Information
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Our Mission
HMS helps protect the integrity of government-sponsored health and human services programs.
We are experts in cost management, focused on delivering comprehensive solutions that allow healthcare dollars to reach more people, save taxpayer money, and make the system work better for everyone.
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What We Do
• We provide cost containment services for government healthcare programs.
• We help ensure that claims are paid correctly and by the responsible party.
• As a result, our clients spend more of their healthcare dollars on the people entitled to them
Last year, HMS recovered over $1 billion for our clients, saving billions more in avoided costs.
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Who We Serve
State Programs– Medicaid and Title XXI agencies– State Employee Benefit Plans– Aids Drug Assistance Program and State Pharmacy
Assistance Program– Child Support agencies
Federal Programs– Centers for Medicare and Medicaid Services– Veterans Administration
Commercial Programs– Managed Care Organizations– Pharmacy Benefit Managers
Strained Program Budget
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Financial Crisis Impact
*NASTAD 2010 Annual Report
Impact of Health Reform on ADAPs
• Additional need for coordination between programs
– Medicaid eligibility expansion– Increase in individuals covered by
insurance – Changes to coordination between Part D and ADAP
• Wrap-around Medicare Part D expenditures counting toward True Out Of Pocket (TrOOP) expenditures
• Narrowing the Medicare Part D doughnut hole
Impact of Health Reform on ADAPs (cont.)
• Drug purchasing changes– An increase in the Medicaid
rebate amount for purchased drugs
– 340B pricing transparency
The Budget Problem
• Traditional approach to cost containment
– Reduce formularies– Restrict eligibility (i.e. FPL)– Client cost sharing– Waiting lists
• Creative solutions do exist that expand access rather than restrict it
Creative Cost Containment Strategies for Public Payers
• Coordination of Benefits– Ensuring Claims are paid by the
responsible party
• Program Integrity– Ensuring that pharmaceuticals are
utilized, billed, and paid appropriately
• Eligibility Services– Streamlining enrollment process
through decision support services
HMS Services for ADAPs
• Coordination of Benefits– Recovery from Commercial
Carriers– Cost Avoidance– Coordination with other
public programs
HMS Services for ADAPs
• Program Integrity– Pharmacy Auditing– Drug Rebates
HMS Services for ADAPs
• Eligibility Integrity– Insurance Continuation– Health Insurance Premium Payment– Medicare Buy-In– Review of Eligibility Criteria
HMS ADAP Case Studies
• NJ ADDP– $6.4 million recovered: 2009– $58.7 million recovered: 1996 to present
• CT ADAP– $4.3 million recovered: 2008 to present
• PA SPAP– Recoveries for the Special Pharmacy
Benefits Program – $5.1 million recovered: August 2009 -
April 2010
Take-Aways
• ADAP Budget Crisis places pressure on benefits and eligibility
• Health Reform helps medical coverage, but not costs
• Creative solutions can relieve financial pressures without impacting clients
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Contacts
Arika PierceDirectorFederal Government [email protected]
Cynthia JonesSr. Director Enrollment [email protected]
Lori KaraianDirectorState Government Relations/ADAP [email protected]
