Specialty pharmaceuticals have contributed substantially to the rise in the nation’s drug costs over the last several years, and these costs are projected to increase by more than 65% by the end of 2017. Today, the market for specialty drugs is over 120 billion dollars, with annual growth estimated at nearly 9%. This growth translates into astronomical costs for plan sponsors. Traditionally, procurement and administration of specialty drugs is accomplished through the “Buy & Bill” model, which is unmanaged and expensive.
In this model, prescribers buy from preferred vendors, administer the therapy during an office visit or procedure, and then bill the plan sponsor for the cost of the drug plus any administrative fees applicable. This model has raised significant concerns for plans sponsors: Are prescribers prescribing for profit rather than for medical appropriateness?
Instead, a specialty management model should focus more on value and outcomes, incorporating limited disruption to physician work flow or additional effort for the plan sponsor to reconcile medical and pharmacy claims.
nirvanaSpecialty™ is the comprehensive specialty management service from RxAdvance that converts the “Buy & Bill” model to “Value-Based & Outcome-Driven” specialty management. Through a streamlined 10 step process, significant cost savings are delivered to plan sponsors. nirvanaSpecialty™ is designed to supplement a plan sponsor’s current PBM without disruption to the physician’s workflow and without requiring medical and pharmacy claims reconciliation or aggregation from the plan sponsor.
Value-Based and Outcome-Driven Specialty Management
Conventionally, physicians buy from their preferred vendors and pharmacies, then bill the plan sponsor for the cost of the drug and other fees, such administrative fees. In the case of RxAdvance’s “Value-Based & Outcome-Driven” model, when a patient visits a prescriber at the point of care to obtain a specialty medication, the physician submits and obtains a prior authorization (PA) from RxAdvance through SureScripts. Upon successful approval of the PA, the physician can submit the prescription through his preferred medium (fax, voice call, mail, EMR-ePA, Web Portal, etc.). RxAdvance’s specialty pharmacy then receives the prescriptions and uses the inbuilt logic to discern if the prescription needs to be adjudicated as a medical claim or pharmacy claim. After adjudicating the claim, RxAdvance delivers the drug to either the patient’s residence or to the physician’s workplace. In the latter case, the patient then re-visits the clinic to have the medication administered.
When it comes to the payments for the providers, RxAdvance submits separate invoices for medical claims and pharmacy claims, collects this balance from the plan sponsor, and then pays the specialty pharmacy as per the agreed-upon rates. The prescriber then submits the medical claims with line items delineated (such as administrative fee, nurse’s time, etc.) to the plan sponsor. In these line items, there will be a line item for drug cost, which will be submitted complete with the drug’s corresponding j-code and a zero-value for drug cost.
nirvanaSpecialty’s services are comprised of 3 major phases; Onboarding, Diagnosis & Administration, and Continuing Care & Monitoring. Immediately after contracting, plan onboarding begins.
RxAdvance integrates all the health plan’s data into the Collaborative PBM Cloud to derive the optimal client-specific specialty management solution.
- Specialty Formulary Management: RxAdvance leverages all available historical data – medical, pharmacy, and lab claims; and AdvanceFormulary™ artificial intelligence (AI) capabilities– to deliver an optimal specialty formulary that produces superior clinical and financial outcomes for the plan sponsor and members. AdvanceFormulary™ is a highly customizable and intuitive platform, embodying the capabilities to provide gap analysis to identify areas of clinical and financial improvement; to support multiple third-party drug databases and classification systems; to configure drug lists, tiers, and utilization management rules; to streamline formulary change management processes for efficient decision-making and implementation; to analyze drug utilization trends; and to harness built-in CMS rules and guidelines.
- Specialty Network Management: These services involve aggressive negotiations with manufacturers and pharmacies to create a narrow network consisting of RxAdvance’s Specialty pharmacy plus a small group of preferred specialty pharmacies. This process ensures that all treatments result in the lowest possible cost for the plan, and the best possible care for the patient.
- Physician Education: Rx Claim submission, PA submission through current work flow, specialty bundled episode risk management services. Next, physicians, nurses, and care teams are educated about the features of nirvanaSpecialty™.
- Utilization Management: Comprehensive utilization management programs created that ensure all the drugs meet P&T protocols such as prior authorization, step therapy, quantity limits, route of administration, and place of administration. The system leverages industry guidelines/ADE indications and therein delivers this information at Point of Care and Point of Sale through Intelligent DUR360°Gateway™.
Diagnosis & Administration
RxAdvance comprehensively manages prior authorizations and facilitates in the acquisition of specialty drugs.
- Prior Authorization Management: As patients begin visiting or calling their physicians, specialty medications are prescribed. Most of these medications require a prior authorization to be successfully processed at a pharmacy. RxAdvance comprehensively manages these prior authorizations, delivering a collaborative, rule-based, and user-configurable PA system using AdvancePA™. AdvancePA™ and AdvanceFormulary™ utilize sound clinical protocols and pharmacy, medical, and lab claims to derive an evidence-based decision. This ensures that each authorization determination is based upon medical necessity, proper prescriber utilization, reduction of ADEs, and evidence-based prescribing patterns.
- Procurement Management: RxAdvance facilitates the acquisition of specialty drugs from their specialty pharmacy network. These preferred specialty pharmacies offer best-in-market pricing by leveraging the RxGalaxy (a wholly owned subsidiary of RxAdvance) wholesaler relationship.
- Adjudication Management: Through AdvanceClaims™, RxAdvance delivers highly flexible, scalable, and automated core claims processing services. Built from the ground up, this system logic determines if the claim should be adjudicated as a medical or pharmacy claim, while offering unlimited flexibility to design benefits, formularies, pricing, pharmacy network contracts, and compliance changes through rule-based user configurable modules. RxAdvance’s fully integrated system of record allows for the derivation of actionable intelligence, which can be delivered at the point of care, point of sale, to members through our mobile application, and to the plan’s clinical and pharmacy staff.
Continuing Care & Monitoring
- Case and Concurrent Management: RxAdvance leverages Patient-Rx360°™ to generate a custom, concise, and coherent care action plan that is assigned to a care manager. Using comprehensive care protocols, care managers, caretakers, and patients work collaboratively to achieve optimal adherence and to monitor adverse drug events and patient health outcomes. Towards the end of the care management program, patients are screened against concurrent drug monitoring criteria and eligible patients are enrolled into MTM and other relevant programs. These program interactions, outcomes, and other related information are shared with all stakeholders.
- Financial Reconciliation: As part of the billing cycle, the prescriber submits the claims to the plan sponsor for administration services only. RxAdvance invoices the plan sponsors separately for medical and pharmacy claims at the pre-negotiated rate. RxAdvance then receives the medical claim from the plan sponsor, performs the reconciliation of pharmacy and medical claims, and then sends the completed claim back to the plan sponsor. All this activity is accomplished with no additional effort to the plan sponsor.
- Monitoring and Measuring: Financial results and health outcomes are measured against predefined metrics to validate and improve nirvanaSpecialty™.