Presentation Notes in PDF Format

Pharmacy Services Administration Organization ‐ PSAO
today, tomorrow and beyond
Subspecialty pharmacy opportunity
The Hemophilia Alliance Member Meeting
Washington D.C. April 26, 2015
Today’s HTC challenges in a changing healthcare environment
• Specialty drugs are targeted by payers as the
most rapidly increasing cost
• Payers, providers, insurers and PBMs are all
consolidating and pushing vertical integration of
their services to steer business and control
• Payers don’t understand the HTC integrated
clinical and factor distribution model leading to
better outcomes and cost control
• HTC access to payer networks
• Threatened HTC sustainability
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What a potential solution may look like
• The HTCs could work together to market their
• Directly to payers
• Indirectly to payers through PBMs or insurers
• The service offering should provide a unified
consistent benefit and pricing
• It would be desirable to provide products and
services as a sub-specialty network
• Easily defined and limited to area of specific
expertise with a correlation of the service
benefit to outcomes
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A PSAO may be the vehicle of choice
• PSAO – Pharmacy Services Administration
• Created in the late 1980’s as an organization of like minded providers of pharmacy services and benefits that join together with their peers to provide a defined group of services (benefit design) that are targeted at a select population (patients with hemophilia and perhaps other limited health issues) and marketing those products and services collectively to payers (directly and indirectly) while avoiding anti‐trust issues.
* Today there are approximately two dozen PSAOs primarily in the retail pharmacy space
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Components of the PSAO
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PSAOs require infrastructure to effectively market their network
• Basic network services
• Recruit, educate and communicate with
network members (HTCs)
• Develop a benefit design and pricing that is
supported by the network members and
flexible enough to be nimble in the
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PSAOs require infrastructure to effectively market their network
• Basic network services (cont.)
• Develop and support a marketing plan
• Develop contracts consistent with service
• Direct payers
• Self insured employers
• Carve-outs from larger benefit
• Indirect payers
• PBMs
• General specialty pharmacy
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Network Benefit Design
Define the services and products that will be
part of the sub-specialty benefit
• Factor and other medications as agreed
upon (HIV, Pain, etc)
• Services that are consistent with the
mission of the PSAO and the HTC
coordinated care model
• available at all network members
• administered in substantially the same
way with consistent standards
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Quality Issues and Quality Assurance
• PSAO network member credentialing
• Provide network quality assurance standards
• Support and/or conduct patient satisfaction
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PSAO back end service
• Maintenance of and adherence to payer
contract terms
• Claims processing/clearing house (direct
• Reporting on quality, outcomes and other payer
• Assay management
• Cost data
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How would network access happen?
• HTCs through Hemophilia Alliance agree to
form a PSAO
• PSAO develops a third party offering (benefit
design, quality assurance, etc.)
• Benefit design is marketed to payers by PSAO
(fully insured and self insured payers)
• Offering accepted by payer as a subspecialty
pharmacy network
• Hemophilia patients can access subspecialty
pharmacy network through their insurance
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How does an HTC participate in PSAO?
• HTC signs a participation agreement with
PSAO giving you access to review contracts
• HTC reviews individual PSAO contract
offerings and key terms and requirements
• Pricing
• Services
• Reporting
• HTC chooses which contracts to participate in
• HTC executes and agrees to terms of chosen
contract(s) with the PSAO.
• HTC communicates participation in contract to
its patients and other stakeholders
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The overall HTC member PSAO
HTC receives payment for factor/drug from PSAO and uses funding to support patient services
HA forms PSAO
PSAO bills payer under contract terms and receives payment
PSAO governance establish benefit parameters
HTC bills for factor/drug to PSAO
Benefit is offered to payers for patient benefit
Patient receives HTC pharmacy services
Patient chooses sub‐specialty HTC network through exchange or from employer [email protected]
The HTC owned PSAO Indirect
HTC receives payment for factor/drug from PBM/insurer
HA forms network through PSAO
HTC bills payer under HA PSAO contract terms and receives payment from PBM/insurer
PSAO governance establish benefit parameters
Benefit is marketed to payers to be a part of their patient benefit
HTC bills for factor/drug to the PBM/insurer
Patient receives HTC pharmacy services through the PBM included benefit
Payer contracts with HC PSAO for their network and benefit to be a part of the overall contracted benefit
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Questions and Panel Discussion
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Key Definitions
• Fully Insured healthcare is where the employer contracts with an insurance company to cover the employees and dependents. The insurance company underwrites the risk. Fully insured plans are subject to State law insurance regulations.
• Self‐funded Healthcare is a self insurance arrangement whereby an employer provides health or disability benefits to employees with its own funds. Thus, the employer is acting as an “insurance company” and underwrites the risk. Self funded health plans, under the provisions of Section 514 of ERISA, are exempt from state insurance regulations.
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Key Definitions
• Third Party Administrator (TPA) – a TPA handles the claims processing for an employer that self‐insures its employees. The risk of loss remains with the employer, and not with the TPA. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, prescription drug card programs, or membership functions.
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Key Definitions
• Pharmacy Benefit Manager (PBM)‐ An administrator of prescription drug programs. PBMs are responsible for processing and paying prescription drug claims, and often developing and maintaining a formulary of drugs. PBMs also may contract with pharmacies and negotiate discounts and rebates with drug manufacturers.
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