Integrating RxOps for Cost Management Solutions

By: Jamie Holowka March 27, 2019

As a pharmacist, in the past 20-plus years, I’ve owned my own pharmacy, worked for a PBM (pharmacy benefit manager), served as a consultant to health plans and more. Now, I find myself in the operations department of a Stop Loss carrier. As pharmaceutical costs continue to rise and new drugs debut with million-dollar price-tags, the market is seeing greater catastrophic claim expenses – and I’m working to share my industry knowledge and understanding of pharmaceutical costs and use across the client population.

Introducing Pharmacy Operations to Business Practices
Recognizing the positive impact pharmacy review and interaction can have on high-dollar claim outcomes, HM Insurance Group (HM) was one of the first Stop Loss/Managed Care Reinsurance companies to introduce Pharmacy Operations (RxOps) into its business model to provide educational opportunities and insight to the self-funded community.

When I joined HM in 2017, I was tasked with ensuring specialty medication claims were reviewed for safety and efficacy as well as being identified as having the potential for ongoing use. This type of review measures volume and frequency and includes cost assessment for specialty medication claims. I also was tasked with reviewing the cost containment programs that clients implement through their administrators to gain knowledge of what is being done in the industry today.

Three Primary Areas of Focus
RxOps currently focuses on three primary areas when working to share insights with our TPA partners: cost containment, risk assessment and education. Each area plays a significant role in identifying potential opportunities for clients interested in better managing their claims expenses without worrying about compromising care.

Cost Containment
There is less angst about high-cost claims when the costs are predictable. Clients benefit when their members are receiving Best Practices. By reviewing the data, RxOps has the ability to share administrator-specific knowledge, which may provide potential strategies for clients.

  • RxOps reviews population health data to identify possible opportunities related to specialty medication use over the total participating population.
  • RxOps may reach out to partners to share industry awareness and experience when medication costs, quantity, frequency or duration may not follow FDA-approved guidelines; the information can empower the plan administrator to drive opportunities or create new ones to increase client satisfaction.

Risk Assessment
RxOps assesses risk on two different levels:

  • Level One is an objective review that determines the baseline impact of a medication regimen in the current plan year and projects that utilization into the next plan year. When an administrator is known to enforce industry Best Practices, the result should be reflected in the projections.
  • Level Two is an enhanced assessment by RxOps that enables discussions related to opportunities for cost efficiencies. Examples include reviewing whether clients have opted into administrator-specific services; reviewing if the client is receiving the agreed upon services; or identifying possible opportunities for programs related to fulfillment location optimization.

Education
Education provided by RxOps is focused on high-cost therapies like gene therapy, HAE (hereditary angioedema), hemophilia, oncology and opiates. Therapies associated with genetic disorders currently play a significant role in health care. It is important to identify clients with services that differentiate who is and who is not eligible for these therapies in order to share our knowledge and industry experience with our TPA partners to help reduce ineffective, high-cost therapies.

As part of our efforts to provide useful information to our partners and clients, we have committed to publishing educational resources that focus on pharmaceutical developments, issues and challenges facing the market. Recent educational publications include:

Pharmacy Focus: Cancer Therapy

Pharmacy Focus: Opioid Updates

Specialty Pharmacy Watch: High Cost Hemophilia Treatment

The pharmaceutical industry continues to keep everyone – carriers, brokers and employers alike – on their toes. HM’s attentiveness to specialized pharmaceutical developments demonstrates the company’s focus on working with our partners and clients to better manage the business challenges associated with high-cost claims now and into the future.

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