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Formulary guidance and transparency from P&T to point of care

Perspectives on Standardized Healthcare

Posted by Matt Breese on Dec 23, 2015

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From P&T to point of care, healthcare stakeholders invest in standardized data more than ever before. Massive shifts in the payer space accelerate the need for normalized and benchmarked information. Whether there’s a mandate from regulating agencies or healthcare companies proactively collaborating to improve data integration across the healthcare network, standardized data provides massive leveragability for payers, providers, patients and manufacturers.

Payers, providers and government agencies demonstrate their willingness to invest time and resources into interoperability among technology platforms. One illustration exists with Carequality, a coalition of healthcare stakeholders across the healthcare spectrum attempting to standardize the way in which the healthcare network communicates. Technology vendors permeate the healthcare landscape, solving different needs for many of the same key players in the industry. However, the process for obtaining services and, more importantly, integrating different systems presents massive obstacles. The Carequality effort seeks a better solution for contracting with technology partners and standardizes the path for more streamlined healthcare data exchange across the industry.

New mandates from the Center for Medicare and Medicaid Services for the 2016 plan year represent a major step in payer transparency. Health plans participating in federally-facilitated marketplaces are required to make certain data elements publicly available via the machine-readable JSON format. The shift to a more standardized dataset enables more streamlined access to drug coverage, provider information and general formulary information.  This new format also enables a completely open source model for healthcare data exchange via healthcare.gov that promotes innovation through an integrated approach to streamlining healthcare.

CMS Medicare star ratings provide an example of how a standardized industry ranking system can influence payer and PBM offerings. The system measures key components like clinical outcomes, care accessibility and patient experience with normalized benchmarks across the industry. The resulting incentives for obtaining more stars include financial benefits and obvious marketing messaging leveragability. Through Medicare star ratings, CMS leverages a method for extracting tangible metrics from otherwise arbitrary and objective assessments of a health plan’s performance. The star rating system provides clear advantages for the consumer during open enrollment with more intelligence around the performance of a health plan. Consequently, recent trends reveal that certain pharmaceutical manufacturers pay close attention to these ratings, specifically when it comes to prescription drug benefits. The resulting information from CMS’s star ratings affects pharma’s payer contracting strategy for their products and leads to more focused efforts based on how a plan performs in the Medicare arena.

A review of drug reimbursement and health plan/PBM coverage of branded and generic pharmaceuticals reveals a clear need for more universal benchmarks. NCPA proposes a consistent language for PBMs to communicate Maximum Allowable Cost reimbursement. A MAC list identifies the maximum amount that a payer or PBM pays for generic drugs and branded drugs where generics are available. Unique and diverse reimbursement approaches permeate the PBM landscape with no two MAC lists being the same. NCPA proposes that a standardized model that clearly identifies criteria for MAC inclusion would tremendously improve transparency for healthcare stakeholders and further promote the utilization of lower-cost alternatives.

Is your organization investing in more standardized data, either internally or through collaboration with industry partners? Tell us about it on Twitter or LinkedIn!

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Topics: Industry Trends, Data & Analytics, Payer