Managed Care/ PBM

Mail Service Operational Assessment

IndustryManaged Care/ PBM
ProblemA pharmacy benefits management company wished to increase profitability by developing more innovative uses of their mail service resources and operations systems. The company wanted to restructure and modernize their business procedures to maximize efficiency.
PHSI SolutionPHSI visited the management company and evaluated current mail service operating procedures and measurement tools. PHSI also reviewed technology software resources available to the company and analyzed financial reports. After gathering information and evaluating the management company’s current strategic plan, PHSI created three separate alternative operational procedures that included management systems, financial incentives, and software usage. These alternative strategic plans were prioritized by the estimated savings opportunity and again by the degree of difficulty and risk to implement the plan.
ResultsThe management company gained new strategies for mail service operational efficiencies in order to run their business effectively, realize maximum profitability, and minimize potential losses.

Conversion from Multiple Platforms to a New Claims Processing System

IndustryManaged Care/ PBM
ProblemA growing PBM wanted to coordinate several books of business under a single claims processing software system using a service bureau arrangement. Previously, the claims processor used First DataBank (FDB) as their drug database, but the new processor uses Medispan's drug database. FDB plan edits and formularies needed to be converted to Medispan GPI codes.
PHSI SolutionPHSI analyzed the formulary and plan edits to isolate FDB codes that required conversion to Medispan codes. Based on NDC matches, NDC, GCN, and GNN codes were converted to Medispan GPI codes. PHSI also converted therapeutic class GC3 codes to GPI codes.
ResultsThe client leveraged PHSI expertise to meet the aggressive conversion schedule and experienced a smooth transition. In the process, the client consolidated a number of high maintenance formularies and plan edits into more efficient GPI wildcard lists that reduced ongoing maintenance efforts.

Rebate Contracting

IndustryManaged Care/ PBM
ProblemAn expanding managed care organization decided to negotiate rebate contracts directly with pharmaceutical manufacturers. The client required external expertise to complete the process while recruiting a support team to manage the process on a go forward basis.
PHSI SolutionPHSI used its manufacturing contacts to pursue and negotiate rebate contracts. PHSI contacted the manufacturers, sent introductory letters, requested rebate proposals, negotiated agreements, and advised manufacturers of formulary status all while coordinating and providing status update reports to our client.
ResultsThe client’s burden of rebate contracting was alleviated, enabling them to focus their attention on the pressing strategic issues related to their expanding business. The rebate process was successfully transitioned once new staff was hired.

PHSI Provides Independent Due Diligence for Client Considering Acquisition

IndustryManaged Care/ PBM
ProblemA managed care client wanted an independent assessment of a potential acquisition and asked PHSI to analyze the prospect's operations, business strategy, and senior management capabilities.
PHSI SolutionPHSI toured the company, analyzed financial statements, interviewed senior management, and reviewed their business strategies to determine if they were short term focused or were robust enough to compete in the market long term. PHSI suggested follow-up items for our client to validate prior to making an offer for the business.
ResultsA report of PHSI findings and recommendations was discussed with our client's senior management enabling them to use the independent assessment in their decision process.

PHSI Evaluates Potential Business Acquisition

IndustryManaged Care/ PBM
ProblemA venture capital firm wanted to invest in a pharmacy organization providing specialized compounding services. The private equity firm had limited operational expertise in the business and asked PHSI to evaluate the organization’s capabilities and ability to handle rapid growth.
PHSI SolutionPHSI toured multiple pharmacy sites and provided a GAP analysis on the operational systems' potential bottlenecks, solutions, and provided an assessment of management talent.
ResultsPHSI assisted the client in finalizing their investment decision through its project findings.

PHSI Helps PBM Develop a Pharmacy Network Contracting Strategy

IndustryManaged Care/ PBM
ProblemA PBM wanted to expand its presence in the Workers’ Compensation arena and negotiate more aggressive pharmacy network rates to become more competitive.
PHSI SolutionPHSI researched the Workers’ Compensation market and recommended several network contracting options for consideration.
ResultsThe client was able to select and implement a pharmacy network strategy improving pharmacy network rates.

Rebate Contracting Process Directed by PHSI

IndustryManaged Care/ PBM
ProblemA pharmacy benefits manager (PBM) wanted to consolidate rebate contracting that was outsourced by line of business amongst three rebate aggregators.
PHSI SolutionPHSI directed the rebate contracting process with brand pharmaceutical manufacturers over a six-month period. PHSI assisted in contract review, financial evaluations, negotiations, and implementation.
ResultsThe PBM went live with one segment of their business at a rebate yield that exceeded the previous rebate aggregators, and they are planning to internalize the rebate process for the remaining two segments.

PHSI Designs MAC Pricing Benefiting HMO and Retail Pharmacy

IndustryManaged Care/ PBM
ProblemA Medicaid HMO wanted to ensure that their Maximum Allowable Cost (MAC) list was controlling generic expenditures while providing a reasonable profit to their retail pharmacy networks.
PHSI SolutionPHSI created a unique model to analyze the costs associated with generic drugs in order to create competitive MAC lists incorporating the needs of all market segments. The MAC list aligned incentives for all stakeholders to promote generic substitution.
ResultsThe Medicaid HMO aligned financial incentives while increasing their generic substitution rate and lowering network complaints on generic pricing.

PBM Positions Itself for Increased Rebate Yield

IndustryManaged Care/ PBM
ProblemA client wanted to improve their rebate yield by either moving their business to an alternative rebate aggregator or renegotiating a more favorable arrangement with their current provider.
PHSI SolutionPHSI reviewed the client’s current rebate situation including formulary position, aggregator contract, and support services. We contacted potential rebate aggregators to discuss opportunities for the client.
ResultsPHSI met with different rebate aggregators to discuss formulary options, rebate yields, and review claims submission requirements. The client improved its rebate yield and cash flow with a new rebate aggregator agreement.

Medicare PDP Develops Community Pharmacy MTM Program

IndustryManaged Care/ PBM
ProblemThe Medicare PDP client needed assistance in designing and implementing a cost-effective MTM program using community pharmacists to provide MTM services.
PHSI SolutionPHSI participated on a client team to analyze disease state protocols and intervention methods from a pharmacy and business perspective. We evaluated proposed protocols and interventions, researched options, and held discussions with the client team.
ResultsPHSI provided the client with recommended MTM protocols using community pharmacists as the focal point while ensuring the program was implementable in practice. PHSI proactively addressed concerns regarding continuous quality improvement and resource allocation.