Take 5 Long-acting Injectable Administration Multiple Locations - - PowerPoint PPT Presentation

Multiple Locations Conference Hashim Zaibak, PharmD Owner and Operator Hayat Pharmacies

Take 5

Long-acting Injectable Administration

Learning Objective

• Discuss four peer-tested ideas that lead to business

efficiencies and better patient care.

Disclosure

Hashim Zaibak, PharmD declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

4 MONTHS!!!

Recent changes in Wisconsin law allow pharmacists to administer non-vaccine injections

Injectable Antipsychotic Administration

Carmen, PMHNP, was looking for an independent pharmacy Other pharmacists did not want to inject Hayat Pharmacists trained on injection techniques

Questions?

Hashim Zaibak, PharmD Hayat Pharmacies zaibakprn@gmail.com

Multiple Locations Conference Pame McHugh, RPh Co-Owner McHugh Pharmacy Group

Take 5

“Dummy” Books

Disclosure

Pame McHugh, RPh declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

Table of contents

• Return to Stock
• Ordering Cheat Sheet
• Failed Invoice from Wholesaler
• Set Holiday Hours for Phone
• Medicare Prescription Drug Coverage

and Your Rights

• Recall Item Return
• Birthday Calls
• Dispill Notes
• Daily Register Report
• POS Weekly Report
• Negative Onhand
• Expired Returns
• ABC Order/C2
• Refill Reminder Report (Previously Matt

Report)

• Vendor Contact Info (varies by store)
• PMP Submission and lookup

Questions?

Pam McHugh McHugh Pharmacy rphmchugh@gmail.com

Multiple Locations Conference Chad Alvarez, PharmD, MBA Senior Director, Retail Pharmacy Carilion Clinic

Take 5

Truck Stop Pharmacy

Disclosure

Chad Alvarez, PharmD, MBA declares no conflicts of interest

• r financial interest in any product or service mentioned in

this program, including grants, employment, gifts, stock holdings, and honoraria.

Carilion Clinic

• Large IDN, Southwest Virginia
• Operate 5 Retail Pharmacies
• Hospitals
• Stand Alone
• Physician Practice
• LTC/Specialty
• October 1- purchased pharmacy in Truck Stop

Carilion Clinic Pharmacy-Raphine

• Largest Truck Stop on the

East Coast

• Parks between 800-1,000

trucks per day

Carilion Clinic Pharmacy-Raphine

Services

• Immunizations/POC
• MTM
• Diabetic Shoes

Future- combine Pharmacy with Urgent Care

Questions?

Chad Alvarez, PharmD Carilion Clinic cealvarez@carilionclinic.org

Multiple Locations Conference David Cippel, RPh President/Owner Klingensmith’s Drug Store

Take 5

Delivery System Operations

Disclosure

David Cippel, RPh declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

The Challenges of Delivery for Rural Community Pharmacy

• Klingensmith's Drug Store is an 8 store

independent chain located in Western Pennsylvania

• Overview of Klingensmith’s Delivery

Services:

• Standard Delivery:
• Mon-Wed-Fri
• Personal Care Homes/Pain

Program/Emergency Deliveries:

• Monday thru Friday

Overview of Delivery Workflow

• Edit Master text styles
• Second level
• Third level
• Fourth level
• Fifth level

Deliveries Reconciled next morning at Central office

Drivers return to central warehouse drop off vehicle-,bag of receipts placed in secure drop box

All stores receive email 1:30PM with attached deliver list Deliveries sorted and drivers depart 1:15PM Drivers arrive 12:45PM to pickup deliveries at store Route finalized based on number of stops Route assigned to driver Exported from store to Delivery Software and sorted by address

Tech/Clerk Enters Delivery Patient into an Access Database at the Pharmacy (Cutoff 11:00am)

Overview of Delivery Workflow

Questions?

David Cippel, RPh Klingensmith’s Drug Store davidc@klingensmiths.com

Multiple Locations Conference Sean Doyle, Principal–Strategic Planning & Management Consultant Fitzmartin Scott Brunner, CAE, NCPA Senior VP Communications & External Affairs,

Project BrightSpot: How NCPA is Looking to Help You Leverage Your Competitive Advantage(s)

Disclosures

Scott Brunner declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. Sean Doyle is the Principal-Strategic Planning & Management Consultant with Fitzmartin. The conflict of interest has been resolved by peer review of the slide content.

Learning objectives

• 1. Discuss the impact of the Amazon/PillPack merger on

pharmacies and lessons learned from other industries.

• 2. Identify opportunities for community pharmacies to

compete, leveraging community pharmacies’ existing competency/value in adherence packaging and same-day, in-person delivery.

D I S R U P T I O N

the Live Independent Initiative

TM FitzMartin Inc. 2019

D I S R U P T I O N

TM FitzMartin Inc. 2019

datacenterknowlege.com

1.

Tech and data platform

1.

Tech and data platform

2.

Logistics

Amazon Prime Whole Foods

1.

Tech and data platform

2.

Logistics

3.

Cash: “No profit. No worries.”

$41.2B

Amazon Online Entertainment Online Shopping Airlines Auto Insurance Hotels Grocery / Supermarkets Shipping Services Banking Life Insurance Pharmacies Travel Websites Health Insurance

61 47 45 44 43 40 40 38 35 30 28 23 13

1.

Tech and data platform

2.

Logistics

3.

Cash: “No profit. No worries.”

4.

Brand and customer experience

1.

Tech and data platform

2.

Logistics

3.

Cash: “No profit. No worries.”

4.

Brand and customer experience

5.

People, a testing ground

Represents 1 of every 151 employed Americans

What makes Pharmacy vulnerable:

1.

Lack of standardization

2.

Little focus on consumer experience

3.

Incredibly fragmented market

4.

Middlemen are value extractors w/ large profit margins

5.

Companies focus on formatting

• r coordinating information

6.

Model relies on opaque pricing

Retailer HealthWarehouse.com Costco Independents Sam’s Club Walmart Kmart Grocery Stores Walgreens Rite Aid CVS/Target Pioglitazone (Actos) $12 $16 $19 $20 $132 $160 $113 $167 $255 $270

A price difference of 22.5x for the same drug

Source: CBInsights, Consumer Reports

Benefits, Claims, Insurance: Amazon as a platform for health benefits management, claims management and billing. Amazon as a platform for employers or small health plans. Amazon offering self-insured employers a common product in conjunction with benefits managers: stop-loss insurance. Amazon and Medicare/Medicaid management ALEXA and HOME CARE Whole Foods medical clinics EMR: data is a perfect fit, AWS is known for security Healthcare supply chain management Device delivery and monitoring Amazon as a/or buys a PBM Genomics Investment: GRAIL PillPack

The State of Business

“...if these independent pharmacies don’t do something to continue to communicate their unique value, then over time their value proposition will erode and people will continue to turn to their alternatives.”

Mark Kaiser - Founding Partner Phase2 Health

Double Our Members’ Net Income Define Our Own Future 10,000,000 Lives Saved

TM FitzMartin Inc. 2019

Fact: We are capable of competing. Fact: We haven’t been telling

• ur story.

Are we going to participate in the conversation?

“Does Your Pharmacy Do That?”

Live Independent 50 Stories, 50 States

TM FitzMartin Inc. 2019

Pharmacist vs Pharmacy

My pharmacist saved my life 2

A man with a cold walks into the pharmacy

And his life is changed with one look

TM FitzMartin Inc. 2019

My pharmacist saved my life 3

Getting Mom to take her medicine changed her life

TM FitzMartin Inc. 2019

I had no idea how close I was to dying

I never expected it would be my pharmacist who would save my life

TM FitzMartin Inc. 2019

TM FitzMartin Inc. 2019

Awareness Contemplating Buying

TM FitzMartin Inc. 2019

TM FitzMartin Inc. 2019

Awareness Contemplating Buying

Find a pharmacist web page

TM FitzMartin Inc. 2019 TM FitzMartin Inc. 2019

Awareness Contemplating Buying

Member Tools: Creating ROI

Member access to a local marketing communications tool kit. Equipping you to win at home and be part of the national media effort. Online member access to a working forum. Show enhanced member value, and recruit more members to join us in our initiative. Ads and media for you to use locally. POP and Instore signage templates. PR support: content ideas, templates. Online use cases and best practices, webinars and remote help.

TM FitzMartin Inc. 2019

Awareness Contemplating Buyin g

• Yes. Yes we

do ...and so much more!

Live Independent– 50 States, 50 Stories:

Inspire with passionate, compelling stories that remind us why we became pharmacists in the first place. Demonstrate the advantages we offer over Amazon/big-box competitors. Show how we change lives, strengthen families, change communities. Publicly declare we will save 10,000,000 lives in three years. Prove the difference. Equip the you to close net new and profitable customers. Launch a national consumer campaign that will include:

National and local PR, Broadcast and digital media Consumer-facing website driving traffic to local members

D I S R U P T I O N

TM FitzMartin Inc. 2019

Self-Insured Health Plans: Opportunities to Both Save and Make You Money

Multiple Locations Conference John Crumly, Mark Haegele, Brian Beach

Risk Alternatives for your Self-Insured Health Plan and Collaborative Care Case Studies

Multiple Locations Conference John Crumly, CEO, PPOK Mark Haegele, Vice President, Lockton Companies

Learning objectives

• 1. Develop questions to ask your current broker about your

health coverage.

• 2. Assess whether a self-funded health plan is right for your

business.

• 3. Illustrate opportunities to sell pharmacy services to other

self-insured plans.

Disclosures

John Crumly, PharmD, is the CEO and Executive Director of

• MaxCareRx. The conflict of interest was resolved by peer

review of the slide content. Mark Haegele is the Vice President of Lockton Companies. The conflict of interest was resolved by peer review of the slide content.

Risk alternatives for your health plan

• Evolution of self funding
• Self funded alternatives
• 100% Risk Retention
• Specific Only
• Traditional – Specific and Aggregate Deductible
• Aggregate Only/Level Funded
• Captives
• State by state implications

Risk alternatives for your health plan

• Evolution of self funding
• Market Trends
• Risk/Reward
• Advantages
• Insurance cost savings
• Transparency
• Access to data
• Administrative cost savings

Risk alternatives for your health plan

Why? Take CONTROL of your employee benefits and create a STRATEGY:

• Make your plan an asset
• Build up a reserve
• Renew based upon your claims, not others’
• Design your own plan
• Reward wellness
• Select your own network structure
• Reinsurance protection
• ERISA Qualified

Potential Savings:

• CLAIMS
• Plan Design
• Wellness
• HRA
• Network
• STOP LOSS PREMIUM
• Specific
• Aggregate
• Less Taxes Paid
• ADMINISTRATION
• Claims Paying
• Customized Services

Macro self-funding vs. fully insured comparison (pros/cons)

Self-Funding Fully Insured Tot

• tal Cos
• sts

Governed by federal regs (ERISA) and not subject to state premium tax (1.75–2.50%). ).

Subject to ACA taxes—PCORI and reinsurance fee

Avoid ACA insurer tax (-2.46%).

Avoid carrier padding and risk charges (-2 to

• -5%).

Tot

• tal Cos
• sts

Volatility

exposure.

Volatility

Tran ansparency

Tran ansparency

Reali ality

Reali ality

• F

Components of premium

Component Description % of Premium Fully Insured % of Premium Self-Funded

Claims

Costs from a healthcare provider or facility for services provided (represents the largest component of premium) 60% 70%

Reserves

Funds set aside to cover liability for claims incurred but not yet reported (IBNR)

Estimate of 1.5 to 2 months of expected paid claims

Fully insured will charge for reserve administration and risk 15% 12%

Pooling Charge/ Stop Loss

A provision that limits the dollar amount a plan will have to pay for any individual claimant to a predetermined level during the policy year 8-10% 8-10%

Administration

Includes claims and eligibility administration, network, risk charges, profits, broker compensation 8-10% 6%-8%

Taxes

State and ACA taxes 5-6.5% 1-1.5%

Margin

Fund established to protect a plan against unexpected claims fluctuations 5-9% 2-5%

• F

Fully Insured Self-Funded

Administration Claims

Administration

Stop-Loss Premium Claims Corridor for High Claims (25%)

Specific/ Aggregate

Fixed Costs for the Employer

Maximum Liability for the Employer Fixed Liability for the Employer

Total Savings 3% - 5%

Fully insured vs. self-funded

• F

Plan is responsible for run-out claims when self-funded plan is terminated.

Plan will only pay ~20% of a normal month’s worth of claims due to lag. It takes 1-2 months for claims to be submitted and paid. 100% should be budgeted and 80% “RESERVED” on plan sponsor’s books for plan termination.

Second Month Third Month Going Forward First Month

Plan will only pay ~50%. Plan will only pay ~80%. By the fourth month, plan should have ~1.5 months of reserves on the books. IBNR reserves must be adjusted regularly.

Establishing IBNR reserves

S E L F - F U N D I N G

What is Stillwater Collaborative Care?

• Provides opportunities to improve the physical and financial

health of community businesses and members.

• Allows us to partner with local communities to make

healthcare affordable and stabilize healthcare cost.

• Plan designed to keep the healthcare dollars local.

Why Stillwater Collaborative Care?

Member Employer Provider

Why choose Stillwater Collaborative Care?

The cost of everything we buy. The cost of health insurance.

325%

How we solved our health care cost crisis.

• Provider owned Population Health.
• Lower contracted rates for local employers.
• Lower Fixed Cost for local employers.
• 100% of Rx Rebates back to local employers.
• Future increases tied to Medicare.
• Transparency.
• Multiple financing alternatives.

Cost Saving Results

Features

Single Family Coinsurance Primary OV Specialist OV Urgent Care Rx Generic Rx Preferred Brand Specialty

SCC Plan

$1,500 $3,000 20% $10 $25 $50 $5 $30 $250

Current Plan

$2,000 $6,000 20% $25 $50 $150 $10 $85 $250

Annual employer premium savings was 18% or $24,000!

Benefit to employees

• Concierge customer services covers: Member Health,

Claim/Plan Questions, Issue resolution.

• Better benefits.
• Lower out of pocket

Concierge

• Provides personalized care.
• Point of contact for questions related to the plan, tier levels,
• r billing.
• Can also assist with establishing members with a primary

care provider or a specialist as needed.

Results - clients

• Twelve employers have signed up.
• 3,020 members on the program.
• The clients’ industry varies: Churches, manufacturing,

healthcare providers, cities, and local businesses.

• Employers save 15-40% on spend.

Results - health

• All members welcomed to the program via SCC’s onboarding call.
• 212 participants received on-site health screenings.
• 55 participants identified as tobacco users.
• Several are now participating in the smoking cessation program.
• Established primary care relationships with multiple members.
• Assisted members with applying for and receiving financial assistance
• Assisted members to resolve claim issues.

Results - claims

Timeframe 1/1/18-12/31/18 Claims processed: 29,211 Member balance bill liability: $0. Eleven claims negotiated. Claims paid as Tier I benefits: 98%.

Results - financial

• SCC has saved the community over $4 Million.
• Clients specifically saved $1.25M by joining the program.
• SMC’s Employee health plan is on track to saved over $2M

for 2018 and reduce claims.

PPOk insurance experience

• Initially, part of a Professional Employer Organization for 13
• years. MaxCare subsidiary was the PBM.
• PEO dissolved had to move to fully insured.
• Only thing transparent were the premium increases.
• 2016 returned to self insured w/ 90 employees.
• Transparent pass through model w/ MaxCare.
• Enjoy benefits of Pharma Copay assistance dollars and rebates.
• Recently added Reference Based Pricing for Hospital.
• Some pain in year 1, but now have access to direct contracts and

concierge partner that minimizes the noise.

MaxCare growth challenges to solutions

• Small sales force –
• Too many RFP’s where we were not the “preferred” PBM.
• “Good, Uneducated or Bad” Brokers.
• Our Solution – Start a Brokerage.
• Now we have an alternative for bad brokers.
• Important to find like minded partners (e.g.)
• PBM Consultants
• Brokers
• Third Party Administrators (TPA)

Brokerage – general agent

• New alternative to fully insured for Oklahoma pharmacists
• Oklahoma State Medical Association (OSMA)
• Pharmacists, staff and families can join MEWA
• Competitive pricing, transparent PBM, no mail order.
• Intangible – physicians and pharmacists communicating as
• rganizations.
• Working on Opioid solution together
• Challenge – Cannot cross state lines.

Local solution to vertical integration

• Clear Benefits and partners
• Provide alternative insurance solutions for our pharmacies and

businesses in local community.

• Self insure
• Join an existing captive insurance company
• Protected cell – each company is underwritten on its own merit for first tier

risk.

• Focus on transparency and keeping business local
• Opportunity for pharmacists to show value with local hospital via

collaborative care model. CPESN Opportunity for transition in care?

• Should more independent pharmacy groups form their own

captive?

Changing the future: Combining Self Funding, Direct Contracts and Reference Based Pricing

Reference Based Pricing

Multiple Locations Conference Brian Beach, PharmD Co-Owner and CFO Kelley-Ross Pharmacy Group

Disclosure

Brian Beach declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

A Different way to pay for Health care

1

What is reference based pricing (RBP)?

2

RBP Solution

Status quo: the problem

The Problem

No regulations on what hospitals can bill for services

What if there was a way to

reduce the cost of healthcare

starting at the source of the problem?

1

Today, for-profit hospitals charge >700% of Medicare and non-profit hospitals charge >550% of Medicare

2

With a traditional PPO “discount”

• f 50%, employers still pay 300%
• f Medicare

3

Status quo: the problem

100

HOSPITAL PRICE

Acetaminophen

(Tylenol)

RETAIL PRICE

Bacitracin

(Neosporin equivalent)

Diabetes Test Strip Gauze Pads

$1.50 each $108.00 each $18.00 each $77.00 a box of 50 $.015 each

$1.49 (bottle of 100)

$4.11 each

$12.33 (pack of 3)

$1.85 each

$27.00 (box of 50)

$0.098 each

$4.90 (box of 50)

Status quo: the problem

Total Hip Replacement

101

HOSPITAL 1 HOSPITAL 2

Discounts can be deceiving

* One of the top 5% largest national PPO networks in the country |

PPO Network Discount

32% 45%

Billed Charges

$54,704 $230,117

Total Plan Payment

$37,466 $125,414

Status quo: the problem

PAYMENTS

PPO pr provid ider pa payments ar are usu usuall lly base based on

• n

pr pre-negotiated rates

102

How Traditional PPO Provider Payment Works

DISCOUNT

Ra Rates ar are oft

• ften de

determin ined by y app apply lyin ing g a a PPO di discou

• unt to
• the

the bil billed ch charge fr from

• m the

the pr provider

PROCEDURE

Vi Virt rtuall lly every pr provid ider has has a a di different bi bille led charge for

• r the

the sam ame pr proc

• cedure

COSTS

Resu esult lt: : unp unpredic ictable le and and illog

• gic

ical l cla laim im cos

• sts

What is referenced based pricing?

103

Provider reimbursements based on a point of reference (most commonly Medicare)

RBP was historically only used for facilities and surgical centers but now includes physicians

Common Network Structure

Hospitals / Facilities Reference based pricing Physicians* Physician-only network or RBP

+

How RBP works

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

RBP Vendor assumes fiduciary status and updates Plan document to include smart and rational levels of reimbursement Member receives treatment normally at hospital/facility Hospital/facility sends bill to Third Party Administrator (TPA) TPA sends bill to RBP Vendor who audits bill and reprices bill in line with Plan document, and returns to TPA RBP Vendor manages additional provider communication should a balance bill arise

105

Balance bill process

Members Responsibility RBP Vendor Responsibility

Members must open their mail and be on the lookout for:

• 1. Provider Bill
• 2. Explanation of Benefits (EOB)

If the Provider Bill does not match the Member Responsibility on the EOB, the Member must call TPA immediately Send RBP vendor a copy of the Provider Bill Correspond with Provider to eliminate balance bill If Provider appeals, RBP vendor will respond to appeal RBP vendor will protect Member on all disputed claims with communication and /

• r additional negotiations

Breakdown of RBP claims

4%

are appealed. RBP vendor will defend and / or further negotiation

15%

are balanced billed. Majority are resolved with an attorney letter, appeal response or additional negotiation of the bill by the RBP vendor

81%

• f the RBP repriced claims are

accepted

Total Number

• f Claims

Total Claims Dollars Hospital / Facility Claim Breakdown

Physician claims

10% 90% 60% 40% 81% 15%

4%

Hospital / Facility claims

Physicians Hospital / Facility

Breakdown of RBP claims

107

To date, there has not been a single lost case awarding the facility additional / full billed amount of the claim

Total Claim Breakdown

Physician Claims

10% 90%

Hospital / Facility Claims

Hospital / Facility Claim Breakdown Example

Based on 1,000 EE Life Group, 18,000 claims processed / year

1,458 Repriced RBP claims accepted 328 Resolved with a phone call or letter

and / or negotiation by the RBP vendor

14 Remain appealed and RBP Vendor will continue further

communication and/or additional negotiations

1,800 10% of claims are Hospital / Facility RBP

Discount comparison: PPO network vs. RPB

Average % Discount for Top 3 Procedure Codes

108

U361 – Operating Room Service – Minor U490 – Ambulatory Surgical Care – SPU 360 – Operating Room Services – General Class PPO NETWORK 1

50.52% 63.52% 49.70%

PPO NETWORK 2

45.51% 56.62% 44.65%

RBP

72.93% 78.70% 73.27%

Grand Total

53.71% 48.02% 73.86%

Client #1

RBP savings examples

MEDICAL COSTS (CL AIMS + FEES) STOP -LOSS PREMIUM RBP SAVINGS (CL AIMS + STOP LOSS) # of Lives PPO RBP % Savings PPO RBP % Savings $ % Client #2 Client #3 173 83 88 $3,439,032 $661,076 $855,618 $2,826,102 $488,915 $578,779 18% 26% 32% $424,135 $235,606 $283,939 $392,833 $191,372 $236,028 7% 19% 17% $644,232 $216,396 $324,750 17% 24% 24%

Keys to success

Continuous member education Member notification via text and phone when RBP claim has been received Superior customer support who exclusively work with Reference Based Pricing plan members Plan language that supports the process

Recap – Why consider reference based pricing?

PROVEN COST-SAVER for employers and members ACCESS TO ANY HOSPITAL / FACILITY in the country FULLY TRANSPARENT method to pay claims

111

• Reduce claims spend by 15-50%
• Maintain or lower out-of-pocket

costs for members

• More predictable claim costs
• Access to providers at any

hospital

• Based on the fair market value
• f the services rendered
• Member outreach when RBP

claim is received to limit member disruption

Kelley-Ross: A Case Study

Multiple Locations Conference Brian Beach, PharmD Co-Owner and CFO Kelley-Ross Pharmacy Group

Kelley-Ross case study

• Part 1:
• Experience with Healthcare coverage for employees
• Part 2:
• Getting paid to provide care beyond rx dispensing

Kelley-Ross case study – part 1

• In 2017, 4 physical locations, 70 employees

(~100 lives)

• Union employees under CBA
• Multi-employer health plan
• Cadillac plan
• Fixed cost per employee with no visibility on true

cost/benefit

• Same premium regardless of dependent count
• Mandatory participation
• 100% employer funded

Kelley-Ross case study – part 1

• Late 2017
• Employees file to vote to decertify Bargaining Unit
• Implications:
• Changed relationship with employees
• Retirement benefit (removal of pension)
• Healthcare coverage
• First steps
• Fully insured discovery
• Limited options for our size for similar coverage

Option 1: HMO plan, no vision/dental coverage included and significant impact to employees Option 2: PPO plan, no vision/dental and changes to OOP Option 3: PPO Plan, no vision/dental and significant increases to employee OOP

Kelley-Ross case study – part 1

• Chance connection led to introduction into Partially/Fully

Self Funded (PSF/SF) concept:

• Transparency
• Base administration fees
• Pass through rebates on rx
• Customize plan to business/employee needs
• Ability to mitigate risk through stop loss carrier

Kelley-Ross case study – part 1

• Decision
• Move ahead with partially self-funded plan
• By EOY had 36 employees with 81 total lives covered under the

plan

• No historical experience to base costs
• Premiums at 25-60% of the previous plan
• KR pharmacies as extended day network pharmacy
• No significant change to network provider access by members

Kelley-Ross case study – part 1

• Outcomes at end of Year 1
• Clarity on expenses
• Fixed Admin Fees
• Semi-monthly check runs for claims
• Overall plan costs flat
• Includes unexpected high cost emergency claim, higher than anticipated

dental plan utilization, and higher rx costs

Kelley-Ross Pharmacy Group

Medical/Rx Experience (CAS) Total Cost Summary 2018 Plan Year

• 9,360

• 11,711

• 15,713

• 41,447

• 20,296

• 17,145

• 23,680

• 22,982

• 17,087

• 22,466

• 37,849

• ASL Violations
• Totals (Net of

• 230,376

Kelley-Ross case study – part 1

• Renewal at year 2
• No major plan changes
• Premiums steady and slight admin fee increases (2%)
• Total expected plan expenses below year 1 and maximum

expenses at single digit increase over year 1

Kelley-Ross case study – part 1

• Future state
• Reference based pricing (RBP) model
• Deep data dive into actual payments to providers
• No “networks”
• Plan payments agreed at time of service
• “Cash in hand” to providers instead of weeks of delays for approval of

claims

• Experience with other employer groups show significant discounts off of

billed charges

Kelley-Ross case study – part 2

• Pharmacist as provider
• WA law already allows billing insurance for services within scope of

practice that are already being paid to other providers

• KR pharmacists currently billing medical insurance plans since mid-

2017

• Early conversations about how to integrate pharmacists into

both PSF/SF plans and also RBP plans

Lessons learned

• Understand the options
• Ask a lot of questions
• Evaluate impact on employees
• Allow plenty of time to decide
• Look at the costs and risks
• What are historical rate increases?
• Risks?
• Important to understand ways to mitigate under any plan, but especially

PSF/SF plans

Matt Lund

Employee Benefits Practice Leader and SVP Brown and Brown Seattle mlund@bbseattle.com

Brian Beach, PharmD

Co-Owner and CFO Kelley-Ross Pharmacy Group bbeach@Kelley-Ross.com

Mark Haegele

Vice President Lockton Companies MHaegele@lockton.com

John Crumly, DPh, MHA

Chief Executive Officer PPOK jcrumly@ppok.com

Questions?