Do It Yourself

Managed Care Analysis

FACT:FACT:

1.1. Selling in the managed Selling in the managed care environment is not care environment is not getting easier..getting easier..

FACT:FACT:

2.2. Managed care is Managed care is constantly changing; the constantly changing; the resulting impact on your resulting impact on your market is hard enough to market is hard enough to comprehend and even comprehend and even harder to manageharder to manage

FACT:FACT:

3.3. This workshop is designed This workshop is designed to give you tools to…to give you tools to…

Leverage Managed Care to Leverage Managed Care to Increase Your Sales!Increase Your Sales!

Today’s ObjectivesToday’s Objectives•• Provide tools and understanding to Provide tools and understanding to

help help youyou evaluate and leverage your evaluate and leverage your marketmarket

•• PrePre--workwork

–– Tailor detail messages to include managed Tailor detail messages to include managed care (Efficacy/ Safety/care (Efficacy/ Safety/ ACCESSACCESS))

–– Tie pullTie pull--through initiatives to product through initiatives to product formulary status (promoting products in formulary status (promoting products in any coany co--pay tier)pay tier)

Why is Managed Care Why is Managed Care Important to Me?Important to Me?

••Approximately 87% percent of Approximately 87% percent of PfizerPfizer’’s prescriptions dispensed in s prescriptions dispensed in 2003 were reimbursed by managed 2003 were reimbursed by managed care organizations (13% is seen as care organizations (13% is seen as Cash)Cash)

••Promotion OpportunitiesPromotion Opportunities

••Opportunity to make more $$$Opportunity to make more $$$

More Reasons to More Reasons to Understand Managed CareUnderstand Managed Care

••I ntegrated Delivery I ntegrated Delivery SystemsSystems

••Some PPOs & employers Some PPOs & employers using formulariesusing formularies

••Market constantly changingMarket constantly changing

••Leader in the DistrictLeader in the District

Getting Started/How To Find Data

• Access Grids From Tracy Lucas

• Payor Data on Computer

• Pharmacists In-House and Retail

• Call Major Employers

• Office Billing Staff

• Run Dummy Prescription

• Drill Down Reports

Key Managed Care Terms

• Pharmacy Benefit Manager (PBM)

• Integrated Delivery System (IDS)

• Formulary• Co-pay

• Preferred Provider Organization (PPO)

• Health Maintainence Organization (HMO)

• Fee For Service (FFS)• Capitation

Key Managed Care Terms Definitions

• PBM – a company that provides a broad range of services to healthcare providers in an effort to control pharmacy costs and utilization

• IDS – the banding together of healthcare providers as a means to coordinate patient care, strengthen the range of services and be more competitive for contracts

Key Managed Care Terms Definitions

• Formulary – a list of drugs preferred by a provider• Co-pay- a means used by providers to off set the

cost of rising healthcare. (usually an amount paid by the patient to offset the total bill for the service)

• PPO – contract with an employer extending lower cost to participants as long as the participants use contracted physicians/services. Becoming more common

Key Managed Care Terms Definitions

• HMO – contract with an employer extending benefits to participants like lower costs, but higher than PPO. May be out of network. Becoming less common and more difficult to sell in than the PPO

• FFS – Physician is paid on the basis of number of patients seen. The result is the patients may reimbursed for the cost of the service (becoming more common)

• Capitation – Physician is paid a fixed sum regardless of the number of patients seen. (becoming less common)

The Peoria Market• Population 112,936 with three hospitals (OSF,

Methodist, and Proctor)• Other cities Pekin, Washington, Morton, East Peoria,

Bartonville, Creve Coeur, Dunlap, Chillicothe, and Metamora (combined have a larger population)

• Median Age = 33.8• 74.3% over 18 and 30.5% over 62• TRx potential Zithromax 3rd, Spiriva 4th, and Zyrtec 3rd • Top three payors for all products are Cat, Cash, IDPA

The Peoria MarketTop Five Employers

• Caterpillar

• OSF Hospital

• Methodist Hospital

• Keystone Steel and Wire

• District 150 Schools

The Peoria Market

Employers Caterpillar OSF Methodist Keystone Dist. 150

PBM Caremark/ Restat

Caremark HCH WHI WHI

Health Plan

OSF OSF HCH HCH HCH

Example of why it is Example of why it is so confusing!so confusing!

Pfizer EmployeePfizer EmployeeOne Patient…Separate BenefitsOne Patient…Separate Benefits

The Peoria Market

Who Pays The Bills?

• Zithromax – Cat, Cash, IDPA

• Zyrtec – Cat, Cash, IDPA

• Spiriva – Cat, Cash IDPA

The Peoria Market Access with PBMs

Cat/

Caremark

OSF/

Caremark

Meth/

HCH

Keystone/

WHI

Dist 150/

WHI

Zithromax 2nd 2nd 2nd 2nd 2nd

Zyrtec 3rd 3rd Not covered

3rd 3rd

Spiriva 2nd 2nd 2nd 2nd 2nd

Payer Current % Market Share Previous % Market Share

CATERPILLAR 24.7 25.08

CAREMARK PRESCRIPTIONS SE 11.39 10.89

RESTAT 9.85 9.88

CASH 8.08 9.61

MEDICAID 6.98 7.2

ILLINOIS SENIORCARE 4.06 3.82

HCSCR - HEALTH CARE SERVI 3.24 2.86

EXPRESS SCRIPTS/DPS (INCL 3.22 2.23

IMPLEMENT!!

• You have comprehension of how to evaluate and leverage managed care opportunities in your market. (Regardless of formulary issues)

• You can synthesize resources available to help you tailor your messages to include access AFTER efficacy. (hand outs)

• You have the knowledge to tie in pull through strategies to formulary status. (examples)

• You can evaluate your market for an opportunity with Tracy Lucas. (Ideas)