Insight, analysis & opinion from Joe Paduda
WorkingRx lost a court case in Utah recently, in yet another setback to the third party biller industry.
This comes on the heels of other successful legal challenges to WRx, which was recently acquired by its only real competitor – Third Party Solutions.
“Utilization changes are the driving force in drug cost changes for WC.”
That’s the key takeaway from the expanded version of NCCI’s annual WC Prescription Drug Study; this 2007 edition goes well beyond prior editions to include more detailed information on cost drivers, stat-by-state variations, generics, and the growth in drug spend during the life of the claim.
But the key is utilization.
The key takeaway? Utilization, not price, is driving drug spend.
Roy Poses MD is one of the more intelligent and thoughtful commenters on the conflicts of interest that are rife in the world of healthcare. Roy’s latest discusses the issue of comparative effectiveness – evaluating and comparing different drugs to see which does a better job treating specific conditions.
Not surprisingly, big pharma is no fan.
Continue reading Which drugs work? And why don’t we know that?
OK, we’re now going to abruptly transition from the broad interest (Canadian health care policy) to the hairs-breadth narrow – this is for the folks who deal with workers comp pharmacy issues.
One of the biggest challenges facing WC payers is getting claimants into their PBM program. My firm has surveyed payers about WC pharmacy management each spring for four years, and this is the one issue where there has been no change over that time.
Retail pharmacies’ difficulties in determining eligibility is the key reason per-script costs are so much higher in WC than in group health, Part D, or individual heath insurance.
Here’s why.
TPS, the last third party biller standing, has wasted no time. Just hours (well, perhaps a couple days) after their acquisition of rival WorkingRx was announced, TPS launched their new strategy. They are positioning themselves as a vertically-integrated pharmacy solution integrating first fill capture with a full-service PBM.
When WalMart introduced the $4 prescription program, my commentary headline was “much ado about not much”. In retrospect, too strong a statement that early on.
The initial program covered less than 1% of the scripts filled at WalMart, and was widely seen as a more of a marketing ploy than major new program. To WalMart’s credit, they quickly increased the number of drugs covered and participating stores; before the latest news fully one-fifth of scripts filled at wallyworld were for $4 drugs.
With the benefit of hindsight, it looks like the program has had two rather significant effects – dramatically reducing drug costs for some individuals, and (possibly) driving down drug costs nation-wide.
Now I’m thinking this may just be the start of a major expansion of WalMart into the health care sector.
Fiserv’s Third Party Solutions sub is acquiring competitor WorkingRx. As a result, if/when the deal closes, there will be only one third party biller.
Terms were not disclosed.
Implications follow.
Here’s another one of those posts that is really really interesting to very very few people.
Third party billers are factors – they buy WC script receivables from pharmacy chains and try to collect from WC payers.
The two TPBs have been on (and off) the selling block for some time; it now appears they are working on a merger.
Continue reading Consolidation in the third party biller business
Sometimes it takes a few deaths for people to wake up. That appears to be the case with Fentora, the powerful narcotic manufactured by Cephalon. Four deaths have now been linked to Fentora, deaths that are all the more troubling because they appear to be from off-label use of the drug.
I’m not surprised.
My firm has conducted a survey of pharmacy benefit management in workers comp each year for the past four, and the latest has been completed. Executives in managed care and claims as well as program managers from 20+ payers responded to the Survey, some for the fourth time.
Here are a few of the highlights.
Continue reading Pharmacy benefit management in Workers Comp – Survey results