The questions that need to be answered is
1. What kind of risk contracting, if any, would you enter into with providers for the use of the new drug in enrolled population? Discuss reimbursement & UM review criteria you could potentially utilize, as well as strategies for risk sharing and cost-shifting (a payment function). (500 words)
2. Describe how you will roll out the new patient education program related to prescription drug abuse to plan members through participating pharmacies (who expect to get paid for the service) with relevant clinical details (a clinical function). (150 words)
Risk Contracting for the Use of a New Drug with Providers
When introducing a new drug to the market, it is crucial to evaluate the potential risks and benefits associated with its use. In addition, payers must consider how they will reimburse providers for prescribing the new drug, as well as how they will monitor its use to ensure that it is being used appropriately.
One option for payers is to enter into risk contracting agreements with providers. Under a risk contract, the payer and provider agree to share the financial risk associated with the use of the new drug. The specifics of the agreement will depend on the drug being prescribed, the enrolled population, and other factors.
Reimbursement criteria for risk contracting agreements may include a requirement that providers use the drug only in patients who meet specific clinical criteria, such as having failed other treatments. The agreement may also require that providers use the drug only in patients who have undergone prior authorization and that the drug is prescribed in accordance with guidelines established by the payer.
Utilizing UM Review Criteria
Utilization management (UM) review criteria can also be utilized in risk contracting agreements. UM review criteria require providers to submit documentation justifying the use of the new drug. This documentation is reviewed by the payer’s clinical team to ensure that the drug is being used appropriately.
Strategies for Risk Sharing and Cost-Shifting
Strategies for risk sharing and cost-shifting may include the use of tiered reimbursement, in which providers are reimbursed at a higher rate for prescribing the new drug to patients who meet specific clinical criteria. Alternatively, the payer may agree to cover a portion of the cost of the drug if the provider agrees to cover the remaining cost.
Overall, the use of risk contracting agreements can provide payers with an effective means of managing the financial risk associated with the introduction of new drugs to the market. However, it is important that such agreements are structured in a way that promotes appropriate use of the new drug and that the reimbursement criteria and UM review criteria are based on sound clinical evidence.
Rolling Out a New Patient Education Program Related to Prescription Drug Abuse
Effective patient education is an essential component of any healthcare plan. When it comes to prescription drug abuse, it is important to educate patients on the risks associated with opioid use and the importance of following prescribed dosages.
Rolling out a new patient education program related to prescription drug abuse can be accomplished through participating pharmacies, which can provide clinical details and relevant information to plan members. To ensure that the program is effective, the following strategies should be implemented:
Incorporate Clinical Details
The education program should incorporate clinical details that are relevant to the patient. This may include information on the risks associated with opioid use, the signs of addiction, and the importance of adhering to prescribed dosages. The information should be presented in a way that is easy for patients to understand, and it should be reinforced through multiple channels, such as pamphlets, videos, and online resources.
Engage Participating Pharmacies
Participating pharmacies should be engaged in the education program, as they are in a unique position to provide patients with information on prescription drug abuse. Pharmacies can provide patients with educational materials at the time of prescription filling or can offer counseling services to patients who are at risk of prescription drug abuse. Additionally, pharmacies can be incentivized through reimbursement strategies to participate in the program.
Monitor Program Effectiveness
The effectiveness of the education program should be monitored to ensure that it is achieving its intended goals. This can be accomplished through surveys or other means of gathering feedback from patients. Data collected from the monitoring process can be used to refine the program and make necessary adjustments.
Effective patient education is essential to promoting safe and appropriate use of prescription drugs. By incorporating clinical details, engaging participating pharmacies, and
Dusetzina, S. B., & Conti, R. M. (2018). Risk sharing and drug pricing. JAMA, 319(21), 2161-2162. doi: 10.1001/jama.2018.3469
National Institute on Drug Abuse. (2018). Prescription opioid use is a risk factor for heroin use. Retrieved from https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use
Centers for Disease Control and Prevention. (2021). Opioid overdose. Retrieved from https://www.cdc.gov/drugoverdose/data/prescribing/overdose-death-maps.html