Medicaid Enteral Prior Authorization: Fill & Download for Free

We should not view the healthcare system in isolation but as part of a human support system. The earlier answers discussed universal health care, but spending $5000 per person on medical care for a person who lives on the streets or in a rat-infested apartment is a misuse of resources. If we cut WIC and other food support in order to pay for universal health care… Which should be a higher priority for any country, universal health care or universal access to higher education? It simply makes no sense to provide great diabetes care in a community where people can only afford foods that make them sick in the first place!The cost of healthcare is a moral issue. As health care costs go up, we draw money from other areas to pay for health care. Any “ideal system” must address cost, allowing a society to direct scarce resources to help not only its sick, but also its socially and economically vulnerable. BTW, when I say “the cost of healthcare”, I mean the cost of the services, not just the insurance.25 years ago, I left a tenure-track academic position to enter the healthcare industry. I could see the writing on the wall. As government spending on healthcare (Medicaid and state employee costs particularly) were rising at absurd rates, state funding for higher ed would go down. (I didn’t foresee a public willing to pay absurd tuition.)What have I learned? I’d start by looking at how we price services. Take a look at the Japanese system where, in 2009, the government paid $98-$160 for an MRI . We need pricing that spurs innovation to reduce healthcare costs, not just to reward new capabilities. Obviously, drugs would be in the crosshairs.Next, we need to simplify healthcare administration. The ratio of non-clinicians to clinicians in American healthcare is unconscionable. Billing, prior authorization, compliance, quality data collection (which Don Berwick made issue #1 in his list), etc. are out of control.Next, we need to pay clinicians more for their time and less for investments in technology. Doctors (and others) shouldn’t make money by ordering a test, but should instead be paid well for their time. When you don’t pay doctors well for their time, it becomes economic necessity to write the antibiotic instead of explaining why the patient doesn’t need one, to schedule surgery when there is a better, less invasive alternative…I could go on, but my point is that we should not look at healthcare in isolation but as part of our social support system.

There are a number of factors:Education - To become a licensed therapist you must have an undergrad degree, a masters degree and about 2000 hours of post-grad supervised therapy sessions before you can take the licensure test. This is a very expensive education plus you don’t earn a lot of money while doing the 2000 hours of supervised practice.Income - Many mental health clinics pay their therapists by commission. This means that the therapist is paid only if the clinic is paid by the insurance company or the client. Since this income is dependent upon when (and if) the money comes in many therapists are uncomfortable not knowing exactly what their checks will be each payday.Insurance Coverage: Most mental health services are covered by some form of insurance. Some companies have onerous rules that must be followed, prior authorizations and payment schedules that run anywhere from 10 to 90 days after the invoice is submitted. A related problem is that people tend to either quit paying their insurance premiums or changing insurance companies without notifying their therapist.Payments: Many companies haven’t raised their mental health payment rates in years. Medicaid (at least in my State) hasn’t raised the rates in something like 20 years. How can a therapist live on rates that barely pays the bills?. Mental health is a small section of the health care industry. It doesn’t have the lobbying power of hospitals and physicians.Therapists: These are very talented and dedicated folks who entered the field because of their desire to help other people. They are also people just like the rest of us - they want to make a decent living, buy a house, have children and pay off their student loans. What many of them find when providing direct mental health services is that the hours are long and intense and the payments are ridiculously low. So what they frequently choose to do is to go into related fields that pay better and have better benefits. Working as a hospital social worker or for one of the many other State, county or city social services agencies can be very compelling, The loss of this talent to the direct mental health services has been pretty devastating.Clients: I haven’t seen any statistics but I suspect that the number of clients seeking mental health services has grown significantly. Negative stigmas about therapy have lessened somewhat and other health care providers are more willing to make referrals. This is good but we must have the talent to treat these people.

This is a complex subject. First some introductory concepts. Then, the details.I. In healthcare the intersection of demand, price, quality and sources of suppliers alone does not determine whether pricing is appropriate. Medical necessity, a complex method of determining whether a product or service should be used is also a factor. Medical necessity is used by payors, including private insurance, Medicare and Medicaid to determine whether a medical procedure should be provided at all. (See Drug Pricing Legislation and Inefficient Markets Theory - No World Borders)II. Drugs are categorized by over 10 different classification systems, however the National Drug Code (NDC) (see National Drug Code Directory), the Generic Product Identifier (GPI) (see Medi-Span® Generic Product Identifier (GPI)), and RxNorm used extensively for electronic prescribing are important standards. (See http://noworldborders.com/2018/03/01/drug-pricing-classification-systems/), (see also RxNorm Overview)III. There are three concepts that are important to understand in pharmaceutical / drug pricing. The first is the flow of physical drugs. The second is flow of funds. the third is eligibility determination for coverage of drug costs by insurance.A. From a flow of drugs perspective, the drug manufacturer provides product to a wholesaler. Wholesalers sell to a pharmacy, physician, hospital or clinic, who can sell / fulfill drugs to an insured beneficiary that has a prescription from a physician or other provider such as a hospital. (See diagram from Academy of Managed Care Pharmacy ).B. From a flow of funds perspective, Drug Manufacturers receive funds from a Wholesaler at a Weighted Average Cost or (WAC) payment subject to prompt pay and other terms. The Drug manufacturers can issue charge backs based on inventory / stock balancing and other factors. The manufacturer may also charge a provider at a negotiated discount rebate for drugs based on volume and market share. Providers and physicians issue WAC based payments back to wholesalers. Beneficiaries issue cost sharing payments to providers. Health plans (payer aka insurance) issue payments at Average Selling Price, or Average Wholesale Price (AWP) or Was negotiated payments to providers as reimbursement. Beneficiaries issue payments to the health plan in the form of premiums. Also this flow has been established for decades.C. From an eligibility perspective, private insurance insureds, Medicare Part D insureds and insureds from Medicaid (state insurance funded in part by the Federal government and distributed by states, which has different names in different states), must be deemed eligible for coverage of drug costs. Eligibility is determined based on a combination of factors. These include the diagnosis or condition of the patient and whether the drug is indicated for the patient’s diagnosis or condition. Second, the health insurance coverage plan design and formulary. A drug (wether brand name or generic) may be listed on a formulary that is identified in the health insurance plan. Third, the usual customary and reasonable price of the drug from the supplier and fourth whether the supplier is a contracted provider to the health plan. If not the drug may be supplied and partially reimbursed as an out of network reimbursement. All of these issues are complex and over time health plans have begun to contract with an outside or partially owned entity to manage this process.Enter the Pharmacy Benefit Manager (PBM) which receive payments from health plans and share of rebates from manufacturers are issued back to the health plan. The Drug manufacturers issue negotiated discounts and rebates for drugs based on volume, market share, formulary placement). PBMs issue contracts to health plans, generally pricing their coverage for drugs at WAC. WAC can be used correctly or it can be manipulated, based for example on last in first out (LIFO) or first in first out (FIFO) pricing. The purchase / payment lots can vary from a small volume of drugs at high price point, or the same drug purchased in high volume at a lower price point. If PHMs contract for a LIFO based WAC they can purchase in high volume at low price to decrease the price point, then purchase a small amount at high price and charge based on LIFO. This can yield artificially high profits. This is not to say that all PBMs operate in this manner, but the use of analytics combined with a detail knowledge of drug classification taxonomies is essential to determine if contractural arrangements are being met. Unfortunately there is no simple answer on price determinations because PBMs use several factors in their negotiations. Here are just a few.PBMs negotiate several provisions in contracts, including: Formulary selection, Dispensing fees and discounts, Utilization management, Mail order discounts, Administrative charges, Discounts or rebate guarantees, Price protection which can affect Medicare bids and inflationary increases, Membership driven discounts to plans with more members, Rebate maximization in Medicare Part D coverage in lieu of discounts, Multi-year agreements, Tiered and select pharmacy network, Limiting days supply, Prior authorization, Biosimilars, and Specialty pharmacy contract provisions.