Alpesh Patel

Hospitals Are Relying More on PBMs to Manage Manufacturers' 340B Contract Pharmacy Restrictions: DCI's 2024 Market Analysis: The 340B contract pharmacy market shows little sign of slowing down. Drug Channels Institute’s exclusive analysis of the 2024 market reveals that: * About 33,000 pharmacy locations—more than half of the entire U.S. pharmacy industry—act as contract pharmacies for the hospitals and federal grantees that participate in the 340B program.  * Five multi-billion-dollar, for-profit, publicly traded pharmacy chains and pharmacy benefit managers (PBMs)—Cigna (via Express Scripts), CVS Health, UnitedHealth Group (via OptumRx), and Walgreens, Walmart—continue to dominate the 340B contract pharmacy market. * Federal grantees are aligned primarily with the vertically intergated organizations' retail pharmacies, while hospitals rely on mail and specialty pharmacies. Over the past four years, manufacturers’ restrictions on 340B contract pharmacies have led hospitals to deepen their relationships with the largest PBMs—even as those PBMs have simultaneously limited hospitals’ direct participation in specialty pharmacy networks. For an updated look at what’s next for the 340B contract pharmacy market, join Adam J. Fein, Ph.D., on June 21 for his latest live video webinar: The 340B Drug Pricing Program: Trends, Controversies, and Outlook. Read more » © 2006-2024 HMP Omnimedia, LLC d/b/a Drug Channels Institute, an HMP Global Company. All rights reserved. This Feed is for personal non-commercial use only. #pbm #lifesciences #financial

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNxbn0

Understanding MIPS Data Validation and Audits is crucial for healthcare providers seeking to maintain compliance and optimize reimbursement. Our comprehensive guide breaks down the CMS MIPS DVA Fact Sheet, providing actionable strategies for successful navigation. Explore our insights and enhance your MIPS reporting practices. #MIPS #CMSAudits #HealthcareCompliance https://lnkd.in/eGAbCKq8

How GoodRx is Evolving Its Reimbursement Approaches to Help Pharmacies and Consumers: Today’s guest post comes from Jim Sheninger, Pharmacy Strategy Officer at GoodRx. Jim describes GoodRx's emerging pharmacy contracting strategies. In addition to working through pharmacy benefit managers (PBMs), GoodRx now also contracts directly with Walgreens, CVS, and other national and regional pharmacies. These direct agreements are based on acqusition cost, which helps pharmacies stabilize gross margins while still providing low pricing for consumers.  To learn more about GoodRx and its pharmacy partnerships, reach out to network@goodrx.com. Read on for Jim’s insights. Read more » © 2006-2024 HMP Omnimedia, LLC d/b/a Drug Channels Institute, an HMP Global Company. All rights reserved. This Feed is for personal non-commercial use only. #pbm #lifesciences #financial

The state of hospital pharmacies in 2024: 10 notes In 2024, healthcare pharmacy executives are focused on standardizing their formularies and streamlining drug purchasing, according to 275 hospital pharmacy leaders surveyed by Bluesight. https://lnkd.in/gDuN-E8h

Believe it or not, we're facing an increase in drug shortages due to various reasons, including limited manufacturers, labor shortages, shortage of raw ingredients, and supplier delays. Here's what you can do: • Ask your pharmacist to conduct an inventory search with other pharmacies in their chain. • Request refills in advance to avoid running out of medication. • Consider setting up mail delivery if it's feasible for you. If all else fails, don't hesitate to call your doctor and explain the challenges you're facing. Together, you can discuss possible alternatives. Stay informed, stay proactive, and stay healthy! #WORKPERX #Healthcare #StayInformed

Partnership is good for payer provider collaboration

Employee recognition ideas. When done right, your #recognition efforts should boost employee retention and engagement while making your team members feel valued and seen. Here are some ideas. https://ow.ly/M3vU50SlSSP #PharmacyAdvisors #HappyEmployees

The SoftWriters #FrameworkLTC blog weighs in on... The Future of Long-Term Care Pharmacies: 6 Trends Shaping the Industry in 2024 and Beyond The LTC pharmacy landscape is undergoing a major transformation! This year, will see a surge in automation, AI exploration, and a growing focus on medication management and in-home services. FrameworkLTC blog delves into 6 key trends impacting LTC pharmacies in 2024: 1. Increasing Use of Automation 2. Exploring Artificial Intelligence ‍3. Expanding Role of LTC Pharmacists 4. Focusing on Medication Management 5. Adapting to Regulatory Changes 6. Increasing Focus on LTC at Home Read the full article and see how FrameworkLTC expects these trends to shape the future of LTC pharmacies. #LTCpharmacy #pharmacy #healthcare #futureofwork #automation #AI #medicationmanagement #homecare #regulatorychanges https://lnkd.in/gQwsYmK8

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNlbq0

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNxbp0