Step-Edit Training Program - · PDF fileStep-edit programs affect your bottom line Step-edit...

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Transcript of Step-Edit Training Program - · PDF fileStep-edit programs affect your bottom line Step-edit...

  • Step-Edit Training Program

    How can you address them?

    What are step-edit programs?

    Why are they important?

  • Step-edit programs affect your bottom lineStep-edit programs create hassles for pharmacists, nursing staff, patients, and physicians. These hassles can influence the behavior of these stakeholders. And their behavior can ultimately reduce your market share and volume.

    Step-edit programs can lead to lower market share

    Step edits create hassles Hassles shape behaviorChanged b Changed behavior shapes growth potential changes market share

    Hassles for physicians, pharmacists, nursing staff, and patients

    Lead to pharmacy switches

    Generally shape physician prescribing habits

    Discourage patients from initiating therapy

    Leads to lower market share and volume

    Did you know? Step edit: a drug benefit rule requiring patients to try a lower cost medication before the health plan or PBM

    will provide coverage for a higher cost medication. Step edits and prior authorization are both pharmacy benefit management techniques.

    Did you know? Prior authorization: a benefit rule requiring patients to receive approval from the health plan or PBM prior to

    receiving coverage for the service or medication being provided.

    Step edits are managed at the point of sale in the retail pharmacy

    Plans believe that step edits are effective and inexpensive to implement

    Step edits complement co-payment tiers as a cost-controlling mechanism

    Step edits typically require the use of inexpensive generic agents prior to the use of more expensive branded agents

  • What can you do about step-edit programs?You can address each stakeholder in the system.

    You can become an expert on the step-edit programs that affect your territory.

    You have responsibility for working with all parties in the system. Since you call on the physicians, nurses, and pharmacists, its imperative that you understand the impact step-edit programs have on each of them and that you have the knowledge and skills to engage them in the process.

    Market Share and

    Volume

  • What you need to know and how to find it outIn order to become an expert on the step-edit programs that affect your territory, youll need to invest some time. But dont worrythere are many people to help you along the way.

    What you need to knowHere is what you need to know about the managed care organizations, health plans, Medicare plans, employers, and physician medical groups that affect your territory:

    Information Type Example

    1. Formulary products. Specific step-edit language. Percent of business

    (TK)Must try and fail on ACEI before starting ARB7%

    Use the chart at the end of this tool to help you keep track of this information.

    How to find it outYou have a number of resources for information about the managed care environment in your territory. But the first person you should go to is your District Manager (DM).

    Resources that provide the information you needThe Edge

    Regional Formulary Grid

    The Managed Care District Analysis Monthly Report

    Obstacle Handler Cards

    Analyzer Reports

    You District Manager

    Regional Account Manager (RAM)

    Regional Account Professional (RAP)

  • The pharmacy is the crucial link in the step-edit system. Patients can become discouraged and fail to follow up on treatment. A 00 WellPoint study showed that 11% of patients who encountered a step edit in filling a prescription did not fill a prescription for any therapy for that condition in the following year.

    Your pharmacy calls are important. You can learn about how the real managed markets dynamics are impacting your business by talking to pharmacists.

    Did you know?A survey of pharmacists found that every pharmacist knew about step-edit programs and, yet, no pharmaceutical representative had ever talked to them about step edits.

    Did you know?Some physician offices have a specific phone line for pharmacists to leave a message about coverage issues. These messages are typically processed once a dayusually in the afternoon (:00 PM). If a pharmacist calls after the messages have been processed for the day, the patient will not get resolution of the issue until the following day. Be sure to keep track of these policies for the large physician offices in your territory, on your handheld and let the pharmacists you call on know about them.

  • Can we add some type here? how step edits work

    $

    1. Patient visits physician

    2. Physician prescribes drug

    4. Nursing staff is the first point of contact for pharmacists

    Some offices have a reimbursement specialist for these calls

    Nursing staff pulls chart for physician

    3a. Patient presents prescription to pharmacist for fill This is the moment of truththe pharmacist has to act on the step edit Pharmacist calls physicians office to make change or appeal the step edit Pharmacist tells patient drug is not covered unless the step edit is followed first

    7. Patient receives drug

    5. Physician reviews prescription Physician makes necessary changes

    or initiates appeal process6. Pharmacist fills prescription

    3b. If the plan has implemented a step edit for a drug, the pharmacist is alerted. Typically, the alert is as simple as a pop-up screen describing the particular step edit

    3c. Pharmacist checks prescription for coverage with health plan or PBM through networked computer

  • 7

  • Patients

    Step edits create hassles Hassles shape behaviorChanged b Changed behavior shapes growth potential changes market share

    Create inconvenience at the point of service

    Patient may have to wait, come back to the pharmacy, or go back to see the physician

    Patient avoids healthcare system

    Leads to increased likelihood of discontinuing treatment or never initiating treatment at all

    Did you know? Many step edits cannot be resolved quickly. Patients who have to wait a long time for resolution may not start

    therapy at all!

    The hassle factor

  • Pharmacists

    Step edits create hassles Hassles shape behaviorChanged b Changed behavior shapes growth potential changes market share

    Pharmacists dislike having to call the physician and the subsequent documentation required to override the step edit

    Most retail pharmacy chains will not allow a pharmacist to override a step edit without written documentation from the physicians office

    Increase pharmacists workload with calls or faxes to providers

    Stop the process of dispensing medication for patients

    Reduce pharmacists ability to deliver optimal customer service

    Patients must wait longer for approval or come back to the pharmacy

    Patients may need to go back to their physician for a new prescription

    Create tension between the pharmacist and the patient

    Patients must pay full price for the brand

    Patients may feel they are receiving suboptimal treatment

    Patients are unable to begin treatment in a timely manner

    Leads to physician changing prescription

    Leads to increased likelihood of discontinuing treatment or never initiating treatment at all

    Did you know? The profit margin for pharmacists on generics are usually greater than those of branded agents. Therefore, the

    incentive to push branded agents may not exist.

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    Nursing Staff

    Step edits create hassles Hassles shape behaviorChanged b Changed behavior shapes growth potential changes market share

    Require additional administrative functions

    Interrupt daily activities while tending to in-office patients

    Nurses attention may be pulled away from in-office patients

    Many physician groups have nurses dedicated to reimbursement issues

    Physicians avoid prescribing medications that are subject to step- edit programs

    Approaches for managing reimbursement issues may create patient hassles

    The hassle factor (contd)

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    Physicians

    Step edits create hassles Hassles shape behaviorChanged b Changed behavior shapes growth potential changes market share

    Physicians dislike calls from pharmacies and the subsequent documentation required to override the step edit

    Physicians are not reimbursed for time spent dealing with step edits

    Place a burden on nursing staff and/or administrative teams

    Create potential ill will among patients due to confusion

    Change desired treatment protocol for patient

    Increases likelihood of discontinuing treatment or never initiating treatment at all

    You can help pharmacists, nurses, and physicians with step-edit programs

    Step-edit programs can significantly impact your market share by reducing the number of prescriptions actually filled at retail pharmacies

    However, you can help the pharmacists, nurses, and physicians you call on by providing relevant information

  • 1

    How to address the effect of step-edit programs in your territoryThis section will help you adapt your message to step-edit objections. There are different approaches you can take when a pharmacist, physician, or member of the nursing staff brings up an objection based on step edits.

    The 5 step-edit approaches

    1. Clinical value approaches: use the objection as an opportunity to show the superiority of product 2. Tolerability: discuss the tolerability of ARBs or RASILEZ as it relates to patient compliance with therapy 3. Low pat