Payers and Reimbursement

Payers & Reimbursement

The payer market continues to transform and reimbursement models are changing frequently - our training helps keep sales teams informed on changes impacting their customers and enables them to best position their products and services in an evolving market.

Administering the Pharmacy Benefit

This module begins with a discussion of the role of prescription drugs in the delivery of healthcare services and what is meant by the pharmacy benefit. It then discusses the role of PBMs in managing the pharmacy benefit and how financial risk is influencing the pharmacy benefit.

Commercial Health Insurance

This module provides an overview of commercial health insurance and looks at the shift from a fee-for-service healthcare payment system to a system dominated by fee-for-value arrangements. It also describes the various types of managed care plans available.

Cost-Containment Strategies in Managed Healthcare

This module describes cost-containment strategies developed by managed care organizations (MCOs) to reduce the unnecessary use of healthcare resources and associated costs.

Current Issues in Managing Healthcare

This module explores issues facing healthcare stakeholders as they make decisions related to managing and improving healthcare.

Employers and Individual Consumers as Healthcare Purchasers

This module focuses on the significant role employers and individual consumers play in purchasing healthcare in the United States.

Federal and State Disease Management Programs

This module discusses the provisions for, and types of DM programs presently and prospectively being developed, at state and federal levels.

Follow the Dollar–from Manufacturer to Patient

This module presents a high-level view of the distribution and payment of pharmaceutical products. It traces products through the supply chain and examines the role of various stakeholders, including suppliers (pharmaceutical companies, wholesalers, and pharmacies), payers (government and health plans), and consumers (patients). Along the way, you will gain an appreciation for the complex relationship between drug spending and those who pay the bills.

Government Healthcare Programs

This module looks at the shift from a fee-for-service healthcare payment system to a system dominated by managed care plans. It focuses on government payment approaches, including Medicare and Medicaid, as well as federal programs that help ensure people without insurance have access to care.

Major Healthcare Payers and Managed Care Payment

This module provides an overview of the major payers and payment arrangements.

Major Healthcare Payers and Managed Care Payment MDD

There are four major healthcare payers in the United States, not counting patients:
1. The federal government, which administers Medicare for older and disabled Americans and contributes to Medicaid budgets at the state level
2. State governments, which administer Medicaid programs for lower-income Americans
3. Private or commercial health plans/insurers, which sell and administer fully-insured health benefits to employers and other large groups, as well as individuals
4. Self-funded employers, which often contract with a third-party administrator or health plan to oversee employee benefits
This module provides an overview of the major payers and payment arrangements in the post-Affordable Care Act market.

Medicare and Medicaid Formularies

This module explores the role of formularies in controlling healthcare costs under two major public programs--Medicare and Medicaid.

Microminutes: Value-Based Reimbursement

This Micro Minute takes a look at how Providers are increasingly participating in value-based payment models and the most popular models used for reimbursement. In addition, the cost-containment strategies healthcare plans are implementing to help control the costs of prescription drugs are also covered.

Overview of the 340B Drug Pricing Program

This module will help you to understand the history of the Program, how it is monitored, and recent changes that have occurred since the adoption of the Affordable Care Act (ACA). You also will learn how to determine the impact of the Program in your market.

Partnering with Payers application eModule

Business acumen and customer insight are two of the most important competencies for account managers who call on payers. These skills help account managers forge lasting relationships focused on achieving mutual goals with their customers. This application tool is designed to help you better understand the needs of your accounts so you can confidently make the business case for a potential partnership with a health plan or a pharmacy benefits manager (PBM).

Population Health Management: A Strategy for Higher Quality and Lower Costs MDD

Recognizing that a small percentage of patients is responsible for a large share of healthcare expenditures, more payers and providers are targeting specific patient populations for intervention. These payers and providers are designing programs that better coordinate care for high-risk patients in an effort to improve quality and reduce costs. This module outlines current approaches to population health management, including patient-centered medical homes (PCMHs), perioperative surgical homes (PSHs), and accountable care organizations (ACOs).The module also discusses the implications of population health management for medical device and diagnostic (MD&D) companies.

Specialty Drugs: Distribution and Reimbursement

This module describes how distribution and reimbursement differ under the medical ("buy-and-bill") and pharmacy benefit models. It explains why these models, which were designed for traditional drugs, become problematic when used to distribute and reimburse specialty drugs. It views these issues from the perspectives of payers, providers, and patients. Finally, it looks at current attempts to adapt and adjust these models to better fit the needs of the specialty drug supply chain.

Strategies for Successful Risk Contracting MDD

This module discusses strategies for successful risk contracting and how sales teams can support such contracts in the field.

Strategies for Successful Risk Contracting Pharma

This module discusses strategies for successful risk contracting and how sales teams can support such contracts in the field.

The Health Insurance Marketplace

Healthcare reform established a new way to shop for private insurance--the Health Insurance Marketplace. This module looks at the main features of the market and how state health insurance exchanges are evolving amid political unvertainty. The module also explores the implications of exchanges for various stakeholders, including life sciences companies.

The Health Insurance Marketplace MDD

Healthcare reform established a new way to shop for private insurance--the Health Insurance Marketplace. This module looks at the main features of the market and how state health insurance exchanges are evolving amid political uncertainty. The module also explores the implications of exchanges for various stakeholders, including MD&D companies.

The Oncology Care Model – Implications for Oncologists and the Industry

The Centers for Medicare & Medicaid Services (CMS) has launched a new payment framework called the Oncology Care Model (OCM) that transforms how oncologists are paid for providing services to Medicare patients. This module explains the most relevant aspects of OCM and how they affect oncologists. This module also describes value-based selling strategies for life science companies in this changing environment.

Thought Leader Insights: Identifying Value-Based Strategies with Today’s Customers

Thought Leader Insights are a collection of podcasts that give you a glimpse into the discussions that industry leaders are having on important topics. In this collection, experts from Premier and Philips discuss key customer issues under value-based payment and how companies can put value at the center of their sales strategies.

Thought Leader Insights: Payers, Providers, and Population Health

Thought Leader Insights are a collection of podcasts that give you a glimpse into the discussions that industry leaders are having on important topics. In this collection, a physician executive from a health plan and two executives from a retail pharmacy chain and a group purchasing organization (GPO) discuss how payers, providers, and other stakeholders are approaching population health management.

Understanding Buy and Bill

The “buy-and-bill” model can be somewhat difficult to comprehend, but understanding how specialty products and payments flow through the supply chain is essential to your role as a pharmaceutical sales professional.

Understanding how MACRA Will Impact Your Business

This job aid covers key concepts you need to know as you consider how you can better serve physicians bracing for new pressures on their practice. This interactive job aid also includes a section of questions to help you determine the impact on your customers.

Understanding MACRA and Its Impact on Physicians

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is radically changing how physicians receive payment from Medicare, the largest payer in the US. This module explains the most relevant aspects of MACRA and how they affect physicians. This module also describes value-based selling strategies in this changing environment.

Understanding the Basics of Risk Contracting

This module discusses the basics of risk contracting as more life science companies consider this strategy to build more meaningful partnerships with their customers.

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