Payers and Reimbursement

The payer market continues to transform and reimbursement models are changing frequently - our payer and reimbursement 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.

Alternative Payment Models eBrief

Alternative Payment Models (APMs) are both Medicare and private payment approaches that may be applied to a specific clinical condition, a set population, or a care episode. In this eBrief, we'll take a closer look at the most relevant information pertaining to APMs, including:
- The purpose of APMs
- The types of APMs
- Questions account teams should consider regarding APMs

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.

Copay Accumulators eBrief

Manufacturers often provide discount cards and coupons to reduce patients' out-of-pocket drug expenses. Recently, health plans and pharmacy benefit managers (PBMs) have implemented copay accumulator and copay maximizer programs that affect these market access strategies. In this eBrief, we'll take a closer look at the most relevant information needed to understand these programs, including:
- How copay accumulators and copay maximizers work in the real world
- The effect of these programs on patients' out-of-pocket costs
- How these programs can affect prescribing behavior and patient access to brand drugs

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.

Drug Price Benchmarks eBrief

How the market sets drug prices is a complex process that involves several key pricing benchmarks. In this eBrief, you will learn about the most important drug pricing benchmarks and how they are used to set prices at different stages along the drug distribution and delivery pipeline.

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.

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.

Follow the Specialty Drug Dollar

This module builds on CMR Institute's foundational course, Follow the Dollar--from Manufacturer to Patient, to provide a more in-depth look at how specialty drugs are accessed and paid for in today's complex environment. It simplifies complicated processes so that your sales reps understand the financial motivations of various stakeholders in the specialty market, including specialty distributors, specialty pharmacies, payers and patients.

Government Healthcare Programs

This module focuses on government payment approaches, including Medicare and Medicaid, as well as federal programs that help ensure people without insurance have access to care. It also looks at the impact of the Affordable Care Act.

Hospital Quality Star Ratings eBrief

A hospital’s Quality Star Rating, referred to simply as its star rating, may help — or harm — its brand and image. The rating, which is based on five areas of quality, is intended to help patients make informed decisions about where they go for care when they do not have an emergency.

Major Healthcare Payers and Managed Care Payment

This module provides an overview of the major payers and payment arrangements. As payers continue to try and contain healthcare costs, they are shifting from traditional indemnity or fee-for-service payment arrangements with providers to various risk-based arrangements, including capitation, bundled payment, and shared savings. Many of these arrangements, which are sometimes called value-based payment, also incentivize providers to improve clinical quality and the patient experience.

Medicare and Medicaid Formularies

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

Oncology Care Model eBrief

Cancer diagnoses make up some of the most common and devastating diseases in the United States, affecting more than 1.6 million people. The Oncology Care Model (OCM) has developed an opportunity to enhance the care of these people while reducing healthcare spending. In this eBrief, we'll take a closer look at the most relevant information pertaining to the OCM, including:
- The purpose of the OCM
- Challenges in Developing the Model
- Questions account teams should consider regarding the OCM

Overview of the 340B Drug Pricing Program

This module will help you to understand the history of the 340B 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).

Payer Finances eBrief

Understanding how commercial health plans and PBMs maintain a robust bottom line is essential for serving these important customers. In this eBrief, you will learn which factors influence payers' profits and how they report their revenues and expenses.

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

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

Talking with Finance Leaders About “As-a-Service” Models vs. Capital Purchases and Leases

This application-based module teaches sales representatives about the basics of hospital finances so they can speak confidently with CFOs about “as a service” models rather than traditional capital expenditures and leases for new technology. This module will define some of the key financial drivers that hospital CFOs monitor and prepare sales representatives to have more productive conversations that align to their customers’ goals. Learners will also have an opportunity to review scenarios designed to help them engage financial leaders in the field.

The Health Insurance Marketplace

This module looks at the main features of the market and how state health insurance exchanges continue to evolve amid political uncertainty. The module also explores the implications of exchanges for various stakeholders, including life science companies.

The Oncology Care First Model Summary Module

This quick summary presents the most important facts about the OCF Model in a visual format. This includes graphic representations to answer the following questions:
- What are the goals of the Oncology Care First Model?
- How are oncologists paid for managing and administering drugs through the OCF model?
- Which quality measures are included in the OCF model?
- How are oncology practices preparing to participate in the OCF model?

The Oncology Care Model – Implications for Oncologists and the Industry

The Centers for Medicare & Medicaid Services' Oncology Care Model (OCM) is transforming 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.

Understanding Buy and Bill

This micro-course outlines five quick facts you should know about drug distribution and the reimbursement model, offering a foundational understanding of the Buy-and-Bill model.

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 Medicare Part D

When it comes to Medicare Part D, there's one word that best describes what's ahead in the years ahead: change! How will these changes affect out-of-pocket costs? Will changes disrupt distribution? What will the impact be to drug access for Americans 65 and older and those with disabilities? This module presents the facts you need to know about Medicare Part D and all the changes ahead.

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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