The chief innovation officer and vice president of pharmacy services at UKHealthCare, Gary Johnson, was frustrated with the lack of detail in standardinfusion center financial reports. The records contained only the charges for thepast fiscal quarter, not the reimbursement collected. Without more detailedinformation, pharmacy leaders were unable to assess the full impactof payer restrictions on the health system’s infusion services.

Look beyond charge reports

Dr. Johnson asked to take over responsibility for infusion revenue integrity tobetter manage pharmacy revenue alongside costs. Pharmacy analystsreviewed information from prior authorizations and other clinical documentationalongside payer reimbursement records to calculate the final amountreimbursed. Ultimately, this data helped the team improve revenue capture andquantify the impact of payer policies.

UK HealthCare chief innovation officer and vice president of pharmacy serviceseducated key leaders to gain a platform for discussing pharmacy issues in payerstrategy. Fostering mutual understanding and trust between himself, payercontracting, and C-suite leaders was critical to this success.

Take time to establish a strong foundation with payer contracting

Dr. Johnson initiated pharmacy’s relationship with the payer contracting team byrequesting a meeting with the team’s director to discuss pharmacy-related issuesin payer contracting. Following the initial meeting, a broader group of three to sixteam members from both departments began to meet every other week. The firstsix months of meetings focused on cross-educating both teams on one another’spriorities and responsibilities. Pharmacy taught the payer contracting team abouttopics such as 340B, and the payer contracting team brought pharmacy up tospeed on health plan contracting, which they were surprised to realize is verydifferent than pharmacy benefit manager (PBM) contracting.

Use education to foster C-suite support of pharmacy initiatives

Ensuring that health system executives understand pharmacy's business andcontributions to the system is also essential to UK HealthCare’s pharmacyenterprise strategy. Pharmacy communicates their successes to health systemexecutives in two ways. First, pharmacy leaders send executives a monthly retailpharmacy dashboard of data on volume, expenses, and revenues. Second,leaders created a monthly 340B steering committee to monitor compliance andsecure strategic support. Steering committee members include the COO, CFO,and CNO. Sharing pharmacy information earned the C-suite's trust and keepsexecutives engaged with pharmacy operations and initiatives.

Collaboration across the health system ensures that UK HealthCare's pharmacyservices team can care for as many patients as possible and receive fairreimbursement. Three teams that collaborate with pharmacy are payercontracting, government relations, and medical group leaders.

Review key contract terms for immediate success

Pharmacy and payer contracting’s strong working relationship allowed meetingagendas to evolve in support of UK HealthCare’s broader payer strategy. Thepayer contracting team engages pharmacy in discussions for both existingcontracts and new contract proposals. Pharmacy reviews identify contract termsother teams don’t understand. For instance, pharmacy identified a term in onecontract stating the payer would reimburse only the 340B cost to the healthsystem. Pharmacy explained the implication to both the payer contracting teamand finance department: UK HealthCare would have lost 40% of their revenueon a substantial Medicaid population.

Engage internal and external legal resources for long-term impact

Pharmacy works with the health system’s government relations team as well asstate and national professional organizations on critical issues they cannotaddress with the payer contracting team, such as stopping legal reforms allowingnarrow PBM networks and Managed Medicaid reforms. In one instance,collaboration with Kentucky senator Max Wise led to substantial edits to a billpassed in favor of independent pharmacies, including hospital-basedpharmacies.

Involve providers to protect specialty pharmacy interests

Pharmacy works closely with the chief medical officer to ensure patient careremains within the health system. This led to restructuring 50% of physicianclinics to facility-based clinics, in order to better serve these patients through UKHealthCare’s specialty pharmacy and leverage 340B pricing. Educatingphysicians on high-quality, in-house specialty pharmacy capabilities prevented2,000 prescriptions from leaking to external specialty pharmacies. Working withproviders led the pharmacy team to discover external specialty pharmacies weresoliciting business from UK HealthCare provider clinics. Embedding pharmacistsin clinics as physician extenders has also helped direct specialty pharmacyvolume internally.