What’s the next thing that will be impacted by value-based care?

In Oklahoma, it’s how the state will soon negotiate prescription drug prices for Medicaid recipients.

In June of this year, the Centers for Medicare and Medicaid Services (CMS) gave their approval for a new pricing initiative that allows the state to factor in how effective a prescription medication is when negotiating the amount paid to the manufacturer.

There are three things that make this shift stand out.

The first is that with this change, Oklahoma will become the first state to introduce this type of value-based paradigm for Medicaid Rx pricing negotiations. Currently, most states set prices using a more limited set of criteria and historical clinical recommendations.

Secondly, it represents yet another expansion of value-based care from care delivery into the world of prescription medication management. Traditionally, VBC has been applied primarily to care – with penalties and incentives based on outcomes and cost. (In a nutshell, it’s expanding from people to products.)

And lastly, this pricing model actually lowers the amount paid to preferred vendors over time. In this unique arrangement, the state of Oklahoma is hoping to gain savings by keeping drug manufacturers more accountable. And on the flip side of the coin, those same companies are hoping to create a longer term revenue stream if they can become the preferred vendor for maintenance medications. (Drug manufacturers are banking on the idea that they will be able to offset short-term price decreases with a longer-term strategy to increase sales volume.)

So why is this relevant to behavioral health and human services organizations?

Even if prescription medications don’t regularly factor into your plan of care today, it’s a trend worth watching. This signals Medicaid’s plans to likely expand their definition of what value-based care is and how it can be applied throughout the care continuum. (What states might be next?)

In addition to that, more individuals are being diagnosed with co-occurring conditions that require maintenance medications. If you are delivering care within value-based or managed care reimbursement models in your state, the cost of those prescriptions need to be factored into you overall plan of care.

Want to learn more about how to prepare for value-based care?

Check out our webinar, How Are You Going to Get Value Out of Value-Based Care. Christy Winter, Manager of Clinical Informatics and Outcomes at Qualifacts, and Eric Krepfle, Revenue Cycle Product Manager at Qualifacts, talks about real-world examples and winning strategies to help you succeed.

Source: HealthPayer Intelligence, June 28, 2018

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