Managing Managed Care Accounts

This chapter covers the following topics:

About Managed Care in Siebel Life Sciences

Siebel Life Sciences has a number of features that help pharmaceutical and medical product companies maintain important data about MCOs (managed care organizations) and PBMs (pharmacy benefit management companies). Some of these features are listed here:

Account Data. MCOs and PBMs are entered as accounts of type Managed Care. The fields in the managed care account form are designed to hold data relevant to these businesses, such as enrollment, prescription spending, and number of participating providers.
Health Plans. Health plans are associated with managed care accounts. Health plan records contain information about the individual plans offered by MCOs, such as the plan name, size, utilization, co-payment.
Formulary. Formularies are associated with health plans. Typically a unique formulary is set up for each therapeutic market, so that a plan has a list of formularies associated with it. Each formulary lists the individual drugs and products available for prescription on the health plan.
Contacts. Two types of contact that are typically associated with health plans are the providers of health-care services (for example, physicians) and members of the P & T committee.
Managed-Care Business Plans. Managed-care account managers create business plans outlining how they can work with MCOs to promote the use of their company’s products by members of the health plan. One way this is done is by influencing the P & T committee to add the products to formularies. Business plan records are associated with managed care accounts. Comprehensive data is contained in these business plans, including SWOT and business analysis views, key contact and account lists, formulary lists, and the objectives of the plan.

The following table defines some terms that are used in this chapter and also in the application’s user interface.

Table Terms Used in Managed Care

Term	Description
health plan	This is a health insurance option (or product) offered by an MCO. Variables in plans are premiums, choice of providers, out of pocket expenses, treatments covered, and so on. Large MCO’s typically offer a selection of health plans.
MCO (Managed Care Organization)	Health care insurer where the insuring company is involved in the delivery of care. This is contrasted with the traditional indemnity plan where the insurer is not involved in care delivery. MCOs offer HMO, PPO, POS health plans.
Formulary	The list of products, usually drugs that are available to patients subscribing to the MCO. Formulary can be managed: In-house by the MCO, or Outsourced to a PBM
PBM (Pharmacy Benefit Manager)	These are organizations that contract with MCOs to administer pharmacy benefits to members. In many cases, the MCO delegates the pharmacy benefit management to the PBM. Large PBMs can have their own P & T committee who develop a universal formulary. Individual MCOs then appoint their own P & T committees who select products from the universal formulary to develop formularies for the MCO’s health plans.
Managed-Care Account Managers	These are the sales representatives who work for pharmaceutical and medical companies and who specialize in working with MCOs and in order to influence which products appear in the MCO’s formularies.
HMO (Health Maintenance Organization)	In this type of health plan, members pay a fixed monthly premium and receive health care without charge or for a small fixed co-payment. There are several different types of HMOs and also hybrids of the different types available in the U.S.A. Some of these types are described in this table.
Staff Model HMO	In this type of health plan, the MCO employs salaried physicians and owns the medical facilities. Typically, the co-payment charge is minimal. Patients can only consult with the doctors in the HMO; though, in very rare cases these doctors refer patients to sub-specialists outside the network.
Group Model HMO	In this type of health plan, the MCO contracts with one or more large multi-specialty physician group practices to provide care. Doctors are not employed directly, instead the group practice employs the physicians.
IPA (Independent Practitioner Association Model)	In this type of health plan, a MCO contracts with many individual and group physician practices to form one or more associations of independent practitioners (IPAs). The IPA pays the physicians, but these physicians remain as contractors, not salaried employees, and maintain their offices independently.
POS (Point of Service)	This type of health plan is a mix of HMO and a traditional indemnity plan. When a patient stays in the HMO network of physicians and follows the referral path, care is fully covered (with the usual co-payment). When the patient seeks care outside the network specialist care without a primary care physician (PCP) referral within the network, the patient is covered at a lower level.
PPO (Preferred Provider Organization)	This type of health plan is similar to POS, except that a patient does not need a PCP referral to see a specialist within the network.
P & T (Pharmacy & Therapeutics) Committee	This committee is a group of health-care specialists, including physicians and pharmacists. The committee determine which products are in the MCO’s or PBM’s formulary.
SWOT analysis	This is a planning tool to help you evaluate the strengths, weaknesses, opportunities, and threats of your business and product in the marketplace. SWOT analysis is a component of a business plan.
Tiered Benefit	A tiered pharmacy benefit is one where the member’s co-payments vary. For example, in a typical three-tiered system, generic drugs require the lowest co-payment, brand name drugs on the formulary require a higher co-payment, and brand name drugs off formulary require the highest co-payment.
Open Formulary	An open formulary is one where the MCO allows any drug to be prescribed.
Closed Formulary	A closed formulary is one where only the drugs on formulary can be prescribed. A closed formulary can be limited or unlimited.
Limited Formulary	A limited formulary is one where only a given number of drugs is allowed in each therapeutic class. In order for a new drug to be added, an existing drug must be removed from the formulary.
Unlimited Formulary	An unlimited formulary is one where there is no set limit on the number of drugs allowed in a therapeutic class.

Scenario for Managed Care

This scenario is an example process performed by a managed-care account manager and by a sales representative. Your company might follow a different process according to its business requirements.

The managed-care account manager and the sales representative are employees of a large pharmaceutical company.

Managed-Care Account Manager Maintains HMO Account Data

The managed-care account manager is responsible for a nationwide HMO account. His job is to influence the HMO so that it buys more of his company’s drugs.

His first task when he is assigned this account is to enter data about the account, such as enrollment and spending data, information about the individual health plans offered by the account, and formulary lists for each plan.

Of particular interest to him are the members of the P & T committee; these are contacts who he wants to influence.

Sales Representative Reviews and Enters HMO Account Data

The sales representative is responsible for detailing the company’s drugs to physicians in her territory. She makes professional calls and influences the prescription habits of the physicians she calls on.

Before she meets with a physician, she wants to know about the health plans that the physician is affiliated with. Of particular interest to her is whether the drugs she details are on the plans’ formularies. Furthermore, if the physician happens to be on the P & T committee, it is most important that she know this so that she can discuss her approach in advance with the account manager.

Managed-Care Account Manager Prepares a Business Plan for the HMO Account

The account manager’s relationship with the HMO can have significant impact on his company’s sales revenues. The account manager plans his approach carefully. He creates a business plan for the account. It contains information about the account, including formulary, key contact, and associated account information, SWOT analysis, and finally his objectives with relation to the account for the coming year.

Process of Using Siebel Managed Care

This example process represents the tasks that are carried out in the Scenario for Managed Care.

Entering Health Plan and Formulary Information

Managed-care account managers can use the Account Plan Formulary view to enter and maintain information about health plan designs and formularies owned or administered by the account and about the products on those formularies. Account managers associate P & T committee members and track formulary review dates to be well prepared for calling on their contacts in the account.

Sales representatives, making professional calls might hear about contacts’ roles in P & T committees. They also can review the Plan Formulary information and add their contacts to the P & T member list as appropriate.

This task is a step in Scenario for Managed Care.

Who Owns the Formulary?

There are two approaches to setting up formularies in Siebel Life Sciences. The formulary can belong to one of the following:

The MCO account
The PBM account

Before deciding which type of account should own the formulary, review Indicating Affiliations Between a Contact and an Account and Entering Formulary Information for Managed Care Business Plans, and consider your own business process.

Creating Health Plan Information For an Account

This task explains how to create health plan information for an account.

To create health plan information for an account

Navigate to the Accounts screen, then the Accounts List view.
In the Accounts list, drill down on an account.
Click the Plan Formulary tab.

In the Plan Design list, create a new record and complete the necessary fields.

Some fields are described in the following table.

Field	Comment
Plan Type	See the table in the topic About Managed Care in Siebel Life Sciences for definitions of the default values in this LOV.
No. of Lives	Number of lives in the health plan. This number cannot exceed the total lives entered for the account. Note: The Total Lives field must be completed in the Account form before you enter a value in this field. (Click on the show more button to see this field.)
% of Total Lives	Equal to [(Number of Lives at Plan Level) divided by (Number of Lives at Account Level)] multiplied by 100.
Utilization	Number of health plan members who are using health plan benefits. This number cannot exceed the number of lives in the health plan.
Utilization %	Equal to [(Utilization) divided by (Number of lives at Plan Level)] multiplied by 100.
Co-Payment	Typically, the co-payment amount for a member visit to a primary care physician. The pharmacy co-payment is entered separately for each product.
P & T Members Name	Names of contacts who are on the Pharmacy & Therapeutics committee.
Pharmacy Distribution	Type of distribution, such as in-house, contracted, or mail-order.

Creating Formulary Information For an Account

This task explains how to create formulary information for an account.

To create formulary information for an account

Navigate to the Plan Formulary view.
For information on how to navigate to the Plan Formulary view, see Creating Health Plan Information For an Account.
In the Plan Design list, select a health plan.

In the Formularies list, create a new record and complete the necessary fields.

Some fields are described in the following table.

Field	Comment
Type	See About Managed Care in Siebel Life Sciences for definitions of the default values in this LOV.
Market	The option selected in this field determines which products are available in the formulary’s Products list.

In the Products list, create a new record and complete the necessary fields.

Some fields are described in the following table.

Field	Comment
Status	Off Formulary — Banned from the formulary. On Formulary — Approved by the formulary. On/Prior Auth — Physicians require MCO or PBM approval before prescribing. On/Restricted — One of the few drugs allowed its therapeutic class. On/Exclusive — The only drug allowed in its therapeutic class.
Tier	If the product is in a tiered formulary, indicate the tier.
Reimbursable	For example, if a product is off formulary, but can be reimbursed with prior authorization, select this check box.
Qty Limit	The quantity allowed for a patient each year.
Competitor	This field is filled in automatically when the product’s type is Competitive Product.

By adding a product to the Products list you indicate it is on formulary and can track its status.

Note: You cannot edit the Competitor field. A check mark appears in this field if the product you selected for the Name field is a competitor’s product. For more information, see Specifying a Competitor.

Repeat Step 3 and Step 4 until you have created a record for every product on the formulary.

Associating Contact Information with Health Plans

Managed-care account managers can use the Contacts By Plan view (Accounts screen) to associate contacts (usually physicians) to health plans. This contact information can be entered in the UI as described here, but is more typically imported from external sources.

Note: Sales representatives use the Contact Affiliations view (Accounts screen) to track similar information about contacts. However, the Contact Affiliations view differs because it associates the contacts to the MCO account and not to the individual health plans.

This task is a step in Scenario for Managed Care.

To associate contacts with account plans

Navigate to the Accounts screen, then the Accounts List view.
In the Accounts list, drill down on an account.
Click the Contacts By Plan tab.
In the Plan Design list, select the plan to which you want to associate a contact.
In the Plan Contacts list, create a new record and complete the necessary fields.

Creating a Business Plan for a Managed Care Organization

The account manager creates a business plan for his MCO account. If the MCO contracts out its pharmacy formulary, the account manager can also choose to create a business plan for the PBM.

Typically business plans are created on a yearly basis, but the frequency varies according to business process. An account would have a number of business plans associated with it; each plan for a different period.

The first step in creating the business plan is creating the business plan record and entering overview information about the account.

This task is a step in Scenario for Managed Care.

To create an business plan for an account

Navigate to the Accounts screen, then the Accounts List view.
In the Accounts list, drill down on an account.
Click the Business Plans tab.
In the Business Plans applet, create a new record and complete the necessary fields.
Drill down on the business plan record.

Click the Account Overview tab.

In the Account Overview form, enter information about the account that pertains to the business plan. Some fields are described in the following table.

Field	Comments
Business Description	Use this text field to note general information about the MCO.
Regional Plans	Use this text field make note of other business plans related to this account. For example, if this is a national business plan, this field might contain the names of regional and local business plans that are related to this national plan.
Contracts Process	Use this text field to note information about the contracts process. For example, notes about any contracts for rebates or discounts that the pharmaceutical company has with the account or with the account’s PBM.
HMO Lives	This is the number of individuals enrolled in the HMO health plans offered by the account.
Total Lives	This is the number of individuals enrolled in all the health plans offered by the account. This field should equal the sum the other three lives fields (HMO Lives, PPO Lives, and POS Lives). This field is the same as the Total Lives field in the Accounts screen. (Click on the show more button to see this field in the Accounts form.)
Network Phy	This is the number of physicians participating in the insurance network. This field should contain approximately the same number as the Physicians field in the Accounts screen, then the More Info view.
Network Hosp	This is the number of hospitals belonging to the insurance network.
PPO Lives	This is the number of individuals enrolled in the PPO health plans offered by the account.
POS Lives	This is the number of individuals enrolled in the POS health plans offered by the account.
Medicare	This is the number of individuals who are enrolled both in Medicare and in the health plans offered by the account.
Medicaid	This is the number of individuals who are enrolled both in Medicaid and in the health plans offered by the account.

Entering Formulary Information for Managed Care Business Plans

The Pharmacy Benefit view allows the managed-care account manager to see, in a view list, all the products in all the formularies associated with a given business plan.

This task is a step in Scenario for Managed Care.

To add PBM and formulary information to a business plan for a managed-care account

Navigate to the Business Plans screen, then the Business Plan List view.
Drill down on a business plan record.
Click the Pharmacy Benefit tab.

In the Pharmacy Benefit list, create a new record and complete the necessary fields.

Some fields are described in the following table.

Field	Comments
Benefit Provider	Specify the account that owns the formularies that are relevant to the business plan. All products in all plans belonging to this account will be listed in the Formulary Status list in this Pharmacy Benefit view. Typically enter the name of the MCO account itself or of the PBM account. See note in Entering Health Plan and Formulary Information.
Tiered Benefit %	Indicate the approximate percentage of lives belonging to health plans with a tiered pharmacy benefit.
Open Benefit % Closed Benefit %	Indicate the approximate percentages of lives belonging to plans with open and closed formularies benefit.
Reimbursement Policy	Enter information about the benefit provider’s reimbursement policy that is relevant to the business plan, for example, the co-payment rates, premium increases, or recent policy changes.
Formulary Approval Process	Enter information about the benefit provider’s formulary approval that is relevant to the business plan, for example, how long it typically takes to have a new drug entered in the formulary.

Go to the Formulary Status list and review the products in the formularies owned by the selected PBM.

Performing Business and SWOT Analysis for a Managed-Care Business Plan

When creating a business plan for managed care, the managed-care account manager needs to analyze both the market and the account. Two views in the business plan view that are useful during the analysis phase of preparing the business plan are:

Business Analysis view for reviewing syndicated prescription data:
- Rx Trend by Plan - Volume
- Rx Trend by Plan - Market Share

SWOT view for entering information about:
- The account’s (MCO’s or PBM’s) strengths and weaknesses
- The opportunities and threats that the managed-care account manager needs to address in the business plan

This task is a step in Scenario for Managed Care.

To enter SWOT information for a business plan

Navigate to the Business Plans screen, then the Business Plan List view.
Drill down on a business plan record.
Click the Business Analysis tab.
Use the Business Analysis view to review prescription trends for the market of interest.
For general information about analysis of syndicated data, see Analyzing Syndicated Data.

Click the SWOT tab, and complete the fields on the SWOT form that appears.

Some fields are described in the following table.

Field	Comments
Strengths	For example, a recent study shows your drug is better tolerated by patients.
Weaknesses	For example, the MCO has very restrictive reimbursement policies for drugs in your market.
Opportunities	For example, a change of policy in the account makes it easier to get a drug added to the formularies.
Threats	For example, a study indicates that a competitor’s product is as effective and less expensive than the product you are promoting.

Associating Contacts and Accounts with Managed-Care Business Plans

When creating a business plan for managed care, the account manager gathers information about accounts and contacts that are associated with the business plan.

Views in the business plan view that are useful for recording related accounts and contacts are as follows:

Account Coverage view: Use this view to list accounts associated with the business plan. For example, if the business plan is for a national account, add the names of the regional accounts associated with the national account.
Organizational Analysis view: Use this view to list key contacts for the business plan and to indicate the relationships between the key contacts.
Key Contacts view: Use this view instead of the Organizational Analysis view if you do not want to indicate the relationships between the contacts.

This task is a step in Scenario for Managed Care.

To associate accounts and contacts with business plan for a managed-care accounts

Navigate to the Business Plans scree, then the Business Plan List view.
Drill down on a business plan record.
Click the Account Coverage tab.

In the Account list, create new records and complete the necessary fields.

Some fields are described in the following table.

Field	Comments
Team	This field indicates which employees in your company are responsible for the account.
Coverage Level	For example, if the business plan is for a national account, the regional and local accounts associated with the national are listed. Use this field to indicate which account is regional or local.

Click the Organizational Analysis tab.
Use the Organizational Analysis view to enter your list of contacts and to indicate relationships between them.
For general information about the organization analysis, see Siebel Applications Administration Guide.

Setting Objectives for the Managed-Care Business Plan

The last but very important stage of creating a business plan is for the managed-care account managers to list what they are going to do to carry out the plan. These are their objectives.

These objectives are created in the Business Plans screen, then the Objectives view, but can also be viewed, created, and edited in the Objectives screen, Objective List, and then the My Objectives view.

This task is a step in Scenario for Managed Care.

To create objectives for a business plan

Navigate to the Business Plans screen, then the Business Plan List view.
Drill down on a business plan record.
Click the Objectives tab.
In the Objectives list, create new records and complete the necessary fields.
Drill down on an objective record to add activities to the objective.
For general information about objectives in Siebel Life Sciences, see Setting and Achieving Objectives.