Step-Edit Training Program

Transcription

1 Step-Edit Training Program What are step-edit programs? Why are they important? How can you address them?

2 Step-edit programs affect your bottom line Step-edit programs create hassles for pharmacists, nursing staff, patients, and physicians. These hassles can influence the behavior of these stakeholders. And their behavior can ultimately reduce your market share and volume. Step-edit programs can lead to lower market share Step edits create hassles Hassles for physicians, pharmacists, nursing staff, and patients Hassles shape behavior Lead to pharmacy switches Generally shape physician prescribing habits Discourage patients from initiating therapy Changed b Changed behavior shapes growth potential changes market share Leads to lower market share and volume Did you know? Step edit: a drug benefit rule requiring patients to try a lower cost medication before the health plan or PBM will provide coverage for a higher cost medication. Step edits and prior authorization are both pharmacy benefit management techniques. Did you know? Prior authorization: a benefit rule requiring patients to receive approval from the health plan or PBM prior to receiving coverage for the service or medication being provided. Step edits are managed at the point of sale in the retail pharmacy Plans believe that step edits are effective and inexpensive to implement Step edits complement co-payment tiers as a cost-controlling mechanism Step edits typically require the use of inexpensive generic agents prior to the use of more expensive branded agents

3 What can you do about step-edit programs? You can address each stakeholder in the system. You can become an expert on the step-edit programs that affect your territory. Market Share and Volume You have responsibility for working with all parties in the system. Since you call on the physicians, nurses, and pharmacists, it s imperative that you understand the impact step-edit programs have on each of them and that you have the knowledge and skills to engage them in the process.

4 What you need to know and how to find it out In order to become an expert on the step-edit programs that affect your territory, you ll need to invest some time. But don t worry there are many people to help you along the way. What you need to know Here is what you need to know about the managed care organizations, health plans, Medicare plans, employers, and physician medical groups that affect your territory: Information Type 1. Formulary products 2. Specific step-edit language 3. Percent of business Example (TK) Must try and fail on ACEI before starting ARB 73% Use the chart at the end of this tool to help you keep track of this information. How to find it out You have a number of resources for information about the managed care environment in your territory. But the first person you should go to is your District Manager (DM). Resources that provide the information you need The Edge Regional Formulary Grid The Managed Care District Analysis Monthly Report Obstacle Handler Cards Analyzer Reports You District Manager Regional Account Manager (RAM) Regional Account Professional (RAP)

5 The pharmacy is the crucial link in the step-edit system. Patients can become discouraged and fail to follow up on treatment. A 2005 WellPoint study showed that 11% of patients who encountered a step edit in filling a prescription did not fill a prescription for any therapy for that condition in the following year. Your pharmacy calls are important. You can learn about how the real managed markets dynamics are impacting your business by talking to pharmacists. Did you know? A survey of pharmacists found that every pharmacist knew about step-edit programs and, yet, no pharmaceutical representative had ever talked to them about step edits. Did you know? Some physician offices have a specific phone line for pharmacists to leave a message about coverage issues. These messages are typically processed once a day usually in the afternoon (3:00 PM). If a pharmacist calls after the messages have been processed for the day, the patient will not get resolution of the issue until the following day. Be sure to keep track of these policies for the large physician offices in your territory, on your handheld and let the pharmacists you call on know about them.

6 Can we add some type here? how step edits work 1. Patient visits physician 2. Physician prescribes drug 3a. Patient presents prescription to pharmacist for fill This is the moment of truth the pharmacist has to act on the step edit Pharmacist calls physician s office to make change or appeal the step edit Pharmacist tells patient drug is not covered unless the step edit is followed first 3b. If the plan has implemented a step edit for a drug, the pharmacist is alerted. Typically, the alert is as simple as a pop-up screen describing the particular step edit 3c. Pharmacist checks prescription for coverage with health plan or PBM through networked computer $ 4. Nursing staff is the first point of contact for pharmacists Some offices have a reimbursement specialist for these calls Nursing staff pulls chart for physician 6. Pharmacist fills prescription 5. Physician reviews prescription Physician makes necessary changes or initiates appeal process 7. Patient receives drug

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8 The hassle factor Patients Step edits create hassles Create inconvenience at the point of service Patient may have to wait, come back to the pharmacy, or go back to see the physician Hassles shape behavior Patient avoids healthcare system Changed b Changed behavior shapes growth potential changes market share Leads to increased likelihood of discontinuing treatment or never initiating treatment at all Did you know? Many step edits cannot be resolved quickly. Patients who have to wait a long time for resolution may not start therapy at all!

9 Pharmacists Step edits create hassles Pharmacists dislike having to call the physician and the subsequent documentation required to override the step edit Most retail pharmacy chains will not allow a pharmacist to override a step edit without written documentation from the physician s office Increase pharmacists workload with calls or faxes to providers Hassles shape behavior Stop the process of dispensing medication for patients Reduce pharmacists ability to deliver optimal customer service Patients must wait longer for approval or come back to the pharmacy Patients may need to go back to their physician for a new prescription Create tension between the pharmacist and the patient Patients must pay full price for the brand Patients may feel they are receiving suboptimal treatment Patients are unable to begin treatment in a timely manner Changed b Changed behavior shapes growth potential changes market share Leads to physician changing prescription Leads to increased likelihood of discontinuing treatment or never initiating treatment at all Did you know? The profit margin for pharmacists on generics are usually greater than those of branded agents. Therefore, the incentive to push branded agents may not exist.

10 The hassle factor (cont d) Nursing Staff Step edits create hassles Require additional administrative functions Interrupt daily activities while tending to in-office patients Hassles shape behavior Nurses attention may be pulled away from in-office patients Many physician groups have nurses dedicated to reimbursement issues Changed b Changed behavior shapes growth potential changes market share Physicians avoid prescribing medications that are subject to step- edit programs Approaches for managing reimbursement issues may create patient hassles 10

11 Physicians Step edits create hassles Physicians dislike calls from pharmacies and the subsequent documentation required to override the step edit Physicians are not reimbursed for time spent dealing with step edits Place a burden on nursing staff and/or administrative teams Create potential ill will among patients due to confusion Hassles shape behavior Change desired treatment protocol for patient Changed b Changed behavior shapes growth potential changes market share Increases likelihood of discontinuing treatment or never initiating treatment at all You can help pharmacists, nurses, and physicians with step-edit programs Step-edit programs can significantly impact your market share by reducing the number of prescriptions actually filled at retail pharmacies However, you can help the pharmacists, nurses, and physicians you call on by providing relevant information 11

12 How to address the effect of step-edit programs in your territory This section will help you adapt your message to step-edit objections. There are 5 different approaches you can take when a pharmacist, physician, or member of the nursing staff brings up an objection based on step edits. The 5 step-edit approaches 1. Clinical value approaches: use the objection as an opportunity to show the superiority of product 2. Tolerability: discuss the tolerability of ARBs or RASILEZ as it relates to patient compliance with therapy 3. Low patient impact: many patients are not affected by step-edit programs; if this is the situation in your territory, encourage physicians to avoid making blanket changes in their prescribing based on step edits; be sure to quantify the impact of step-edit programs on the physicians you call on 4. Negative patient impact: some patients are negatively affected; the information you gather can help ease the process for all involved 5. Get specific: use your knowledge of the plan specifics to serve as a resource for pharmacists, physicians, and nursing staff Did you know? The Edge is a valuable tool for helping you communicate concern and understanding of the physician s point of view, prepare to ask meaningful questions, and creatively gain access. Use it to gather all the step-edit information you need as part of your precall planning. 12

13 Selected Novartis Success Principles for Performance Frontier Selling Creates Call Continuity Plan precall by using notes to build the call continuum Relationship Focused Invests in a business-relevant relationship; actively seeks common ground Communicates concern and understanding for physician s point of view Purposefully Probes and Listens Asks meaningful questions (eg, regarding patient types and treatment paths) Adapts Message Responds to physician s concerns, goals, or priorities Direct in Closing Ends with a direct call to action Has the Will to Win Creatively gains access Coordinates With Teammates Takes lead with all Novartis resources Works directly with copromotion partners 13

14 How to address the effect of step-edit programs in your territory (cont d) Pharmacists 1. Objection: Lack of authority to override the step edit must call the doctor or health plan Strategy: Acknowledge that these calls require nonproductive work time and make it difficult for pharmacists to do their job. Since different health plans have different requirements, pharmacists may find it difficult to keep up with all of them. Be prepared: Educational opportunity. Research the largest health plans in your territory to determine what information each requires of physicians in order to have the prescription filled. Talk to your DM, who will manage discussions with the RAM. Also, ask you customers what the step edit looks like what are they required to do. Intervention: Tools: Get specific discuss plan requirements with pharmacists so that they can consult with the physician Clinical value communicate the clinical significance of helping the patient get on the medication that the physician prescribed WellPoint reprint and discussion of the negative impact of step edits 2. Objection: The hassle factor Strategy: Acknowledge that these calls require a tremendous amount of time and energy and make it difficult for pharmacists to do their job. Explain the clinical significance of helping the patient get on the medication that the physician prescribed. You can also probe for information about the specific communication problem. Intervention: Get specific discuss plan requirements with pharmacists so that they can consult with the physician Clinical value communicate the clinical significance of helping the patient get on the medication that the physician prescribed 14

15 3. Objection: Customers blame me for step edits Strategy: Acknowledge that patients are typically unaware of what step edits are and why they may have been implemented. Explain that patients are at risk of not getting treatment because of the step edit. Probe for ways to help the pharmacist work with patients to get step edits resolved. Also acknowledge that step edits exist because health plans are trying to minimize the cost of therapy. Always redirect back to the clinical discussion. Intervention: Tools: Get specific encourage pharmacists to begin a dialogue with their customers and use this as an opportunity to educate customers about what their options might be: 1. Pay full price in order to begin treatment right away with what the doctor has prescribed.. Return to the doctor s office and get an alternative prescription.. Wait until the pharmacist receives an answer from the doctor s office. Clinical value communicate the clinical significance of helping the patient get on the medication that the physician prescribed Bramley reprint demonstrating improved compliance on ARBs vs other RAS agents and competitive categories P H A R M A C I S T S 4. Objection: My patients are happy with generics (Pharmacists have incentives to promote generics.) Strategy: Acknowledge that generics are a valuable option. Explain the improved compliance with ARBs. You can also point to value-added programs such as the BP Success Zone that improve compliance. Patients that are compliant with medications are also a benefit for pharmacists. Intervention: Clinical value communicate the clinical proven value of your product. Highlight any value-added programs. 15 R E S O U R C E S

16 How to address the effect of step-edit programs in your territory (cont d) Physicians Addressing step edits with a physician can be a double-edged sword. You may be introducing an objection that the physician didn t previously have. Discuss with your DM when a proactive approach is appropriate. 1. Objection: Hassle factor follow-up calls due to step edits Strategy: Acknowledge the burden of these calls and follow-up activities. Use the HEOR reprints to validate the clinical significance of helping a patient resolve a step edit. Be prepared: Research the largest health plans in your territory. Find out what they ask physicians to do to get the prescription filled. This information is available from your RAM. Communicate this information to the physician. Intervention: Tools: Clinical value talk about the clinical importance and benefits of your product Low patient impact explain that many patients are not affected by step edits Negative patient impact explain how patients may delay or not even start therapy when they encounter a step edit Get specific look for ways to help the nursing staff meet step-edit challenges WellPoint reprint demonstrating patients lost to therapy Bramley reprint demonstrating improved compliance on ARBs vs other RAS agents and competitive categories 16

17 2. Objection: No step edits with generics Strategy: Redirect the conversation to the clinical benefits of your product. Intervention: Clinical value present supporting evidence for your product. Use the Bramley reprint to show the tolerability and compliance of ARBs 3. Objection: Tier 3 objection Strategy: Know the plans in your territory that are affected by step edits or tier 3 status. If it is small, encourage the physician to focus on the majority of patients. Look for ways to help nursing staff handle the minority of patients affected by step edits. Redirect discussion back to clinical value. Intervention: Low patient impact help physicians understand that the majority of their patients are probably not affected by step edits Get specific for those who are affected, leverage Novartis co-payment offset programs Clinical value return discussion to clinical benefits of your product P H Y S I C I A N S 17

18 How to address the effect of step-edit programs in your territory (cont d) Nurses 1. Objection: Hassle factor frustration with administrative hassles or lack of time or personnel to handle step edits Strategy: Take time to acknowledge the burden that these calls and follow-up activities place upon physicians and their staff. This step helps build rapport with the nurse. Also, explain the risks to the patient of a step edit. Probe for ways to help the nurse with administrative tasks. And redirect the discussion to the negative clinical impact of step edits. Intervention: Remember: Get specific find out the step-edit procedures of your largest prescribers in the area. Communicate this information to nurses. Redirect discussion to clinical value Some physician offices have a specific phone line for pharmacists to leave a message about coverage issues. These messages are typically processed once a day usually in the afternoon (3:00 PM) Some physician offices have a specific reimbursement specialist to handle these calls Be sure to keep track of these policies for the large physician offices in your territory and let the pharmacists you call on know about them. 18

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20 How to address the effect of step-edit programs in your territory (cont d) How to fill out this guide Work with your DM and use the Product Analyzer Tool to identify the top plans in your territory with step edit programs 2. Get the information needed for those plans through the Managed Care District Analysis Monthly report Territory Step-Edit Guide Use this guide to keep track of all the relevant step-edit information for the plans that affect your territory. 1. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 2. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 3. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business:

21 4. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 5. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 6. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 21 R E S O U R C E S

22 How to address the effect of step-edit programs in your territory (cont d) Territory Step-Edit Guide Use this guide to keep track of all the relevant step-edit information for the plans that affect your territory. 1. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 2. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 3. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 22

23 4. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 5. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 6. Product: Plan/PBM name: Formulary Products: Specific step-edit language: Percent of business: 23

24 2006 Novartis Printed in U.S.A. 10/06 CVF-OT-0064-A Printed on Recyled Paper