Pharmacies File Suit Against Texas Human and Health Services Commission - Managed Care Contracts Begin Delegating Reimbursement
Posted Feb 18 2012 4:39pm
Here we go again with contracts being changed and according to this story there’s not enough time for the patients on Medicaid to react and adjust. This is all brought about by using an HMO contract which many in the US today are controlled by insurers, but not sure on this one. At any rate we now have a middle man who will be running analytics for “least cost routing” and how that will impact their reimbursements, the pharmacies do not know with the Pharmacy Benefit Manager.
One example of contract changes we have seen recently in the news is that Blue Cross patients can no longer get their prescriptions filled at Walgreens, again a pharmacy benefit manager contract dispute lead to all of this. Currently the pharmacies bill the state directly and when the analytics come into play the patients could see a major shift here with perhaps some being transferred to mail order.
The mail order might save money but the pharmacies could stand to lose quite a bit of business and what dollar amounts will be left for reimbursement for those that are filled at their locations is the question and will there be enough business left for them so they don’t have to go out of business if enough patients are changed?
This is the big question and where today’s data analytics algorithms come through and make big changes with one swoop not allowing the “human” side of the business to either plan or catch up so this story is Chapter 18 in the series of the “Attack of the Killer Algorithms” at the Medical Quack. You can view a digest of the previous chapters at the link below, same or similar actions taking place with algorithms running on servers 24/7 making life impacting decisions about all of us. In some cases with a multitude of “flawed data” on the web where companies are mining data, it is really becoming a nightmare with consumers chasing flawed data to correct so accurate information is given and in some cases we really do have “discrimination by the algorithms” taking place. BD
Lopez Pharmacy has been open for business in Brownsville for the past eight years. A team of three pharmacists and eight technicians help service about 5,000 patients.
Most clients depend on Medicaid according to owner and lead pharmacist Jose Luis Lopez. "Per day, we roughly expedite about 300 to 450 prescriptions," Lopez said
However Lopez said all that could change when legislature goes into effect on March 1. He said currently, when Medicaid patients fill their prescriptions, pharmacies bill the state directly.
They also bill the state for costs of any other services they offer the community, such as home delivery. In an attempt to save money in healthcare costs, the state will now have HMO's and managed care managers bill the pharmacies.