Case Studies.
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- Prescription Drug Contract Review Uncovers Hidden Fees
- Member Overcomes Prescription Drug Addiction
- Client Experiences Dramatic Savings and a Decrease in Rates
- Physical Promotion Program Results in Five-fold Increase In Preventive Care
Prescription Drug Contract Review Uncovers Hidden Fees
- Overview & Challenges
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Employer with 35,000 employees was prepared to sign a new contract with their Pharmacy Benefit Manager (PBM) - one of the top three PBM's in the nation.
PBM contract had already passed review by the company's Human Resources, Finance and Legal departments, as well as, that of a national benefits consulting firm and was ready for signature.
Benefits Manager boasted that he had negotiated a "zero Admin fee" deal with the PBM.
Impressed but skeptical, NextLogical offered to perform an in-depth review of the contract for a small fee and was engaged by the group.
- Deliverables
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NextLogical's pharmacy benefits expert, Lilli DuVal, a former founding partner of a PBM (now part of Express Scripts), spent several hours analyzing every paragraph of the 45-page PBM contract.
Lilli was easily able to confirm that the PBM had indeed offered the group a "zero Admin fee" deal - at least on the surface.
However, because of Lilli's meticulous review of every provision of the contract and her understanding of the PBM industry's "tricks of the trade", she uncovered more than $1.3 million in "hidden" administrative fees which the group was liable to pay.
- Results
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Employer was able to re-negotiate their contract and saved over $1 million.
Member Overcomes Prescription Drug Addiction
- Overview & Challenges
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Mid-sized metropolitan employer with 200 employees.
Clinical analysis of prescription drug utilization seemed to indicate the abuse of the prescription pain reliever OxyContin. At least one member was receiving doses exceeding normal levels.
In addition to being addictive, Oxycontin has a high "street value" where the pills are often sold for illegal drug use. Whenever excessive dosing of OxyContin (and certain other drugs) is found, the concern must be addressed that employees might be filling the prescriptions and selling them.
If the use of OxyContin was legitimate, the presence of this drug in the workplace still constituted an immediate safety concern for this employer and the public.
- Deliverables
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Without notifying the employer of the member's identity, NextLogical was able to intervene and assess the clinical efficacy of OxyContin prescriptions.
During Open Enrollment meetings scheduled later that month, NextLogical's Vice President of Medical Management, Danielle Herndon, RN, CCM, addressed the issue of responsible drug use and her availability to help members with healthcare and prescription drug questions or problems.
Immediately following the meeting, an employee approached Danielle and explained that he was addicted to OxyContin and wanted to get off the drug. Furthermore, he had tried several times to detox himself from the drug but was unsuccessful.
Danielle recommended a course of action that included a three-day detox program from the premier substance abuse facility and specialist physician in the region.
- Results
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The detox program was successful and the employee has been off of OxyContin completely since October 2004.
The member has regained control of his life and has saved nearly $300 per month in prescription drug copayments.
Savings to the employer-sponsored plan has been approximately $1,200 per month.
Client Experiences Dramatic Savings and a Decrease in Rates
- Overview & Challenges
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Metropolitan employer with 450 dispersed employees including a large Spanish-speaking population.
Group had received successive years of 35% plus rate increases from their major national insurance carrier and was looking for a real solution to their healthcare problem.
NextLogical was retained two months prior to the renewal to negotiate the renewal, improve the healthcare plan and reduce costs.
- Deliverables
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NextLogical's first task was to analyze plan data and begin negotiating the renewal with the incumbent carrier.
Next, we performed a clinical review of the available claims data and identified which claimants and disease states were creating the most expense for the plan.
Effectively marketing the health plan to alternative carriers was critical in light of the incumbent's request for a 39.5% rate increase. NextLogical developed a comprehensive Request for Proposal (RFP) and obtained competitive quotes from several major carriers and TPAs.
- Results
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For the first renewal, NextLogical negotiated a competitive bid from an alternative carrier which resulted in an annual cost savings for the employer of over $395,000.
Based on our understanding of the group's specific medical risks, NextLogical developed and distributed to employees and their families a series of disease management literature focused on the most prevalent and costly disease states.
NextLogical also worked with the carrier's medical management department to ensure that at-risk members were actively managed and receiving appropriate Disease Management and Case Management support.
During the second year's renewal, NextLogical negotiated improved benefits and a plan reduction of approximately 7% or just over $290,000 in reduced premiums.
Total premium savings over two years: $685,000.
Physical Promotion Program Results in Five-fold Increase In Preventive Care
- Overview & Challenges
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High-visibility metropolitan employer with 500 employees in several sites.
NextLogical conducted an analysis of claims data and discovered a deficiency in adult wellness/preventive care. We were concerned that a lack of adult preventive care would lead to higher future claims for chronic diseases, as well as, catastrophic claims for exacerbations such as heart attack, stroke, cancer therapy, etc.
- Deliverables
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In order to improve adult wellness ratios, NextLogical developed a Physical Promotion Program which rewarded employees and their spouses who received a well visit during the promotional period.
In order to better accommodate employees, NextLogical contracted a firm to conduct on-site blood draws and Health Risk Assessments (HRAs). Blood test and HRA results were provided to the members, their attending physicians and the medical management function within the plan.
- Results
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Employee response to the program was overwhelming and positive.
Nearly half of all enrolled employees participated in the promotion driving the total number of preventive care visits up by a factor of five.
Many plan members were diagnosed with early stage disease and were able to get involved in treatment before experiencing catastrophic events.
Employees and their spouses gained a greater awareness of the importance of preventive care and early diagnosis. Participants look forward to next year's promotion.
What People Are Saying About Next Logical
"The Enterprise Group has worked with Richard Sien and NextLogical for over two years now and we have been very impressed with their expertise, diligence and customer service orientation."
"In particular, Richard has brought total order to the chaos of our benefit program and has helped to bring our overall costs to below industry averages. We couldn't be more satisfied with the results that he has been able to deliver."
Helen Whitehead,
Chief Administrative Officer