Understanding and Managing Pharmacy PMPM Risk Through the Use of AMCP Dossiers and Value Frameworks

A significant number of drug approvals have occurred in the past few years. The availability of new drugs at increasing prices have increased pharmacy PMPM cost risk. There are two useful tools that can help stakeholders plan for and manage this increased risk: the Academy of Managed Care (AMCP) Format for Formulary Submissions (known as the AMCP Dossier) and value frameworks. The intent of this session is to improve actuaries' understanding of valuable information contained in the AMCP Dossier and introduce relevant value frameworks and illustrate how they can help to inform actuaries and payer coverage decisions through value assessment. There will be focus on what the value frameworks can help with today, and what questions still remain about the utility of the frameworks in the formulary decision making and health plan budgeting process. At the conclusion of this session, attendees will be able to: • Describe the purpose of the AMCP Dossier and the types of information included • Select relevant AMCP Dossier information for actuarial modeling • Describe the benefit of value frameworks to a health plan’s clinical and actuarial teams • Be familiar with how value frameworks like ICER could be used to augment the current formulary process. • Describe the challenges of using value frameworks for a health plan’s clinical and actuarial teams

Karl Gregor, PharmD, MS (Moderator)

VP

Karl Gregor leads an Optum consulting practice that provides actuarial- and pharmacy-focused training, analytics, and strategic solutions to Health Plans, PBMs, Providers and Life Sciences companies. He has 26 years of experience working in the pharmacy industry. Prior to his current role, Karl led Optum’s Access & Value Solutions consulting practice, which focused on European and North American reimbursement assessments and solutions for a wide variety of pharmaceutical, device, and diagnostic companies. Prior to Optum, Karl held US, European, and Global Health Economics and Outcomes Research leadership and research roles at Eli Lilly and Company. He also led a pharmacoeconomics research team at the PBM previously known as PCS Health Systems. He has a Doctor of Pharmacy degree and a Master degree in Pharmacoeconomics and Health Policy. He also completed a Health Economics Research Fellowship.

Jim Davidson, PharmD, MBA

Jim is a pharmacist with over 15 years’ experience across multiple settings including retail, hospital clinical pharmacy, pharmacy reimbursement analytics and consulting, and pharmacy managed care administration. In past work experience, Jim was instrumental in providing CMS and State Medicaid Agencies guidance on reimbursement policy and payment methodologies including the use of acquisition cost based reimbursement and the 340B program. Most recently Jim was Senior Director of Pharmacy for a Managed Care plan serving over 300 thousand Medicaid, ACA Marketplace and Medicare beneficiaries where he was directly responsible for operational, financial and quality oversight of the pharmacy benefit. Responsibilities included PBM oversight, pharmacy financial forecasting, utilization trend review, P&T meeting presentations, savings initiatives development and member and provider quality outreach programs to improve HEDIS measures and maintain NCQA accreditation. Jim worked closely with plan finance and actuaries to validate pharmacy spend and utilization trend assumptions during the health plan BID and rate validation processes.

Kim Gwiazdzinski RPh, MBA

VP Value & Outcomes, Coeus Consulting Group

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Webcast Session
07/21/2020 at 11:00 AM (EDT)  |  75 minutes
07/21/2020 at 11:00 AM (EDT)  |  75 minutes
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