Pharmacy Strategy Development
Mike has assisted numerous organizations with developing pharmacy growth strategies. For example, Mike led the development of a Growth Playbook for a Regional Managed Medicaid health plan. This Playbook was a five-year growth strategy analysis of opportunities to expand within Medicaid into nearby Medicaid regions, and to expand into Medicare Part D and commercial lines of business. This playbook provided, in the context of the Affordable Care Act, an overview of all expansion opportunities, varying strategic options, resource and investment needs, and operational impacts. The analysis included revenue projections based on demographic and estimated reimbursements, as well as scenario-based impact analyses based on variables such as membership growth (and decline) projections, premiums, and anticipated government reimbursements.
PBM Operations: Transitions and Implementations
Mike has led and supported numerous PBM transitions and implementations for health plans of all lines of business, including commercial, Medicaid, and Medicare. For example, Mike helped lead the successful PBM transition and implementation for a large, national Blues plan of 5.1 million members, and approximately 230,000 claims adjudicated per day. In addition, Mike led operational implementation of three PBMs for a mid-sized regional Blues plan during the 2006 Medicare Part D rollout, resulting in close to 2 million members successfully enrolled.
PBM Contracting and Procurements
Mike has seen, analyzed and negotiated every form of PBM contract known in the industry for all lines of business, including Commercial, Medicaid, and Medicare. Working for both health plans and PBMs, he has unique insights into how PBM contracts are developed and negotiated from both sides. Mike's experience includes leading health plans through the PBM procurement process end-to-end: inclusive of business scope development, RFP creation, evaluation criteria, proposal assessment, negotiations, and contracting phases. In addition, Mike has negotiated contracts with health plans on behalf of PBMs.
Pharmacy and Governmental Regulatory Expertise
Throughout his career, Mike has been responsible for providing pharmacy industry expertise to his clients, keeping abreast of the latest trends within the PBM industry overall, as well as Medicare Part D and Medicaid pharmacy regulations. For example, Mike coordinated Part D client audits on behalf of a PBM. These audits focused on SAS-70 and NCQA delegated entity regulations, which spanned the entire operations of the organization. Mike worked with MA and PDP clients to prepare and participate in CMS audits, assisted with responses to CMS Corrective Action Plans (CAPs), developed management responses and oversaw the implementation of these CAPs. Mike has also provided guidance to his clients regarding new CMS regulations issued via annual CMS Call Letters and memos.