Audits: Necessary Tools or Big Business?

Nicholas Karalis, RPh
Published Online: Wednesday, November 2, 2011
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Audits are a powerful tool for health care and should be used to measure outcomes and performance. Our columnist share his personal view on what he sees in the current climate.

I think all stakeholders would agree that health care reform is inevitable. Our health care system needs an overhaul. The solution should include 3 simple parts: we need to cut costs, improve care, and make access easier. Of course, the goal must be to improve patient outcomes in a manner that reduces waste and errors and that is fiscally responsible. We need to consider being proactive with preventative care and then consistently measure and publish the results for public review.

The patient must be considered a key stakeholder within the health care paradigm and be allowed to make joint decisions on his or her therapy and course. Today, the number 1 reason people search the Internet is for healthrelated information. If knowledge is power, then we need to ensure that patients, physicians, and payers all have accurate, factual, unbiased information with which to make decisions.

Our pharmacy recently went through 2 audits by one of the national audit companies. The audit company sent 2 separate letters dated the same day, one stating they would be doing an onsite audit for one of the 3 largest PDP plans, and other letter stated they were doing a desk audit of another of the largest PDP plans.

When the onsite auditor spent 6 hours at our facility, I commented on the fact that all the claims reviewed were for Medicare, Medicaid, or dual-eligible patients that were being treated for HIV, cancer, hepatitis C, or a dual diagnosis. When I asked why the PDP and her audit company choose the sickest, poorest patients to audit, the response was, “We are not looking at the patients, just their prescriptions. Medicare is looking to recoup dollars and I would expect more of these audits.” She also went on to state that our pharmacy had the highest compliance rate that she had ever audited. Those comments really made me think about how we are going about health care reform.

Audits are a powerful tool for health care and should be used to prevent fraud, validate proper use and dose, ensure accurate payment of contractual terms, and most importantly, measure outcomes and performance. Instead we have allowed a necessary and important tool to become “big business.” First, we allowed simple claim processors to become multibillion dollar profiting companies controlling market share, patient choice, and ultimately, medical decisions.

Now, we are watching audit companies being bought by major corporations investing in technology using complex algorithms to comb through claims data in order to “recoup dollars” for payers. How did we get here? Could our pharmacy’s exceptional compliance rate actually alarm one of these programs and trigger additional audits? Isn’t the patient and their outcome still the priority? Do the PDP mail order and specialty pharmacies get audited?

If we are truly looking for solutions, manufacturers should not limit distribution, insurance companies should not steer patients, PBM plan designs should include more than just their own specialty pharmacies, and audit companies should not use entrapment style programs. The system should be easier, cheaper, and better. Let’s not overcomplicate things. SPT

Nicholas Karalis, RPh, is a specialty pharmacist and co-owner of Elwyn Specialty Care, which offers specialty pharmacy services in HIV, oncology, hepatitis C, multiple sclerosis, rheumatoid arthritis, Crohn’s disease, psoriasis, and other areas. A leading voice in community pharmacy, he is a founding member and board member of the Community Specialty Pharmacy Network, as well as a board member of the Cardinal Health National Home Health Care Advisory Board. Mr. Karalis is an editorial board member of Specialty Pharmacy Times

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