Dual Eligible Patients: How to Improve Care and Lower DIR Fees All Year

While the Medicare Open Enrollment Period may be over, did you know that, for over 12 million Dual Eligible patients, virtually every day can be Open Enrollment? That’s why it’s so important that your pharmacy has a software solution that can identify these patients, improve their care, and lower your DIR fees. So, how can Amplicare make that happen?

Let’s start off with a hypothetical.

First, assume that your current DIR fees are 10% of ingredient cost or the average wholesale price (AWP) — the national average is between 10-15%. 

Next, assume your pharmacy currently has 100 Dual Eligible patients, and each patient has $2000 worth of prescription billings.

If all that is true, how much would you be paying in DIR fees? 

We hope you answered $20,000 because that’s the correct answer.

Now, do you know how many Dual Eligible patients your pharmacy has, and how much money DIR fees cost you? If not, it’s ok. Many pharmacists don’t. Below, we share highlights from our latest webinar about how your pharmacy can drive profit, increase retention and improve care for your Dual Eligible patients.

The first thing we need to establish is where we are now. 

DIR fees are increasing rapidly. Just take a look at this chart:

The blue bar graph represents the net value of pharmacy-related DIR price concessions in billions, while the orange line represents DIR as a percentage of total pharmacy revenues. 

That’s a massive increase in fees. The reason is because DIR fees shifted from a dollar-based model to a percentage-based model—significantly increasing the fees on more expensive medications. 

For pharmacies looking to improve profitability, it’s imperative to focus on patients enrolled in plans with no DIR fees or with a more favorable DIR fee structure. 

In the past few years, there has been a rise in the number of regional plans with no DIR fees for pharmacies. In total, there are 171 plans that don’t have DIR fees. Their availability differs by state, and sometimes county, so it’s important to find which plans work best for your pharmacy and patients.

So how can you grow your business with these plans that don’t have these retroactive fees? 

It helps to know these facts about Dual Eligible patients:

• They can switch their Medicare plan once every quarter between January and September. This adds up to a total of three additional times per year. 
• Once a patient enrolls in a plan, the Special Enrollment Period (SEP) is considered used for the quarter. For instance, say a patient enrolled in a plan in March (Q1), this change would count toward the Q1 SEP.
• On average, it takes a plan two weeks to process a dual eligible enrollment. If the patient is enrolled into a plan with no DIRs, the pharmacy will stop paying DIRs for that patient instantly. 

Prioritizing these patients for plan comparisons is an expedient way to lower DIRs and improve patient care.  

When it comes to Dual Eligible patients, the benchmark status of a plan is also an important consideration.

There are 259 benchmark plans across the country. When you have a plan with no DIR fees that’s also a benchmark plan, it’s a double benefit for Dual Eligible patients. 

What are benchmark plans, you might ask? Benchmark plans give dual eligible patients more flexibility than other plans to choose coverage that works for them.

• Benchmark plans typically have premiums below the specified amount for the state and are a more cost-effective option for many patients when compared to plans with premiums. 
• If a patient receives Extra Help from Social Security, this additional assistance will help pay for the full cost of their Part D premiums.
• When helping patients compare plans, it is advisable to focus on benchmark plans as patients will not have to pay additional monthly premiums.

When comparing plans with Amplicare, you’ll be able to see the DIR fee estimate and the benchmark status of each plan available to your patients. 

With the Medicare Open Enrollment Period now over, it’s more important than ever for your pharmacy to focus on providing win-win opportunities for your patients and your pharmacy.

To get more details on how Amplicare can help you provide better care for your Dual Eligible patients while lowering your DIR fees, check out our latest webinar today.

Watch the Dual Eligible Webinar Now