Impact of Various Utilization Management on Per-Member Per-Month Spending for Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs)
By Alan K. Fou, PharmD; Mark Shinmoto, PharmD; Elton Teng, PharmD; Jeffrey He, PharmD; Rachel K. Hudson, PharmD, MBA
Rising pharmaceutical costs are a major concern for patients and payors alike and are straining our healthcare system. High demand and high prices in the U.S. for GLP-1 drugs are noticeably contributing to the overall rise in drug spend.
Employing a sustainable management strategy for pharmaceuticals like GLP-1s is necessary to achieve an appropriate balance of clinical and cost considerations.
Ventegra is predicated on the core belief that healthcare in the U.S. should be a societal good, which requires finding a way to maximize the benefits of healthcare while minimizing the financial burden on individuals and society.
As a clinically driven organization, we engage our clients, provide them with solid and reliable clinical information, and assist them to make educated clinical and business decisions that work best for them and those they serve.
We help develop effective strategies to shift utilization patterns and realize marked decreases in PMPM costs through effective utilization management programs (e.g. step edits, quantity limits, etc.) as well as other benefit design choices.
Recently, our 2024-2025 Managed Care Fellow, Alan Fou, Pharm D and our clinical team presented a closer look at the impact of various UM strategies on per-member per-month spending for GLP-1's.
Our drug list and formularies are designed to provide our clients with a choice of pharmacy products that meet all of the essential clinical conditions while addressing economic needs, and providing quality of care, affordability and choice.
Ventegra was founded to create balance between profitability and affordable patient care in an industry burdened by misplaced priorities. Our team applies our core values of integrity and transparency to create new healthcare delivery channels that are more consolidated and efficient. We channel our resources to positively impact the lives of others and create value for society as a whole.
Policies
HIPAA Compliance Policy
Ventegra has adopted a General HIPAA Compliance Policy in order to comply with the Health Insurance Portability and Accountability Act (“HIPAA”), as amended by the Health Information Technology for Economic and Clinical Health (“HITECH”) Act of 2009 (Title XIII of division A and Title IV of division B of the American Recovery and Reinvestment Act “ARRA”) and the HIPAA Omnibus Final Rule (Effective Date: March 26, 2013). We acknowledge that full compliance with the HIPAA Final Rule is required by or before September 23, 2013.
Ventegra hereby acknowledges our duty and responsibility to protect the privacy and security of Individually Identifiable Health Information (“IIHI”) generally, and Protected Health Information (“PHI”) as defined in the HIPAA Regulations, under the regulations implementing HIPAA, other federal and state laws protecting the confidentiality of personal information, and under principles of general and professional ethics. We also acknowledge our duty and responsibility to support and facilitate the timely and unimpeded flow of health information for lawful and appropriate purposes.
This policy governs general HIPAA Compliance for Ventegra. All personnel of Ventegra must comply with this policy. Demonstrated competence in the requirements of this policy is an important part of the responsibilities of every member of our workforce. Officers, employees, Business Associates, contractors, affected vendors, temporary workers, and volunteers must read, understand, and comply with this policy in full and at all times.
Privacy Notice
Effective Date: March 1, 2021
This privacy notice discloses the privacy practices for this site. This privacy notice applies solely to information collected by this website, except where stated otherwise. It will notify you of the following:
What information we collect;
With whom it is shared;
How it can be corrected;
How it is secured;
How policy changes will be communicated; and
How to address concerns over misuse of personal data.
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We will use your information to respond to you, regarding the reason you contacted us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request, e.g., to ship an order.
Unless you ask us not to, we may contact you via email in the future to tell you about specials, new products or services, or changes to this privacy policy.
Your Access to and Control Over Information
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See what data we have about you, if any.
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Have us delete any data we have about you.
Express any concern you have about our use of your data.
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We take precautions to protect your information. When you submit sensitive information via the website, your information is protected both online and offline.
Wherever we collect sensitive information (such as credit card data), that information is encrypted and transmitted to us in a secure way. You can verify this by looking for a closed lock icon at the bottom of your web browser, or looking for "https" at the beginning of the address of the web page.
While we use encryption to protect sensitive information transmitted online, we also protect your information offline. Only employees who need the information to perform a specific job (e.g., billing or customer service) are granted access to personally identifiable information. The computers/servers on which we store personally identifiable information are kept in a secure environment.
Notification of Changes
Whenever material changes are made to this privacy notice updates will be reflected here on our website.
Other Provisions as Required by Law
Numerous other provisions and/or practices may be required as a result of laws, international treaties, or industry practices. It is up to you to determine what additional practices must be followed and/or what additional disclosures are required. Please take special notice of the California Online Privacy Protection Act (CalOPPA), which is frequently amended and now includes a disclosure requirement for “Do Not Track” signals.
If you feel that we are not abiding by this privacy policy, you should contact us immediately via telephone at 858-551-8111 or privacyandsecurity@ventegra.org.
Fraud, Waste & Abuse
Part of our efforts to improve the healthcare system, Ventegra is committed to detecting, preventing and correcting fraud, waste and abuse.
What are Fraud, Waste, and Abuse?
FRAUD is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)
WASTE is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
ABUSE includes any action(s) that may, directly or indirectly, result in one or more of the following:
Unnecessary costs to the health care system, including the Medicare and Medicaid programs
Improper payment for services
Payment for services that fail to meet professionally recognized standards of care
Services that are medically unnecessary
Abuse involves payment for items or services when there is no legal entitlement to that payment.
How to Report Fraud, Waste, and Abuse
If you suspect fraud, waste, or abuse in the healthcare system, please report it. To report suspected fraud, waste, or abuse, you can contact Ventegra:
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Contact Information.
HOW TO CONTACT US:
Ventegra, Inc.
450 North Brand Blvd
Suite 600
Glendale, CA 91203
Corporate: (858) 551-8111
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