Out of Drug Benefit Design

Our answer: neither. With today’s advanced technology, we can often use computer simulation to achieve risk-free results.

Admittedly, we’re just using the question to help get your attention. We want to introduce you to the concept of drug benefit simulation with SimPlan+ and the considerable contribution it can make to the management of your drug benefit programs.

     Clearly, this tool can remove the blindfold of experimentation and prevent or minimize costly mistakes as you make changes or modifications.

How The Administrator Uses SimPlan+

     The first step is to prepare a definition of the old and/or new plan that the computer can “read” for the adjudication simulation. For this purpose, DP/Rx provides an easy to use software package: the “Plan Model Builder” (PMB)

     Using the PMB with an ordinary Desktop Computer, you will create two plan definition files: one details specifics of the plan used with your previously- paid claims history data; the other details the specifics of your test or comparison plan.

     Our PMB package is extremely user-friendly. It guides you through a “fillin-the-blanks” set of screen forms that allow simple one-character or numerical response entries. When completed, the PMB automatically creates a diskette of these plan definitions in a format compatible with SimPlan+ computer processing input.

     The third and final step is your review and evaluation of the SimPlan+ output reports on their return from the processing center. Comparison of the two plan results is made with an eye toward determining whether the targeted objectives were fully achieved. Did the changes cause the anticipated effect? If the results are viewed as effective and appropriate to the intended objectives, you can then order the implementation of the actual plan changes.

     If further “tweaking” of the changes is indicated, you return to the first step and call the experimental plan definition back for modifications. It is then altered to accommodate the shortcomings of the first attempt and the process is run again.

     The characters in the string are used for calculation or adjudication logic by the interpretive component of the SimPlan+ program when executed by the DP/Rx service center. This is the same component that is used for on-line adjudication, hence the calculations of the simulated version are identical to the real—time and on-line processor.

     The entire process of creating the definition for one plan from scratch (moving through 12 pages of definition options and selections) usually takes less than one-half hour. And once the existing plan is created, you simply copy that version for the new plan skeleton. Then you need to spend just a few minutes customizing the adjudication parameters you want for the new comparison plan.

     You will probably want to maintain a library of plan definitions and use them for testing or for application in the adjudication process. These too may be copied for quick modification to try other options for change.