Module 2
Drug Spend Under Total Cost Accountability
Medicare's largest ACO program excludes Part D entirely. What is inside your benchmark, how to finance specialty exposure, and why adherence runs opposite to everything else.
By the end of this module, you will be able to:
- Determine what drug spending sits inside a benchmark and whether it is gross or net
- Finance specialty drug variance rather than trying to manage it clinically
- Design for higher adherence as a total cost of care strategy
- What Counts in the Benchmark Medicare's largest accountable care program excludes Part D entirely. Knowing exactly which drug spending is in your benchmark changes the whole strategy. About 5 min
- Specialty Drugs Under Risk A handful of members on high-cost therapies can determine whether a population contract succeeds. That is a risk problem before it is a pharmacy problem. About 5 min
- Adherence as a Value Lever The one place in value-based care where the accountable organization should want to spend more on a service, not less. About 5 min
Module quiz
Answer all questions to see your score.
1. Is Part D spending inside a Medicare Shared Savings Program benchmark?
This creates an asymmetry: an ACO has a direct stake in the infused therapy and none in the oral equivalent dispensed by a pharmacy.
2. What is the correct first response to specialty drug exposure in a small population?
A single member starting a high-cost therapy can consume a small population's entire margin. That is variance, and no amount of care management prevents someone from developing a condition.
3. What is primary nonadherence and why does it matter?
An organization without pharmacy data cannot detect patients who never started, which is a direct instance of only being able to manage what you can see.