Clinical VantageSM. A Winning Advantage. Commanding. Comprehensive. Strategic. That s Clinical Vantage, a suite of clinical programs from

Transcription

1 SM Clinical Vantage

2 Clinical VantageSM A Winning Advantage Commanding. Comprehensive. Strategic. That s Clinical Vantage, a suite of clinical programs from Prescription Solutions designed to fit your pharmacy benefit needs. Clinical Vantage provides solutions that use evidence-based clinical and technological innovations designed to improve overall clinical outcomes for your members and reduce your health care expenditures. 2

3 The Clinical VantageSM Approach Clinical Vantage is driven by four key objectives. Viewed separately, each objective provides specialized solutions for your particular needs. Taken together, they provide powerful synergies to help you achieve your clinical and economic goals. Creating Customized Solutions Creating Customized Solutions Consultative Analysis Predictive Modeling p. 5 Maximizing Savings Drug Formulary Management p Formulary Education Initiative - Pipeline Drug Forecast Achieving Optimal Health Client/ Member Improving Quality and Safety Improving Quality and Safety p. 7 Disease-Specific Clinical Programs Drug Interaction Alert Program (DIAP) - Prior Authorization - Clinical Edits Generic Medication Utilization Programs - Generic Utilization Strategy Program - Generic Copay Waiver Program - Mandatory Generics Program Geriatric RxMonitor Program Polypharmacy Program - Value Optimizer Prescription Drug List (PDL) Quality Improvement Initiatives Mail Service Pharmacy Program (HEDIS ) Maximizing Savings Medication Therapy Management Programs (MTMP) Adherence/Refill Reminder Programs Comprehensive Audit Program Narcotic Drug Utilization Review Program Achieving Optimal Health p. 21 Specialty Pharmacy Care Management Disease Therapy Management (DTM) 3 4

4 Creating Customized Solutions Behind Clinical Vantage SM is a broad, strategic perspective. We customize clinical programs to address our clients specific needs applying our analytical expertise along with evidence-based guidelines. Consultative Analysis Many clients believe their pharmacy benefits program could be improved but often are unsure how to most effectively generate change. Our consultative analysis is the answer. Through comprehensive review of our clients pharmacy utilization data, we identify robust clinical intervention programs that can improve the quality of care and health outcomes for our clients members, while providing a cost-effective pharmacy benefit. The key components of the clinical consultative analysis include: Evaluation of the client s pharmacy data according to utilization and cost Development of clinical program recommendations, including description and rationale Projection of potential cost savings Recommendations on other clinical benefits Predictive Modeling This program explores the cost savings and quality improvement measures that might be achieved to better serve a client s members. Our predictive modeling tool looks at current and prospective clients pharmacy claims data, using the resulting analysis to provide an estimate of how many members could benefit from our clinical programs, as well as the estimated savings from select clinical programs. We also can provide prospective clients with an estimate of the cost savings and return on investment that could be realized by the placement of clinical edits on selected medications. The models we use for this program include: Prior Authorization Model Step Therapy Edit Model Quantity Limit Edit Model Each model we run results in a client-friendly report containing these important data variables: medication name, prescription count, potential cost savings (total and PMPM) and return on investment. 6

5 Improving Quality and Safety Ensuring quality, safety and appropriate medication use are our primary concerns when it comes to prescription medications. Clinical Vantage SM programs are available to promote proper medication use, monitor medication utilization, and help prevent drug misuse and overuse. Examples from our full suite of Clinical Vantage programs include: Disease-Specific Clinical Programs Our disease-specific clinical programs aim to identify gaps in therapy that contribute to increased morbidity, mortality, and overall health care costs. We do this by identifying patients who are potentially missing important medications for their chronic diseases, as recommended by evidence-based national guidelines. Through our member intervention programs, we provide educational materials about chronic disease management and the benefits of appropriate medication use. The goal is to help patients make informed decisions about their health and medications. We also promote proper physician prescribing that is consistent with published medical literature and national guidelines. To assist providers in caring for their patients, we provide education materials highlighting the most up-to-date clinical information along with patientspecific reports listing their patients who may benefit from the clinical intervention. By using both provider and member outreach, our disease-specific clinical programs serve as a powerful tool to bridge the gap in care. $1,200 $1,100 $1,000 $900 $800 $700 $600 $500 $400 $1,192 $857 Pre-Intervention Post-Intervention Asthma Intervention lowers costs: For one client, the overall mean annual asthma-related health care costs per member decreased by $335. 8

6 Drug Interaction Alert Program (DIAP) Patients who take multiple prescription medications are not always aware of the potential interactions of these drugs, and because many patients often see multiple doctors, there is a possibility that a physician does not have the complete prescription drug picture of a patient. Our DIAP is designed to reduce the incidence of harmful drug-drug interactions through outreach to health care providers. If a member has a pharmacy claim for a drug that interacts with a previously filled medication, our system detects it on a real-time basis, and we alert the prescribing physicians. This program can be supplemented with a general member education component to raise awareness of drug interactions. 50% 40% 30% Geriatric RxMonitor Program Appropriate use of medications for people age 65 years and older is of particular importance to many clients. The program reduces inappropriate medication use for this population by alerting prescribers of identified high-risk medications that can cause adverse events in the elderly. In doing so, we apply the National Committee for Quality Assurance s HEDIS (Healthcare Effectiveness Data and Information Set) guidelines in promoting safe use of high-risk medications in the elderly. Polypharmacy Program The use of multiple medications by a patient presents particular challenges for members and their health care providers. We promote safe and appropriate multiple medication use by notifying physicians about potentially harmful drug-disease interactions and inappropriate duplicate therapies. 20% 10% 0% 41% Intervention (N=8,399) 31% Control (N=14,769) Our clinical intervention program, designed to reduce drug-drug interactions (DDIs), was associated with a significantly higher resolution rate compared with a control group (41% vs. 31%). For the three most prevalent DDIs identified, a total annual medical cost savings of $500,230 (or $4.96 PMPM) was estimated for members receiving the intervention. 9

7 Quality Improvement Initiatives (HEDIS ) We are deeply focused on promoting best practices based on national standards by supporting clients with our Quality Improvement Initiatives, designed to follow NCQA s HEDIS measures. Sample programs include: A disease-modifying antirheumatic drug initiative to optimize the use of these drugs by patients with rheumatoid arthritis. The program also seeks to enhance provider and member awareness of current clinical recommendations from the American College of Rheumatology. A suite of diabetes-focused programs to encourage members and providers to appropriately manage this condition, including maintaining a healthy lifestyle, adhering to diabetes medications, preventing diabetes-related complications, and providing education to assist members in self-management of diabetes. These programs include: physician communications such as letters, reports of identified members, and education pieces detailing statin prescribing principles, as well as letters and education materials to members. An ACEI/ARB initiative to optimize the use of angiotensin-converting enzyme inhibitor and angiotensinreceptor blocker therapy in patients A statin initiative, aimed at with diabetes, hypertension, and/or decreasing morbidity and mortality nephropathy. Provider and member associated with high cholesterol communications are key elements of in patients with diabetes and/or this program. CAD. Program interventions include 15% 10% 5% 65% Relative Increase 0% 7.3% Control 12.1% Intervention In the four months following our statin initiative targeting patients with coronary artery disease (CAD) and/or diabetes with no pharmacy claims for a statin, 138 (12.1%) of members started a statin medication, compared with 51 (7.3%) of the controls (p=0.001). Members in the intervention group were 65% more likely to start a statin than control group members (p=0.006). Estimated coronary event cost avoidance is $0.85 PMPM for members receiving the intervention. 12

8 Medication Therapy Adherence/Refill Comprehensive Audit Program Narcotic Drug Utilization Management Programs Reminder Programs Fraud and abuse pose serious health Review Program (MTMP) These programs help prevent complications caused by adverse drug reactions (ADRs), poor medication adherence, or other identified therapeutic deficiency. Our MTMPs promote partnerships between the pharmacist, patient (or caregiver), and health care provider to enhance communication, improve collaboration among all parties, and ultimately, optimize therapeutic outcomes. We offer programs that increase adherence rates in a number of chronic and high-impact disease states. These programs are designed to promote appropriate utilization, improve health outcomes, and manage overall health care costs by reducing medical costs associated with patients who do not stay on prescribed therapy. We provide semi-monthly refill reminder phone calls to patients who do not refill their chronic medications on time. We also offer provider interventions, such as physician reports identifying members who are not adhering to risks and complications for patients and result in higher costs for each level of the entire health care system. Given our commitment to improving outcomes while controlling costs, we know it is imperative to keep these threats in check. Our pharmacy auditing and monitoring program detects suspicious, inappropriate, and potentially fraudulent claims, which can avoid unnecessary costs. Median Total Opioid Medication Cost Savings Per Patient This program is designed to minimize the occurrence of drug abuse, diversion, and inappropriate use of opioid analgesics (e.g., addictive painkillers). We do this by targeting and alerting health care providers about members who are using opioid analgesics that may require evaluation. their medications. $25 $20 $15 $10 $5 $0 $14.75 $19.23 $24.00 PDP MAPD Commercial Prescription Solutions clients members adherent to their antidepressant medications had $2,361 lower annual total health care expenditures compared with non-adherent patients. 70% 82% of clients members receiving Prescription Solutions refill reminder calls subsequently refilled their prescribed medications in the period we reviewed. Source: Prescription Solutions proprietary data. Total number of members included in the evaluation: 4045 Results are based on per intervened upon member. Narcotic DUR drives results: Implementing our narcotic drug utilization review program helps clients significantly reduce narcotic drug costs. 13

9 Maximizing Savings Improving clinical outcomes by enhancing health care quality and safety has the added benefit of reducing health care costs. Clinical Vantage SM programs deliver cost savings to our clients by preventing misuse or unnecessary use of medications, promoting cost-effective medications (or the right medications at the lowest possible cost), and monitoring treatment effectiveness. Examples of our effective cost savings programs include: Drug Formulary Management We carefully consider the client s needs and goals when managing the drug formulary, which is the backbone of any pharmacy benefits program. We aim to reduce medication costs by proactively promoting generics and other lower-cost therapies, and using evidence-based and pharmacoeconomic analysis to review the therapeutic advantages and disadvantages of medications. Our suite of drug formulary management programs includes: Formulary Education Initiative We maximize awareness of and compliance with our clients drug formulary through frequent customized mailings to both members and health care providers. 16

10 Pipeline Drug Forecast This service helps our clients stay on top of the most current pharmaceuticals available. To anticipate release dates for new products into the United States market, project PMPM impact of a new drug, and to aid in positioning new drugs in relation to current formulary agents, we monitor: New drugs in pipeline development New drug approvals New indications, formulations, and labeling changes First-time generic approvals Anticipated drug approvals within the next two months Prior Authorization We help our clients manage the appropriate use of high-cost and/or highly utilized categories of drugs that are likely to be used for off-label indications or beyond recommended duration. We develop our prior authorization criteria based on up-to-date, evidence-based national guidelines and clinical evidence from the medical literature. Our goal is to increase formulary awareness and to ensure treatment effectiveness through monitoring of patient response. Clinical Edits Quantity Limits and Step Therapy Edits are designed to ensure the clinically appropriate use of medications by preventing excessive dosages, and encouraging effective therapy changes including the use of generics. These services are based on FDA recommendations and other evidence-based guidelines. Generic Medication Utilization Programs Prescription Solutions is an industry leader in driving clinically appropriate use of generic medications. Our utilization rate for generic medications is undeniably among the highest in the industry. We employ creative and effective strategies for clinical interventions, benefit and formulary designs that increase the utilization of generic medications, resulting in significant savings for our client. The following tools can be used either alone or in combination to help our clients maximize savings: Generic Strategy Drives Savings 70.9% 73.0% 64.6% 59.8% 54.6% 45.0% Generic Utilization Strategy Program Through this clinical intervention program, we encourage members and their health care providers to optimize use of AB-rated generics whenever clinically appropriate. We do this by implementing both a memberdirected as well as a health care provider-directed program to educate each about the availability, effectiveness, and safety of lowercost generic products. 9.6% 5.2% 4.8% 6.3% 2.1% One client experienced a 28% total jump over 5 years in their generic utilization rate from 45% to 73% with our Generic Medication Utilization Programs. Their average savings was more than $400,000 per year. 18

11 Generic Copay Waiver Program This program is designed to promote the use of select generic medications through a limited time, zero dollar copay incentive offering. After the copay waiver period ends, members can continue to receive their generic medication for their standard generic copayment, saving money over the typical brand tier copayment amount. effective date and the brand has not been approved by prior authorization, the member will assume responsibility for the brand copay plus the difference in price between the generic and brand medication. Value Optimizer Prescription Drug List (PDL) This 2-tier closed formulary is designed to promote increased utilization of generic Mail Service Pharmacy Program Prescription Solutions award-winning and nationally accredited Mail Service Pharmacy offers patients convenience, cost-effectiveness and safety. It also helps members live healthier lives through better compliance with their treatment plans. Our approach to mail order is a blend of high technology with the personal touch of experienced facilities offer 24/7 services and provide precise processing of high volumes of prescriptions with fulfillment turnaround of less than two days and greater than 99.9% accuracy. Mandatory Generics Program This program supports clinically appropriate use of generic and mail-order prescriptions to help control costs. Key features of this innovative and clinically pharmacy personnel. Prescription Solutions state-of-the-art mail service equivalents through increased sound PDL include: inclusion of copay for selected brand 80% of the same drugs and nearly medications. If a member chooses 95% of the generic medications to continue to use the brand found in our standard formulary; medication following the program inclusion of seven of the top ten brand drugs; and elimination of prior authorization access for medications not covered by the identified plan. 19

12 Achieving Optimal Health Clinical Vantage SM programs are designed to help people live healthier lives, which, in turn, can result in lower health care costs. We believe in a comprehensive approach to managing treatment and improving outcomes for members with chronic diseases. Specialty Pharmacy Care Management Specialty pharmacy is the fastest-growing area of health care, representing nearly 25% of the nation s total drug spend. In addition, seven of the top 10 drugs in the FDA pipeline are specialty drugs. These drugs are not only extremely expensive, but also pose medication adherence difficulties for many patients. Our specialty pharmacy program helps clients manage the rising cost of specialty medications through delivering high-touch service and advanced care management strategies including superior customer support, case review, comprehensive member education and guidance, medication adherence support, and prior authorization. These services can significantly reduce medical costs and improve outcomes. Disease Therapy Management (DTM) Our DTM program provides personal care to the high-risk patients with the goals of improving quality of life, promoting self-management, increasing medication adherence, and reducing overall health care costs. We achieve these goals through: Telephone consultations with program participants Development of patient-specific care plans Ongoing care management services based on member needs Distribution of educational materials and important drug updates and alerts Notification and communication with health care providers Referral services to external organizations for financial assistance or other disease management support The program is supported by our skilled staff of nurses and clinical pharmacists, all of whom have the clinical expertise to understand the complexities of the chronic conditions and medication therapy included in our DTM program. We offer this program to patients who use our Mail Service Specialty Pharmacy to obtain medications that treat a variety of serious chronic disease, such as hemophilia, hepatitis C, multiple sclerosis (MS), and rheumatoid arthritis. Medication Adherence (MPR) After Completion of MS DTM Program* Index Injectable MS Medication DTM Specialty Retail All Injectable MS Medication After completion of the MS DTM program, medication adherence was significantly higher for the MS DTM group compared with the retail pharmacy network (p<0.001) *Analysis of medication adherence was conducted in members who completed 6 months of MS DTM program and were continuously enrolled in the Plan during the data review period. There were 156 members in each cohort. 22

13 Clinical VantageSM: Customization of Services We give our clients the flexibility to select a single program or multiple interventions to achieve their goals. The Clinical Vantage continuum starts from low-touch programs and includes high-touch programs, with associated increases in quality of care and/or cost savings. Drug Utilization Management Drug review prior to dispensing or at point-of-service LOW TOUCH Education Campaign Member/Provider Mail/Fax Intervention Member/Provider Telephonic Intervention Using an Interactive Voice Response (IVR) System Member Personalized (1:1) Outreach by Specialized Pharmacists/ Nurses Member HIGH TOUCH Clients have flexibility to select single or multiple program types to meet their needs. For example, an educational campaign program can be coupled with a mail/fax intervention or a personalized outreach by specialized pharmacists/nurses. 23 INCREASING QUALITY OF CARE AND/OR COST SAVINGS Clinical Vantage programs cover a wide range of therapeutic categories and populations. Allergies Allergic Conjunctivitis Allergic Rhinitis Seasonal/Perennial Allergies Arthritis Ankylosing Spondylitis Juvenile Rheumatoid Arthritis Osteoarthritis Psoriatic Arthritis Rheumatoid Arthritis Blood Disorders Anemia Hemophilia Neutropenia Thrombocytopenia Von Willebrand Disease Cardiovascular Diseases Acute Coronary Syndrome Angina Chronic Heart Failure Dyslipidemia Hypertension Peripheral Arterial Disease Post-Myocardial Infarction Stroke Diabetes Diabetes Type 1 Diabetes Type 2 Metabolic Syndrome Eye Disorders Age-related Macular Degeneration Glaucoma Gastrointestinal Condition Duodenal Ulcer Erosive Esophagitis Gastric Ulcer Gastroesophageal Reflux Disease Zollinger-Ellison Syndrome General Care Drug-Drug Interactions Drug-Herbal Products Generic Medications Injection Site Selection Medication Adherence Medication Safety Chart Over-the-Counter Medications Polypharmacy Growth Deficiencies Growth Hormone Deficiency Prader-Willi Syndrome Turner Syndrome Hepatic Disorders Hepatitis B Hepatitis C Infectious Diseases Bacterial/Viral Infections HIV/AIDS Influenza Onychomycosis Otitis Media Mental Health Attention Deficit Hyperactive Disorder Bipolar Disorder Depression Generalized Anxiety Disorder Insomnia Neuroleptic Malignant Syndrome Schizophrenia Neurological Conditions Alzheimer s Disease Dementia Migraine Multiple Sclerosis Parkinson s Disease Oncology Acute Lymphoblastic Leukemia Breast Cancer Chronic Myeloid Leukemia Colorectal Cancer Esophageal Cancer Gastric Cancer Kidney Cancer Leukemia Liver Cancer Lung Cancer Lymphoma Multiple Myeloma Ovarian Cancer Pancreatic Cancer Rectal Cancer Osteoporosis Osteopenia Osteoporosis Pain Arthritic Pain Cancer Pain Fibromyalgia Low Back Pain Neuropathic Pain Renal Disorders Chronic Kidney Disease Nephropathy Respiratory Conditions Asthma Cystic Fibrosis Chronic Obstructive Pulmonary Disease Respiratory Syncytial Virus Skin Disorders Atopic Dermatitis Psoriasis Seborrheic Dermatitis Special Age Group Appropriate Use of Medications in the Elderly Appropriate Dosing in Pediatrics Thyroid Conditions Hyperthyroidism Hypothyroidism Secondary Hyperparathyroidism Transplant Bone Marrow Transplant Heart Transplant Intestine Transplant Kidney Transplant Liver Transplant Lung Transplant Pancreas Transplant Urological Conditions Benign Prostatic Hyperplasia Urinary Incontinence Women s Health Endometriosis Menopause 24

14 SM Put Clinical Vantage to Work for You Clinical Vantage s program objectives creating customized solutions; improving quality and safety; maximizing savings; and achieving optimal health give you the commanding perspective and clear view needed to help create an effective pharmacy benefits program with improved clinical outcomes and/or cost savings. Prescriptions Solutions has been providing its unique and valuable perspective on total pharmacy and medical management for 20 years. We are proud to be the first pharmacy benefit manager to achieve all four URAC Pharmacy Quality Management accreditations and our clinical programs have been recognized by URAC two years in a row for innovation and robust program impact. That award-winning approach benefits more than 10 million members nationwide, and we are ready to serve your members today. To learn more about Clinical Vantage programs and how they can work for you, please contact your Prescription Solutions representative.

15 2300 Main Street, Irvine, CA Prescription Solutions. All rights reserved. Prescription Solutions is an affiliate of UnitedHealthcare Insurance Company. PS0693