Managed Care Spotlight: A Case Study
Managed Care Spotlight: A Case Study
Pharmacist counseling of at-risk Medicare patients
Merging MCO, PBM efforts retains members
Surveys of Medicare beneficiaries indicate they want drug benefits. Officials at Diversified Pharmaceutical Services in Bloomington, MN, say 75% of Medicare beneficiaries choose to enroll in managed care plans just to get that coverage. They say out-of-pocket drug costs are a key determinant of health care consumer satisfaction and that the exhaustion of the drug benefit doubles the member disenrollment rate.
From the provider’s perspective, the pharmacy benefit can be a double-edged sword.
"If you give patients medication, it will keep them out of the hospital," says Patricia Flannery, BSN, is senior director of Health Systems for United HealthCare. "So you are hoping for a cost offset in the future. However, we want to retain patients, and they disenroll when they hit the limit, no matter what that limit is. So we have to find a way to manage the benefit and retain the patient."
Many managed care organizations are struggling with the pharmacy benefit and with their Medicare strategies. Some want to drop the benefit, while some are trying to manage it better and keep costs down. But the reality is that the pharmacy benefit is often the first thing to be cut.
After consulting with its medical directors, pharmacy managers, sales directors, members, and physicians, United HealthCare decided it would try to approach pharmacy as a service provided by processes that can be improved. That’s different than thinking of pharmacy as the place where subscribers pick up drugs. Working with its prescription drug benefit manager, Diversified Pharmaceutical Services, the firm set out to devel op a program that would integrate with overall care coordination, decrease medication costs, and increase patient satisfaction. That program was called "Rx for Healthy Living."
To make it work, the agency had to be specific about what population would benefit the most and how to reach it. United HealthCare serves some 440,000 Medicare beneficiaries. Research indicated Medicare members taking five or more different prescription drugs were most likely to miss prescription refills, take incorrect dosages, or mix incompatible medications. Those members, identified through pharmacy data, became the focus of the program.
The company sent those patients surveys designed to assess how they were taking their medications and whether they were experiencing any difficulties with them. About half of them responded.
"A clinical pharmacist would review each survey profile and make recommendations. The profile gave them access to more information than they could get from claims. It gave them prescription information, along with information on over-the-counter drug usage, vitamins, and herbals, since we find more and more cases of herbals interacting with prescription medications. They also were able to get detailed information on how these patients were taking their medications, whether they miss doses, and whether they understand why they are taking their medications," says Raymond Brown, PharmD, MS, director of specialty clinical services at Diversified Pharmaceu tical Services.
Responding to patient needs
Members then were offered intervention on three levels, depending on the severity of their situation. These measures could be taken individually or in combination, according to the needs of the patient:
1) Members receive a follow-up letter from a pharmacist, with tips and recommendations on taking their medications.
2) Members receive a phone call from the pharmacist to discuss their medication issues.
3) Physicians are sent information on the patient’s drug use, including notice that incompatible medications are being mixed.
Of the members who chose to participate, 45% required a consultation, and 15% had serious clinical issues.
"The average consultation resulted in four recommendations," says F. Everett Neville, PharmD, director of senior clinical programs. "Two were cost-related, like switching to generics. Cost was the primary concern of members, since most do not have unlimited benefits and many say they don’t take their medications because they can’t afford them." The other major recommendations concerned evaluations of whether multi-drug regimens could be decreased or whether drugs were being adequately used.
Specific cases
The cases included a patient who was on the diuretic furosemide at a daily dose of 40 mg but was not taking potassium. The patient had a prescription for potassium, but hadn’t filled it because he didn’t know what it was for.
Another could not afford her medication, so the pharmacist recommended generic alternatives to her physician. The physician agreed to most of the recommendations, and the patient was able to afford the drugs. Overall, 90% of the patients said they felt the program was helpful, and 96% said they wanted it to be continued. United HealthCare has continued the program, even as it analyzes the quantitative data, including the return on investment for readmission rates.
Officials say Rx for Healthy Living may be expanded to include patients referred by nurse care coordinators, along with those identified through the pharmacy data.
"It is a matter of being able to get an open dialogue going between patients and clinicians," says Brown. "To do this, you have to make it as easy as possible for the patient. It is just basic good use of pharmacy skills to open that dialogue."
The program required the use of three staff pharmacists who exclusively communicated with plan members, and one staffer to make calls and set up consultations. They used a computer program to track the data. The company initially sought to hire pharmacists with experience in counseling and consulting, but it now offers a training course and peer review sessions to existing staff.
Sources
• Patricia Flannery, BSN., Senior Director, Health Systems, United HealthCare, Edina, MN. Telephone: (612) 936-1300.
• Raymond E. Brown, PharmD, MS, Director, Specialty Clinical Services, and F. Everett Neville, PharmD, BS, director of Senior Clinical Programs, Diversified Pharmaceutical Services, Bloomington, MN. Tele phone: (612) 820-7000.
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