MEDecision

Five Considerations to Differentiate Health Plan Clinical Services in a Competitive Market

blog.nospam@nospam.medecision.com (Clarice Holmes) — Thu, 06 Oct 2011 04:08:00 -1000

In today’s changing healthcare landscape, health plans need to differentiate their clinical services in an increasingly competitive market. Clinical programs and tools, which improve health outcomes and cost savings, are fast becoming core components of a successful care management strategy.

A new industry report by IDC Health Insights – Care Is the New Core: Healthcare Payer Top 10 for Health Management in the Reform Decade – asserts:

“Future solutions will integrate health and wellness with clinical solutions not only to support the 360-degree consumer experience but also to enable health plans to identify and manage the healthy; identify early-stage chronic conditions and propensity, many of which can be managed through health and wellness programs; and effectively manage illness and provide cost-effective evidence-based care.”

These collaborative health management solutions exist in the market today. We suggest health plans consider five key factors when seeking a platform to best improve their clinical strategy. Look for tools and applications that are:

1. Developed by healthcare professionals – registered nurses, board-certified physicians and registered pharmacists – using evidence-based medicine, best practices and national guidelines,

2. Accreditated and certified by leading national third-party organizations, such as URAC and NCQA, to validate standards of clinical excellence

3. Integrated with advanced analytics capable of identifying treatment opportunities for at-risk members to effectively close gaps in care and meet HEDIS quality measures,

4. Joined with web-based patient education programs that help ensure the patient’s adherence to treatment regimens by alerting the care manager to the patient’s activity.

Using these tools to ensure consistent clinical excellence allows health plans to identify members for preventive treatment and interventions, deliver high-quality, individualized care plans and evaluate and report on progress success.

5. Which leads me to the fifth key factor to consider - reporting tools. It is critical that health plans measure and report outcomes on staff compliance to standardized processes, member adherence to treatment plans, case closure rate, reduction in hospital admission and emergency room visits, among other things.

With this valuable information, health plans know where to target process improvement initiatives for better patient outcomes and can demonstrate the differentiated value of their care management programs to employer groups, government plans and insured businesses.

Clarice Holmes, RN, CPUM, CCM, is Senior Vice President of Medical Services for MEDecision, the leading provider of collaborative health management solutions. Learn more about MEDecision at www.MEDecision.com. Follow the company on Twitter at @MEDecision and on Facebook at www.MEDecision.com/Facebook.

Please feel free to publish the above blog in full or in part with attribution according to the Creative Common license.

The ACO Regulations: Laying the Foundation for the Medical Home

blog.nospam@nospam.medecision.com (Matt Adamson) — Thu, 09 Jun 2011 09:07:00 -1000

In last week’s blog I shared my thoughts on a few of the shortcomings of the new ACO regulations issued by the Centers for Medicare & Medicaid Services (CMS). Though I think the regulations would have greatly benefitted from including more incentives for a broader range of organizations to transition to the ACO model, they did include quite a few positive aspects by laying the groundwork in patient-centered medical homes. The new regulations emphasize the importance of the medical home model by placing onus on primary care physicians, care coordination, patient-centeredness and health information exchanges (HIEs).

From a workflow perspective, the clinically integrated medical home provides the best roadmap for ACO preparedness. Given the level of interest in the medical home from commercial payers, it also provides a solid path toward achieving some level of shared savings or bonus payments to help pay for a more incremental set of investments. This means that primary care physicians need to assess their prospects for achieving meaningful use and medical home accreditation against their ability to convince payers to make them a part of their medical home strategy as early adopters.

This begins with the implementation of an EMR so that the paper-based data within the practice can be turned into electronic information. Electronic information is required so that stakeholders outside of the practice can be easily brought into the care team, which includes specialists, pharmacists, behavioral health, labs and most importantly the patient. Health information exchange (HIE) can then be implemented so that the clinical records can be integrated into the workflow of those involved with the patient. Because there are few sustainable models for HIE in the current market, payers are finding that the medical home model provides a tangible way for them to support payment for it.

Once integrated, the next step is to pursue a higher level of care coordination capability by providing the ability to manage chronic conditions and care plans from within the medical home. This becomes possible as physicians are offered incentives to have a health coach or care coordinator as a member of the care team. A person in this role can utilize systems that support population management and care management in the medical home and complete the HIE circle.

Data pulled through the HIE, made actionable through analytics designed for clinical decision support and then distributed to users in a form that can improve patient care will change the way that care is delivered. Physician practices that become medical homes and support care coordination can become the centerpiece for accountable care. Building the ACO process from the ground up in this manner might provide the best opportunity for improving health outcomes and lowering costs.

Do you think the ACO regulations do enough to support the PCMH model? How do you think they will impact the future of the medical home/ACO movement?

Matt Adamson is vice president of health solutions for MEDecision, a leading provider of collaborative health management solutions. Learn more about MEDecision at www.MEDecision.com. Follow the company on Twitter at @MEDecision and on Facebook at www.MEDecision.com/Facebook.

Please feel free to publish the above blog in full or in part with attribution according to the Creative Common license.

The Proposed ACO Regulations are Out – Now What?

blog.nospam@nospam.medecision.com (Matt Adamson) — Thu, 02 Jun 2011 02:59:00 -1000

As many of you know, the Centers for Medicare & Medicaid Services (CMS) recently issued a widely-anticipated set of regulations on accountable care organizations (ACOs) into the Federal Register on April 7, 2011. Now that my colleagues and I have had some time to digest all 127 pages and gather additional insight from others, I’d like to share some thoughts on what the new regulations mean for the future business success of ACOs.

At MEDecision, I’ve had the opportunity to interact with organizations looking to transition to an ACO model but who could not make their business case without first assessing the impact of the regulations. Unfortunately, while the ACO model itself provides great opportunities for lowering costs and providing a higher level of quality care for patients, the overall business value contained within the current regulations seems too risky for the majority of physicians or hospital systems to fully support. Ron Klar, writing in the Health Affairs Blog, said recently, “Existing ACO-like integrated systems will find the financial deal inadequate (they want capitation), while provider groups contemplating becoming an ACO will find the organizational and operational requirements and costs excessive.”

Based upon the Physician Group Practice Demo, the average ACO start up costs are around $1.7M. The proposed shared savings model within the ACO regulations would not likely allow an ACO to recoup that investment with the minimum 5,000 patients until long after the three-year initial ACO contract is complete. After the second year, ACOs can be penalized for not achieving savings measures as well so there is the potential to create an even more negative financial downside. Where are the monetary incentives to set an ACO up for continued growth and success?

Another seemingly disappointing factor is that the patient has been left out of the “accountable” part of the care equation, which makes the ACO proposition even more risky. As Dr. Sheryl R. Skolnick and Nick Leventis pointed out in ACO Watch, “Patients participating in an ACO would be able to see or visit any provider they choose and ACOs are expressly prohibited from preventing such free choice. ACOs could be penalized if the patient boomeranged back to the hospital for an unnecessary readmission. How is the ACO supposed to be able to achieve a better outcome and lower spending if the patient leaves the ACO for care at a provider not affiliated with the network?” There is also no patient accountability around adherence to care plans administered by the ACO within the regulations.

Unfortunately, the new regulations don’t support what many, including myself, had hoped to be an opportunity for an explosion in growth of ACOs. Rather, they have benefitted a small collection of privileged groups – large hospital systems with ACO models already in place – rather than smaller systems of private practices and patient-centered medical homes (PCMHs). Instead of an influx of organizations and physician groups taking leaps towards becoming ACOs, it seems the regulations have encouraged a select few to only begin taking baby steps. CMS estimates that 75-150 groups will apply to become ACOs, which may be a stretch given the cost versus the revenue equation presented. CMS might have missed a great opportunity here and we hope that as the industry weighs in on this version of the CMS savings program so that it can be revamped to provide more incentives for participation.

Now while this blog post may seem a little gloomy about the future of ACOs, I haven’t found all parts of the regulations to be hindering to their development. The regulations take a step in the right direction by recognizing the PCMH model as a key foundation to building an ACO. In my next blog, I’ll talk more about the opportunities within the regulations for the PCMH to serve as a roadmap to building ACOs and the good things that come along with it!

What do you think of the new ACO regulations? In what ways did CMS get the regulations right? Where did they miss the mark? How do you think the regulations will affect ACOs in the near future?

Please feel free to publish the above blog in full or in part with attribution according to the Creative Common license.

MEDecision Powers a Successful MTM Program

blog.nospam@nospam.medecision.com (Eric Demers) — Tue, 22 Mar 2011 03:22:00 -1000

In the wake of reform, healthcare is clearly heading toward more member-focused, value-based care delivery and management models such as accountable care organizations (ACOs) and the patient-centered medical home (PCMH). It has become widely accepted that these approaches are our best hope for improving the quality of care, reducing waste and maintaining costs. In the past few blogs, we’ve established that medication therapy management (MTM) is crucial to the success of these new models. This is especially true given the impact that medication-related adverse events have on the total cost of healthcare and the quality of life for millions of Americans.

As we’ve discussed, the best opportunity to optimize therapeutic outcomes lies in MTM programs that are powered by analytics, business and clinical intelligence derived from comprehensive data within the health plan and robust care coordination tools. Given their rich data stores and experience in care management across populations, health plans are the entity best suited to provide the tools needed for effective MTM programs.

At MEDecision, we’re leveraging our 20-plus years as a leading innovator of health information technology solutions to develop the technologies to empower insurers in their efforts to implement MTM initiatives. Our products have always been designed to drive value, improve quality and lower costs. Our current suite provides the all-inclusive, member-focused collaborative health management tools necessary for successful ACOs and patient-centered medical homes and, consequently, MTM programs within them. It includes:

InFrame™: A set of provider-focused tools to facilitate health management for physicians, ACOs and medical homes as members transition to various care delivery settings across the healthcare continuum.

Nexalign^®: InFrame’s applications are powered by the Nexalign decision support services solution to provide the business and clinical intelligence needed to manage an effective ACO.

Alineo^®: InFrame also integrates with the Alineo health management platform to enable health plans to provide comprehensive MTM programs to employer groups and other traditional lines of business.

Quality and value are two words that are going to be used quite regularly in the “new” era of healthcare. Anyone who attended HiMSS11 a few weeks ago got a pretty clear sense that we’re not just talking about changing the system this time around, it’s really happening. We’ve been anticipating this for some time at MEDecision, and so we’ve focused on refining and aligning our products to help users achieve maximum quality and value. We like to think that, in this sense, our legacy of innovation continues stronger than ever.

To learn more about how MEDecision’s solutions can power your MTM program, please check out an archive of last week’s webinar on the topic: Medication Therapy Management: An Opportunity to Lower Costs and Improve Outcomes

Eric Demers is executive vice president and chief strategy officer at MEDecision, a leading provider of collaborative health management solutions. Learn more about MEDecision at www.MEDecision.com. Follow the company on Twitter at @MEDecision and on Facebook at www.MEDecision.com/Facebook.

Please feel free to publish the above blog in full or in part with attribution according to the Creative Common license.

Four Major Points from the Third Annual Medical Home Summit (Part Two)

blog.nospam@nospam.medecision.com (Matt Adamson) — Mon, 21 Mar 2011 04:02:00 -1000

In the previous blog we looked at two of the four major points I felt were made at last week’s Medical Home Summit in Philadelphia. Today we’ll look at points three and four…

Point #3: Those at the event seemed to recognize that pharmacy and behavioral health are crucial parts of the medical home/ACO approach – not just ancillary services.

If care coordinators don’t have access to medication therapy and behavioral health information, there are far too many lost treatment opportunities. Thankfully, a number of presenters at the conference highlighted this fact.

Marie Smith, a University of Connecticut Pharmacy professor discussed how being more closely aligned with primary care will allow pharmacists to better understand the patient’s medical condition as it relates to the medication list. From there it is the “systematic assessment of each medication for appropriateness/indication, efficacy, safety and adherence (in this sequence) to achieve optimal therapy goals that can resolve 70-80% of medication–related problems in primary care.”

Terri Maxwell and Jillian Baer of Hospice Pharmacia, a subsidiary of ExcelleRX in Philadelphia, described a similar approach, with a focus more on the opportunities of managing poly-pharmacy more closely. Ms. Maxwell defined polypharmacy as the “use of multiple drugs and/or the administration of more medications than clinically indicated.” Polypharmacy management offers some fertile ground for improvement; particularly when administered within the context of the medical home. Patients seeing multiple specialists for chronic and acute conditions often receive prescriptions to treat the adverse drug reactions resulting from the other medications on the list. From this perspective, getting the list right not only saves money, it results in higher quality outcomes – patients actually often feel better when the drug list is reduced.

Bringing behavioral health into the medical home also results in a lot of low-hanging fruit. The University of Colorado Depression Center’s Benjamin Miller (@miller7 on Twitter) gave a presentation describing some of the opportunities. One involves the cost of care when treating heart conditions, high blood pressure, asthma, diabetes, etc. Some examples showed annual cost savings of as much as $2,000 per patient if mental health was treated too. Rachel Block, Deputy Commissioner at the New York Department of Health, advocated that “basic physical and mental healthcare should be available in all settings.” I left her presentation with the feeling that New York has determined that providing coordination between primary care and mental health is a major component of its health IT strategy. Like many of the issues and opportunities, making this happen involves the clinical integration of behavioral health with primary care and payment reform. I think that both presentations showed that we have work to do, but we are pointed in the right direction and require tools to enable this type of collaboration.

Major point number four from the Summit was that the PCMH begets the ACO which, in turn, begets the PCMH. Got that?

The term Accountable Care Organization/ACO is currently healthcare’s hottest topic. During the Summit, the new Center for Accountable Care group of the Patient Centered Primary Care Collaborative (PCPCC) held a conference call during which at least 20 people were in the hallway of the conference listening in and taking part in the discussion. During this, we learned that there were more than 100 participants involved. What I am getting at is that it is clear there is great interest in the topic — and it will grow exponentially when CMS releases its ACO regulations at the end of the month.

The presentations at the summit demonstrated that there has to be a level of care coordination within the ACO construct in order to drive the savings required to sustain the model. In addition, the PCMH joint principles could easily be used as joint principles of an ACO, so you can see where the ACO and PCMH share the same genome. It is also assumed that ACOs will largely be comprised of a number of medical homes all coordinating care with other ACO members such as specialists, hospitals, pharmacy, mental health, etc. This makes it likely that many ACOs will spring up first within areas where there is a concentration of medical homes. Conversely, payment reform will be driven by the proliferation of the ACO. This may lead to the establishment of more medical homes because it provides additional incentive to become involved with the ACO since it lessens risk for interested primary care physicians. The safe assumption is that legislation will produce the impetus for payment reform along with business opportunities that will make the ACO happen and, when it does, many of the hurdles to a faster rollout of the medical home will start to break down.

I am sure other Summit participants would highlight other major points of the event, depending on their perspective and the actual sessions they attended. Hopefully, this two-part blog provides a somewhat useful summary. I would recommend this conference for anyone looking for an affordable way to deepen their understanding of the medical home concept. To the event organizers, I would suggest adding “ACO” to the title. It would probably create even more buzz and result in a larger audience without having to change the program all that much. Both concepts involve clinically integrating the PCMH Neighborhood and using payment reforms to provide accountable care.

When the ACO regulations come out in a few weeks, look for more information from us about the relationship between the ACO and the PCMH and the technology that will be required to make it happen.

Matt Adamson is vice president of health solutions for MEDecision, a leading provider of collaborative health management solutions. Mr. Adamson is currently responsible for defining the vision and strategy for MEDecision’s medical home products and services, representing MEDecision with stakeholders interested in furthering the medical home movement in the U.S. Learn more about MEDecision at www.MEDecision.com. Follow the company on Twitter at @MEDecision and on Facebook at www.MEDecision.com/Facebook.

Four Major Points from the Third Annual Medical Home Summit (Part One)

blog.nospam@nospam.medecision.com (Matt Adamson) — Thu, 17 Mar 2011 10:10:00 -1000

Some of my MEDecision colleagues and I attended the Third Annual Medical Home Summit in Philadelphia earlier this week. Once again, the event was an opportunity to completely immerse oneself in the various trends and topics that have emerged around the PCMH recently and to experience a variety of different perspectives.

While I found virtually every minute of the conference to be worthwhile, there were four major points I took away from it. I’ll focus on the first two today and the other two in the next blog.

First, it seems employers are ready to take control. Well, almost.

Dr. Paul Grundy, chair of the Patient Centered Primary Care Collaborative kicked off the conference by speaking not so much as a leader of the medical home movement, but as the lead of a large employer (IBM) that provides health coverage for over 100,000 employees. He implored the employers in the audience: “Stop buying from unaccountable care organizations…move your jobs out of those places fast.” He then quoted Kaiser’s George Halverson, saying: “We don’t have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked micro systems, each performing in ways that too often create sub-optimal performance…for patients.” Dr, Grundy offered statistics showing that implementing medical homes in existing care delivery systems has resulted in a 9.6% reduction in total costs on average, and has improved quality across the board.

Another presenter was Andrew Webber, president and CEO of the National Business Coalition on Health, which brings employers together with a vision to provider better health and better care at lower costs for their employees. He stated that “A consumer/patient centered, primary care-anchored delivery system, focused upstream on health improvement, disease prevention and chronic care management” would allow employers to realize his organization’s vision, provided the right value-based initiatives were available.

There is no doubt the medical home is working. There was a distinct energy in the room and a prevailing feeling that employers were wondering why they’re not already involved in medical homes. The answer, of course, is because there are still a number of hurdles to clear. One involves the relationship between payers (employers and health plans) and primary care physicians and who is going to take the first leap.

Physicians still must undergo a rather painstaking and costly implementation and transformation process in order to attain a patient-centered approach that significantly impacts costs and the quality of care. And, most primary care practices don’t have the resources to take it all on simply in the hope that future reimbursement models will make it worthwhile. Without reimbursement contract realignment, the medical home can only tread water. While some large employers and a few health plans are showing some willingness to pay up front to help select practices get there, the majority of payers have been waiting and hoping for it to happen so they can simply join an already transformed care delivery system.

Right now it seems that we are still moving a slow boat of opportunity toward adopting this better system of care. Fortunately, more payers are climbing aboard to move things along more quickly as overall healthcare costs continue to escalate and legislation is introduced that makes the gamble worth it for those charged with buying commercial healthcare.

The second major point to emerge from the conference is that care coordination is the lynchpin for success. Unfortunately, we can’t completely agree on what it is.

Practically every speaker talked about how their medical home programs have been successful due to the introduction of some element of care coordination within the primary care practice. It is clear that having someone responsible for various aspects of patient follow up, transitions in care and proactive population management results in healthier patients and lower costs. However there is not a great deal of agreement over specific role definitions or what to call these resources. In the presentations our team attended, names given to those in this role included care manager, care coordinator, nurse navigator and medical home facilitator. The credentialing requirements also vary. Some models require a nursing or nurse practitioner background, while others look at leadership or project management capabilities as the most important attributes. The time allotment also varied widely; from 4-6 hours per week coordinating patients for 2-3 primary care physicians to one care coordinator for every 150 patients. Other implementations solely utilize health plan care managers to perform the function as needed.

These differences reflect a healthcare landscape that has a high degree of inconsistency in areas of reimbursement models, available skill sets, technology and the ability for practices to absorb all of the change required to implement medical homes from one implementation to the next. While all presenters indicated at least some degree of success at a number of measurable quality and cost factors and described the ability to coordinate care as a central tenet of that success, I believe this variability is creating yet another hurdle. Taking the next step means coming to agreement on fewer versions and descriptors for the care coordination function so that repeatable tools, processes and revenue models can be developed to support this very important role and allow a faster, larger scale rollout.

The good news coming from this conference is that everyone recognizes the value of the role, which is a good foundation for agreeing on the details.

Matt Adamson is vice president of health solutions for MEDecision, a leading provider of collaborative health management solutions. Mr. Adamson is currently responsible for defining the vision and strategy for MEDecision’s medical home products and services, representing MEDecision with stakeholders interested in furthering the medical home movement in the U.S. Learn more about MEDecision at www.MEDecision.com. Follow the company on Twitter at @MEDecision and on Facebook at www.MEDecision.com/Facebook.

Technology is Essential for Successful MTM Programs

blog.nospam@nospam.medecision.com (Eric Demers) — Tue, 15 Mar 2011 02:58:00 -1000

In the past two blogs we’ve looked at why medication therapy management (MTM) is important for evolving care management and delivery models such as accountable care organizations and patient-centered medical homes, and how MTM presents a real opportunity for health plans. So let’s assume that readers understand those two points and are interested in actually instituting an MTM program. What exactly is involved?

Well, in a word, technology. It’s essential to have the proper systems in place that can perform the specific tasks and procedures necessary for an effective MTM program. Unfortunately, most of today’s provider systems don’t offer the population-based analytics needed for MTM, nor do they have the care coordination tools to manage members and their medications as they move across the continuum of care. For this reason, it’s helpful to take a very close look at the exact requirements for MTM solutions.

Essentially, the technology to support an MTM program should be comprised of three main components.

The first is a comprehensive medication list within a member’s clinical record summary. It is comprehensive in the sense that it aggregates all prescriptions that come through the health plan, regardless of where they originated, which is something that electronic medical record systems and pharmacies cannot do today. This will include the member’s medication possession ratio, decided through analytics, which identifies under-utilization of medication therapy, and the ability for the care manager to add member-reported medications. These are an important piece of the puzzle, as over-the-counter herbal supplements, for example, can interfere with medication such as chemotherapy.

The second component is population-based analytics and reporting for measuring and managing medication therapy programs using claims, pharmacy, HIE and lab data, including:

· Generic/formulary versus brand equivalents. Health plans and ACOs can use analytics to help optimize generic utilization.

· Polypharmacy. Health plans and ACOs can easily identify patients on multiple medications.

· Adverse drug events. Analytics applied to claims, pharmacy and clinical observational data (such as vital signs and lab data against the member’s medication profile) can help prevent the 1.5 million adverse events that are caused by medication errors each year.

· Drug therapy efficacy. Analytics applied to longitudinal health plan data can help determine the efficacy of drug therapy programs by identifying dosage problems, duplicate therapies or the need for additional drug therapy.

· Medication Adherence. Analytics can be used to provide information about populations in general and at the provider and member levels to help identify and manage adherence issues.

The last IT component of an MTM program is provider-based care management tools. In addition to the comprehensive medication list, care coordinators or managers within a medical home need certain other core resources, such as:

· Medication therapy review. This provides the ability to assess medication therapies to identify medication-related problems and create a plan to resolve them.

· Medication-related plan. The ability to:

o    Incorporate medication therapy information into a patient’s plan of care in order to optimize their treatment plan and overall health

o    Document pharmacy or provider consults.

o    Support the pharmacist’s plan of care for values that they may manage.

· Personal medication record. This includes a comprehensive record of the patient’s medications, including member-reported over-the-counter medications, herbal products and dietary supplements.

Over the course of our 20-plus years in the industry, MEDecision has forged a reputation for being at the forefront of innovation to support healthcare’s changing needs. The ACO, PCMH and MTM trends are no different. In the next blog we’ll take a look at how our technologies can help health plans deliver successful MTM programs and capitalize on the various benefits they stand to offer.

Eric Demers is executive vice president and chief strategy officer at MEDecision, a leading provider of collaborative health management solutions. Learn more about MEDecision at www.MEDecision.com. Follow the company on Twitter at @MEDecision and on Facebook at www.MEDecision.com/Facebook.

Please feel free to publish the above blog in full or in part with attribution according to the Creative Common license.

Integration and Virtual ACOs

blog.nospam@nospam.medecision.com (Matt Adamson) — Mon, 14 Mar 2011 02:59:00 -1000

I read a great article by Joe Flower on KevinMD.com (linked here) about integration and virtual accountable care organizations (VACO) that I thought was right on point. I like that Joe references the use of pharmacists and tighter management of the medication list as key drivers of higher quality outcomes at a lower cost. At MEDecision, we have found that a there is a great opportunity with the implementation of MTM programs and have pointed a portion of our product strategy toward that so health plans and ACOs can take advantage of this capability (in fact, on Wednesday we’re conducting a webinar on MTM, which you can learn more about here).

In addition, I would encourage us all to begin thinking and using the idea of VACO in future communications because it is likely the only way we can take the model beyond where it is today – centered mostly on IDNs. Health plans that develop programs to support the creation of VACOs should find themselves at a competitive advantage when the exchanges take effect in 2014 and there are a number of opportunities for health plans to provide value to the ACO beyond reimbursement. Because the connectivity among VACO entities will be more fluid, we cannot expect that all members of the ACO will use the same EMR, so some form of health information will be needed to connect all of the stakeholders within the ACO. We are really talking about a clinically integrated PCMH Neighborhood that has the added component of managing bundled payments in partnership with health plans to help manage the risk – ACO.

Read more about this in this previous blog: Optimization of the New PCMH Neighborhood.

Medication Therapy Management: An Opportunity for Health Plans

blog.nospam@nospam.medecision.com (Eric Demers) — Tue, 08 Mar 2011 03:00:00 -1000

In taking a thorough look at medication therapy management (MTM), as we do in our latest e-book and upcoming webinar, it’s important to understand that it’s not necessarily a new topic. MTM initiatives exist today and have for some time. The point we’re making is that ownership and administration of them needs to shift to health plans in order for MTM to have maximum impact.

In 2010, 99.9 percent of MTM programs were provided by pharmacists[i]. However, most of these were/are geared toward maximizing medical prescription utilization rather than optimizing health outcomes. In part, this is because pharmacies lack comprehensive medical information about patients. Similarly, providers’ efforts to effectively deliver MTM programs are limited by their lack of both comprehensive medical records and care coordination as patients move across the continuum of care.

Historically, pharmaceutical companies have focused on just one aspect of MTM: medication adherence. This is because they’ve lost hundreds of billions in revenue due to unfilled prescriptions. To combat this, the industry has spent incredible amounts of money developing solutions — things like packaging designs and patient education programs— often with mixed results.

Combine these factors with the increasing recognition among employers that medication adherence is crucial to maintaining a healthy workforce and keeping overall healthcare costs down, and the need for stronger and more effective MTM programs becomes obvious.

Health plans are the most likely to have the tools needed to optimize health outcomes and lower overall costs through MTM. Yet today, many payer-led programs are extremely basic; involving little more than simple letter campaigns. And the majority of health plan-driven MTM programs generate drug savings but not a full return on investment.[ii] Some health plans are incorporating certain components of MTM into programs to reduce hospital readmissions; focusing on member education, adherence, polypharmacy (the use of multiple medications by a single patient) and drug interactions. Despite slow adoption of MTM programs by health plans, industry studies do provide enough evidence to suggest that they are a way to reduce adverse medication events, improve health outcomes and reduce costs, with at least one study reporting an ROI of 3.5:1.[iii]

The federal government has recognized the need to support health plans in implementing MTM programs and the information technology (IT) required to make them work. In fact, the reform law’s new mandates for medical loss ratios (MLR – something we examined in-depth in a previous e-book and webinar) consider MTM to be an activity that improves healthcare quality and, therefore, something that qualifies as a medical loss expense.

Clearly, there is vast potential for effective MTM programs. There’s no doubt that the need exists to better manage how patients perceive, understand and adhere to their medication regimes and how, with the proper technologies, health plans are ideally positioned to make it happen.

What do you think? Do you agree that better managing patients’ medications is a good idea and something that can significantly improve the cost and quality of care? Are health plans, in fact, the one stakeholder in the healthcare system that can successfully administer these programs?

[i] 2010 Medicare Part D Medication Therapy Management (MTM) Programs, Centers for Medicare and Medicaid Services, June 8, 2010.

[ii] Medication Therapy Management Digest: Perspectives on the Value of MTM Services and Their Impact on Health Care. American Pharmacists Association, April 2009, p. 18.

[iii] Ibid

Medication Therapy Management is Essential to the Success of Emerging Healthcare Models

blog.nospam@nospam.medecision.com (Eric Demers) — Thu, 03 Mar 2011 07:04:00 -1000

As I pointed out in the previous blog, one of the biggest buzzes at HiMSS11 was the growing prevalence of proactive, value- and outcomes-based care delivery models such as accountable care organizations (ACO) and the patient centered medical home (PCMH). We’re all aware by now that this is an outgrowth of reform, which is largely targeting the excessive wasteful spending that plagues the U.S. healthcare system.

With that established, it’s important to examine the factors that comprise wasteful spending in healthcare, and medication-related problems are one of the most significant. They account for some 1.5 million preventable adverse events each year that cost the health insurance industry an estimated $177 billion in additional healthcare programs[i].

Congress coined the term medication therapy management in the 2003 Medicare Modernization Act. It is defined by the American Pharmacists Association as “a distinct service or group of services that optimizes therapeutic outcomes for individual patients.” As we move to more comprehensive and patient-centric care management models that replace fee-for-service with outcomes-based reimbursement that emphasizes care coordination as patients (especially those with multiple co-morbidities) move across the care continuum, MTM will be critical.

And this creates a unique opportunity for health plans. Since they accrue the most comprehensive data regarding a member’s health services and medications, payers are best positioned to ensure optimized health outcomes through MTM tools and programs. Consequently, this will significantly increase the need for health information technology tools for population-based and individualized analytics, quality reporting and care management.

We cover the MTM issue and its various implications in the latest edition of our MEDecision Insight Series of e-books. I invite you to download “Medication Therapy Management — A Case for Health Plan Intervention” here and share your thoughts with us on this topic, which I think will only grow in relevance and prominence in the coming weeks and months. Also, we’re conducting a complimentary webinar on MTM on Wednesday, March 16. You can register for that here.

I hope you can join us.

[i] Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model, the American Pharmacists Association and the National Association of Chain Drug Stores Foundation, Version 2.0, March 2008, p. 3.

Please feel free to publish the above blog in full or in part with attribution according to the Creative Common license.