Keenan Pharmacy Care Management (KPCM)

Transcription

1 Keenan Pharmacy Care Management (KPCM) This program is an exclusive to KPS clients as an additional layer of pharmacy benefit management by engaging physicians and members directly to ensure that the best possible drug therapies are chosen, based on their clinical effectiveness and overall cost to patients and the plan. KPCM uses an automated care management system to assess the prescriptions being written and identify appropriate therapeutic alternatives. Recommended prescription modifications are communicated to physicians and only if approved by the prescribing physician, new prescriptions are issued. The Current switch/acceptance rate from physicians is 70%. Program Options When implementing the program, the employer may choose one of three options: Preferred: any therapeutic change in prescription the doctor orders is automatically prescribed for the member. Voluntary: any therapeutic change ordered by the physician is discussed with the member for their approval prior to prescribing the change. Modified Voluntary: if the member does not respond to approve or decline the change, the therapeutic change ordered by the physician is sent to the member s pharmacy. Plan sponsors and participants both benefit from quality of care improvements and cost-savings. Immediate, measurable, and verifiable cost-savings Savings guarantee - Savings must exceed fees, otherwise fees are returned Lower out-of-pocket expense for members Exclusive rates through KPS The preferred program is a $1.50 PMPM with 100% ROI. Below are some Client Savings Examples.

2 Your clinical account executive will work with you to identify which clinical programs make sense for your plan given your claims data and unique benefits culture, taking into account member impact, savings, and rebate impact. Better health, drug, and pharmacy choices increase the effectiveness and affordability of clinical care. Our solutions improve patient health and safety and coordinate patient care across healthcare providers. These solutions prevent drug-related adverse events, detect potential issues, address gaps in care, identify savings opportunities, and improve adherence. The following Keenan Pharmacy Services Clinical Prevention Programs, are offered to coalition members at no additional cost. Prior Authorization Drug Quantity Management Retrospective Drug Utilization Review Specialty Rx Step Therapy Please see the KPS Clinical Addendum which outlines additional program fees. Programs we recommend are outlined below: Advanced Utilization Management Step Therapy Our Step Therapy program manages out prescription-drug waste within specific therapy classes by guiding patients to frontline medications before stepping up to more costly backup medications. Within specific therapy classes, several clinically effective medications are often available to treat the same condition. Step therapy takes advantage of these opportunities to direct a new patient to a clinically effective, lower-cost medication. Evidence-based clinical protocols for each step therapy module ensure patients receive cost-effective drug therapy that is clinically appropriate for their condition. Options For plan sponsors without current step therapy programs, the Comprehensive version of this solution allows members to opt out before implementation of a mandatory program. Plan sponsors that implement this program can offer a zero-dollar copayment over a three-month period to members taking targeted medications when they move to a generic. The Focused version enables any plan sponsor to allow members taking targeted prescription drugs to opt out prior to either the implementation of new programs or the removal of grandfathering from current programs. Benefits Benefits of Select Step Therapy include:

3 Voluntary program that allows plan sponsors to implement step therapy at any time Plan sponsors can increase savings while minimizing member disruption Estimated savings of $78 PMPY or more when used with the Advantage and implementing step therapy without grandfathering Removing grandfathering maximizes savings in current programs and allows members to try generics not available when the drug was originally prescribed Communications As illustrated below, we send a series of letters that explain the program and offer members the choice to participate. Prior Authorization Express Scripts prior authorization drives plan savings and patient safety by monitoring the dispensing of high-cost medications and those with the potential for misuse. Our program ensures drug coverage consistent with the plan s intent for the prescription benefit, while maintaining member and physician satisfaction. Twenty-four hours a day, personnel specially trained on our prior authorization program s diseases, drugs, and coverage criteria provide review services, giving physicians and pharmacists quick, easy access to information and ensuring effective treatment by monitoring patient response to therapy Limited List Advantage List Advantage Plus List Nonessential Therapy List A select group of high-cost drugs with proven potential of inappropriate use An expanded list of high-cost drugs with proven potential for inappropriate use A list of traditionally undermanaged drugs with a proven potential for inappropriate use A list of drugs with significant utilization for lifestyle indications and off-label inappropriate use

4 Oncology Package Pharmacogenomics List Proactive List Adjunctive Specialty List High Risk Prior Authorization (Medicare) An actively managed list that targets existing and new, high-cost oral oncology medications with potential for inappropriate use Includes quantity limits on most drugs An evidence-based list requiring a pharmacogenomic test be conducted prior to approval, as results of the test will guide therapy An actively managed program that targets new high-cost drugs with a low or unknown potential for off-label use An actively managed list that targets a subset of high-cost specialty medications with proven potential for inappropriate use Designed to drive patient safety by monitoring the dispensing of CMS-classified, high-risk medications Drug Quantity Management Drug quantity management reduces wasteful spending in the pharmacy benefit by aligning the dispensed quantity of prescription medication with dosage guidelines approved by the Food and Drug Administration. This supports safe, effective, and efficient use of drugs while giving patients access to quality care. In addition, dosing consolidation ensures that the pharmacy dispenses the most cost-effective product strength. For example, when appropriate, our Drug Quantity Management program guides a member to take one 40 mg tablet instead of two 20 mg tablets. Our Drug Quantity Management program delivers value by: Dispensing the most cost-effective product strength Identifying administrative errors through ongoing audits Limiting medication stockpiling and associated waste Encouraging clinically appropriate prescribing patterns We offer several drug quantity management models that: Ensure optimal quantities of medication are dispensed per copayment for the defined list of drugs Ensure optimal quantities of medication are dispensed according to a defined number of days for a defined list of drugs Allow custom capabilities to set limits based on a maximum dose per day Standard lists for our models include: Limited: A large list of limits in categories with a proven history of excessive use and stockpiling Advantage: A large list with a focus on chronic disease states, including specialty drugs Advantage Plus: A select group of traditionally under-managed medication classes that treat select chronic disease states Oncology*: An actively managed list that targets existing and new, high-cost oral oncology medications. * This list is only included in the Oncology Package.

5 Process Our adjudication system reviews each electronically submitted claim to ensure it complies with the plan s applicable benefit, formulary, and clinical safety parameters. Through our Drug Quantity Management program, online edits applied to drugs on the quantity limit list allow coverage up to a predefined amount per dispensing or days supply. For medications used to treat chronic conditions, we determine this amount using a 30-day regimen based on dosing guidelines and medical literature approved by the Food and Drug Administration. Prescriptions for quantities exceeding these limits will reject, alerting the pharmacist that the covered quantity has been exceeded. As appropriate, the pharmacist may correct the number of units submitted for coverage, dispense the amount allowed for the prescription up to the quantity limit, or contact the prescriber to discuss a possible change in dosage. To fill a prescription for a greater quantity, the prescribing physician may request a prior authorization for the original amount and strength prescribed. Reporting We provide quarterly savings and activity reports for our Advanced Utilization Management, including Prior Authorization, Step Therapy, and Drug Quantity Management. RationalMed RationalMed is an Express Scripts advanced Health Choices solution that improves clinical and financial outcomes by integrating and evaluating medical, pharmacy, and lab data to identify critical, actionable health and safety issues and gaps in essential care, and then direct effective outreach to physicians, pharmacies, and patients. RationalMed looks at the plan s total population, not just those patients with chronic and complex conditions. This clinical safety program helps prevent unnecessary and costly hospitalizations, adverse events, and addresses gaps in essential care all with no disruption for members and guaranteed savings for your plan. Evidence-based pharmacy-related standards of care are communicated to drive positive changes in physician behavior in response to potential safety concerns and gaps in essential therapy, testing, and suboptimal medication adherence. RationalMed focuses on the most important safety concerns across all disease states including pulmonary, endocrine, renal, urinary, and cardiovascular disorders.

6 ScreenRx As the industry s first actionable adherence solution, ScreenRx combines early detection with tailored interventions to improve member adherence and deliver healthcare savings to the plan. ScreenRx identifies members at risk of becoming non-adherent in the future and offers them tailored, proactive interventions before non-adherence becomes a significant issue. ScreenRx puts Health Decision Science into action by applying actionable data, behavioral science, and clinical specialization to improve health and financial outcomes an approach not offered by any competitor. Actionable data Our predictive models allow us to screen early for non-adherence and reach out to patients who are at an elevated risk before adherence becomes a problem. Behavioral science We have learned that 69% of non-adherence is due to behavioral issues such as forgetting or procrastinating, which calls for behavior-based interventions, such as renewal assistance and reminder devices. Our resources are scalable and applied to make the greatest impact on outcomes. Clinical specialization For those patients with clinical concerns such as side effects, we have specialist pharmacists at our Therapeutic Resource Centers who are experts at intervening effectively with at-risk patients. Specific to Medicare, our Enhanced ScreenRx offering is fully aligned with Centers for Medicare and Medicaid Services (CMS) Star Ratings and offers unique advantages, including: Medicare-specific predictive model built to serve this unique population Targeted population outreach Interventions and member communications designed for the Medicare population Focus on top Star Rating disease states affecting the Medicare population, including diabetes, high blood pressure, and high cholesterol For Medicaid, ScreenRx offers unique advantages. Our offering helps clients close more adherence gaps through member-tailored interventions for the most expensive and prevalent Medicaid disease states such as: Asthma/chronic obstructive pulmonary disease (COPD) Depression Diabetes High blood pressure High cholesterol ScreenRx Maximizes Results By focusing on the conditions for which we can make the biggest impact and on the patients most likely to respond to outreach, ScreenRx yields maximum results closing up to 20% rate of adherence gaps.

7 For a typical plan with 10,000 covered lives, 240 patients become newly adherent, delivering $82,560 in total healthcare savings a year.* *Performance varies by population. During the period from June 2014 through June 2015, ScreenRx contributed to nearly $81.2 million in total healthcare savings and more than 330,000 closed gaps in care for patients. Of patients targeted and impacted by ScreenRx, the solution added 27.4 million incremental days of adherence. Tailored member interventions delivered through ScreenRx demonstrate: 14% increase in adherent patients over those with no intervention 17% more patients remain adherent than those with no intervention Delivery of the right intervention to the right patient at the right time Effectiveness in sustaining member adherence For a significant Medicare study, a six-month pre-post analysis was completed on eight Medicare plans with more than 428,000 lives, to evaluate the change in the percentage of members with a proportion of days covered (PDC) 80%. A combined measure of adherence to diabetes, hypertension, and statin medications increased by 3.9 absolute percentage points (p<0.05). The results from this case study may underestimate the true impact of ScreenRx on adherence, as the current ScreenRx solution offers additional pharmacist follow-up outreach interventions and enhanced modeling. These additional features were not a part of ScreenRx during the pre-post analysis. ExpressAlliance ExpressAlliance offers an industry-unique approach to coordinating patient care. Our flexible portfolio of services enhances adherence, reduces drug errors, exposes clinical waste, and coordinates care for the plan s patients with chronic and complex conditions. Through the exchange of timely and actionable pharmacy data, we enable the pharmacy as a central component of a patient s plan of care. ExpressAlliance helps achieve maximum clinical and financial value from your healthcare partners. ExpressAlliance puts Health Decision Science into action by applying actionable data and clinical specialization to improve health and financial outcomes an approach not offered by any competitor. Patient-level and population views of actionable healthcare opportunities empower your authorized healthcare professionals with better data and insights to help them identify patient issues faster, prioritize patient outreach, and maximize the effectiveness of patient counseling. ExpressAlliance uses its own set of pharmacy utilization triggers to rank the sickest members with the greatest amount of pharmacy risk factors within the plan s population. This method of continuous patient evaluation is used to assist users with identification of those members suitable for targeted outreach. This innovative display and report also utilizes the Express Scripts Adherence Index SM to help identify members with future risk of non-adherence for diabetes, lipids, and hypertension medications. ExpressAlliance also offers secure, online access to real-time patient eligibility, medication history, clinical gaps in care, and potential savings opportunities.

8 Maximizing the Value of your Healthcare Programs ExpressAlliance maximizes the value of your healthcare programs by providing your healthcare team with access to actionable patient and population healthcare opportunities that: Enhance patient care and satisfaction Help you achieve maximum clinical and financial outcomes from your healthcare programs and partners Enhance the delivery of your healthcare program(s) When access and care are coordinated to reduce treatment gaps, maximize effectiveness, and improve outcomes, patients experience more coordinated, higher quality care, and are empowered to make healthier decisions. Additional Support We also offer the following solutions to help achieve your disease management goals: Blood Glucose Monitoring Offers members a convenient way to try formulary test strips and receive a no-cost formulary blood glucose monitoring kit. Medication Adherence Leverages behavioral science to provide support for members to address the complex reasons for therapy non-adherence. My Rx Choices Engages members via a suite of communications and tools, offered as part of our base solution, to make choices about their prescription benefit that are clinically sound and cost effective. Plan Design Modeling and Consultation Determines the financial impact associated with covering preventive medications and reduces the risk of unexpected costs. Value-Based Incentive Design Reduces or waives copayments for select therapy classes with the goal to improve member participation in disease management or lifestyle management programs. Standard drug lists support member engagement for diabetes, hypertension, coronary artery disease, heart failure, lipid asthma, COPD, and smoking cessation management.