Managed Care PDF

Managed Care Mattie M. Follen, PharmD, MS Objectives At the conclusion of this lecture, students will be able to: Identify the goals and types of managed care organizations Define each type of managed care organization and differentiate between them Explain formulary management, drug utiliz...

Managed Care Mattie M. Follen, PharmD, MS Objectives At the conclusion of this lecture, students will be able to: Identify the goals and types of managed care organizations Define each type of managed care organization and differentiate between them Explain formulary management, drug utilization review, and disease state management Identify the purpose of a Pharmacy & Therapeutics Committee Discuss outcomes research and list the different methods used in economic evaluations Describe the current directions in managed care Managed Care System to deliver health care while reducing costs and improving the quality and access to medical and pharmacy care Managed care pharmacy – deliver effective medications while improving overall health care for the patient Managed Care Organization Goals: Prevent disease Focus attention on wellness Improve medication therapy Base decisions on the entire population versus the individual Control cost Managed Care Background Managed care organizations (MCOs) trace back to prepaid health plans in the early 1990s Precursors for current health maintenance organizations (HMOs) HMO Act of 1973 Authorized federal funds to help develop HMOs and preempted state laws that prohibited prepaid plans National Committee for Quality Assurance (NCQA) Non-profit organization formed in 1990 Measures health plan performance through a set of performance metrics Health Plan Employer Data and Information Set (HEDIS) Types of Managed Care Organizations Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Point-of-Service (POS) Plans Exclusive Provider Organization (EPO) Consumer Directed Health Plans (CDHP) Pharmacy Benefit Manager (PBM)  Health Maintenance Organization (HMO) Members prepay a premium to receive medical services provided by physicians or other medical providers under contract Managed Care Organizations HMO Subtypes: Staff model Group model Network model Independent practice association  Preferred Provider Organization (PPO) Managed Care Includes a contracted network of physicians and hospitals from which the member may choose Organizations Advantage – offers less control over providers than HMOs Managed Care Organizations Point-of-Service (POS) Members may go out of network for an increased deductible or co-payment Hybrid of PPO and HMO Exclusive Provider Organization (EPO) Limits or does not cover out of network services, physicians, or facilities Similar in structure to PPO plans Managed Care Organizations Consumer-directed Health Plan (CDHP) Combines a high deductible health plan with a tax advantaged health reimbursement arrangement or a health savings account (tax-exempt money set aside to pay for qualified medical expenses for the individual) Pharmacy Benefit Manager (PBM) Acts on behalf of the insurer, MCO, or government program to help maximize appropriate drug utilization and contain costs Provides a combination of clinical and business services Government Programs Millions of people receive their health-care benefits through government programs The Social Security Act of 1965 Established Medicare and Medicaid Medicaid – provides general public assistance to the poor and disabled Medicare – pays a major proportion of medical costs for those aged 65 years and older Medicare Modernization Act of 2003 established Part D  - Inpatient hospital services - Some nursing home services Part A – Hospital Insurance - Some home health-care costs - Hospice - Physician services - Outpatient hospital services not covered under Part A Part B – Outpatient medical services - Durable medical equipment - Ambulance services Components Allows beneficiaries to enroll in private plans other than the traditional Medicare program of Medicare Part C – Medicare Advantage health plan - Private fee for-service - HMOs - PPOs Outpatient prescriptions - Traditional Medicare with a freestanding prescription drug plan Part D – Prescription drug coverage - Integrates medical and prescription benefits  MCOs utilize many tools to improve the Clinical Tools quality of patient care while containing cost In Managed Clinical Tools: Formulary management Care Drug utilization review (DUR) Disease state management Formulary Management Formulary – list of medications and related information used in the diagnosis, prophylaxis, treatment of disease, and promotion of health Represents the clinical judgement of physicians, pharmacists, and other experts Formulary management allows for identification of the most medically appropriate and cost-effective drug therapy Uses evidence-based processes to select formulary medications Hospitals, acute care facilities, home care settings, and long-term-care facilities may have formularies as well Pharmacy and Therapeutics (P&T ) Committee Responsible for deciding which drugs are included on a formulary as well as managing, updating, and administering it Comprised of physicians, pharmacists, and other professionals in the health- care field Must meet regularly to keep the formulary current  Open formulary Provides coverage for all medications regardless of whether or not they are listed on the formulary Some products may not be covered (e.g. OTC agents or cosmetic products) Formulary Closed formulary Management A limited number of drugs are available and non- formulary drugs are not covered Partially/Selectively Closed Formulary Similar in structure to an open formulary; however, a few selected drugs are not covered Example of Formulary Co-Payment Tiers Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Non- Types of drugs Preferred Lifestyle or Generic preferred/Non- Self-injectables included formulary brand cosmetic formulary brand Co-payment Coinsurance (eg, Coinsurance (eg, (defined amount a percentage of a percentage of paid by the Lowest fixed Intermediate fixed Highest fixed the total cost of the total cost of member each amount (eg, $15) amount (eg, $30) amount (eg, $60) product paid by product paid by time a service is the member) the member) rendered)  Tool used by MCOs to promote the appropriate and effective use of medications that create positive patient outcomes Drug Ongoing, systematic process that looks at data Utilization before, during, and after dispensing medication to a patient Review Helps to control costs by decreasing the number of medications prescribed inappropriately or unnecessarily  1. The primary emphasis must be to enhance quality of care for patients by assuring appropriate drug therapy 2. The criteria and standards must be clinically relevant 3. The criteria and standards must be nonproprietary and Seven must be developed and revised through an open professional consensus process Principles of 4. The interventions must focus on improving therapeutic outcomes 5. Confidentiality of the relationship between patients and DUR practitioners must be protected 6. Principles must apply to the full range of activities, including prospective, concurrent, and retrospective drug use evaluation 7. Must be structured to achieve the principles of DUR  1. Identify optimal drug use – should be determined based on objective and measurable diagnoses and drug-specific criteria 2. Measure the actual use of medications – primarily obtained from prescription drug claims Five Steps of 3. Compare optimal and actual medication use – identifies discrepancies in patient's therapy or in DUR a physician's prescribing patterns 4. Take action to correct the identified discrepancies or problems 5. Evaluate the effectiveness of the DUR process Categories of Drug Utilization Review Prospective DUR Reviews performed before a medication is dispensed to a patient Ex. Guideline development and education Concurrent DUR Reviews performed at the time of dispensing or during the course of treatment Ex. Pharmacist verifies medication dosages, directions, interactions, therapeutic duplications, contraindications, and drug allergies Retrospective DUR Reviews performed after the patient has received the medication Designed to flag drug-related problems Disease State Management (DSM) Method used to improve quality of life and reduce health-care costs associated with chronic and costly medical conditions Goal is to identify and treat chronic disease states Slow progression Prevent complications Minimize treatment variability Improve patient care Common chronic conditions for DSM – diabetes mellitus, CHF, COPD, coronary artery disease, asthma, and hypertension Medication therapy management (MTM) programs optimize the therapeutic drug outcomes for all conditions the patient may have and not a single disease state Outcomes Research Evaluates a medical treatment in regards to clinical, economic, or humanistic results Outcomes research helps to determine how to improve care in a given population, with consideration of cost effectiveness and cost efficiency of health-care resources One component of outcomes research is pharmacoeconomic (PE) evaluation Different cost analyses describe PE evaluations Methods Used in Economic Evaluations Cost-minimization analysis (CMA) Compares costs of interventions that are considered therapeutically equivalent Cost-benefit analysis (CBA) Determines the benefits of an intervention and converts the benefit to a dollar amount Cost-effectiveness analysis (CEA) Determines if competing strategies have an advantage based on cost and clinical outcome Cost-utility analysis (CUA) A form of CEA that assesses the patient’s functional status or quality of life  Electronic prescribing Current Directions Specialty pharmacy and the Value of Patient-centered medical homes (PCMH) Managed Care Implementation of the Affordable Care Act (ACA) Electronic Prescribing (e-prescribing) The use of computing devices to enter, modify, review, and send drug prescriptions Many benefits of e-prescribing and its use is gaining momentum Federal government offered incentive plans for providers who use the technology to improve safety, quality, and efficiency One of the most important advantages to e-prescribing is improved accuracy Standardized data entry format Allows access to the patient's medication profile and electronic medical record May address issues with formulary adherence and quantity limits Pharmacies benefit from improved efficiency Specialty Pharmacy No universally accepted definition of specialty pharmaceutical products Specialty distributers and pharmacies were created to address challenges associated with chronic disease states i.e., high cost, special handling requirements, reimbursement complexities, increased clinical support, customized dosing, complex delivery methods Specialty pharmacies allow for a more focused expertise that is not readily available through traditional retail and mail order pharmacies Fundamental Services Employed to Maximize the Value of Specialty Pharmaceuticals Medication management Utilizes prior authorization and step-therapy to encourage the use of preferred products, appropriate use of medications, and to reduce the incidence of adverse events Involves ongoing monitoring of disease progression, lab test results, and other pertinent clinical outcomes Patient management Education of patients Necessitates pharmacist involvement to promote patient adherence, adverse event monitoring, and coordination of changes in therapy Cost management Includes bulk purchasing and variations in benefit design (ex. placing co-payments on a higher tier and increasing the percentage of coinsurance paid by the patient) Distribution Takes into consideration special handling to maintain the integrity of the product during delivery processes Addresses the need for non-drug supplies such as syringes, needles, and disposable containers  Patient- Coordination of care for an individual patient through a team-based collaboration between health-care professionals Centered Medical Key components of a PCMH: Personal physician Focus on the whole person Home Access to quality care Active decision-making on the part of the (PCMH) patient regarding their own health The Affordable Care Act (ACA) Health reform law signed into action in March 2010 Structured around insurance reform and health system reform Allows consumers to comparison-shop for the best plan to meet their needs Other provisions of the ACA: Specifies a minimum set of benefits Allows children to stay on their parents' plan until age 26 Prevents denial of coverage based on pre-existing conditions Some provisions of the law are already in effect, others will be phased in over time Stakeholder Involvement Stakeholders Sharing of Financial Risk/Impact on Cost Commitment to Excellence/Impact on Quality Health-care providers - Take advantage of - Accept discounted (physician, hospital, performance incentives reimbursement rates pharmacy) (Pay for Performance) All stakeholders share in the financial risk and commit to the provision of - Choose MCOs that meet excellent care Health plans (employer - Incur lower premiums national quality standards for using cost-saving The balance between cost and group, Medicaid, Medicare) benefit designs - Promote appropriate DUR, DSM, and MTM programs quality is essential for managed care to function efficiently - Remit premium payment plans - Undertake health and - Incur fees to access care Members wellness education to (co-payment, make informed decisions coinsurance, deductible) References Clayton S, Martin K, Shalek K. Managed Care. In: Nemire RE, Kier KL, Assa-Eley M. eds. Pharmacy Student Survival Guide, 3e. McGraw Hill; 2014. Accessed July 26, 2022. https://accesspharmacy.mhmedical.com/content.aspx?bookid=1593&sectionid=99826362