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.

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.  

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?

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. 

Another HiMSS conference is in the books and, despite some aching feet and sleep deprivation, one can’t help but reflect back on the week and form some general impressions…

In speaking with my MEDecision colleagues who attended the show, there was agreement that proactive care management is emerging as the future of healthcare. It seemed that the predominant theme at the show among vendors and customers alike was finding ways to better manage the health of patients and populations, rather than their illnesses. At MEDecision, we’ve said many times that it costs less to keep people healthy than it does to care for them when they’re ill, and it seems that thinking is permeating the industry. Of course, this is due in large part to reform and its emphasis on proactive versus reactive care, but the bottom line is that value-based, proactive care management is real, it’s happening now and it’s only going to keep growing.

Collaboration and health information exchange between payers and providers were once again prominent themes at the show this year too. However, unlike HiMSS 2010 where the concepts and ideas were just sort of floated, this year there was a genuine sense of urgency to make progress. Last year we talked about collaboration and health information exchange between providers and payers as really good ideas and something we should do someday. That has changed. There seemed to be a very strong sentiment at the show that waiting much longer isn’t an option and that we need to find ways to connect the two communities and share data from disparate sources to support proactive clinical decisions at the point of care. This may be an outgrowth of the first point. It’s certainly a lot easier to proactively manage patients when you have all of the available data, clinical intelligence, decision support and so on.

All of this was rather inspiring to us MEDecision folks because it validates the direction we’ve been taking with our products and strategies for the past year or so. I think we have a bit of head start over some of our counterparts in that promoting proactive care management and the sharing of clinical data across platforms and delivery mechanisms is something we’ve been perfecting for years. It’s nothing new to us. I think we’re definitely right in tune with the industry’s needs and where they’re headed in the future.

So despite a long and intense few days, it’s safe to say that my MEDecision colleagues and I left HiMSS11 with great optimism. It will be fun to watch how things evolve over the coming weeks and months.

Today marks the beginning of another active and busy HiMSS for MEDecision. As always, we have a lot planned to promote our message, which this year will focus on how our various technologies can help build successful patient-centered medical homes and accountable care organizations. If you're already at the show, planning to be here at some point this week or just generally interested in seeing all that we have going on, go to www.medecision.com/himss for a complete overview. You can also see some of our HiMSS activities on YouTube at www.medecision.com/YouTube.

We hope to have more updates for you as the week progresses. 

At first glance, the new medical loss ratio (MLR) mandates may seem daunting for health plans, but the Department of Health and Human Services (HHS) has outlined a number of care and quality improvement measures that fit the bill. As promised in my previous blog, today we’ll take a quick look at these categories and discuss how health plans can utilize new health information technologies to meet some of these requirements, while improving care and reducing costs. Here are the five categories:

As we forge ahead in healthcare’s post-reform era, one of the hot topics in the industry is medical loss ratio (MLR). MLR is the minimum percentage of premiums that health plans must devote to clinical services and other activities that improve care, rather than to administrative and overhead costs or revenue. For many plans, it’s a whopping 85%. Starting this year, health plans must meet the new MLR mandates or refund the difference to policyholders beginning in 2012. The pressure is on, but there’s no need to sweat. Many activities in which health plans are currently engaged or planning to deploy, such as health information technology (IT), meet the requirements.

The MLR mandates might seem a bit harsh and complex, but the reason they exist is relatively simple: wasteful spending. It is estimated that the American healthcare system wastes upwards of $1.2 trillion annually[i]. The legislation, in essence, is seeking to coordinate care to make it more proactive and preventative. The thinking is that keeping people healthy is cheaper than treating them when they’re ill. Ideally, this approach will mean lower expenses, less waste and, most importantly, healthier people.

To test this concept, let’s take a look at what contributes waste in the current healthcare system and theorize some ways to reduce it.

The Chronically Ill

Approximately 80% of the United States’ $2.2 trillion in healthcare costs can be attributed to patients with chronic illnesses[ii]. They get the highest levels of medical management from health plans in today’s MCO-focused system, yet 60% of them adhere poorly to evidence-based treatments. This generally results in excessive (and often unnecessary) ER visits and hospital admissions.

Duplicate Services

Current malpractice laws often force physicians to practice defensive medicine, ordering multiple and often duplicative and redundant tests and procedures. The reform law doesn’t address this issue, so it’s likely to continue. That’s additional burden for an already overtaxed system.

Provider Utilization

Reform may bring some 50 million uninsured individuals into the ranks of the insured. It’s estimated that these patients will receive 40% of the amount of health resources of members who already have insurance. The influx of new patients will dramatically increase provider utilization rates.

So what are some ways to help counteract these primary sources of waste?

First, we need health plan members to be more proactive. Too often, chronically ill patients don’t fully understand their role in the care process, leading to poor drug and care adherence. With the proliferation of email, text messaging, mobile phone applications and other communications advancements, it’s easier than ever for health plans to interact with members to keep their care plan on track. As these exchanges grow and expand, it will be necessary to provide health plans with actionable, clinically-validated data.

In order to prevent the problem of duplicative services and eliminate waste, it’s also necessary to deliver information to the point of care. Most patients see more than one provider, something even more prevalent among the chronically ill. Through health information exchanges, real-time data can be delivered to providers in virtually any format and through a multitude of devices to provide a consistent and more complete view of each patient’s medical situation.

Another way to address the excessive costs associated with the chronically ill is through drug therapy, or medication therapy management (MTM). MTM applies analytics technology to the available medical information for individual patients to enable better adherence, avoid drug interactions and identify proper usage of generics. It has been shown to help identify and enforce the best use of drugs and decrease ER visits and admissions. In some cases it has produced a 4:1 return.[iii]

Also, incentives for payers and providers must be aligned. Shifting reimbursement models from fee-for-service to accountable care organizations will encourage providers to proactively engage with patients because providers will share in generated savings. The growth of the value-based insurance design concept will have a similar impact. All of this will require advanced technology and care management tools that can link multiple providers and health plans so that care is appropriately coordinated.

Together, each of these methodologies can help foster more coordinated medical management. And, under reform, the cost of implementing them can be attributed to MLR. To this end, in the next blog I’ll closely analyze the U.S. Department of Health and Human Services’ five categories of clinical- and/or quality-related activities that qualify as MLR costs and examine how health plans can utilize health IT to meet the MLR requirements.

In the meantime, what do you think about the impact of MLR regulations? Will they impact health plans as much as some think? And how can technology help alleviate the burden?

We talk more about the new MLR mandates in the second of our new series of e-books called MEDecision Insights. I invite you to download your complimentary copy of “Medical Loss Ratios: Important Implications for Care Management” and share your thoughts with us today. Get your e-book here: http://www.medecision.com/insightseries.

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Eric Demers is senior vice president of health and life science at MEDecision, a leading provider of collaborative healthcare 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.

[iii] Frojo, Renée. “Health Plans Demand More ROI Data as CMS Toughens its Regs on Medication Therapy Management,” AIS Health, Inc., October 19, 2010. http://www.aishealth.com/DrugCosts/DBN_Plans_Demand_More_ROI_Data.html.

Timing and geography converged rather nicely for MEDecision last week as we attended two important events in Chicago: the Blue National Summit and the URAC Quality Summit. Needless to say it was a busy few days for some of us, but overall a very productive and successful experience all around.

The highlight of the week took place at the URAC Quality Summit. There, URAC President and CEO Alan Spielman presented MEDecision with notice that we received URAC accreditation for our disease and case management programs. This is extremely significant because, as those who have been through this process can attest, gaining URAC accreditation is exacting. We’re extremely happy with the outcome. Being URAC accredited enables us to offer certain advantages to existing and potential customers seeking their own accreditations, so it is truly a key differentiator.

It was also encouraging to see that the predominant themes at Blue National Summit very much reflected our perceptions of the market and where it’s headed. The patient-centered medical home continues to gain momentum and is shaping up to play a significant role in the future of healthcare, particularly in the post-reform era. There was also a lot of talk about remedying issues like unsustainable costs and sub-optimal care quality and access. The proliferation of wellness and prevention as foundational to care management was another popular topic, as was the anticipated growth of healthcare analytics and the need for increased collaboration and partnerships throughout the system.

I think the majority of us in health IT who attended both events left with reason for optimism. In all of these discussions there are obvious (and emerging) opportunities for technology. Beyond doubt, healthcare is on the cusp of unprecedented change and, either by mandate or by choice, the industry’s reliance on technical solutions will grow exponentially. Change of this magnitude naturally brings with it an amount of uncertainty and anxiety, but I think it can also be an era of tremendous opportunity. Last week in Chicago fueled my eagerness to see how it plays out for each of the various constituents.