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For health plans, driving value is critical. It helps ensure that provided care enables members to achieve positive health outcomes, which in turn results in reduced medical spending for health plans. To build guidelines around value-based care, the Affordable Care Act established the medical loss ratio (MLR).
Large group healthcare plans are required to reach an annual MLR of 85% or risk paying a rebate to policyholders. As the MLR is calculated (roughly) by the amount of plan premiums used to cover healthcare claims, plus expenses that improve healthcare quality—it’s largely a reflection of how successful the plan is in providing value to its members through improved health outcomes, safety and wellness.
When it comes to MA plans, quality is also tied to the CMS Star Ratings system, and achieving 4.0+ Stars on individual measures. One of the measures expected to experience significant change is the medication therapy management (MTM) measure. MTM is a structured, pharmacist-led approach that ensures members are taking the right medications in the right dosages to achieve the desired result for their health. MA plans are required to provide comprehensive medication reviews (CMRs) as part of MTM, and these are also invaluable to help plans uncover and resolve DTPs.
CMS has suggested MTM program changes that, if implemented, will dramatically expand eligibility for enrollment in the MTM program. To accommodate, plans will need to increase the budgeted spend required to scale up the MTM program accordingly. Consequently, MA plans will need to be strategic about the way they engage with members around their medications, and determine how to best fund an expanded MTM approach.
The importance of maximizing DTP gap resolution
When plans are able to broaden the identification of drug therapy problems (DTPs) in the member population, they’re able to improve the health outcomes of members and, in turn, reduce medical spending. Therefore, the more DTPs a plan is able to uncover and resolve, the more value they can provide in terms of maximized health outcomes and associated cost savings.
What is a DTP?
DTPs are drug-related events that interfere with optimal treatment therapies, such as when a patient experiences an unwanted side effect or is given the wrong dosage of their medication.
These events are unfortunately common, particularly among elderly patients and/or polypharmacy patients. Researchers estimate that adverse drug events are implicated in nearly 100,000 hospitalizations among the elderly each year. One study found a total of 3,100 DTPs during 3,309 patient-pharmacist visits for just 452 patients, which averages nearly 7 issues per individual over the study period.
DTPs can occur due to a mix of technology shortfalls, multiple prescribing providers, OTC therapies, workflow bottlenecks and gaps in member education. Preventing errors requires a coordinated approach to maintaining accurate medication lists, identifying discrepancies and correcting issues before they can cause harm to patients.
To continue on the right trajectory with reducing costs and improving member therapy and experience, health plans need a solid approach in place to identify and resolve DTPs.
Examples of drug therapy problems
DTPs can take many forms. In the 1990s, pharmacy experts began to divide DTPs into concrete categories, including:
- Primary medication nonadherence, when a member has received a medical diagnosis, but an initial pharmacy fill for prescribed medication hasn’t been completed, thereby leaving the diagnosed condition untreated.
- Secondary medication nonadherence, whether intentional or otherwise, which can be highly problematic for patients. Up to 50% of patients do not take their medications correctly, leading to tens of thousands of avoidable deaths each year and approximately $500 billion in unnecessary spending.
- Unnecessary drug therapy, where a patient is taking a medication that is not contributing to improving their condition. This could occur when a drug is no longer needed, but isn’t removed from the patient’s regimen, or if the patient is prescribed multiple similar medications for the same condition without actually magnifying the positive effect of the therapy.
- Contraindicated medications, where the patient has been prescribed medications, often but not always by different physicians, that conflict with each other and can lead to acute events from negative drug-drug interactions.
- Gaps in drug therapy, when a patient should be taking a drug that could improve their condition, but has not been prescribed the correct medication. Gaps in therapy commonly occur among individuals with chronic diseases who could benefit from medications such as statins, RAS antagonists or diabetes drugs like metformin.
- Incorrect drug use, when a patient is prescribed a drug that does not treat the targeted condition. This could include the use of antibiotics for viral infections.
- Incorrect dosage, including high or low dosage. Prescribing the wrong dose or failing to correct the dose after an adverse side effect is a common occurrence. Elderly patients may be particularly sensitive to incorrect dosages, since they metabolize drugs differently than younger individuals and may be taking other medications that interfere with the effectiveness of new therapies.
- Adverse drug reactions, which occur when a patient has an allergic response or other unintended reaction to a therapy. Adverse drug reactions include harmful interactions with other drugs, making it even more important for prescribers to fully understand a patient’s existing medication list.
It is imperative that health plans catch DTPs before they cause issues with a member’s health. Closing these gaps early can significantly reduce avoidable spending on expensive emergency department use and hospital admissions or readmissions, while improving member experiences and supporting better long-term health outcomes.
For MA plans, savings realized from an MTM strategy that maximizes closure of DTP gaps can drive significant cost reduction to partially or wholly fund expanded MTM activities and other member-focused interventions.
Data-driven approach: How health plans can uncover and resolve the most DTPs
Staying one step ahead of DTPs requires health plans to take an organized approach to identifying medication issues and leveraging strong, trusted, ongoing relationships with members and their healthcare providers to solve potential problems.
Leveraging medical and pharmacy claims. Predictive analytics that leverage a combination of medical claims and pharmacy claims for a plan’s member population are imperative to uncovering the maximum number of DTPs for targeted resolution. This alignment of medical claims alongside pharmacy claims (unique to the Adhere Platform™) allows for more comprehensive identification of DTPs, such as primary nonadherence, and other instances of non-optimal medication utilization. The right analytics platform, such as the Adhere Platform, gives plans better insight into population health needs, as well as tracks members’ engagement with MTM activities year-over-year. The savings realized from this type of approach can also deliver higher medical cost reduction to fund anticipated MTM program expansion.
Regular comprehensive medication reviews. CMRs are a key component of the MTM process, conducted at least annually by qualified health professionals. These real-time, interactive encounters can take place face-to-face or via telehealth. CMRs involve a full review of the member’s entire medication profile, which may include a discussion of prescription drugs, over-the-counter medications, vitamins or herbal supplements, and the use of illicit substances.
Pharmacy professionals should be directly involved in conducting CMRs, as their extensive training in potential drug interactions and correct dosing is essential for avoiding many of the major categories of DTPs.
Expanded pharmacy resources. With the proposed CMS guidelines for the MTM program, MA health plans will need to expand their pharmacy resources to account for the anticipated significant increase in members who will require medication management services. Plans can either hire a larger number of pharmacy professionals for their in-house teams or consider partnering with a virtual pharmacy expert that already has the staffing and the technology in place to handle the upcoming influx of MTM needs.
Securing the right resources in this area is especially important since MTM is not a “one-and-done” activity. Members with complex health needs often experience planned and unplanned hospitalizations or other transitions of care, and will ideally receive a CMR after each of these events to ensure no errors have been made during the move from one setting to another.
Ongoing member support. In addition, members need assistance with medication adherence in their day-to-day lives. Regular check-ins can give plans important insight into a member’s ability to understand their latest care plan, access their medications, and take their prescriptions as directed without unwanted side effects.
These interactions give pharmacy staff the opportunity to optimize medications and encourage positive behavior change before a DTP develops—especially if plans or their partners leverage analytics tools to flag and prioritize outreach to high-risk individuals. By targeting outreach and employing motivational interviewing skills to get to the heart of a member’s clinical and non-clinical challenges with medication adherence, plans can prevent DTPs while simultaneously improving their performance on critical Star Ratings measures around adherence and member experiences.
Involvement of prescribing providers. Plans must be sure to involve prescribing providers in the process and close the feedback loop when medications are adjusted after a CMR. Healthcare providers have equally strong incentives to ensure their patients have the right prescriptions and the right tools to remain adherent. Strong relationships and communication with providers when a problem arises allows a plan to leverage another point of contact with the member, while offering providers a chance to understand what led to the issue and use the information to continually improve care delivery.
By developing a coordinated and structured approach to identifying and resolving DTPs, health plans can avoid costly and disruptive medication-related events for members. To prepare for upcoming MTM requirements, maximize health outcomes, deliver better experiences to members and reduce future medical spending, health plans will need to proactively invest in the resources, technologies and strategies that help identify and avoid the risks of DTPs before they occur.
For more information about reducing your plan’s medical spending through maximized DTP resolution, contact us today to request a consultation.