Avoidable Drug-Impacted Medical Costs account for approximately $350 billion of overall medical costs. Of these costs, 75% are incurred by just 2–5% of the population. This population constitutes the most unmanaged portion of managed care. These individuals are vulnerable to improper care due to multiple chronic conditions, poor adherence to drug regimens, limited cognitive abilities, lack of timely care interventions, and absence of social support. Avoidable Drug-Impacted Medical Costs are costs that could have been avoided had a patient's medications been administered appropriately. Providers and payers currently focus on costs incurred within hospitals, clinics, and other facilities within the healthcare ecosystem. However, the costs incurred while patients are at home remain unmanaged. Outside of the clinical sphere, patients are expected to follow strict medication regimens and care plans that are not appropriately adjusted until their next doctor's appointment. Left alone, many of these patients are unable to follow complex care plans without supervision and home health coaching, making them more likely to require unexpected and expensive medical care such as hospitalizations and ER visits. These costs can be significantly reduced through an accountable drug benefit and care management program.
In addition to its full service PBM offering, RxAdvance offers nirvanaAccountableCare™ as a custom risk-sharing solution designed to supplement a plan sponsor’s incumbent PBM services with a truly accountable drug-impacted medical cost and chronic care risk management program. nirvanaAccountableCareTM enables collaboration amongst all care continuum stakeholders to transform costs into shared savings for all parties– the payer, provider, patient, and RxAdvance.
PBMs today have antiquated platforms with limited service offerings, including a lack of integration of medical, pharmacy, and lab data. Therefore, these PBMs are unable to derive actionable intelligence and are unable to push this information into the workflows of the various stakeholders in the care continuum. This is why PBMs are unable to offer avoidable drug-impacted medical risk sharing contracts. Neither health plans nor PBMs are paying attention to these costs, therefore missing an opportunity to enhance member health.
nirvanaAccountableCare™ was launched to respond to this untapped opportunity. RxAdvance’s platform, integrated vision, and comprehensive approach throughout the care-continuum enables RxAdvance to partner with plan sponsors to identify avoidable drug-impacted medical costs and managed the most unmanaged portion of managed care through risk sharing.
nirvanaAccountableCare™ is a total care delivery model that reduces avoidable drug-impacted medical costs in 6 steps: Risk Stratification Using Advanced Clinical Clusters, Comprehensive Medication Review and Personalized Care Plan Derivation, SmartAdherence™ Management, SmartHomeCarePlan™ Management, SmartHomeCareDelivery™ Management, and Risk and Shared Savings Management.
RxAdvance's custom risk-sharing solution leads to reduction in Avoidable Drug-Impacted Medical Costs, saving plan sponsors 20-25% through:
Six Step Process:
RxAdvance implements a comprehensive 6-step process to achieve optimal savings and to enhance the health of patients who require additional targeted care. RxAdvance closely monitors actual saving opportunities versus previous projections, while ensuring that the overall quality of patient care is not compromised. Throughout these 6-steps, while RxAdvance's goal is to share savings with plan sponsors, prescribers, and members; our primary objective is to provide superior care and management to the most unmanaged portion of managed care.
RxAdvance uses historical claims data to identify and quantify Avoidable Drug-Impacted Medical Costs and to stratify members based upon risk levels using advanced clinical clusters. Based upon extensive analysis, RxAdvance has found that about 10% of the total population can be classified as Advanced Critical Illness and Multiple Chronic Illness patients (Figure 1). This population is responsible for 75% of hospital admissions and 57% of total healthcare costs.
RxAdvance’s Point-of-Care Intelligent DUR360o Gateway™ integrates and analyzes the members’ medical, pharmacy, and lab information to create a comprehensive member profile. Proprietary algorithms are applied to map each member to an Advanced Clinical Cluster along with members who share a similar age, gender, socioeconomic, and clinical profile. The impact of medication non-adherence on future medical costs is calculated for each cluster. Members are then stratified based on their risk levels and potential cost savings and are assigned to an appropriate care level. RxAdvance offers a three-tiered solution to address the specific needs of chronic care members. Each tiered solution increases in complexity based upon the level of care required by individual members in the corresponding risk band.
Figure-1: Example: Cost and risk pyramid using historical data of one million members. Proprietary algorithms are used to identify members in band-1 “advanced/critical illness” and band-2 “multiple chronic illnesses.” These members are clinically fragile with multiple avoidable events, incurring highest Avoidable Drug-Impacted Medical Costs.
Advanced Clinical Clusters Selection Methodology
Advanced Clinical Clusters are leveraged to effectively group members who have similar health profiles. This approach
facilitates creating automated, custom care plans, and managing patients who require specific, targeted needs from
RxAdvance’s care advisors. Furthermore, these clusters allow RxAdvance to evaluate member adherence to drug
regimens and care plans. Savings opportunities can then be computed for members within each cluster.
1. Identify members with a multi-year continuous enrollment
2. Integrate medical, pharmacy, and lab claims to build member level clinical and cost history
3. Assign medication adherence flag (Y or N) to this distinct population of patients
4. Assign chronic condition flag from the CMS identified chronic conditions
5. Identify members having multiple chronic conditions
6. Apply proprietary algorithms to build Advanced Clinical Clusters within the member population
7. Segment Advanced Clinical Clusters into adherent and non-adherent segments for cost comparison
8. Identify Advanced Clinical Clusters with highest per member adherence impact on total costs (medical and pharmacy)
9. Compute the potential reduction of Avoidable Drug-Impacted Medical Costs for each identified member within the Advanced Clinical Clusters
During this step, when the nirvanaAccountableCare™-qualified member visits their primary care physician, a personalized medication list and customized care management plan is created. The primary care physician reviews both the medication list and care plan, and obtains the member’s consent to begin the care regimen.
Physician-Led Comprehensive Medication Review (CMR)
When a prescriber is writing a new prescription, or renewing an existing prescription, the prescriber will be alerted in his/her own work flow (EMR/PM/e-Prescription software) with both existing Adverse Drug Events and additional events due to new/current prescription/s. The prescriber will also be alerted with patient Medication Therapy Management (MTM) eligibility and the opportunity to conduct a comprehensive medication review (using CMS and plan rules) and reconciliation. The prescriber will also be alerted to correct all ADEs in an organized manner and will have the ability to quickly issue a new Medication Action Plan (MAP) with essential medications to improve overall quality of patient life. Along with medication reconciliation, this service also includes the creation of a Personal Medication List (PML).
Duplicate Therapy Reduction
Due to the fragmented systems that are pervasive in healthcare today, a patient’s laboratory, medical, and pharmacy data are rarely integrated in a single system. As a result, different specialists (often unknowingly) prescribe overlapping medication therapies for a single patient. A core component of the medication reconciliation process accomplished through the physician-led CMR is the identification and elimination of all duplicate therapies through RxAdvance’s Collaborative PBM Cloud™ technology. Removal of these duplicate therapies allows the primary care physician to improve both the quality and cost of the patient’s medication regimen, right at the point of care.
Adverse Drug Event (ADE) Reduction
The core objective of the medication reconciliation process, accomplished through the physician-led CMR, is the reduction of Adverse Drug Events (ADEs). This step identifies drugs that are causing more harm than good to the patient and eliminates them from the member’s medication list. nirvanaAccountableCare™’s identifies all adverse drug events and communicates these to the patient. A corrective action plan is then created, captured, and implemented. The prescriber will now also have the ability to quickly issue a new Medication Action Plan and Personal Medication List with essential medications to improve overall quality of patient life. Patients are educated about their new medications and methods of improving their drug regimen.
Customized SmartCarePlan™ Creation
nirvanaAccountableCare™’s proprietary algorithms analyze the age, gender, clinical, and socioeconomic data of at-risk members to provide a customized baseline care plan. After a member is assigned to a specific Advanced Clinical Cluster, a SmartCarePlan™ is shared with all stakeholders including care advisors, primary care physicians, family caregivers, and the member himself via RxAdvance’s Collaborative PBM Cloud™. This ensures uninterrupted care, even when the patient is at home. SmartCarePlan™ includes customized medication lists, vital reminders, exercise routines, nutrition coaching, and preventative care scheduling, including gaps in care and continuity of care measures. These tools help improve compliance management protocols as well as provide alerts at thresholds optimized for the individual member’s condition.
RxAdvance’s unique value proposition for adherence includes delivery of an intelligent, prefilled, disposable SmartTray™. After drug utilization review at the point of care, RxAdvance’s SmartTray™ is appropriately filled with the patient’s medications and paired with the nirvanaSmart™ device.
SmartTray™ Delivery Management
RxAdvance provides a fully automated, comprehensive medication adherence management solution that engages all care stakeholders at every touch point in the care continuum. SmartTray™ delivery management includes the following actions:
Comprehensive Adherence Monitoring
Following successful installation, the nirvanaSmart™ will monitor and notify the patient with voice alerts when it is time to take their medication, and will further remind the patient with to-dos to capture vital sign measurements. Based upon the patient’s disease states, medications, and vital sign values, nirvanaSmart™ appropriately alerts patients for care coordination. It also pushes real-time alerts to caregivers (such as family members) via their smart phones, and to RxAdvance care advisors and care/case managers at the health plan within their respective work flows. On an ongoing basis, the Collaborative PBM Cloud™ analyzes patient adherence and automatically generates alerts that are tracked by care advisors who are able to reach out to non-adherent patients. Dedicated RxAdvance care advisors are able to engage with members to build a social connection and to collect vital well-being information not otherwise available.
Through nirvanaAccountableCare™, identified members not only undergo comprehensive adherence monitoring, but are also provided with complete bluetooth-enabled vital signs monitoring devices, dynamic care plan management, and timely care coordination. With these comprehensive technology-driven services, a patient’s clinical team is empowered to provide a high level of care at right at the patient’s home, as if under direct observation.
Vital Signs Monitoring
nirvanaSmart™ seamlessly pairs with and integrates data from bluetooth-enabled monitoring devices that are included with nirvanaAccountableCare™ services. Based upon the patient-specific care plan, these devices monitor the patient’s blood pressure, weight, temperature, blood glucose levels, pulse, and oxygen saturation at appropriate intervals. Measurements obtained via these devices are then compared to patient-specific threshold values.
Dynamic Care Plan Management & Smart Care Coordination
In real time, RxAdvance integrates vital measurements and updates clinical/lab information to dynamically adapt a patient’s baseline care plan. This newly derived care plan, comprising of “updated” threshold measures such as blood pressure and weight, triggers actionable intelligence alerts that are pushed directly into the workflows of RxAdvance’s care coordination team members. These alerts can also help RxAdvance and the plan sponsors to identify the precursors to major health events and enable the care coordination team to take timely corrective actions.
When a member’s vitals cross pre-defined thresholds, an alert is generated and a designated RxAdvance care advisor will immediately review the member’s clinical status. Care advisors then contact the member to address all concerns. If appropriate for the member’s condition, the care advisor will prompt a home visit from RxAdvance’s physician network. Network physicians within a 10-mile radius of the member’s location will be alerted of the patient’s status and their need for a home visit via the nirvanaSmart™ mobile application . Any RxAdvance network physician will have access to the member’s location, complaints, and clinical status and may accept the visit. During the home visit, the physician will address the patient’s current clinical problems to prevent an unnecessary ER visit or hospitalization. In addition, the physician will also be informed of opportunities available to optimize medications, perform comprehensive gaps in care measures, and other value-added care coordination activities.
Through nirvanaSmart™, any changes in clinical condition,medications, and other care coordination activities performed by the visiting doctor will be updated in the member’s medical record. This information will then be shared with all stakeholders across the care continuum, including family members, caregivers, physicians, and health plan case managers, to ensure uninterrupted member care.
As part of implementation activities, key performance metrics, success criteria, and program monitoring timelines are defined. All computations are clearly documented before the program is initiated to ensure consistency of measurements. These metrics will be defined and included in more detail in the master services contract/agreement. Typical stakeholders include participating members, plan sponsors, prescribers (primary care physician and network physicians), and RxAdvance, all of whom will sign individual agreements.
Figure-1: Example trend: Avoidable Drug-Impacted Medical Cost trend “before” and “after” implementing RxAdvance program. Using proprietary algorithms, RxAdvance will analyze three years’ integrated data with many variables such as multiple therapies, ADEs, non-adherence patterns, vital sign monitoring, and timely intervention and plot such trends with age band and disease conditions as part of implementation
RxAdvance will fund the cost to run the program in exchange for the opportunity to capture a portion of the savings that result from reduced Avoidable Drug-Impacted Medical Costs (Figure 2). RxAdvance will utilize its resources to implement, monitor, and deliver financial outcomes. However, RxAdvance seeks support from the client’s clinicians, case managers, and supporting staff in facilitating communications with patients and providers surrounding this new program to improve patient quality of life. These communications will be conducted through electronic communications and provider workshops, which will derive incentive programs for prescribers and patients. Successful implementation heavily relies on the support of the client, as the client fosters the relationship with the members and prescribers.
The program in its entirety is continually monitored for effectiveness and to identify any opportunity for appropriate recalibrations in order to achieve superior outcomes and savings. RxAdvance will work with the client to compute cost reduction results and to mitigate clinical risks. Based upon the results accomplished and the cost savings achieved, the resulting reward will be shared between the client and RxAdvance in accordance with predefined contractual terms.
Figure-2: After deduction of program costs, savings are shared between all stakeholders: the plan sponsor, patient, physician, and RxAdvance. Exact breakdown of savings is subject to change, and will be agreed upon during contracting.