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Improving Quality-Prescribing Decisions for Your Members, Without Having to Change your Benefits

Our methodology is to integrate clinical therapeutics with prudent business principles to achieve cost contraction as a result of improved quality management. .

    The Quality Management Program Utilizes:
  • Patient Specific Queries™
  • Identifying gaps in care and managing improvements by directing change and monitoring that change to achieve better clinical effectiveness and lower risk
  • Treatment Calendar™
  • Identifying the most complicated patients by aggregating the various edits from our Patient Specific Queries for improved quality of care with a clinical approach
  • Trend Management™
  • Oversight of financial trend and clinical usage

    Our approach to manage pharmacy costs includes communication with Providers:
  • Education
  • Problem flagging
  • Feedback on performance
  • Patient education & involvement

Physicians will prescribe cost effectively when they are included in planning and implementation. Payers can expect to see performance improvement savings of 8-11%.

The goal is to educate prescribers in clinical therapeutic decision-making and cost-effective prescribing, which is consistent with managed care contracts. These programs can integrate effectively with Client/Health Plan and PBM drug-switching programs if currently in use or planned for by Client.

The results are improved quality-prescribing decisions for your members, without having to change your benefits.

Our Quality Management Program™ has proven results in markets nationwide to increase the quality of patient care while decreasing costs associated with managing the pharmacy and medical benefits. Savings accrue from physician-accepted general education about evidence-based practice and information about the cost-effectiveness of competing medications. We’ve found that Providers change their prescribing practices when they are incentivized. Our program focuses on the gaps, directs the change, and incentivizes providers.

Quality Management Program for Populations at Work

Problem: A client asked us how to measure pharmacy quality improvement so that their CFO and Financial Analysts could identify true savings.

Methodology: We established an overall pharmacy intervention program based on physician prescribing practices using a main intervention group, a control group, State Medicaid as well as a State Employee group for comparisons. Our approach was based on a monthly communication of actual physician prescribing, behavior modification program tracking trends in spend and per-utilizer-per month costs vs. Best-In-Class comparators that included over 70% of pharmacy spend. The reference group was formed based on similar Plan type, benefits, patient volume, diagnostic profiles, severity, physician specialty, and geography. State Medicaid and State Employees were used as additional comparators trended over the same time periods. The program continued uninterrupted for eight (8) years and was re-evaluated every year.

Outcome: Savings were quantified on a quarterly, bi-yearly and annual basis every year for 8 years. Annual trends were consistently less than 2% vs. national trends of 11%. The comparators were never less than 11+% trends annually, while the Medicaid and Employee Plans averaged 7% and 12%.

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