Today, twenty to twenty-five percent of incurred medical costs are unnecessary and avoidable. Approximately half of these costs are due to physician and hospital overuse, abuse, misuse, and incompetence, while the other half is attributed to avoidable drug-impacted medical costs.
Neither health plans nor PBMs are paying attention to these costs, leaving an immense opportunity completely untapped.
RxAdvance was launched to respond to this untapped opportunity, among others. RxAdvance’s platform, integrated vision, and comprehensive approach throughout the care continuum enable RxAdvance to take complete risk to convert avoidable drug-impacted medical costs to savings for the plan sponsor. This is done through cutting-edge analytics and a unique approach enabling collaboration between patients, pharmacists, prescribers, and plan sponsors. RxAdvance then shares these savings between all stakeholders in the care continuum—the payer, patient, physician, and RxAdvance.
In addition to its full service PBM offering, RxAdvance offers a fit-in solution, nirvanaAccountableCare™. nirvanaAccountableCare™ is a custom risk-sharing solution designed to supplement a plan sponsor’s incumbent PBM services with a truly accountable drug-impacted medical cost management program. Through a comprehensive eight step process, nirvanaAccountableCare™ partners with plan sponsors to reduce avoidable drug-impacted medical costs, therein improving both the quality of care for patients and the plan’s own bottom line.
RxAdvance uses historical claims data to identify, quantify, and rationalize mutually agreeable “avoidable drug-impacted medical costs” with the client. Based upon the normalized data from plans of varying sizes and lines of business for the years 2014 and 2015, RxAdvance found that about 10% of the total population are classified as Advanced Critical Illness (Risk Band-1: 4%) and Multiple Chronic Illness (Risk Band-2: 6%) patients (Figure-1).
Figure-1: Example: Cost and risk pyramid using one million commercial lives.
RxAdvance uses proprietary algorithms to identify members in band-1 “advanced/critical illness” and band-2 “multiple chronic illnesses”. These members are clinically fragile, with multiple avoidable conditions, and therefore lead to the highest avoidable drug-impacted medical costs for the plan. As part of the implementation program, RxAdvance uses proprietary algorithms to analyze three years’ integrated data with many variables including multiple therapies, ADEs, non-adherence patterns, vital sign monitoring, and timely intervention. With this insight, a pyramid such as this will be built for the client, whereby approximately 50% of the top 10% highest risk patients will be targeted for nirvanaAccountableCare™ services. This insight will further allow RxAdvance to build a graphical analysis of the past and future trends of avoidable drug-impacted medical costs, where savings attainable through the implementation of nirvanaAccountableCare™ will be defined (Figure-2).
Figure-2: 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 program.
From the above exercises, the savings opportunity for plan sponsors is defined. Further, eligible members are identified and enrolled in nirvanaAccountableCare™ services, as described in the following tabs.
When a member visits his primary care physician, RxAdvance alerts the physician in their workflow (EMR/PM/e-Prescription software) of the patient’s high risk status and eligibility for a Comprehensive Medication Review (CMR) through nirvanaAccountableCare™. The overall goal of this Physician-Led CMR is to use nirvanaAccountableCare™ technology to both perform medication reconciliation to optimize the patient’s prescription drug regimen and to enroll the high risk patient in further medication adherence, medication therapy management, and care management services through nirvanaAccountableCare™. These processes are incentivized to the prescriber through an alert describing the reward from the health plan or PBM for conducting the CMR. In the case of risk sharing providers, the service also provides information about the total medical cost reduction opportunity for that particular patient. The Physician-Led CMR process also includes patient education and counseling (brand versus generic, high cost versus low cost generics, mail-orders, drug-any possible interactions, multiple therapies, medication adherence, HEDIS/Quality scores (health plan derived data)). Finally, after the CMR and reconciliation, an action plan (MAP – Medication Action Plan) is developed, communicated, and captured in the Collaborative PBM Cloud™ platform.
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 the 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.
A core component 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. nirvanaAccountableCare™ identifies all adverse drug events and communicates these to the patient, and a corrective action plan is created, captured, and implemented. At this time, the prescriber will also have the ability to quickly issue a new Medication Action Plan (MAP) and Personal Medication List (PML) with essential medications to improve overall quality of patient life. At this stage, the physician will also discuss the patient’s eligibility to take part in a medication adherence program, and further a care coordinator from RxAdvance will contact the patient. As part of this program, all of the patients’ medications are funneled to one centralized pharmacy, which assumes the responsibility for organizing and delivering all oral medications to the patient’s home via prefilled electronic disposable pill tray.
One of the core tools harnessed through nirvanaAccountableCare™ is nirvanaSmart™, a fully automated, comprehensive medication adherence management solution that engages all care stakeholders at every touch point in the care continuum. Part of electronic disposable pill tray delivery management through nirvanaSmart™ includes the following actions:
Following successful installation, nirvanaSmart™ appropriately alerts the patient for care coordination. Based on the patient’s disease state, medications, and vital sign values, nirvanaSmart™ will monitor and notify the patient of when it is time to take their medication with voice alerts. nirvanaSmart™ also communicates this information in real time to caregivers via smart phone alerts, and to RxAdvance care coordinators and health plan case managers via their respective work flows. On an ongoing basis, the Collaborative PBM Cloud™ platform reports patient adherence and automatically generates alerts that are tracked by care advisors who reach out to non-adherent patients. Another distinct feature of this service is the ability of RxAdvance advisors to build a social connection with the patients while collecting vital information about their well-being.
Apart from capturing patient adherence activity, nirvanaSmart™ also captures vital signs data. RxAdvance then integrates this vital signs data together with the patient’s medical history and medications to create patient-specific actionable intelligence. This intelligence is then pushed in real time into the workflow of the client’s clinical and pharmacy staff through the Collaborative PBM Cloud™ platform and becomes part of the patient’s registry. This action helps the client’s clinical and pharmacy staff take corrective action towards those patients who are enrolled but not adherent or whose vitals are beyond threshold values. This vital signs information can help RxAdvance and their client to identify the precursors to major health events (such as emergency visits) and can help to make timely care coordination decisions as part of each patient’s case/care management.
The Collaborative PBM Cloud™ platform captures the patient’s diagnoses, drugs, age, gender, weight, and respective vital readings. This data is integrated, converted to actionable intelligence, and used to establish a patient-specific care plan. Such actionable intelligence also triggers timely care coordination with the patient’s primary care physician or a physician house call through RxAdvance partner companies. RxAdvance’s systems will integrate directly within the client’s existing case/care management workflows.