Avoidable Drug-Impacted Medical Costs Risk Sharing

Comprehensive Service Offerings



nirvanaspecialty services

Avoidable Drug-Impacted Medical Costs account for approximately 15% of a health plan’s overall medical costs. Of these costs, 75% are incurred by just 1% of the population. This population constitutes the most unmanaged portion of managed care. These individuals are vulnerable not only due to multiple chronic conditions and poor adherence to complex drug regimens but also to limited cognitive abilities, lack of timely care interventions and missing social support. The current focus by providers and payers has been on costs incurred within the healthcare ecosystem-such as hospitals and clinics, while the costs outside this sphere of attention, while the patients are at home, remain unmanaged. Patients are expected to follow a medication and care plan at home, that does not change until their next encounter. Left alone, many of these patients are unable to follow complex care plans without dynamic supervision and home health coaching, making them more likely to need unexpected, expensive medical care such as hospitalizations and ER visits. These costs can significantly be reduced by filling this gap in care with 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 & Shared Savings Management.

Avoidable Drug Impacted Medical Costs Include

  • Reduced ER Visits
  • Reduced Hospitalizations
  • Reduced Readmissions
  • Reduced Length of Stay Days
  • Reduced Hospital Acquired Infections and Post-Hospitalization Sepsis
  • Reduced Intensive Care Stay Days
  • Reduced Immobilization Condition such as VTE and Pressure Ulcers
  • Reduced Inpatient Rehabilitation Days
  • Reduced High Cost Urgent Care and Emergency Surgery
  • Reduced Costs and Complications of Chronic Conditions
  • Improved Member Engagement in Preventive Care Utilization
  • Improved Medication Compliance and Adherence to Regimen
  • Optimized Targeted Care, Proactive Identification and Timely Intervention in High Risk Members
  • Reduced Inpatient Observation Days for Vital Monitoring
  • Stabilizing at-Risk Members to Prevent Rapid Migration to Higher Risk Tiers

Six Step Process:

RxAdvance implements a comprehensive six step process to achieve savings mutually targeted by RxAdvance and the plan sponsor. During the contract year, RxAdvance closely monitors actuals versus projections and works with the plan sponsor to ensure that the overall quality of care is optimized.  During the contract year, savings are computed using the difference between the projected avoidable drug-impacted medical costs in the absence of RxAdvance program versus actual costs, and savings are shared with health plan, prescribers, members, and RxAdvance.

Risk Stratification using Advanced Clinical Clusters

After completing the formal contracting activities, as part of opportunity analysis, 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 three (small, medium, & large) plans 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). Based on RxAdvance’s analysis of multiple plans (Medicare, Medicaid, and Commercial plans), a similar distribution exists in all health plans in all lines of business. RxAdvance will identify population segments which are at risk of rapid migration to higher risk bands and identify specific members who are most likely to benefit from nirvanaAccountableCareTM. RxAdvance integrates medical, lab and pharmacy claims to create member demographic, clinical and socioeconomic history. Member utilization of clinical services is used to identify trends in medical costs both at plan and individual member levels. By utilizing these analyses and engaging client executive sponsors, RxAdvance will collaboratively work with the client to rationalize the program. Each member is assigned to an Advanced Clinical Cluster along with similar members who share Age, Gender, Socioeconomic and Clinical Profile.


 Example: Cost and risk pyramid using one million commercial lives. Proprietary algorithms are used to identify members in band-1 “advanced/critical illness” and band-2 “multiple chronic illnesses”. These members are clinically fragile coupled with multiple avoidable conditions incurring highest avoidable drug-impacted medical costs. Using proprietary algorithms RxAdvance will analyze three years’ integrated data with many variables such as Polypharmacy, ADEs, Non-Adherence Patterns, Acute Care Utilization, Preventive Care Utilization,  Vital Sign Measures, Lab Measures, and Socio-economic data to build such pyramids with age band and disease conditions as part of implementation program.

Advanced Clinical Clusters Selection Methodology
We segment the addressed clinical population into specific advanced clinical clusters to identify members most likely to benefit from nirvanaAccountableCare™

    1. 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 Saving – avoidable drug impacted medical costs” for each identified member within the Advanced Clinical Clusters

Comprehensive Medication Review and Personalized Care Plan Derivation

During this step, when the nirvanaAccountableCare™ qualified members visits a primary care physician a personalized medication list is created along with a customized care management plan. The Primary care physician reviews both care plan and the medication list and obtains member consent. The following sections explain how the personalized medication list and customized care plan are derived.

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 comprehensive medication review (using CMS and plan rules) and reconciliation. Now, 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 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 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.

Adverse Drug Event (ADE) Reduction
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. A corrective action plan is then created, captured, and implemented. Now, 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.

Customized SmartCarePlan™ Creation
nirvanaAccountableCare™’s proprietary algorithms use age, gender, clinical, and socioeconomic data for each individual at-risk member to provide a customized baseline care plan for the member. The SmartCarePlan™ is delivered to all the stakeholders including member, care advisor, primary care physician and family care giver through RxAdvance cloud to ensure uninterrupted patient care even when the patient is away from healthcare facility. The care plan includes customized medication lists, vital reminders, exercise routines, nutrition coaching, and preventive care scheduling to improve compliance to management protocols as well as provide alerts at thresholds optimized for an individual member’s condition.


RxAdvance’s unique value proposition for adherence comprise of delivering an intelligent electronic prefilled SmartTray™ with a successful drug utilization review at point of sale and monitoring the adherence through nirvanasmart™. Both these steps are described in detail below:

SmartTray™ Delivery Management
One of the core services of RxAdvance is 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 includes the following actions:

  • Outreach and educate: During this stage, RxAdvance advisors proactively reach out to recommended/qualified patients, educate them about the program, and enroll/onboard the patient
  • Aggregate, organize, and deliver: During this stage, RxAdvance aggregates, organizes, and delivers medications through a disposable pill tray that is implemented in two stages:
    • Install: During this stage, a Bluetooth-enabled and patented nirvanaSmart™ is shipped to and installed in the patient’s residence. This device is fully integrated with and wirelessly connected to the Collaborative PBM Cloud™. This nirvanaSmart™ is also capable of collecting all the vital signs from any Bluetooth-enabled measuring equipment such blood pressure monitor, glucometer, or weighing scale, pulse & oxygen meter etc. In real-time, it collects, consolidates, and transmits the member’s adherence and vital signs data to the Collaborative PBM Cloud™.
    • Dispense: After installation, RxAdvance aggregates and delivers all medications to the patient’s home on a weekly or bi-weekly basis from a centralized location using our electronic prefilled disposable pill trays.

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 values. Based on the patient’s disease states, medications, and vital sign values, the nirvanaSmart ™ appropriately alerts patient for care coordination.  It also alerts caregivers such as family members via smart phone alerts, RxAdvance care coordinators in their work flow, and care/case managers at the health plan within their work flow in real time.  On an ongoing basis, the Collaborative PBM Cloud™ 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 and collect vital information about their well-being.

SmartHomeCarePlan™ Management

Through nirvanaAccountableCare™, identified members not only undergo comprehensive adherence monitoring, but are also provided with complete bluetooth-enabled vital signs monitoring, dynamic care plan management, and timely care coordination. These comprehensive technology-driven services allow RxAdvance and the nirvanaAccountableCare™ team to provide a level of care equivalent to inpatient hospital services from the patient’s home.

Vital Signs Monitoring
nirvanaSmart™ seamlessly pairs with and integrates data from Bluetooth-enabled vital signs monitoring devices, which are paired and 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
RxAdvance integrates real time vital measurements and updated clinical/lab information to dynamically adapt patient’s baseline care plan. This newly derived care plan that comprises of “updated” threshold measures (such as blood pressure and weight) can trigger actionable intelligence alerts that are pushed real time into the workflow of RxAdvance’s care coordination team. These alerts can also help RxAdvance and their client to identify the precursors to major health events (such as emergency visits) and enable the care coordination team to take timely corrective actions.

SmartHomeCarePlan™ Delivery Management

When a member’s vitals cross the pre-defined thresholds and an alert is generated, a designated care advisor will quickly review the member’s clinical status and get in touch with the member to address concerns. If appropriate for the member’s condition, the care advisor will alert the physician network for home visit. Network physicians within 10 miles radius of member location will be alerted via the nirvanaSmart mobile application about the member requiring home visit. Any of these physicians can view the member’s location, complaints, and clinical status and accept the visit. During the home visit, the physician can address current clinical problems to prevent 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 care coordination activities.

Risk and Shared Savings Management

As this is a risk sharing proposal, all stakeholders who participate in the program are regularly monitored for results and are rewarded based on their performance as measured against pre-defined metrics which will be included in more detail in the master services contract/agreement. Typical stakeholders comprise of participating members, payers, prescribers (primary care physician and network physicians), and RxAdvance. Of course, the actual savings and sharing of these savings defer from client to client, however they will be discussed in detail with the client before developing the master services agreement/contract and will be captured in each of the respective contracts, such as members, payer, prescribers (primary care physician), network physicians, and RxAdvance contracts.

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 program.