Ed. Note: This article was originally published in HealthLeaders-InterStudy’s California Health Plan Analysis, Winter 2012, Vol. 11, No. 1 on March 7, 2012.

First-Quarter Outlook For California Patient Care Management

Multiple developments in California point to further efforts to make medication therapy management more central to overall care management. There are already signs that MTM has a defined role to play in the risk reward proposition of accountable care organizations. New fronts are also emerging through value-based pharmacy benefit managers.

Care coordination/medication therapy management:

Pharmacy benefit manager Ventegra, Sterling Self-Insurance Administration and two university schools of pharmacy are working together to offer employers the kind of integrated benefit and care delivery model that has been the hallmark of HMO stalwart Kaiser Foundation Health Plan.

“Kaiser’s model allows for a free flow of communication across all care settings and between providers, including physicians, nurses, pharmacists and other healthcare providers,” says Ventegra CEO Robert Taketomo, Pharm.D., MBA. “They look at healthcare on a local level to identify variations in condition prevalence and practice patterns. They understand the need to manage patient care in an integrated way that doesn’t involve a back-and-forth between medical and pharmacy benefits.”

The idea is to expand pharmacy benefit management into pharmaceutical care management—a holistic approach to healthcare benefits that addresses medical utilization and pharmacy benefits, says Taketomo.

Sterling, an established presence in the health savings account market, launched a portfolio of self-insurance products in August 2011 that use this pharmaceutical care management strategy. The self-insurance products were initially launched in key California markets, but are now available nationwide.

As part of its PBM program, Ventegra uses a medication therapy management program designed by clinicians from the University of Southern California School of Pharmacy and the University of California San Diego School of Pharmacy. Components of the MTM program include creating, assessing and adjusting prescription drug treatment plans, as well as monitoring and counseling patients. The program is also designed to foster collaboration between physicians, pharmacists and patients to address any drug therapy issues that are identified. The schools of pharmacy also help to provide clinical and academic support for the evidence-based drug formularies used by Ventegra and its clients.

Sterling Self-Insurance Administration CEO Cora Tellez says the program being developed with Ventegra dovetails with the company’s focus on efforts to foster a higher degree of care coordination. “The role of the pharmacist puts us ahead of the game in patient care management. The schools of pharmacy provide a superior level of clinical analysis. As part of our program, pharmacist clinicians are routinely evaluating the medication regimen a member is taking. The pharmacist can then take action with a doctor and/or member,” Tellez says. “As we develop our integrated approach, the entire spectrum of healthcare providers who treat our members should be able to access a complete clinical profile from our HIPAA/HITECH-compliant health data vault. Our goal is to eliminate the ‘silo therapy’ that is a condition of our current, fragmented healthcare delivery system.”

Another care management incentive incorporated into Sterling’s self-insurance products is allowing drug company rebates to be paid directly to members or employers. “If the employee is picking up the tab because the deductible has not been met, the rebate goes to them. Otherwise, it goes to the employer,” says Tellez. Sterling reports that this benefit is unique to its product. Passing along rebates to members could incentivize patient adherence to prescription drug treatment because it alleviates the cost burden and MTM programs generally promote the most effective prescription drugs rather than those with the lowest cost.

Sterling’s patient-care management model also includes incentives through its Sterling HealthAssets accounts. The funds in the accounts, which are fully funded by Sterling (employers are encouraged, but not required to contribute to the accounts), are available to members who participate in a workplace wellness program. The program requires a biometric screening during the first year of enrollment. The screening is used to establish a risk profile for a three- to five-year wellness plan. The wellness programs are designed by partner Viridian Health Management, which was recently awarded an $8 million contract from the Centers for Disease Control and Prevention to create a national workplace health program.

Ventegra’s model for administering pharmacy benefits includes the elimination of spread pricing—the difference between the amount PBMs typically pay pharmacies for each claim versus the bill they submit to health plans for that claim. Ventegra achieves this by having one maximum allowable cost list for all contracted pharmacies so that what is paid to the pharmacy is the same as what is billed to a health plan. Sterling’s self-insured plans include a level-funding option and a traditional self-insurance design. For the former, Ventegra and Viridian are a mandatory component but are optional for the latter. Both product lines are for groups with more than 50 employees.

Independent of its Sterling partnership, Ventegra also markets its portfolio as a potential component of accountable care organizations, offering integrated pharmacy and medical claims data, forwarding all pharmaceutical rebates and discounts, and encouraging ACOs to become their own PBM with the aid of flexible formularies and managed care expertise from Ventegra.

Accountable care organizations:

Of the 32 organizations named Pioneer ACOs by the Centers for Medicare & Medicaid Services in December 2011, six are based in California—more than in any other state. They include Brown & Toland Physicians (Bay area), Monarch Healthcare (Orange County), HealthCare Partners (Los Angeles and Orange counties), Primecare Medical Network (Riverside and San Bernardino counties), Sharp Healthcare (San Diego County) and Heritage California ACO (Southern, Central and Coastal California). All of these entities are physicians groups, except Sharp Healthcare, which includes both physicians and health system facilities.

Many of these organizations already have in place, or are developing, ACOs that target commercial PPO members. This will assist them in meeting the provision that requires Pioneer ACOs to have half of their revenues derive from similar payment structures with other public and private payers.

Their selection as Pioneer ACOs also means that these entities have demonstrated their ability to provide coordinated care management, including such initiatives as medication therapy management programs tha thelp address prescription drug utilization. For example, Monarch Healthcare had an existing medication therapy management program that includes monitoring patients who are taking more than six prescription drugs and who may have been recently hospitalized.