A COMPREHENSIVE APPROACH TO MANAGING DIABETES

Transcription

1 A COMPREHENSIVE APPROACH TO MANAGING DIABETES Programs and services to help individuals avoid costly complications and improve outcomes ENTER

2 Supporting each member with targeted guidance and services. Without careful management, diabetes can quickly lead to cardiovascular disease, kidney damage and a host of other difficult complications. OptumRx diabetes management helps customers and individuals achieve positive health outcomes and control costs through five core strategies. We also offer enhanced clinical management programs for customers that want to offer additional personalized support. T C Total diabetes management for total health Core strategies Click on icons to jump to that section, or hit Enter and continue to scroll. E P Enhanced programs The power of Optum 2.

3 T Total diabetes management for total health Preventing complications that drive costs Only about 55 percent of people with diabetes successfully manage their glucose levels. That means 45 percent are at greater risk for developing cardiovascular disease, nerve damage and other complications that often lead to additional outpatient care, emergency room visits and hospitalization. OptumRx can help you reduce that risk and keep costs down by providing individuals and their physicians with the guidance and support they need to not only adhere to their therapy but manage total health. Personalized support to improve diabetes management 55% 45% successfully manage don t, and are at greater glucose risk for complications and increased cost of care 3.

4 C These core diabetes management strategies are tailored to help you manage costs and ensure that members have access to effective and cost-effective treatment. Core strategies Strategy 1: Concurrent drug utilization review (CDUR) By reviewing medication utilization during the claims process, we can identify at the point of sale whether a medication is safe, cost-effective and clinically appropriate for an individual with diabetes. This helps ensure that members avoid medications that may interact with others drugs, or otherwise be harmful to them based on other conditions they may have. Strategy 2: Utilization management We help manage appropriate drug utilization and member safety by: Requiring prior authorization, step therapy, or quantity limits for specific medications We have claims edits in place to ensure that prescriptions are adhering to national treatment guidelines on diabetes medications that have demonstrated the best cardiovascular outcomes We apply utilization management edits and interventions at the point of sale, so pharmacists and members can discuss possible lower-risk, lower-cost medication alternatives from the formulary. 4.

5 C These core diabetes management strategies are tailored to help you manage costs and ensure that members have access to effective and cost-effective treatment. Core strategies (cont.) Strategy 3: Review medical necessity Using evidence-based clinical standards of care, we review prescriptions to make sure they are clinically appropriate and to avoid treatments that could be ineffective or cause an adverse reaction. Strategy 4: Emphasize lower-cost alternatives The more members have to pay for their medications, the less likely they are to fill their prescriptions or take them as prescribed 1. To help remove cost barriers and improve medication adherence, we let members know whenever lower-cost alternatives are available. Strategy 5: Real-time pharmacy claims audit Lower-cost alternative alerts available when members access optumrx.com or call us with a question. Automated filters and algorithms We monitor 100 percent of pharmacies and claims and, within seconds, flag those with the highest risk for review. Synthethic insulin -specific reporting We also provide reports on claims for certain fast-acting synthethic insulins that are and with significant cost at the pharmacy. The audit process helps prevent fraud, waste and abuse by identifying: False claims Identification theft (member or provider) Document forgeries Billing for one product but dispensing another 5.

6 E These add-on programs offer extra diabetes management support. Enhanced programs Medication adherence program Medication adherence is critical to managing diabetes and avoiding complications. Our Medication Adherence Program helps members stick to their regimen by letting them and their physicians know when a prescription for diabetes, high cholesterol, or hypertension medication is submitted to a pharmacy, but is never filled, or is late to being filled. Customer case study: Improved adherence One large customer representing 192,000 lives improved medication adherence using the OptumRx medication Adherence program: 2 3.1% higher average (PDC) among members who received an OptumRx intervention 2.2% more adherent members across the entire customer population 40% higher refill rate 6.

7 E These add-on programs offer extra diabetes management support. Enhanced programs (cont.) Medication Therapy Management (MTM), Retrospective Drug Utilization (RDUR), RDUR Safety, and RDUR Review Gaps in Care Our MTM program, combined with our RDUR Gaps in Care program, provides personalized support to help individuals better manage their diabetes, improve health outcomes and reduce costs: Medication Therapy Management program By evaluating medication therapies, we can identify and share opportunities to improve adherence, reduce risk for drug-drug interactions, and participate in appropriate clinical programs. Each member receives a personalized pharmacist consultation to review diabetes-related action items such as glucose management and wellness exams. RDUR Safety & Gaps in care programs We review past pharmacy and medical claims to identify members whose therapies may be unsafe or inappropriate. We then work with the member and physician to start a more clinically appropriate therapy. Common causes include: Drug-drug interactions Overuse Member age or condition A high dose Duplicate medications Gaps in therapy/care Customer case study: Significant savings A large commercial managed care organization with more than 500,000 lives reduced costs through all OptumRx RDUR programs. 78,000 MTM- and RDUReligible members medical and pharmacy claims analyzed 12 months of claims evaluated to compare outcomes between programenrolled group and control group $34.66 saved per treated member per month compared to control group 3 7.

8 P 2 The power of Optum Optum solutions surround members with proactive support We are part of Optum, a leading health services company that helps make the health system work better for everyone. And with the power of Optum data, analytics, technology and expertise, we also offer add-on programs for even more targeted diabetes management support. Programs for high-risk members Drive member engagement by allowing them to view, track and share their biometric data through our integrated health and wellness website. Optum nurses and health coaches can view the latest biometric numbers and create an action plan tailored to the individual. Care reminders Help individuals and their physicians manage health proactively to avoid complications by sending HealtheNotes and HealtheNote Reminders. We monitor 100 percent of your population, providing personalized communications that deliver measurable results. Additional solutions surround members with proactive support Biometric solutions Provide biometric screening for your entire population to better understand health risks and inspire individuals to take action based on expert support and guidance. Care reminders: Proven results Members who receive reminders are: 49% more likely to resolve a diseasemonitoring issue more likely to resolve a potential medication 30% adherence issue Wellness coaching Reduce health risks and help prevent additional chronic diseases with one-on-one wellness coaching by phone, in-person consultations and by mobile device. Our wellness coaches have helped more than 50 percent of participants achieve their program goal, whether it was managing a chronic condition, preventing one, or maintaining a healthy lifestyle. 8.

9 P The power of Optum (cont.) Connected Condition Management Connected Condition Management is an integrated solution that connects medical, pharmacy and lab data to identify health risks and clinical opportunities beyond pharmacy for people with diabetes and other chronic conditions. Connected Condition Management leverages many different Optum company assets to drive improved outcomes.* Members are stratified using our treatment algorithms, and segmented based on risk: high, moderate and low. Next, we target specific kinds of interventions that are associated with each members risk profile. For example, high risk members are highlighted for enrollment in disease management programs, which includes a dedicated nurse for follow-up. These Optum nurses answer questions and help at-risk members learn how to better manage their condition, symptoms and medication. And because lab results are part of the 360-degree view, pharmacists and physicians can monitor glucose levels and medication adherence. The goal of this holistic focus on total health to improve outcomes and reduce overall costs. Proven results Customers have saved $0.90 $2.69 PMPM through OptumRx Connected Condition Management. 4 We offer performance guarantees for customer satisfaction, clinical evidence-based measures, and financial results. * This solution requires medical claims and is available for customers with 10,000 or more lives. 9.

10 See how we can help OptumRx is a full-service pharmacy care services company serving more than 65 million members with innovative prescription drug benefits services. Our resource library is full of great ideas and examples of how we are helping clients achieve better health outcomes and lower overall costs. OptumRx is part of Optum, a leading information and technology-enabled health services business dedicated to making the health system work better for everyone. 1. American Journal of Managed Care. Impact of Type 2 Diabetes Medication Cost Sharing on Patient Outcomes and Health Plan Costs. ajmc.com/journals/issue/2016/2016- vol22-n6/impact-of-type-2-diabetes-medication-cost-sharing-on-patient-outcomes-and-health-plan-costs. June 17, OptumRx customer analysis Benchmark outcomes are not a guarantee of future results. 3. OptumRx customer claims analysis Outcomes are not a guarantee of future results. 4. OptumRx book of business Outcomes vary by customer and are not a guarantee of future results. 5. Patient Preference and Adherence. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Published online July 22, Statement regarding financial influence This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article. optumrx@optum.com 2300 Main Street, Irvine, CA All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners. M54610-H Optum, Inc. All rights reserved.