Medical Benefit Management and Integration with the Pharmacy Benefit

Tampa—According to data from Medical Mutual, a health insurance company with headquarters in Ohio, more than 15% of cancer diagnoses are incorrect. Furthermore, 45% of patients with cancer do not comply with or complete their prescribed treatments, while 35% of treatment plans deviate from evidence-based guidelines, resulting in $25,000 in wasteful spending per patient.

Sonny Borja-Barton, PharmD, vice president, pharmacy management, Medical Mutual, said the variation in oncology care and other disease states led Medical Mutual to partner with Care Continuum on a medical benefit management program. She discussed Medical Mutual’s relationship with Care Continuum at the AMCP specialty pharmacy meeting. Care Continuum, which is owned by Express Scripts, helps clients save money on medically billed specialty drugs through utilization management, site of care management, and reimbursement management.

After starting the program and seeking clients in 2012, Dr. Borja-Barton said the program was implemented last year with utilization management and claims management protocols in place. This year, the companies are beginning to examine patient safety and waste claim edits and an oncology decision support pilot program. Next year, they will continue the oncology decision support pilot program and start with site of care management.

Dr. Borja-Barton noted that 60% of Medical Mutual’s claims and spending were related to cancer, while other companies are also dealing with an increase in oncology costs. When Medical Mutual considered how to cope with the increase in oncology spending, the company considered buying a company that offered solutions or building its own system at an estimated cost of more than $9 million over 3 years. Medical Mutual chose to partner with Care Continuum because the company offered a lower cost service, provided industry expert guidance, and helped Medical Mutual implement the program faster than the other options.

Care Continuum provided Medical Mutual with medical channel management, when better control through the pharmacy benefit was available. In the medical benefit, the companies partnered on traditional pharmacy benefit management tools, such as medical utilization management, site of care management, and reimbursement management.

For complex disease states such as oncology, they worked on decision support tools and full therapy management. The oncology decision support tool includes an evidence-based treatment plan review, treatment delivery and support, and an integration of medical and pharmacy claims data. Meanwhile, the oncology pilot program utilized a clinical pathways program and measured quality of life, costs of care, emergency room visits, and hospital readmissions.

According to Dr. Borja-Barton, Medical Mutual benefited clinically and financially from Care Continuum’sguidance. She said there were more than 2100 clinical denials and dose adjustments since implementation and more than $5 million in savings during an 8-month period, thanks to denials, dose adjustments, preferred products, and other utilization management techniques. Medical Mutual also had more than $4.5 million in claims savings in 8 months.

Dan Brouillet, senior director, medical benefit management, Care Continuum, said the company focuses on reducing costs and waste. Through Care Continuum’s utilization management program, the company focuses on the safe and appropriate use of high-cost specialty drugs by discouraging inappropriate off-label medication use, enforcing a universal safety plan, implementing a step therapy program to move from infused to self-injected therapy, and encouraging the use of generic drugs when possible.

Care Continuum also has a site of care management program in which it directs patients to the lowest costs and most clinically appropriate site of care, as well as a reimbursement management program to verify claims are paid accurately and at the contracted rate to help achieve rebates.