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Intro to synchronization

At OptumRx, we use the word synchronization to describe all of the ways we collaborate to deliver improved, coordinated care for the people we serve. Synchronization simply means connecting the data of traditional pharmacy coverage with data from non-pharmacy services for better outcomes.

When combined with evidence-based medical practice guidelines, this data creates useful insights. For example, when we engage with a member, our synchronized data ensure that we have a clear view of her conditions and preferences. That means we can present health or savings options that we can be pretty sure she will accept.

Perhaps the simplest example of the synchronization idea takes place when a member calls one of our customer service representatives with a basic coverage question. Regardless of why the member called, our representative will know, for example, whether she isn’t refilling her prescriptions, or that she might need extra help from a nurse or other medical professional. [Learn more about this here.]

Our synchronized data delivers better care outcomes and a lower overall cost of care. See below for details about overall medical PMPM savings, reductions in ER visits and inpatient admissions.

Specialty ups the ante

Moving to someone who requires a specialty medication takes us into a far more complex world. Providing access to specialty medications can be extremely challenging for a number of reasons:

Specialty medications may require complicated dosing schedules, or present challenging side-effects, or both.

Many specialty patients suffer from other conditions as well. 91% of OptumRx specialty patients suffer from multiple conditions, including 27% who suffer from depression.1

Multiple conditions mean multiple medications. We have found that the average specialty patient has 2.5 conditions, and they take an average of 13.6 different drugs per year.1,2 These additional therapies can be complicated and affect a patient’s ability to stay adherent.

Specialty patients are at-risk for adverse drug events when they are discharged from an inpatient hospital stay. Hospital patients often receive new medications or have changes made to their existing medications.3 Studies show that up to 71% of adverse health events experienced by patients discharged from the hospital are drug-related.4 Specialty patients are especially vulnerable to missing therapies, duplicate therapies, incorrect dosages, or high-risk medications.3

For these reasons, managing specialty pharmacy patients requires constant and timely communication between the entire health care team. We want to shine a light on the systems and processes that connect OptumRx specialty pharmacy clinical management programs with other Optum clinical services. This will demonstrate the true power of synchronization to engage each member for a smarter and more holistic health care – even under the most demanding clinical conditions.

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Jason’s care journey

“Jason” is a real person (we have changed his name here). As one of our specialty pharmacy patients, Jason needed expert, personalized support in order to successfully manage not just one but two very complex medical conditions: a coronary artery bypass graft (CABG), and rheumatoid arthritis (RA).

CABG involves bypassing a blocked blood vessel in the heart. There are many potential risks, including bleeding, blood clots, infection, pneumonia, and kidney failure. Those who are recovering at home from CABG require very careful monitoring, and may need additional care.5

Synchronization opportunity #1: Post-Hospital Discharge notification

The first step in establishing a proper post-hospitalization care routine for Jason came when our synchronized data automatically notified us that Jason had been discharged from the hospital.

The hospitalization and discharge was tracked through our unique blended census reporting tool, which tracks the status of our hospitalized population much more quickly than relying on medical claims information. This proprietary census tool shares discharge alerts on a daily basis with OptumRx.

The important point is that Jason started to benefit from our synchronized pharmacy and medical data systems immediately. This is in contrast to conventional PBMs: They rely on just pharmacy claims data to generate these kinds of notifications – weeks or even months later.

[NOTE: These automated post-discharge alerts notify OptumRx specialty pharmacy regarding patients taking specialty medications who are served jointly by both OptumRx and United Healthcare, and who will require intervention. This system can also work when there is a different medical insurer, as long as the proper data feed is provided. Speak to your consultant or OptumRx representative for details.]

Impact

An internal OptumRx study found that daily notification of hospital discharges helps our clinicians contact patients in as few as three business days on average. These contacts drive clinical interventions, including counseling, disease-state education and prescription adherence. Overall, these interventions were found to significantly reduce hospital readmissions and generate savings for clients:

  • 33% lower readmissions at 60 days post discharge.1
  • Average savings of $17,500 per avoided readmission for each oral oncology patient.1
  • Average savings of $14,900 per avoided readmission for each transplant patient.1

Synchronization opportunity #2: Medication reconciliation

As we’ve seen, changes can develop in someone’s drug treatment regimen during hospitalization. In addition, almost 80% of patients are discharged from the hospital without having proper instruction in the use of their medications.4

Medication changes and lack of instruction can place recently-discharged patients at-risk for adverse drug events. Within 24 hours, Brendan, a OptumRx specialty pharmacist, reached out to Jason to perform one of the most critical care interventions: the post-discharge medication reconciliation.

Together, Jason and Brendan reviewed Jason’s complete medication plan, from the time he was admitted, and each time he was transferred, and finally when he was discharged. Then they discussed his treatment regimen now that he was going to be at home.

Brendan counseled Jason on the use of his medications, and on adherence, and reminded him to follow-up with his doctors.

Impact

Synchronization vastly simplifies the medication reconciliation process. Brendan was able to thoroughly understand and document Jason’s treatment history, which helps reduce the chances of adverse drug events, missed therapies, and readmission.

Synchronization opportunity #3: Multiple conditions

While every CABG patient faces an elevated risk of being re-admitted to the hospital, Jason also has another serious condition: rheumatoid arthritis (RA). RA is a form of arthritis that causes pain, swelling, stiffness and loss of function in the joints.6

Like many people with RA, Jason uses a biologic-based anti-rheumatic drug. Since this class of drug works by partially suppressing the immune reaction, people who take them can be at an increased risk of infection – even when they are not having open-heart surgery.7

Therefore, in order to reduce the risk of infection, Jason’s doctor had recommended that he temporarily suspend using his biologic anti-rheumatic drug before, and for at least two weeks following his CABG surgery.

During Brendan’s initial post-discharge conversation with Jason, he uncovered two critical facts:

  • Jason did not have a concrete plan for when to restart his RA medication.
  • While Jason did have follow-up appointments scheduled with the cardiac specialist and with his primary care physician, he did not seem to have as much support for other care in the home.

Consequently, Brendan did two things:

  • First, he gave Jason suggestions on how to manage his RA symptoms during the period of time during which he would not be able to take his RA medication.
  • Second, Brendan notified OptumHealth that Jason might benefit from coordinated in-home care to support his recovery.

Impact

All of Jason’s information was automatically shared with the OptumHealth nurses. A nurse was able to access Brendan’s notes concerning Jason’s need for in-home care, so she scheduled a call to discuss how to make these arrangements.

In summary, the simple fact that Jason was discharged from the hospital triggered three separate care interventions:

  1. We were immediately made aware that Jason had been discharged.
  2. Jason received hospital discharge counseling.
  3. Jason received additional support through OptumHealth for his home care needs.

Shared, synchronized data made all of this happen within hours or days of Jason’s release from the hospital.

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Synchronization opportunity #4: Ongoing care

Follow-up calls from the pharmacist are useful ways to uncover additional health and savings opportunities. These conversations, combined with other data such as disease-specific clinical assessments, or other patient reported outcomes, help us connect patients to the best available resources and care.

For example, 27% of our specialty patients suffer from depression.1 While depression is not considered a specialty condition, our clinicians are trained to screen for the signs. If they suspect that a patient is at-risk for depression, they can quickly connect them to OptumHealth behavioral health services.

In one of their follow-up calls, Brendan, the OptumRx specialty pharmacist, noticed from the OptumHealth nurse notes that Jason did not have a heart rate/blood pressure monitor that he could use in his home. Brendan knew that consistent monitoring is very important following CABG, so he flagged this issue for OptumHealth and asked them to re-examine the matter.

Shortly, an OptumHealth nurse was able to confirm that Jason’s benefit plan did have a provision to cover an in-home blood pressure monitor. A few days later, Jason received a blood pressure monitor at his home.

Impact

In this follow-up call, Brendan was primarily concerned with Jason’s medications. But synchronization allowed him to correct a potential gap in his non-pharmacy care by giving him access to Jason’s shared case notes.

Synchronization opportunity #5: Clinical program referrals

Brendan suspected that Jason might be having problems with his weight, as this is fairly common in the CABG demographic. And during a follow-up call, Jason admitted that he was significantly overweight. He realized that he probably didn’t have a very good diet, and as a recent heart surgery patient, he was worried about it.

Similar to depression screening, Brendan knew he needed to balance being supportive without prematurely pushing a specific course of action. As Brendan later remarked, “Once the patient gets offended, they don’t want to talk to you anymore.”

Brendan flagged the system to refer Jason into an OptumHealth lifestyle management program. Soon, one of the Optum specialists contacted Jason and he began to learned about healthier diet choices, and even explored some exercise ideas he could employ as soon as his cardiologist cleared him to begin exercising again.

[Note: These services and referrals are only available if the patient has OptumHealth as part of their benefit design. Speak to your consultant or OptumRx representative for details.]

Impact

Synchronization made getting Jason into the right condition management program simple and fast. With all of his case history information contained within one seamless network, professionals from different disciplines were able to identify Jason’s needs and offer support.

Synchronization opportunity #6: Collaborating with external clinicians

As mentioned in opportunity #3, Jason was instructed to avoid taking his biologic RA medication after his discharge. In their first consultation, Brendan, gave Jason some tips for how to avoid RA flare-ups during this time.

Continued monitoring confirmed that while Jason had successfully managed his RA symptoms for longer than expected, eventually his symptoms became disruptive. Brendan then reached out to Jason’s rheumatologist to discuss whether it was time to resume his RA treatment.

Impact

With our synchronized data, Brendan was able to present Jason’s entire medication history and his multiple health interventions from the time he was discharged until the present. This comprehensive data helped to simplify and clarify the doctor’s treatment decision to resume the RA medication.

 

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Bright future

This is a real story. Jason was someone with two very serious health conditions. These required different OptumHealth professionals to work seamlessly together in order to deliver a high-quality health outcome.

In this case, Jason came out of his experience feeling much better than when he began:

  • His RA symptoms are well controlled.
  • His cardiac follow up has been trending in the right direction.
  • He is very happy with his diet changes and is feeling better.

OptumIQ™

Synchronization is just one specific application of what we call OptumIQ. OptumIQ represents our unique combination of data, analytics and health care expertise. Ultimately, OptumIQ is how we use data while synchronization is what we do with the data to deliver value well beyond the typical pharmacy benefit. Synchronization empowers pharmacists, nurses, and clinicians to better support our patients who are receiving specialty medications.

In addition to the improved health and cost outcomes from our hospital discharge counseling program discussed above, OptumIQ also makes it easier for members to engage in our programs. Because of the way we synchronize care, we are able to guide patients to actions that close gaps in care. Targeted member engagement through synchronization at specialty has resulted in significant improvements for our pilot participants: 150% improvement in engagement scores and 60% improvement in overall health ownership.1

As always, please contact your consultant or OptumRx representative with any additional questions.

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References

  1. OptumRx internal analysis. 2016 data.
  2. Managed Care Connect.com. UnitedHealth, Specialty Pharmacy Driving Changes in Health Care. May 4, 2018. At: https://www.managedhealthcareconnect.com/content/unitedhealth-specialty-pharmacy-driving-changes-health-care.
  3. PSNet/Agency for Healthcare Research and Quality. Medication Reconciliation. Last Updated: June 2017. At: https://psnet.ahrq.gov/primers/primer/1/medication-reconciliation.
  4. Journal of the American Pharmacists Association. Post-discharge pharmacist medication reconciliation: Impact on readmission rates and financial savings. Jan/Feb 2013. At: https://www.semanticscholar.org/paper/Postdischarge-pharmacist-medication-reconciliation%3A-Kilcup-Schultz/6a10407ea6ed5ad19102f2cf4f91304fdba47a4d.
  5. Johns Hopkins Medicine. Coronary Artery Bypass Graft Surgery. Accessed at: https://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/coronary_artery_bypass_graft_surgery_92,P07967 on 07.17.2018. 
  6. U.S. Department of Health and Human Services, National Institutes of Health. Rheumatoid Arthritis. Page last updated July 25, 2018. At: https://medlineplus.gov/rheumatoidarthritis.html
  7. Johns Hopkins Arthritis Center. “Rheumatoid Arthritis Treatment.” April 4, 2017. At: https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/.
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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.

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