PerformRx, a member of the AmeriHealth Caritas family of companies, is a pharmacy benefits manager (PBM) covering more than 3.5 million lives. In partnership with 2 affiliated, Pennsylvania-based Medicaid managed care organizations (MCOs)—a large, Philadelphia-based Medical Assistance managed care health plan and AmeriHealth Caritas Pennsylvania—PerformRx implemented a collaborative drug therapy management (DTM) program for patients with diabetes treated with polypharmacy.
DTM is a service that optimizes drug therapy to improve therapeutic outcomes for patients by eliciting changes in suboptimal drug regimens, reducing the incidence of adverse drug events, and improving adherence. Although DTM has demonstrated impressive quality improvements and cost savings as a stand-alone service in managed care, it is often insufficiently targeted to the most responsive members. High-risk patients with diabetes, for example, are often diagnosed with additional comorbidities and are thereby managed with polypharmacy. Polypharmacy is associated with reduced medication adherence and increased risk of medication-related problems and hospitalization.
AmeriHealth Caritas has implemented a collaborative PBM/MCO-administered DTM program employing both a pharmacist and a care manager (CM) to optimize the medication regimens of high-risk patients with diabetes treated with polypharmacy (≥15 medications). First, pharmacists review patient records, including pharmacy and medical data, to determine whether the patient’s diabetes and/or comorbidities are being adequately managed and to identify gaps in pharmaceutical care. Based on this review, the pharmacist may then make evidenced-based recommendations falling into 1 (or both) of the following 2 categories: consult with the member’s primary care provider to address identified evidenced-based provider recommendations (eg, change in medication regimen), or request an AmeriHealth-based CM to consult with the member to address identified member recommendations (eg, strategies to improve adherence). High-priority evidenced-based recommendations (eg, drug–drug interactions) are fast-tracked with greater urgency by a call to the provider and/or rapid CM-initiated outreach to the member.
After the CM speaks with the member, the reviewing pharmacist follows up with the CM to determine the outcome of the outreach no later than 20 days after the initial outreach, and may conduct additional follow-up as needed. The pharmacist then reviews claim data to assess the outcome of the recommendation (eg, whether the recommendation was accepted or rejected by the member or provider) within 90 days after the pharmacist recommendation is made to the member and/or provider. In instances where adding/changing a medication has been implemented, the pharmacist conducts an additional review for medication appropriateness and adherence and notifies the CM for additional member outreach to assess medication efficacy and side effects.