Growth of Remote Therapeutic Monitoring Lands New Opportunities for Case Management.

PURPOSE/OBJECTIVES: An increase in the use of remote therapeutic monitoring (RTM) has been spurred by nationwide factors including the COVID-19 pandemic, authorized reimbursement of RTM by the Centers for Medicare & Medicaid Services, and more frequent use of big data analytics in health care delivery. This article discusses the use of RTM by care teams at the point of care and explores the role of the case manager in RTM to address patients' unmet needs. PRIMARY PRACTICE SETTINGS: Although RTM may be utilized across inpatient and outpatient levels of care, this article focuses on outpatient care such as community clinics, provider groups, and home health care. FINDINGS/CONCLUSIONS: When implemented along with care management interventions, RTM applications have the potential to improve patient adherence, enhance communication between patients and their providers, streamline resource allocation, and address social determinants of health impacting patient care and outcomes. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: RTM reimbursement models are rapidly evolving, utilizing real-world and patient-reported data to identify and initiate timely, individualized solutions that meet the holistic needs of each patient. Use of an RTM system allows the case manager to build rapport with the patient while quickly identifying care gaps and delivering appropriate interventions that can maximize patient outcomes. RTM can drive savings and bring revenue to the system or practice while providing salient documentation of social determinants of health that can be addressed with validation of proven care coordination interventions.

A regional analysis of payer and provider views on cholesterol management: PCSK9 inhibitors as an illustrative alignment model.

BACKGROUND: Multiple barriers exist for appropriate use of the proprotein convertase subtilisin/kexin type 9 enzyme inhibitors (PCSK9i) in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH) with inadequately controlled hypercholesterolemia despite standard therapies. Among these barriers, high payer rejection rates and inadequate prior authorization (PA) documentation by providers hinder optimal use of PCSK9i. OBJECTIVES: To (a) identify and discuss provider and payer discordances on barriers to authorization and use of PCSK9i based on clinical and real-world evidence and (b) align understanding and application of clinical, cost, safety, and efficacy data of PCSK9i. METHODS: Local groups of 3 payers and 3 providers met in 6 separate locations across the United States through a collaborative project of AMCP and PRIME Education. Responses to selected pre- and postmeeting survey questions measured changes in attitudes and beliefs regarding treatment barriers, lipid thresholds for considering PCSK9i therapy, and tactics for improving PA processes. Statistical analysis of inter- and intragroup changes in attitudes were performed by Cox proportional hazards test and Fisher's exact test for < 5 variables. RESULTS: The majority of providers and payers (67%-78%) agreed that high patient copayments and inadequate PA documentation were significant barriers to PCSK9i usage. However, payers and providers differed on beliefs that current evidence does not support PCSK9i cost-effectiveness (6% providers, 56% payers; P = 0.003) and that PA presents excessive administrative burden (72% providers, 44% payers; P = 0.09) Average increases pre- to postmeeting were noted in provider beliefs that properly documented PA forms expedite access to PCSK9i (22%-50% increase) and current authorization criteria accurately distinguish patients who benefit most from PCSK9i (6%-22%). Payers decreased in their belief that current authorization criteria accurately distinguish benefiting patients (72%-50%). Providers and payers increased in their belief that PCSK9i are cost-effective (44%-61% and 28%-50%, respectively) and were more willing to consider PCSK9i at the low-density lipoprotein cholesterol threshold of > 70 mg/dL for patients with ASCVD (78%-83% and 44%-67%, respectively) or FH (22%-39% and 22%-33%). Payers were more agreeable to less stringent PA requirements for patients with FH (33%-72%, P = 0.019) and need for standardized PA requirements (50%-83%, P = 0.034); these considerations remained high (89%) among providers after the meeting. Most participants supported educational programs for patient treatment adherence (83%) and physician/staff PA processes (83%-94%). CONCLUSIONS: Provider and payer representatives in 6 distinct geographic locations provided recommendations to improve quality of care in patients eligible for PCSK9i. Participants also provided tactical recommendations for streamlining PA documentation processes and improving awareness of PCSK9i cost-effectiveness and clinical efficacy. The majority of participants supported development of universal, standardized patient eligibility criteria and PA forms. DISCLOSURES: The study reported in this article was part of a continuing education program funded by an independent educational grant awarded by Sanofi US and Regeneron Pharmaceuticals to PRIME Education. The grantor had no role in the study design, execution, analysis, or reporting. AMCP received grant funding from PRIME to assist in the study, as well as in writing the manuscript. McCormick, Bhatt, Bays, Taub, Caldwell, Guerin, Steinhoff, and Ahmad received an honorarium from PRIME for serving as faculty for the continuing education program. McCormick, Bhatt, Bays, Taub, Caldwell, Guerin, Steinhoff, and Ahmad were involved as participants in the study. Bhatt discloses the following relationships: Advisory board: Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Level Ex, Medscape Cardiology, PhaseBio, PLx Pharma, Regado Biosciences; Board of directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data monitoring committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); Site co-investigator: Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; Unfunded research: FlowCo, Merck, Novo Nordisk, Takeda. Bays' research site has received research grants from 89Bio, Acasti, Akcea, Allergan, Alon Medtech/Epitomee, Amarin, Amgen, AstraZeneca, Axsome, Boehringer Ingelheim, Civi, Eli Lilly, Esperion, Evidera, Gan and Lee, Home Access, Janssen, Johnson and Johnson, Lexicon, Matinas, Merck, Metavant, Novartis, Novo Nordisk, Pfizer, Regeneron, Sanofi, Selecta, TIMI, and Urovant. Bays has served as a consultant/advisor for 89Bio, Amarin, Esperion, Matinas, and Gelesis, and speaker for Esperion. McCormick, Caldwell, Guerin, Ahmad, Singh, Moreo, Carter, Heggen, and Sapir have nothing to disclose.

Self-Reported Training Adequacy, Experience, and Comfort Level in Performing Schizophrenia-Related Clinical Skills among Psychiatry Residents and Fellows.

OBJECTIVE: In the context of an educational program on schizophrenia for psychiatry trainees, this survey study analyzed associations between self-reported training adequacy, experience in providing patient care, and comfort level in performing schizophrenia-related clinical skills. The influence of the education on comfort level was also assessed for each skill. METHODS: Survey respondents were psychiatry residents and fellows who participated in a schizophrenia education program at an in-person workshop or through online videos recorded at the workshop. In a pre-program survey, participants reported their experience in providing schizophrenia patient care and rated their training adequacy and comfort level for performing seven clinical skills involved in diagnosing and treating schizophrenia. The post-program survey included items for reassessing comfort level in performing the skills. RESULTS: Across the seven clinical skills, the proportion of respondents (n = 79) who agreed or strongly agreed that their training was adequate ranged from 29 to 88 %. The proportion of high ratings for comfort level in skill performance ranged from 45 to 83 %. Comfort level was significantly associated with training adequacy for all seven clinical skills and with experience in providing patient care for four skills. For all skills, comfort level ratings were significantly higher after versus before the educational workshop. Commonly indicated needs for further training included education on new therapies, exposure to a broader range of patients, and opportunities for longitudinal patient management. CONCLUSIONS: Psychiatry trainees' self-reported, disease-specific training adequacy, experiences, and comfort level have unique applications for developing and evaluating graduate medical curriculum.

Incorporating the treat-to-target concept in rheumatoid arthritis.

BACKGROUND: Recent publications have proposed revisions to disease classification criteria, new definitions of remission, and guidelines for implementing treat-to-target strategies for the management of patients with rheumatoid arthritis (RA). Despite developments leading to this practice-changing approach, the concept of treat to target has not yet been widely accepted or implemented in managed care. At the 24th Annual Meeting Expo of the Academy of Managed Care Pharmacy (AMCP), held in San Francisco on April 18, 2012, a 4-hour activity titled Incorporating New Treat-to-Target Guidance and Strategies in RA: What Managed Care Needs to Know was conducted in association with AMCP's Continuing Professional Education Partner Program. The practicum featured didactic presentations, a roundtable session, and an expert panel discussion detailing research evidence, ideas, and discussion topics central to the treat-to target concept in RA and its applications to managed care. OBJECTIVES: To (a) discuss recent advances in RA management, (b) evaluate strategies to optimize the use of disease-modifying antirheumatic drugs(DMARDs), and (c) explain how to incorporate the treat-to-target paradigm in contemporary clinical practice and clinical care models in order to improve outcomes for patients. SUMMARY: The past decade has seen a tremendous amount of change in the field of rheumatology. The early and aggressive treatment of RA, including the use of novel biologic agents, has been shown to have favorable patient outcomes in reducing synovial inflammation, delaying joint damage,and maintaining functional status, leading to the recently published revisions in classification criteria and updated recommendations for the utilization of conventional DMARDs and biologic agents in the treatment of RA. The revised classification criteria can be used to diagnose RA patients at an earlier point in the disease course by placing greater emphasis on clinical features that manifest early in the disease process. The concept of achieving tight control of RA and treating to target has been well established and utilizes early diagnosis, aggressive treatment, and regular monitoring,leading to positive outcomes in a significant number of patients with RA who achieve current treatment goals of low levels of disease activity or clinical remission.

Evaluating risks, costs, and benefits of new and emerging therapies to optimize outcomes in multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is a complex, chronic, and often disablingneurological disease. Despite the recent incorporation of new treatmentapproaches early in the disease course, care providers still face difficultdecisions as to which therapy will lead to optimal outcomes and whento initiate or escalate therapies. Such decisions require proper assessmentof relative risks, costs, and benefits of new and emerging therapies, as wellas addressing challenges with adherence to achieve optimal managementand outcomes.At the 24th Annual Meeting Expo of the Academy of Managed CarePharmacy (AMCP), held in San Francisco on April 18, 2012, a 4-hour activitytitled "Analyzing and Applying the Evidence to Improve Cost-Benefit andRisk-Benefit Outcomes in Multiple Sclerosis" was conducted in associationwith AMCP's Continuing Professional Education Partner Program (CPEPP).The practicum, led by the primary authors of this supplement, featureddidactic presentations, a roundtable session, and an expert panel discussiondetailing research evidence, ideas, and discussion topics central to MSand its applications to managed care. OBJECTIVES: To review (a) recent advances in MS management, (b) strategiesto optimize the use of disease-modifying therapies for MS, (c) costs ofcurrent MS therapies, (d) strategies to promote adherence and complianceto disease-modifying therapies, and (e) potential strategies for managedcare organizations to improve care of their MS patient populations and optimizeclinical and economic outcomes. SUMMARY: Advances in magnetic resonance imaging and newer therapieshave allowed earlier diagnosis and reduction of relapses, reduction in progressionof disability, and reduction in total cost of care in the long term.Yet, even with the incorporation of new disease-modifying therapies intothe treatment armamentarium of MS, challenges remain for patients, providers,caregivers, and managed care organizations as they have to makeinformed decisions based on the properties, risks, costs, and benefits ofeach individual drug as part of an individualized shared decision-makingprocess. Case management and collaborative practice models, which incorporateself-management, medication therapy, formulary management, andcontinuous education, while promoting symptom management, medicationadherence, and a health-promoting lifestyle, are important in the overallmanagement of MS and can provide outcomes-based interventions aimedat controlling costs while maximizing treatment efficacy.