Accuracy of pharmacy benefit manager medication formularies in an electronic health record system and the Epocrates mobile application.

BACKGROUND: Physicians commonly use formulary medication coverage information generated by electronic heath records (EHRs) and the Epocrates mobile drug database application when making medication selection decisions. Nonformulary selections may lead to higher out-of-pocket patient costs and nonadherence with prescribed regimens. Nonformulary selections also contribute to higher overall health plan spending. However, the accuracy of these systems compared with actual insurance coverage is not known.  OBJECTIVE: To assess the accuracy of formulary status icons generated by an EHR system and the Epocrates mobile application for patients with Alabama Medicaid and Blue Cross Blue Shield of Alabama (BCBS), the primary insurance providers in the state of Alabama. METHODS: Patients of all ages who had a chart review performed at the outpatient family medicine or pediatric clinics at the University of Alabama at Birmingham Huntsville Medical Regional Campus from May to October 2013 were included in this retrospective analysis. Patients who were not insured by either Alabama Medicaid or BCBS were excluded. Patients who did not have new medications added at the time of the visit were also excluded. For each medication prescribed, the formulary status provided in the EHR system and Epocrates was compared with the actual Medicaid and BCBS formularies published online, and the accuracy of the 2 databases was determined.  RESULTS: A total of 1,529 medication records were analyzed. The EHR and Epocrates provided accurate formulary information for 93.1% and 89.4% of medications, respectively. Formulary information generated by the EHR was 96.3% accurate for Medicaid patients and 80.1% accurate for BCBS patients. Epocrates was 88.2% accurate for Medicaid patients and 94.4% accurate for BCBS patients. A total of 936 medication records from the pediatric clinic were analyzed, and the majority of these patients (88.4%) had Medicaid insurance. In this population, the EHR was more accurate (96.9%) than Epocrates (86.6%). Of the small number of pediatric medication records (n = 109) associated with patients who had BCBS, Epocrates was more accurate (92.7%) than the EHR (83.5%). In family medicine, 593 medication records were analyzed. Again, for Medicaid patients, the EHR was more accurate (95.3%) than Epocrates (91.5%). For those with BCBS, Epocrates was more accurate (95.3%) than the EHR (78.2%). When over-the-counter (OTC) medications (n = 232) were analyzed separately from prescription medications, it was found that overall the EHR was 90.5% accurate, and Epocrates was 41.4% accurate. It is important to note that when only prescription medications were analyzed, the accuracy rates were high (93.6% for the EHR and 98.0% for Epocrates). CONCLUSIONS: Formulary information generated by the EHR system and the Epocrates mobile application is a useful tool for physicians when prescribing medications, but neither source is completely accurate. Prescribers should be particularly cautious when making OTC formulary decisions using the Epocrates mobile application, since the formulary information provided for these medications was found to be the least accurate.

Finding their way home. Despite mixed evidence, providers and payers are adopting patient-centered medical homes to improve health and cut costs.

Medical homes are proliferating, though not everyone is convinced they'll produce savings. Don't tell that to the Michigan Blues, which since 2008 has helped more than 1,200 primary-care practices qualify as medical homes, with another 1,000 in the process. The insurer calculates that the project saved it $155 million in 2012 alone. "Those are dollar savings observed in claims data--these are not back-of-the-envelope calculations," says Dr. David Share, of the Michigan Blues.

Enhancing the quality of international orthopedic medical mission trips using the blue distinction criteria for knee and hip replacement centers.

BACKGROUND: Several organizations seek to address the growing burden of arthritis in developing countries by providing total joint replacements (TJR) to patients with advanced arthritis who otherwise would not have access to these procedures. Because these mission trips operate in resource poor environments, some of the features typically associated with high quality care may be difficult to implement. In the U.S., many hospitals that perform TJRs use the Blue Cross/Shield's Blue Distinction criteria as benchmarks of high quality care. Although these criteria were designed for use in the U.S., we applied them to Operation Walk (Op-Walk) Boston's medical mission trip to the Dominican Republic. Evaluating the program using these criteria illustrated that the program provides high quality care and, more importantly, helped the program to find areas of improvement. METHODS: We used the Blue Distinction criteria to determine if Op-Walk Boston achieves Blue Distinction. Each criterion was grouped according to the four categories included in the Blue Distinction criteria--"general and administrative", "structure", "process", or "outcomes and volume". Full points were given for criteria that the program replicates entirely and zero points were given for criteria that are not replicated entirely. Of the non-replicated criteria, Op-Walk Boston's clinical and administrative teams were asked if they compensate for failure to meet the criterion, and they were also asked to identify barriers that prevent them from meeting the criterion. RESULTS: Out of 100 possible points, the program received 71, exceeding the 60-point threshold needed to qualify as a Blue Distinction center. The program met five out of eight "required" criteria and 11 out of 19 "informational" criteria. It scored 14/27 in the "general" category, 30/36 in the "structure" category, 17/20 in the "process" category, and 10/17 in the "outcomes and volume" category. CONCLUSION: Op-Walk Boston qualified for Blue Distinction. Our analysis highlights areas of programmatic improvement and identifies targets for future quality improvement initiatives. Additionally, we note that many criteria can only be met by hospitals operating in the U.S. Future work should therefore focus on creating criteria that are applicable to TJR mission trips in the context of developing countries.

The changing definition of contrast-induced nephropathy and its clinical implications: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2).

BACKGROUND: The traditional definition of contrast-induced nephropathy (CIN) has been an absolute rise of serum creatinine (Cr) of ≥0.5 mg/dL, although most recent clinical trials have included a ≥25% increase from baseline Cr. The clinical implication of this definition change remains unknown. METHODS AND RESULTS: We compared the association of the two definitions with risk of death or need for dialysis among 58,957 patients undergoing percutaneous coronary intervention in 2007 to 2008 in a large collaborative registry. Patients with a preexisting history of renal failure requiring dialysis were excluded. Contrast-induced nephropathy as defined by a rise in Cr ≥0.5 mg/dL (CIN(Traditional)) developed in 1,601, whereas CIN defined either as Cr ≥0.5 mg/dL or ≥25% increase in baseline Cr (CIN(New)) developed in 4,308 patients. Patients meeting the definition of CIN(New) but not CIN(Traditional) were classified as CIN(Incremental) (n = 2,707). Compared with CIN(New), CIN(Traditional) was more commonly seen in patients with abnormal renal function, which was more likely to develop in patients with normal renal function at baseline. Compared with CIN(Incremental), patients meeting the definition of CIN(Traditional) were more likely to die (16.7% vs 1.7%) and require in-hospital dialysis (9.8% vs 0%). CONCLUSIONS: Our data suggest that the traditional definition of CIN (a rise in Cr of ≥0.5 mg/dL) in patients undergoing PCI is superior to ≥25% increase in Cr at identifying patients at greater risk for adverse renal and cardiac events.

Rosiglitazone prior authorization safety policy: a cohort study.

BACKGROUND: Prior authorizations (PA) are intended to promote safe and cost-effective medication use. Unwanted outcomes may occur, however, such as a patient forgoing drug therapy after a PA. The label for rosiglitazone was revised in November 2007 to include the warning of contraindicated use with nitrates or insulin, creating an opportunity for a PA directed at safe use. OBJECTIVE: To evaluate antidiabetic drug utilization after the implementation of an electronic PA that denied a claim for rosiglitazone if the patient had a history of either insulin or nitrate supply in the previous 60 days. METHODS: This quasi-experimental study used pharmacy claims for 1.4 million commercially insured members who were exposed to a rosiglitazone PA beginning on January 1, 2009, compared with a group of approximately 2 million commercially insured members who did not have this safety PA intervention. Continuously enrolled members were identified who had a rejected (intervention group) or paid (comparison group) claim for rosiglitazone during the period from January 1, 2009, through June 30, 2009. Pharmacy claims were assessed for the presence of nitrates, insulin, rosiglitazone, other antidiabetic therapy, or no antidiabetic therapy supply on days 30, 60, 90, and 180 after the rejected/paid claim. A time-series analysis using rosiglitazone claims for all health plan members from January 2008 through December 2009 was used to evaluate the impact of the PA on rosiglitazone utilization overall. RESULTS: At 30 days, there were 134 patients (60.4% of 222) in the comparison group with concurrent supply of rosiglitazone with insulin and/or nitrates versus 4 patients (2.4% of 168, P less than 0.001) in the PA intervention group, and the utilization rate remained significantly higher at 180 days in the comparison group (37.8%, n = 84) versus the PA group (2.4%, n = 4, P less than 0.001). Beginning at 60 days, there was no significant difference in the percentage of members with no antidiabetic therapy in the comparison and PA intervention groups (9.9% vs. 15.5%, respectively, P = 0.133), and the rates remained similar through 180 days (15.3% vs. 13.7%, respectively, P = 0.760). The PA was associated with an absolute decrease of 5.1 average monthly rosiglitazone claims per day per million members (P less than 0.001). CONCLUSIONS: This PA, intended to reduce known cardiovascular event risks among health plan members with type 2 diabetes, was associated with a significant reduction in concurrent use of rosiglitazone with nitrates or insulin.

Setting a national minimum standard for health benefits: how do state benefit mandates compare with benefits in large-group plans?

Many proposed health insurance reforms would establish a federal minimum benefit standard--a baseline set of benefits to ensure that people have adequate coverage and financial protection when they purchase insurance. Currently, benefit mandates are set at the state level; these vary greatly across states and generally target specific areas rather than set an overall standard for what qualifies as health insurance. This issue brief considers what a broad federal minimum standard might look like by comparing existing state benefit mandates with the services and providers covered under the Federal Employees Health Benefits Program (FEHBP) Blue Cross and Blue Shield standard benefit package, an example of minimum creditable coverage that reflects current standard practice among employer-sponsored health plans. With few exceptions, benefits in the FEHBP standard option either meet or exceed those that state mandates require-indicating that a broad-based national benefit standard would include most existing state benefit mandates.

Michigan P4P program given high grades.

Program focuses on quality of care indicators, patient safety, and community health. Facilities can potentially receive incentive of up to 4% of hospital inpatient DRG payment each year. Program is not static; as performance data is accumulated, the "bar" can be continually raised.

An innovative approach to managing depression: focus on HEDIS standards.

This article reviews a disease management program that was developed to improve the treatment of depression in members of a managed care organization (MCO). The program's focus is on medication monitoring to improve members' compliance with their antidepressant medication regimen. Within the first year of the program's implementation, medication compliance rates improved by more than 10%. This was accomplished through a collaborative team effort among the MCO, the MCO's behavioral health vendor, the MCO's pharmacy benefit management provider, and a physician advisory committee. The program's positive outcomes demonstrate that patient monitoring works when there is collaboration among healthcare providers and physician support is achieved.