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Healthcare Plan Information

GEHA Patient Safety - Updated September 2013

Activity Description Goal/Expected Outcome Measurement
RationalMed Drug Utilization Review (DUR) GEHA uses RationalMed predictive modeling to evaluate several sources of patient data (medical, pharmacy, lab, and patient self-reported information) and identify GEHA patients who may be at risk for near-term hospitalizations, adverse events and longer-term health complications. The program notifies the prescribing physician and pharmacists of potential safety issues. Reduced hospitalizations and appropriate use of prescription drugs. GEHA measures how many patients have been helped through this program.
Concurrent Drug Utilization Review (DUR) Concurrent DUR provides real-time patient data to pharmacists at the time of purchase. This clinical database screens each prescription against a patient's prescription drug history, reflecting all prescriptions acquired in the retail, home-delivery, and specialty pharmacy settings and integrates it into a single record. Patient information contained in individual profiles includes drug therapies, alert history, communications history, customer service history, demographic information and patient-reported disease and allergy information (if provided), and medical claims history if provided by client or medical vendor. Fewer patient health complications related to prescription drugs. GEHA measures how many patients have been helped through this program.
High Drug Utilization This program identifies patients who may be at risk for overuse of narcotic drugs. Pharmacists determine if interventions are necessary. This program ensures that drug usage is appropriate for the patient. GEHA receives reports on drug utilization and expense.
Managed Prior Authorization/Smart Prior Authorization Express Scripts prior authorization drives patient safety by monitoring the dispensing of high-cost medications and those with the potential for misuse. Our program ensures drug coverage is consistent with the GEHA's intent for the prescription benefit, while maintaining member and physician satisfaction. This program helps ensure that medications are used appropriately. GEHA measures how many patients have been helped through this program.
Prescription Drug Appeal Process Drugs not normally covered by GEHA may be approved through Prior Authorization. GEHA's Medical Director determines if the medication is appropriate for the patient's diagnosis. This program helps ensure that certain medications are covered for the patient when medically necessary. N/A
Prescription Drug Packaging On prescriptions filled for GEHA members, Express Scripts provides a cap that can be used as a childproof cap or an easy-open cap. This program helps ensure that medication is not accessible to small children. N/A
Prescription Drug Recalls Express Scripts contacts patients and physicians regarding drug recalls and drug advisories. This program helps ensure that patients have clinically sound medication. GEHA measures how many patients are contacted.
Six Sigma Quality Standard Six Sigma is a program that ensures the correct prescription medication is in the correct bottle when sent by the home delivery facility. Fewer health complications related to prescription drugs. N/A
Health, Allergy and Medications Questionnaire This form asks each covered family member for information on allergies and health conditions. This information is keyed into the patient profile and accessed when prescriptions are filled. This program helps ensure that patients do not receive medications that could have a negative impact on their health. N/A
Patient Package Inserts Each mail order prescription is accompanied by an insert that discusses the medication's side effects and how it should be taken. A phone numberis listed for more information. Inserts help patients understand their medication. GEHA measures how many prescriptions are filled by Home Delivery.
Specialist Pharmacists Express Scripts delivers expert care through 15 Therapeutic Resource Centers for patients who fill prescriptions by mail order. Each Therapeutic Resource Center focuses on a chronic or therapeutic condition, such as diabetes or cardiovascular disease, and is staffed by Specialist Pharmacists with specialized training and experience. Specialist Pharmacists ensure patient safety through the clinical review of prescriptions, patient counseling, and physician consultation. This comprehensive review of patient-level data, evidence-based clinical protocols, and gaps in care information enables Specialist Pharmacists to more effectively manage, prioritize, and optimize specific therapies for each patient. Optimized therapy for members with chronic conditions. GEHA measures how many prescriptions are filled by Home Delivery.
CareLogic® Express Scripts CareLogic® programs provide disease-focused care for patients with asthma, bleeding disorders, cystic fibrosis, growth hormone, hepatitis C, human immunodeficiency virus (HIV), immune disorders, multiple sclerosis, oncology, pulmonary arterial hypertension (PAH), respiratory syncytial virus (RSV), rheumatoid arthritis/inflammatory conditions, and transplants. The programs are staffed by specialized clinicians and provide patient assessments, proactive adherence support, outcomes tracking, patient advocacy and education, detailed reporting, and support for the prescriber-patient relationship and plan of care.  Included are scheduled one-on-one consultations between patients and our specialized team of clinical experts according to individual therapy needs. Patients enrolled in CareLogic® programs maintain adherence at a 4% to 8% higher rate than patients who are not enrolled in these programs. GEHA measures how many patients have been helped through this program.
ePrescribing Through ePrescribing, physicians can access patients' benefit, formulary information, and medication history at the time they write prescriptions. Improved patient safety and fewer adverse drug events. GEHA measures the percentage of members utilizing ePrescribing
Concierge Center This call center assist members with refill reminders, help with forms, referrals for services and educational materials. This program helps members use and understand their prescription drug program. N/A
Health Balance For selected cases, GEHA Certified Case Management nurses coordinate patient care, with an emphasis on education, wellness, illness prevention and maintenance care. Nurses help to assess and plan care, coordinate services, provide referrals and monitor overall treatment. By coordinating services between patients and health care providers, GEHA helps to improve patient satisfaction, improve quality of care and reduce costs. GEHA measures patient satisfaction, how many patients have been helped through this program and program savings.
Maternity Program This program is available to expectant mothers, who are encouraged to visit the health plan website and view available information for pregnant members; including a pregnancy book and information about maternity benefits. High risk maternity patients may be followed by a care management nurse if home services are required. A proactive educational approach heightens the expectant mother's awareness of health-related issues and can reduces complications. Early and ongoing assessment of high-risk factors helps reduce or even prevent obstetrical or neonatal problems such as low birth-weight and premature births. GEHA measures how many patients participate in the program.
Hospital Precertification Before a hospital admission, GEHA evaluates the medical necessity of the proposed stay and the number of days required to treat the patient's condition. The patient is responsible for ensuring precertification is received. Precertification helps ensure that patients receive appropriate treatment in the appropriate setting. GEHA measures hospitalization statistics: length of inpatient stays and avoided inpatient days.
Hospital Quality Guide HealthGrades rates and compares hospitals for more than 90 specific medical conditions and procedures. Members can view information on individual hospitals, or make comparisons between hospitals on such topics as clinical services, patient safety record, safe practices, appropriate care, and overall quality rating. Information helps patients make informed choices. N/A
HIT Education Our website includes a Patient Safety page with links to the Leapfrog Group and to the HHS Hospital Compare website: Information helps patients to identify safety concerns such as allergic reactions, drug interactions, etc. GEHA assesses the utilization of this link.
Never Events and Hospital Acquired Condtions GEHA implemented a uniform policy for identification, review and possible non-payment of certain hospital-acquired conditions (HAC), avoidable complications “never events” to reduce the risk of serious adverse events in hospitals for our members. The policy is intended as guidance for handling of GEHA member claims involving HAC or never events. Consistent with CMS policy, GEHA holds to the basic philosophy that payment will not be made for “never events” or avoidable complications and we are working with the PPO networks to deny payment on these claims with no patient liability. GEHA will not pay for care associated with never events or hospital acquired conditions. GEHA monitors claims associated with potential never events and hospital-acquired conditions.
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