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Healthcare Plan Information

GEHA Patient Safety - May 2004

GEHA's Patient Safety program is directed by its Pharmacy and Medical Case Management departments. For more information, call GEHA at (800) 821-6136.

Activity Description Goal/Expected Outcome Measurement
Concurrent drug utilization review (DUR) CVS/caremark’s concurrent DUR system can perform up to 500 edits in real time on every prescription to ensure that prescriptions meet administrative, plan-design and member-safety criteria. The concurrent DUR program reviews the following areas: conformity with plan design; member eligibility; formulary compliance; refill limits; dosage limits; dispensing accuracy and consistency; and potential drug safety issues (e.g., drug-drug, drug-allergy, drug-gender and drug-pregnancy interactions; inferred drug-disease interactions; high dose and low dose alerts; and therapeutic duplications). Ensures the prescription meets both administrative and member safety criteria. GEHA receives overall reporting on this product.
Core safety and monitoring program Helps identify potential fraud, waste and abuse by reviewing claims through an automated series of edits that identify individuals with high-cost drug-use patterns suggesting potential abuse or misuse. Control fraud, waste and abuse GEHA receives reports on drug utilization and expense.
Prior authorization Requires that certain prescriptions meet defined criteria before they are covered by the plan; requires prescribers to confirm medical necessity and allows members to appeal a denied claim. This program helps ensure that medications are used appropriately. GEHA measures how many patients have been helped through this program.
Prescription drug appeal process CVS/caremark is responsible for first-level appeals for benefit coverage. GEHA's Medical Director reviews second-level appeals for medical necessity. This program helps ensure that certain medications are covered for the patient when medically necessary. GEHA measures through CVS reporting.
Prescription drug packaging CVS/caremark Mail Order provides a cap that can be used as a childproof cap unless an easy-open cap is requested by the member. This program helps ensure that medication is not accessible to small children. N/A
Prescription Drug Recalls Patient-level or Class I recalls, members and their prescribers will be notified of the recall via letter. Instructions will be provided regarding what action the member needs to take, as applicable. This program helps ensure that patients have clinically sound medication. N/A
Health and allergy question within mail-order form The mail-order 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 number is listed for more information. Inserts help patients understand their medication. GEHA measures how many prescriptions are filled by CVS/caremark mail order.
CVS/caremark Specialty Pharmacy Pharmacist-led Specialty CareTeams are central to CVS/caremark's industry-leading achievements in adherence, persistency, and member satisfaction. CareTeams are experts in the conditions and therapies they help manage, so they are able to provide personalized and detailed support, education, monitoring, and care coordination. By addressing each member’s unique clinical needs, CareTeams help improve adherence and persistency to prescribed therapies. Improving member health and reducing overall costs. 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. Reporting available for ePrescribing.
Retrospective safety review Reviews claims within 72 hours of adjudication to identify potential medication safety concerns Improving member health and reducing overall costs. GEHA measures how many patients have been helped through this program.
GEHA Health Balance For selected cases, GEHA -Care 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 reduce 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 the number of hits to the website for maternity materials. If in case management, GEHA measures the number of patients - managed.
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.
Non-surgical outpatient cancer treatment precertification Before administration of chemotherapy and radiation procedures, GEHA evaluates the requested treatment against evidence-based protocols. Precertification helps ensure that patients are receiving treatments that have been studied and approved by specialists for specific types of cancer Number of cases precerted and number that were compliant/non-compliant with evidence-based protocols.
Radiology precertification The program is designed to help physicians optimize the use of imaging studies in conjunction with an overall treatment plan. The patient is responsible for ensuring that precertification is received. Precertification provides a safeguard against unnecessary procedures. GEHA measures the types of procedures performed.
Health Advice Line Members can speak with a registered nurse or access the Health Information Library any time, 24 hours a day. The nurse can help members understand symptoms and determine appropriate care and setting to address needs (i.e., urgent care, ER or provider’s office). Members can also choose to listen to recorded messages on more than 1,000 health topics. Information helps patients make informed choices. GEHA measures how many patients use this service.
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: http://www.geha.com/Health-and-Wellness/Wellness-Center/Patient-Safety. 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 conditions 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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