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Healthcare Plan Information

Rural Carrier Healthcare Patient Safety Initiatives

Improving the Quality of Healthcare

Rural Carrier Benefit Plan, with assistance from underwriter Mutual of Omaha, is committed to setting standards that encourage best practices and promote and increase patient safety, the reduction of medical errors and ongoing opportunities for member education.

Current Patient Safety Initiatives and Expected Outcomes

  1. Disease Management Program
    Our disease management program Healthydirectionssm for congestive heart failure seeks to improve patient outcomes and includes disease and patient monitoring, follow-up, and education. The program manages a patient's symptoms in conjunction with his/her physician's treatment plan. Members enroll in the program voluntarily, directly or through plan contact. All aspects of the patient's disease are coordinated in a team effort between the physician, the patient, and the disease manager.

    CarePatterns® is Caremark's most intensive clinical offering in Disease Management Programs. They offer disease management programs to RLC members on osteoarthrities, diabetes, and asthma. These programs monitor a patient's entire care, not just drug therapy. The CarePatterns® programs improve the patient's quality of life while reducing the overall cost of treating their disease, through coordinating the activities of all parties – patient, physician, pharmacist, and Caremark's own team of specially trained nurses and case managers. These programs stress patient education and compliance with prescribed treatment.

    CarePatterns® programs evaluate all outcomes, comparing pre- and post-enrollment measures for cost, utilization, symptom severity, and patient functionality.

  2. Centers of Excellence/Medical Specialty Network
    Our medical specialty network consists of 14 centers of excellence that are credentialed initially and annually and are specifically contracted to provide transplant services to our members.

    These transplant centers have demonstrated greater-than-average outcomes and less-than-average complication rates and are selected using a strict list of criteria including, but not limited to: Provider Transplant Program, Transplant Team, Facility, Patient Outcomes, Quality Assurance Programs, Data Management.

  3. Drug Utilization Review-Caremark
    Caremark's pre-dispensing drug utilization review (DUR) edit checks are performed on an on-line, real-time basis between the mail and retail network pharmacies. All prescriptions are compared against previous histories of prescriptions filled by the same pharmacy, by other participating retail network pharmacies, and by the mail service pharmacy. All drug interactions are detected on-line when each prescription is entered into the pharmacy's system. If an interaction is identified, the pharmacist will review the patient history and may contract the prescribing physician prior to filling the prescription.

    Caremark's pre-dispensing drug utilization review activities are an integral component of our overall commitment to safety and quality. Pharmacy attention to identifying potential drug interactions and/or duplicate therapies, and discussing these potential problems with the prescribing physician(s), ensures that the correct amount of the appropriate drug is being delivered.

    The following edit checks are completed on-line, real-time as a prescription is being dispensed:

    • Duplicate Drug Therapy. Caremark examines each prescription submitted and checks against any other drugs in the same class and rejects the prescription if duplicates occur. This edit protects the patient from potentially over medicating, which could be life threatening.
    • Too-Early Refill. This edit is driven by days' supply. It prevents abuse, over-medication, or stockpiling, which can be unsafe. Caremark examines the claim prescription number, the date of service, and the days' supply. If the claim is transmitted before the allotted days' supply has run out, the claim will be rejected and an appropriate message will be displayed to the pharmacist telling him/her the reason for the reject, the prescription number, drug, quantity, and date filled.
    • Low-Dose/High-Dose Alert. This edit checks each prescription submitted for incorrect dosage or excessive or questionable daily dosage. An appropriate message will be sent to the pharmacist indicating the usual dosage for the prescribed medication.
    • Incorrect Daily Dosage. If the prescribed daily dosage exceeds the recommended daily dosage (based on quantity dispensed and indicated days' supply), a reject message is returned to the pharmacist.
    • Excessive or Questionable Days' Supply. Caremark compares the submitted supply to the program's parameters. If the supply submitted exceeds the program's parameters, the low- high-dose edit will be used to check for excessive days' supply according to the recommended normal dosage, thus alerting the pharmacist to potential over-use of medications.
    • Drug to Drug Interaction. Caremark examines all medications currently being taken and then examines the new prescription being submitted to see if the new prescription could possibly have adverse reactions when used in conjunction with any of the other medications a patient is currently taking.
    • Drug Age Interaction. Caremark examines all medications currently being taken, the medication being submitted by the pharmacist, and the age of the patient. It can then be determined if the medication is appropriate for a patient of that age.

    All Caremark drug utilization review procedures allow pharmacist override when the pharmacist has reviewed the data with the patient and/or physician and has determined that the prescription is safe and effective to dispense.

  4. Optum Nurse Line
    Offers 24 hours, 7 day a week access to a trusted source of information. This nurse line can assist with questions about newly diagnosed health concerns, chronic conditions, urgent situations or tips about staying well and strong. The member may speak with a caring nurse, who is an experienced registered nurse who will carefully listen to their concerns and give information to help choose the right care for the situation the member is faced with. The member can also click onto their website and gain instant access to a wealth of reliable health and well-being information. The member also has access to a toll-free number, to listen via audio message, information from the Health Information Library.

  5. Credentialing of PPO Providers
    An integral part of developing or expanding Mutual of Omaha's managed care organization is the selection of participating providers. The ability of an organization to attract those physicians who will render quality medical care and will share in the overall objectives of the organization is a principal factor in the success of that organization.

    Credentialing plays a major role in the provider selection process. The information collected about each applicant and the standards used to evaluate this information significantly contribute to the selection of medical practitioners capable of providing quality medical care. Consistent use of the same information, requirements, and standards affords the best opportunity for developing quality provider networks.

    The recredentialing process is conducted at least every two years, based on the date the provider was initially approved by the Credentialing Committee, and shall be ongoing and up-to-date.

    Subject to any relevant contractual provisions, a provider's participation status may be terminated if Mutual of Omaha becomes aware of, any infractions of the required credentialing standards.

    Mutual of Omaha will verify that each of the health delivery organizations and institutions with which it contracts, i.e., hospitals, skilled nursing facilities, home health care agencies, free-standing surgical centers, and others, has met the required credentialing standards.

  6. Total Care Management (TCM)
    Mutual of Omaha's Total Care Management (TCM) approach, led by our Professional Medical Management Team, combines a customer-centered strategy that focuses on high-quality medical care provided in the most appropriate setting, while managing costs. Our TCM programs include Utilization Management, Case Management, Healthy Pregnancy, Disease Management, Medical Specialty Network and our National Ancillary Network.

    Our Professional Medical Management Team is comprised of Board-certified Medical Directors supported by Board-certified medical physicians and other medical consultants, providing review expertise in specific specialty areas. Care Coordinators, who are registered nurses, and licensed mental health practitioners, help ensure effective coordination of specialized care for plan members. Doctors of Pharmacy (registered pharmacists) provide expertise in rational drug therapy and cost-effective use of medications in treating medical conditions.

    A key component to the success of our TCM program is full-system integration within Mutual of Omaha. This integration allows for real-time data to be accessed by multiple areas within the company to provide for consistent communication.

  7. Utilization/Medical Management Programs
    The Mutual of Omaha Corporate Utilization Management (UM) Program is a formal process that evaluates necessity, appropriateness, efficiency, quality, and efficacy of medical services provided for insureds and their dependents. Mutual of Omaha, through their website and upon request has available to physicians, evidence based criteria.

    Independent Accreditation Agencies and Other Associations
    Mutual of Omaha is very dedicated in supporting efforts to assist in efforts for affordable quality healthcare by eliminating redundancies and inefficiencies. Mutual of Omaha is an active participant in the Coalition of Affordable Quality Healthcare (CAQH).

    Mutual of Omaha Companies is committed to providing quality, cost-effective health care and this is supported by our full accreditation for Utilization Management from URAC (Utilization Review Accreditation Commission). Accreditation from URAC is an indication that a managed care organization has the necessary structures and processes to promote high quality care and preserve patient rights.

    Goals and Outcomes of Patient Safety Initiatives
    Through the above initiatives, and under the direction of Mutual of Omaha's patient safety officer, Anthony Metcalfe, M.D., Senior Vice President, Medical Management, our goals are to increase member awareness and provide safety measures for their healthcare. Through our programs, we strive for a total care management approach for our members, which provides for consistent and coordinated care. These programs provide education to our members, which allows for a more informed consumer who can actively participate in their healthcare decisions.

    Measurement of Patient Safety Initiatives
    Measurement of these activities are monitored through our utilization reports, patient surveys and overall member activity.

    We continue to monitor and evaluate additional opportunities for patient safety and education.

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