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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.

    Additional programs are offered using the same criteria as above for complex chronic medical conditions through Accordant Health Management. These programs are:

    • Seizure disorders
    • Rheumatoid Arthritis (RA)
    • Multiple Sclerosis (MS)
    • Chron’s Disease
    • Parkinson’s Disease
    • Systemic Lupus Erythematosus (SLE)
    • Myasthenia Gravis
    • Sickle Cell Disease
    • Cystic Fibrosis (CF)
    • Hemophilia
    • Scleroderma
    • Gaucher Disease
    • Polumyositis
    • Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIPD)

  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
    Point of Service (POS) Safety Review is our baseline safety solution. Our system can perform up to 500 concurrent DUR edits on every prescription – in real time, at mail and retail – to help ensure the prescription meets both administrative and member safety criteria. Whether a prescription is presented through our mail service pharmacies or our retail network, CVS/caremark systems automatically evaluate the prescription in the context of the member’s complete drug history. When appropriate, real-time alerts are issued to the dispensing pharmacist regarding potential issues.

    All prescriptions are first checked for member eligibility and plan design features. They are then compared against previous histories of prescriptions filled by the same pharmacy, by other participating retail network pharmacies, by the mail service pharmacies, and submitted paper claims. All drug conflicts are detected online when the prescription is entered into the computer system. If a conflict is identified, the pharmacist reviews the member’s history and may contact the prescriber to make any adjustments prior to filling the prescription. Our program enables the pharmacist to override an edit when they have reviewed the data with the member or prescriber and have determined that the prescription is safe to dispense.

    Our concurrent DUR program includes key edits such as drug-drug interactions, drug-allergy interactions, drug-age alerts, and therapeutic duplication.

  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 Network 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.

    Aetna 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 provider category’s credentialing standards.

  6. Care Management
    Our administrator’s Care Management approach, led by their 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. Their programs include Utilization Management, Case Management, Healthy Pregnancy, Disease Management, Medical Specialty Network and our National Ancillary Network.

    Their 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 program is full-system integration within our administrator’s organization. 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
    CVS/caremark manages up to 500 drug utilization edits that include our prior authorization criteria, quantity limits, and step therapy protocols for non-specialty medications - all designed to help improve savings and clinical outcomes for you and your members. In addition, we offer additional Specialty Guideline Management programs for the management of specialty products, biologics, and other injectable medications.

    Our criteria are developed to ensure safe, effective, and appropriate utilization of selected drugs.  Our core Point of Sale (POS) Utilization Management solutions include step therapy and quantity limits, while our enhanced solution (provided at an additional cost) includes prior authorization.

    These programs are designed to assist clients in meeting applicable regulatory requirements when they provide conditional drug coverage.  For example, prior authorization can ensure proper member safety by screening for appropriate usage including dosage and duration of therapy.  Step therapy can identify that a prerequisite condition exists (e.g., diabetes) or that a first-line drug has previously been tried. Quantity Limits can be used to restrict drugs which are subject to overuse. Drugs suitable for prior authorization, step therapy and quantity limits are:

    • Subject to significant safety concerns
    • Subject to overuse, misuse or off-label use
    • Limited to a specific patient population
    • Sometimes used for conditions that are not included in the pharmacy benefit (e.g., cosmetic use).
  8. Independent Accreditation Agencies and Other Associations
    Our administrator is very dedicated in supporting efforts to assist in efforts for affordable quality healthcare by eliminating redundancies and inefficiencies. They are an active participant in the Coalition of Affordable Quality Healthcare (CAQH).

    Our administrator is committed to providing quality, cost-effective health care and this is supported by our full accreditation for provider recognition programs from the National Committee for Quality Assurance (NCQA, ; and 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 our wellness programs, 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, overall member activity, and investigations of quality of care complaints reported to Quality Management.

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

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