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Healthcare Plan Information

Improving the Quality of Healthcare- Foreign Service Benefit Plan

The Foreign Service Benefit Plan (FSBP), with assistance from our administrator Coventry Health Care, An Aetna company and our Pharmacy Benefit Manager, Express Scripts (ESI), 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. We pledge to assist OPM in providing Plan members with information and education regarding patient safety.

Current Patient Safety Initiatives and Expected Outcomes

Disease Management Program

The FSBP's disease management program for congestive heart failure (CHF), diabetes, asthma, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD) and chronic kidney disease (CKD) 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. The Plan has an exclusive disease management program for members overseas. Members are automatically enrolled in the program. All aspects of the patient's disease are coordinated in a team effort between the physician, the patient, and the disease manager.

Institutes of Excellence/Medical Specialty Network

Our administrator’s medical specialty network has contracts with national providers for organ and tissue transplant procedures. These providers meet standards for excellence in the services they provide and the outcomes they achieve. 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 and Data Management.

Drug Utilization Review

Express Scripts’ Concurrent Drug Utilization Review (Concurrent DUR) program supports patient safety at the point of service by preventing drug-related adverse events. Concurrent DUR performs online, real-time drug utilization analysis at the point of prescription dispensing, whether the dispensing occurs at the retail pharmacy or at the Express Scripts Pharmacy.

Each electronically transmitted claim is reviewed to identify the most pertinent clinical patient safety or utilization concerns and generates an alert to the dispensing pharmacist in real time before the member receives the prescription(s).

Eleven standard modules review the claim for concerns relating to: drug-age, drug-disease, drug-drug interactions, gender, overutilization, underutilization, drug-allergies, pregnancy, additive toxicity, drug name confusion, and therapy duplication. These edits (along with refill too soon, which is a Plan benefit design program) encourage appropriate medication use and support increased patient safety and decreased adverse events.

Concurrent DUR reduces wasteful medical spending by helping to reduce emergency room utilization, hospitalizations, and urgent care visits through identification and correction of clinical safety and utilization concerns.

Express Scripts integrates members’ prescription drug history, reflecting all prescriptions acquired in both retail and home delivery, into a single, real-time record that is comprehensively screened against each new prescription to identify patient health and safety concerns. Concurrent DUR then delivers targeted alert messaging to dispensing pharmacists.

Patient information contained in an individual patient profile includes, but is not limited to

  • Alert history
  • Communications and customer service history
  • Demographic information and patient-reported disease and allergy information (if provided)
  • Drug therapies
  • Medical claims history, if provided

RationalMed

RationalMed integrates and analyzes prescription and medical data to identify actionable patient safety issues across the Plan’s total population, not just for those with chronic and complex conditions. This clinical safety program helps prevent unnecessary and costly hospitalizations, adverse events, and addresses gaps in essential care — all with no disruption for the Plan’s members and guaranteed savings for the Plan.

Express Scripts’ RationalMed safety program offers more than a decade of experience and has a proven track record of improving clinical and financial outcomes. RationalMed supports member safety and helps to lower FSBP’s healthcare costs.

RationalMed offers the following benefits:

  • Protects the Plan’s entire population, including covered dependents, against thousands of evidence-based drug risks
  • Delivers extra safety to our members and extra savings for the Plan
  • Affects evidence-based changes in therapy and treatment through proven interventions
  • Ensures real-time access to actionable data
  • Integrates with the Plan’s other Express Scripts and health management solutions to enhance care coordination
  • Improves clinical and financial outcomes with high physician and patient satisfaction
  • Leverages medical claims data to enhance other PBM services

Specialized Care that Improves Safety, Effectiveness, and Affordability

Express Scripts’ Specialist Pharmacist care model delivers safer, more effective and more affordable pharmacy care.   ESI’s revolutionary service model is a breakthrough innovation in pharmacy practice delivered to members through specialist pharmacists who are experts dedicated to the care and treatment of people with specific chronic and complex conditions.  These uniquely qualified pharmacists work in pharmacies dedicated to cognitive services and treatment for conditions such as diabetes, cancer, high blood pressure, asthma, heart conditions, high cholesterol and mental wellness.  Express Scripts improves patient safety, adherence with essential medications, and affordability of drug regimens, closing important gaps in care, and optimizing therapies for members with chronic conditions through the care delivered by the Specialist Pharmacist.

Members can benefit from the expertise of a Specialist Pharmacist at any time by calling toll-free and asking to speak with a Specialist Pharmacist.  Members have access to Specialist Pharmacists, regardless of whether they fill their prescriptions through a retail pharmacy or through mail service.  When members at high risk for a gap in care call Express Scripts, they have the opportunity to speak with a Specialist Pharmacist.  For those highest risk members managing complex conditions, Specialist Pharmacists may reach out to the member or their physician through an outbound call to address important gaps in care.

Credentialing

An integral part of developing or expanding Aetna’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.  Aetna credentials network providers to NCQA, URAC or state standards whichever is the highest for the products the provider is enrolled in.

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 every three years, or as indicated within a provider’s contractual agreement, based on the date the provider was initially approved by the Credentialing Committee, or more frequently if quality problems or complaints arise. 

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 credentialing standards.

Health and Wellness

The Plan offers a broad array of benefits and services to support members’ healthcare needs. Through collaboration among our clinical professionals, members and health care providers, we promote the appropriate use of health care resources so that services are screened for the most appropriate, safe and cost-effective setting while supporting members with chronic or complex medical conditions.  We manage the full spectrum of our members by taking a proactive approach to produce the best clinical and financial outcomes. We guide our Plan members into the appropriate service as necessary and provide health and wellness tools to help them become better consumers of health care. These services complement the Plan with an integrated wellness focus:

  • Utilization Management - ensures only necessary medical services are provided and reimbursed;
  • Behavioral Health Services - reviews mental health/substance abuse services to determine if they are necessary and appropriate and also manages Plan benefits for these services;
  • Disease Management Program - offers a collaborative approach of prevention, education and ongoing support between the Plan member, physician and case managers for members with certain chronic conditions;
  • Healthy Pregnancy Program - promotes healthy pregnancies through education and coordination of specialized care;
  • Medical Specialty Network - provides access to a nationwide network of organ and soft-tissue transplant medical centers that are recognized as "Institutes of Excellence";
  • The Plan's provider network - delivers seamless care through a team of independent ancillary providers, including home health care, durable medical equipment, home infusion therapy, hospice, medical supply and orthotics/prosthetics services; and
  • Case management - assures that better outcomes for Plan members with conditions that lead to extended, highly specialized or resource-intensive care, can effectively manage member benefits and medical care. Members are referred to our Case Management program based upon an identification process by our utilization management, claims and customer service areas and predictive modeling system. Our case management program navigates members through the continuum of care, facilitates an appropriate use of Plan benefits, minimizes a member's out-of-pocket costs, and ensures better compliance with treatment. The end result is reduced claim costs by managing care in the appropriate setting, integrating our services and education our members on how to manage their illness and maintain a healthy lifestyle.

Utilization/Medical Management Programs

The Plan's Utilization Management (UM) Program is a formal process that evaluates necessity, appropriateness, efficiency, quality, and efficacy of medical services provided for Plan members.  Our administrator, through their website and upon request, has evidence based criteria available to physicians.

Independent Accreditation Agencies and Other Associations

The Plan is committed to providing quality, cost-effective health care and this is supported by our administrator's full accreditation for Utilization Management, Disease Management and Case Management from URAC, a nationally recognized accreditation agency.  Accreditation from URAC is an indication that an organization has the necessary structures and processes to promote high quality care and preserve patient rights.

Express Scripts has full accreditation for its mail order and specialty pharmacy network through URAC. The recognition applies to all services offered by Express Scripts through its entire network of mail-order pharmacies. Express Script's pharmaceutical utilization management programs meet all applicable National Committee for Quality Assurance ("NCQA") standards, as well as any applicable federal or state laws and regulations.  In addition, Express Scripts is a Verified Internet Pharmacy Practice Site by the National Association of Boards of Pharmacy

Goals and Outcomes of Patient Safety Initiatives

Through our wellness programs, our goals are to increase member education and implement safety measures to improve outcomes.  The provision of education to our members allows for a more informed consumer who can actively participate in their healthcare decisions.  The Plan helps insure quality care by reporting any potential safety concerns such as complications or adverse events identified through the utilization processes to the Quality Improvement staff for investigation and action as necessary.

Measurement of Patient Safety Initiatives

Measurement of these activities are monitored by the Quality Improvement Committee.  Various reports are used for monitoring purposes, such as cost and utilization reports, patient surveys, complaints of quality of care and overall member activity.  In addition, quality improvement projects are undertaken and results reported to the committee on a quarterly basis.

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

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