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Insurance Services Programs
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| Five Steps to Patient Safety | FAQ | Glossary |
GEHA Benefit Plan Patient Safety Initiatives
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 |
|---|---|---|---|
RationalMed Drug Utilization Review (DUR) | RationalMed merges GEHA medical, lab and prescription claims data to identify patients at a high risk for drug-induced hospitalization. The program sends alerts to the patient's physician. | The expected outcome is fewer health complications related to prescription drugs. | GEHA measures how many patients have been helped through this program. |
Concierge Center Medco Health Solutions | 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 |
Concurrent DUR edits | As each prescription in filled, concurrent DUR checks the patient's profile to look for potential problems with therapy duplication, drug interactions, appropriate dosage, refilling a prescription too soon, drug name confusion, and appropriateness for a patient's age and disease. | The expected outcome is fewer health complications related to prescription drugs. | GEHA measures how many patients have been helped through this program. |
Retrospective DUR | This program analyzes a patients' drug history to identify possible problems with drug interactions, dosages and duration of treatment. It alerts physicians and provides data on personal prescribing habits, peer prescribing statistics, and current standards for care. | Guidelines are based on best medical practices and developed in collaboration with independent medical experts. The expected outcome is fewer health complications related to prescription drugs. | GEHA measures how many physicians are provided resources through this program. |
| High DUR | 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 | Drugs with a high potential for improper use require Managed Prior Authorization. Medco's clinical pharmacists communicate directly with the prescriber, ensure that drug usage is consistent with written criteria, and approve or deny payment according to preset standards. | This program helps ensure that medications are used appropriately. | GEHA measures how many patients have been helped through this program. |
| Prior-Authorization for Prescription Drugs | 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. | GEHA receives reports on patients using this program. |
| Prescription Drug Packaging | Childproof caps are used for all medication dispensed at retail and mail order pharmacies. Easy open caps are provided upon request. | This program helps ensure that medication is not accessible to small children. | N/A |
| Prescription Drug Recalls | Medco 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 mail order facility. | The expected outcome is 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, mail order prescriptions | Each leaflet discusses a medication's side effects and how the medication should be taken and lists a phone number for more information. | These leaflets help patients understand their medication. | GEHA measures how many prescriptions are filled by Home Delivery. |
| Physician Newsletters | Patient Safety information is included in newsletters for physicians. | This communication effort helps physicians stay informed on prescription news and information. | N/A |
Cardiovascular Care Management Program | This program supports patients who take prescriptions for hypertension or high cholesterol, providing information on the proper use of medication, healthy lifestyle changes and reducing risks for heart disease. The program communicates with physicians when patients may not be getting appropriate treatment. | The program helps patients better understand and control their risks for heart disease. It also helps physicians identify patients who might benefit from a change in therapy. | GEHA measures how many patients have been helped through this program. |
Diabetes Care Management Program | This program helps patients understand and follow their diabetes treatment plan. Through phone calls and mailings, the program promotes self-management skills under the direction of the patient's physician. The program communicates with physicians when patients may not be getting appropriate treatment. | Through patient education, this program helps patient control their blood sugar and reduce their risk for developing long-term complications. It also helps physicians identify patients who might benefit from a change in therapy. | GEHA measures how many patients have been helped through this program. |
Digestive Health Care Management Program | This program helps patients with gastrointestinal disorders, providing education about therapy options and self-management techniques under the direction of the patient's physician. The program communicates with physicians when patients may not be getting appropriate treatment. | This program helps ensure that patients receive the appropriate medication dosage and duration of therapy. It also helps inform physicians on current clinical best practices for digestive health. A goal is reducing the need for long-term drug therapy. | GEHA measures how many patients have been helped through this program and measures program savings. |
| Respiratory Care Management Program | This program helps patients with asthma, providing education about the condition and self-management techniques under the direction of the patient's physician. It promotes appropriate treatment for asthma, in accordance with best clinical practices, and helps patients identify and avoid associated allergy triggers. | This program helps patients better manage their asthma and avoid expensive crisis interventions. | GEHA measures how many patients have been helped through this program. |
| Multiple Sclerosis Program | The program helps patients with MS improve their quality of life, providing education about current drug therapy and the management of treatment side effects. Included is a welcome packet and membership to the National MS Society, along with phone counseling from pharmacists. | This program helps MS patients comply with their medication treatment plan, reducing flare-ups and progression of the disease. | GEHA measures how many patients have been helped through this program. |
| Hepatitis C Program | This program helps Hepatitis C patients, teaching the importance of continued therapy and how to manage treatment side effects. Included is a welcome packet and membership to the American Liver Foundation, along with phone counseling. The program also provides information to physicians on diagnosis and treatment. | Patients who respond to therapy need fewer follow-up physician visits, may avoid the costly and painful complications that can occur as a result of cirrhosis, and may eliminate the need for an eventual liver transplant. | GEHA measures how many patients have been helped through this program. |
| Medical Case Management | 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. |
| High Risk Maternity Program | This program is available to expectant mothers, who are encouraged to call the program's toll-free phone number as soon as a pregnancy has been confirmed. All participants receive educational materials for each trimester of pregnancy. Mothers with high-risk pregnancies may be referred for Medical Case Management. | 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. | N/A |
| 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. |
| Radiology Precertification | Non-Medicare members are required to precertify certain radiology procedures. | Precertification provides a safeguard against unnecessary procedures. | GEHA measures how many procedures are avoided because they were not medically necessary. |
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