Medication adherence is negatively impacted when medication gaps occur during the member’s medication regimen. As the prescription volumes increase and members move across payer networks the potential for multiple medications, (which results in confusion and lack of full knowledge of these medications) can be quite common. It is common knowledge that a medication regime’s effectiveness lies in the proper completion of the prescribed medication in a consistent manner.
There are many correlations between diet, medication (dosage and frequency) and using any recommended combination of medications. The very nature of drug nomenclature and its complex formulations can be challenging for the layperson to understand the role that the medication is supposed to play in their treatment. Also, in today’s information overload it is easy to forget important details of dose, timing, and not realize the negative impact of medication gaps (Reference Forgetfulness Block depicted in Building Blocks Model).
Monitoring and tracking the fills for a member in a proactive manner is critical to anticipate and close the medication gap before it occurs. The gaps could occur from all sources payers, providers, members and pharmacies. Pharmacy benefit management companies apply drug utilization rules that may result in valid rejects for early refills or quantity in excess of the prescribed regimen. These rejected claims need immediate investigation and follow up to see if the member had lost their meds, were on vacation or any other mitigating circumstances. Based on the investigation and resolution of the issue the PBM can then generate the appropriate communications that can be channeled through either Member Services (phone call with the claim details and follow up action), Pharmacy Outreach (to reprocess the rejected claim) and to the Provider ( so that they can have a positive outreach to the member).
Our organization has the required skills and experience in the medication adherence domain to help you develop a customized adherence workflow. The solution would include developing a reject review process using analytical tools that can alert the appropriate staff in a timely manner. Based on the intervention we could design custom message templates that can be used to communicate via print or mobile messages. Additionally, we could design programs that will monitor the fill status at the member level and reach out based on them reaching specified thresholds for medications. By eliminating, the medication gaps through active communications payer organizations can effectively manage costs by eliminating unwanted hospital admissions and costs of uncompleted therapies.
Our qualified staff of medical, pharmacy benefits and system integrators are available to engage with your operation and clinical teams to deliver solutions. Should you be interested please reach out to us here.