Information produced by Northwest Pharmacy Services Clinical Management Team during retrospective review is analyzed for trends and patterns common among a population of members. With this information, policy recommendations are made to the client regarding member education, benefit design or other interventions to improve future program value. Through this method of utilization analysis, NWPS is able to identify for clients the underlying causes that contribute to the significant increases in drug plan costs. We center our prospective analysis on the following key factors:
- Patient Consumption Habits: To determine potential over utilization or abuse.
- Physician Prescribing Habits: To reveal physician-prescribing practices, which increase drug plan costs.
- Pharmacy Dispensing Habits: To uncover low generic dispensing and other practices, which increase drug plan costs.
- Overall Drug Use Patterns: To aid clients in achieving target drug use goals.
All clients have the option of utilizing the Northwest Pharmacy Services Clinical Management Team to perform formal retrospective review. The team reviews the utilization review reports produced by the NWPS claims processing center. The reports, compiled by NWPS, focus on high utilizers of drugs and providers to identify a group of patients who may be characterized as poly-pharmacy users. These patients are not always users of large numbers of different drugs, but they may frequent multiple physicians and pharmacies. Specific audit report criteria include:
- Total prescriptions for the quarter greater than or equal to X,
- Average prescription cost per quarter greater than or equal to $X.XX,
- Total controlled substance prescriptions per quarter greater than or equal to X,
- Prescribers accessed each quarter greater than or equal to X,
- Pharmacies accessed each quarter greater than or equal to X, and
- At least X different prescriptions in the same therapeutic class.
It is important to identify these patients quickly as they are particularly vulnerable to unnecessary use of medical care services. Furthermore, uncoordinated care in these cases can lead to drug/drug interactions, therapeutic duplications, inappropriate drug consumption, or compliance problems. Real time communication with clients, members, physicians, or our pharmacy network, may be facilitated through our toll-free help desk. Our help desk staff consists of experienced pharmacy technicians who have access to real-time claims processing data and plan specifications. Our licensed pharmacists interact with our help desk personnel to resolve medication related issues, e.g. drug interactions and prior authorizations.
NWPS has documented significant cost savings to the client and improved care for the members from these clinical efforts by improving adherence to treatment and avoiding unnecessary utilization of high cost pharmaceuticals.