Alicia Hoisington

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Experts are paying closer attention to medication reconciliation as a means to curb cost, but providers are finding that the implementation isn't always easy. 

"Medication reconciliation has assumed new importance over the last decade, as an increasing number of patients have been prescribed multiple prescription medicines," says Nick McNeill, senior health policy associate, NEHI, a not-for-profit, health policy institute. 

He says that a patient's lack of understanding of the medications he or she should be taking can lead to medication errors, adverse drug events, hospital readmissions, and other negative outcomes that increase costs. New care models including comprehensive medication reconciliation before discharging a patient home or to other outpatient settings can help control costs today and in the future. 

But implementing a program can be difficult. McNeill says that providers face challenges compiling a truly accurate list of a patient's medications prior to hospitalization. The process can involve contacting family members, primary care doctors and pharmacists for the right information. Oftentimes, multiple prescriptions will be prescribed by various doctors who may not communicate with one another. 

"Medication reconciliation may also not be done because certain practice disciplines are constrained by state scope-of-practice rules," McNeill says. "For example, nurses may or may not be authorized to prescribe or re-prescribe medications based on a medication reconciliation done in the home." 

In addition, hospital staff experience some of the same difficulties, he says. For example, the Joint Commission required hospitals to implement formal medication reconciliation practices in 2006. Since then, the Commission has suspended the requirement twice due to implementation hurdles. 

McNeill says that there is no "on-size-fits-all" solution. That is, no one payment mechanism can ensure that medication reconciliation is done on a more regular basis.  

"A more systematic approach to medication reconciliation and good regimen design would require the circulation of timely and accurate data through health information technology and supportive payment policies that allow doctors or other providers-including pharmacists-the financial and logistical resources to properly review patient medication regimens," he says. 

McNeill cites five core attributes that new models of care have in common: 
● Accountability for essential medication-related tasks, in which care coordinators own the medication management process;
● Teamwork to actively coordinate disparate health care professionals, both inside and outside the hospital and in the broader community;
● Medication reconciliation at the hospital and in the home to reconcile medications the patient might be taking which are unknown to hospital staff, discharge planners and primary care providers; 
● Direct engagement with the patient and with family caregivers to teach, counsel and motivate them regarding appropriate use of the patient's medications; and
● Follow-up after discharge with the patient and key care providers -such as the hospital, primary care physician and pharmacist-to provide feedback on the patient's progress.     

In spite of best intentions, providers struggle to apply these core attributes in a real-world setting. McNeill says that providers are being asked to do more in less time.  

Most clinicians have 10 to 20 minutes with patients. It isn't enough time to complete the requirements for successful medication reconciliation in addition to the five other core attributes, as well as completing non-medication related care services.  

"I would recommend that the provider keep the patient in the forefront of their thinking," he says. "These new transitional care models aim for a high level of 'patient-centeredness.'" 

He says that clinical results and outcomes should be driven by patient goals that may influence which medications are prescribed, how they are dosed and administered and what their goals are after they leave the hospital. 

"Coordination of care is essential," he says. "Teamwork between team members from multiple disciplines-nurses, physicians, hospital and community pharmacists and others-based on which professionals are available with the right skills, at the right time, at an appropriate cost, is absolutely crucial." 

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Experts are paying closer attention to medication reconciliation as a means to curb cost, but providers are finding the implementation isn't always easy.

Medication reconciliation drives readmission reduction strategy

The pressure is on to reduce costs, and many plans are finding creative ways to outsource operational functions. One of the main reasons for outsourcing is the predictable and often fixed costs that help plans direct financial resources to medical care rather than administration.  

"Anything in the backroom has been subjected to outsourcing for a while now," says Peter Kongstvedt, MD, principal of P.R. Kongstvedt Company, LLC, in McLean, Va. "We see outsourcing when a plan has to reproduce [administrative functions] and has to be compliant with every requirement and every new standard. It gets to be a lot of money. And contracting with a firm that will provide that, and then spread those costs over a large base, can be very cost-effective." 

According to Markets&Markets, a Dallas-based market research firm, the payer outsourcing market will grow about 30% between 2011 and 2016. The traditional areas of outsourcing include: claims processing; human-resources services; member services; and finance. 

Record service demand will be driven by chronic illness, lifestyle diseases and an aging population. Payers will need to handle more claims than ever before. According to HfS Research, a research analyst firm, 35% of the payers it surveyed are outsourcing manual claims processing, enrollment and billing. 

Don Hall, MHE editorial advisor and principal of DeltaSigma, a healthcare consulting firm, says the top reasons for outsourcing claims are cost and quality. Paper claims can be sent to an outside processor and electronically returned with accurate, speedy results. The cost of outsourcing the task to offshore organizations can be substantially less than in the United States. Hall says that in addition to current administrative firms operating in India, Vietnam is also emerging as a player in claims outsourcing.  

Standardization is a driving force to control claims-processing costs. The more unique provider-contract arrangements a plan has, the more difficult it is to autoadjudicate claims. Increasing the number of standardized or similar contracts speeds up the outsourced administrative function.  

Typically, larger plans contract group members through brokers, but the market is changing to direct-member marketing. Some plans have developed Facebook pages to find and retain members. 

With the implementation of health insurance exchanges quickly approaching, today's plans are concerned that innovative and non-traditional benefit companies will crop up, Hall says. A traditional plan's existing members will be able to view the competitive field and might choose a new health plan once all the options are laid out.  

Joint marketing might be one way to help retain members. For example, Aetna and Costco recently announced a product in nine states, in which retail consumers can purchase a policy with one of five health benefit choices geared toward individuals. 

"In essence, you can say that Aetna is outsourcing its marketing to Costco," Hall says. "The reality is that the world is changing so fast in healthcare that a lot of the things we thought wouldn't be outsourced-like marketing-are now on the table, and [plans] are looking at what is it that they're ultimately selling." 

Hall believes insurers are looking at other retail areas to create innovative platforms for their products. For example, in November 2011, Blue Shield of California opened a 500-square-foot, brick-and-mortar retail space within a larger grocery store to attract customers to sign up for its plan offerings. Retail space has become a trend to reach members individually instead of in the typical business-to-business model.  

Ultimately, Hall says, a product is more valuable to a consumer if it's really low cost. Any operation that can be outsourced to get to that low price point is up for consideration. 

The pressure is on to reduce costs, and many plans are finding creative ways to outsource operation functions.

Outsourcing makes sense

 - As the motivation for implementing health exchanges increases, some states have made little progress. And that doesn't bode well for plans that are eager to start crafting new products. 

"The smart money now would say that exchanges in one form or another will be up in each state on the current time table," says Paul Lambdin, director, Deloitte Consulting LLP, who follows health exchanges. "A bet on a delay is just that-a bet." 

Even though plans are eager for exchanges to reach the market, most are trying to build their strategies with little guidance from states. 

According to Birhanzel, plans that focus on a single market or a few geographical areas have the ability to tailor offerings to what the particular states are building. If plans aren't entirely sure what states are building, they can at least follow the known exchange policies and tweak as needed. Large national plans face a bigger challenge.  

"They're going to face probably almost every flavor of those different [state model] options," says Birhanzel.  

He says it's important for plans to think in terms of an 80/20 rule. That is, 80% of requirements are likely to be common across states. Plans can begin to build capabilities based on that 80%, knowing that the 20% could vary greatly state by state. 

"The challenge is to not only show up, but to be positioned to win," says Lambdin. "The two biggest challenges will be getting to the right price point and dealing with an individual consumer effectively and efficiently."  

Lambdin says that plans' readiness for exchanges applies across three pillars:  				

As the motivation for implementing health exchange increases, some states have made little progress.

Alicia Hoisington

Articles

Medication reconciliation drives readmission reduction strategy

Outsourcing makes sense

Plans ready to bet on exchanges, some states dragging their feet