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West Virginia University and Health Plan Collaborate for Disease Management

Although West Virginia has lagged behind national trends in the growth and evolution of managed care, several small markets have seen considerable growth in managed care penetration during the past few years. The Health Plan of the Upper Ohio Valley has received full accreditation from the National Committee on Quality Assurance and has more than 100,000 members in southeastern Ohio and northern West Virginia. This year it entered the Medicare-Choice arena and expects to significantly increase its enrollment. This progressive-minded health maintenance organization (HMO) has begun developing disease management programs and has teamed with West Virginia University to develop its strategies for Type 2 diabetes.

The Department of Pharmaceutical Systems and Policy at West Virginia University (WVU-PSP) has expertise in outcomes research and pharmaceutical care systems design. The department provides research support and administers the Prior Authorization Program for the West Virginia Medicaid Pharmaceu-ticals Program. The department is an associate member of the Disease Man-agement Purchasing Consortium and Advisory Council and also serves as a consultant to a network of innovative pharmacy practitioners know as the Ohio Valley Pharmaceutical Care Net-work (OVPCN). This experience is proving useful in the design of disease management strategies for The Health Plan.

WVU-PSP is supporting The Health Plan in several ways. The first area of support is in collection and analysis of baseline data for Health Plan members. Claims data for 3,200 Health Plan adults with diabetes have been analyzed to determine the current utilization trends for persons with both Type 1 and Type 2 diabetes. WVU-PSP also developed a questionnaire that was mailed to the Health Plan members who have diabetes to assess their health-related quality of life, adherence to healthy behaviors, knowledge of diabetes, past diabetes-related education, confidence in being able to control their diabetes, and satisfaction with care. The survey data has been combined with the claims data to identify opportunities for improvement in diabetes care.

The second area of support is in the development of pharmacy-based education and monitoring services for persons with Type 2 diabetes. WVU-PSP worked with OVPCN to develop standardized diabetes services among seven pharmacists at five pharmacy sites. These sites are pilot-testing the services this year to refine them before expanding the number of providers. The services comprise an initial assessment and education of the patient as well as continual monitoring. The initial assessment of the patient includes weight, blood pressure, HbA1c, microalbumin, lipid profile, foot exam, and adherence to diet, exercise, medications, and preventive-care visits. All of this information is collected in the pharmacy and is forwarded to the patient�s primary care physician along with recommendations from the pharmacist. The patient is then offered an education program that covers the basics of controlling diabetes. The information is tailored to the individual patient�s needs; however, the average patient receives three hours of instruction over several sessions. Follow-up monitoring is conducted as scheduled appointments every three months. These sessions are expected to last 15�30 minutes and include assessments of the patient�s adherence to their treatment regimen in addition to the collection of other pertinent subjective and objective data. Data are forwarded to the patient�s physician after each session.

A unique feature of these services is that the pharmacists are individually credentialed providers for The Health Plan. The pharmacists are compensated directly from the HMO for their professional services. The pharmacists submit their claims to The Health Plan on HCFA-1500 forms using CPT codes that were specially created for these services by the HMO. These special codes allow The Health Plan to track the provision of the pharmacist�s services separately from the physician�s services for the same patients.

The third component of the WVU-PSP services is an ongoing system for follow-up and assessment of the diabetes care program. The completeness of the pharmacists� care records and appropriateness of their recommendations will be analyzed, and recommendations for improvement will be given to the pharmacist network. The survey and claims data will allow the tracking of utilization and patient outcomes to determine the impact of the pharmacists� services. These analyses will facilitate the process of continuous quality improvement for both OVPCN and The Health Plan.

This collaborative relationship has provided benefits to both participants. The Health Plan has gained additional support for its disease management endeavors, and the WVU School of Pharmacy has gained better training capacity for its students. A summer internship at The Health Plan for WVU pharmacy students has been developed, and The Health Plan data are facilitating several graduate student projects. WVU-PSP and The Health Plan are currently exploring the possibility of replicating this collaborative approach for other disease states. We hope that this relationship will continue to grow.

David Nau, R.Ph., Ph.D.
Assistant Professor
Department of Pharmaceutical Systems and Policy
West Virginia University School of Pharmacy
Morgantown, West Virginia