|  2017 TGC Penrose Healthcare Solutions

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The Rx VBHC Series: SESSION 6 | The BUSINESS CAPABILITIES & INFRASTRUCTURES needed to Support MAB Implementation for Better Patient Outcomes and Sustainability





SESSION 6: Now, let us focus the on collaborative and interdependent alliances Dr. Sam leveraged to build, develop, and strength the BUSINESS CAPABILITIES & INFRASTRUCTURES needed to support implementation of MAB for better patient outcomes and sustainability.​




I.   The Purpose for Building/Developing/Strengthening Business Capabilities & Infrastructures


     Think about the home you live in and its usual purpose: a place that keeps you secure, enables you to grow and develop, and is an investment for the future. What if you found out that the framework of your house was built with cheap, faulty materials, capable of collapsing on a strong windy day? What would you do? How would you feel?

     Now compare the workplace to this analogy. Imagine your team has just developed an incredible clinical initiative that would improve the health outcomes of your patients, help your organization meet its goals and achieve a sustainable competitive advantage, and expand its geographic reach and influence. As your team is about to roll out the initiative, they realize the structures necessary to support the successful implementation, scalability, and sustainability of this initiative are faulty or weak at best. How successful are you going to be in executing this new initiative? It has been said that when you don’t invest in infrastructure, you pay sooner or later.

     Today in healthcare, many organizations are developing strategies and initiatives to improve care delivery. However, the success, scalability, and sustainability of the outcomes are in part, dependent on having the right processes, products, infrastructures, and capabilities in place and made available to support providers and team members—structures that many teams sometimes minimize, overgeneralize, or pay little attention to.

When aligned effectively, an organization’s business capabilities (a combination of processes, tools, and structures) will support the delivery of specified outcomes, creating unparalleled value for that organization. The critical capabilities and infrastructures needed to successfully implement, support, optimize, and sustain MAB across the continuum of care include: an effective pharmacy benefit management (PBM) and drug use management infrastructures, an evolving drug supply chain management system, “big data” and analytics, efficient health information technology systems, and a solid compliance infrastructure, to name a few.

     Dr. Sam and his team recognized the need for these business capabilities and infrastructures to support their MAB Rx Strategy for short and long-term success in addition to making a series of good decisions aligned with their resultant strategy, supremely well executed over time. So he partnered and created alliances with colleagues and other entities to ensure an effective, supportive infrastructure, capable of supporting the successful implementation of MAB on behalf of patients, especially patients with multiple chronic conditions.



II.   Some of the Infrastructures and Capabilities that Dr. Sam’s team leveraged and partnered with to ensure the Success, Scalability, and Sustainability of MAB in clinical practice


1.      Pharmacy Benefit Management (PBM) and Drug Use Management (DUM) Infrastructures

Dr. Sam's teams partnered with their PBM who had developed a very effective drug use management program. PBMs have become one of the most effective infrastructures that have contributed to bending the cost trends of prescription drugs, while at the same time contributing to improving patient health outcomes through their drug use management programs and strategies. The PBM's DUM program was able to support Dr. Sam's organizational efforts by providing programs and services designed to help maximize drug effectiveness; addressing high cost drugs (especially biologics and oncology medications); improving drug expenditures by appropriately influencing the behaviors of prescribing physicians, providers, and patients; and providing specialty disease management services. Few large organizations have their own comprehensive PBMs and DUM programs, and some are internalizing many components of these program capabilities as they consolidate. But most organizations, health plans, employer groups, unions, and the government still contract with PBMs to handle one or more of the following (known as ABCD capabilities):

  • Administrative services: This involves processing and analyzing claims, billing, enrollments, and data reporting.

  • Benefits management services: These services develop and manage formularies and prior authorization programs, contract with network pharmacies, manage a maximum allowable costs list, negotiate rebate arrangements, operate mail-order pharmacies and mail-order claims, and perform drug utilization reviews.

  • Clinical services: Larger PBMs are now offering clinical, medical, and analytic services, such as therapy or disease management programs that incorporate MAB, programs to ensure patient adherence, specialty pharmacy and distribution services, data analytics, and predictive modeling.

  • Drug Use Management programs: In these programs, physician, administrative, and pharmacist champions leverage clinical expertise, data, studies, and other evidence-based information to influence the behaviors of prescribers and patients to maximize drug effectiveness, address high cost drugs, improve drug expenditures, and at the same time, improve clinical outcomes. They also use analytics for transparent peer comparison reports and to develop insights necessary to ensure optimal value for all.

Dr. Sam leveraged these capabilities to ensure MAB’s success and its scalability and sustainability - See details in Chapter 9 of the MAB Handbook.


2.      Drug Supply Chain Management

     In the new value-based healthcare landscape, organizations are looking for new strategic opportunities to lower costs while improving the quality of patient outcomes and care. In most of these organizations, pharmaceuticals are in the top three expenditures after labor costs, so organizations are now looking at the drug supply chain to identify opportunities to reduce costs, impact the delivery of healthcare, and serve as value centers within the organization, while simultaneously contributing to optimizing quality.

     What is the drug supply chain? The basic drug supply chain is the means through which prescription medicines are delivered to patients, originating with the drug manufacturer. The drug supply chain, however, is much more complex than this basic structure and involves multiple organizations and entities that play differing but sometimes overlapping roles in drug distribution.

    The chain also involves contract negotiations, quality and utilization management process screening by PBMs, and various commercial relationships. While there has always been a focus on the supply chain in relation to on-time delivery, there is now increased focus on strategic inventory management, supply chain optimization, and data utilization to control costs and drive value amid shifting regulatory compliance, emerging markets, item-level serialization, and product diversification. An effective drug supply chain infrastructure is critical to support the success, scalability, and sustainability of the MAB components to create organizational value. See specific examples in Chapter 9 of the MAB Handbook.


3.      Big Data and Analytics

Over the next few years, there will be a significant increase in providers' financial reimbursements linked to quality outcome measures through MACRA and other value-based initiatives. Organizations, providers, and payers recognize that their approach to improving the Triple Aim measures in HEDIS, MACRA, QPP, Medicare Stars ratings, and other quality measures—and addressing quality care gaps—must be more deliberate and strategic to ensure success, remain competitive, and maximize reimbursements. Optimizing MAB will be critical to meet many of these new expectations, and the use of big data and clinical and business analytics tools will be foundational.

Dr. Sam worked with the analytics services to create real-time, actionable surveillance and intelligence data to help reduce costs and optimize quality care. As his organization continued to transform to a value-based care and population health system, this enterprise intelligence resource complemented the electronic health records to provide leaders and clinicians with a comprehensive picture of what’s happening with their population, down to individual providers’ panels of patients. This enabled providers, organizations, and health systems to react quickly to enhance clinical outcomes, efficiency, safety, and affordability.

As more clinical information becomes available through electronic medical records, and with reimbursements increasingly tied to clinical outcomes, organizations are accelerating the use of big data and analysis to do the following:

  • Access real-time data about their patients, stratify risk, and set up population health management initiatives for success

  • Tailor patient registries to leverage data to focus care management programs on the patients who will benefit the most

  • Provide compelling insights, intelligence, and information to improve outcomes and effectiveness of care

There are three types of analytics that are frequently used to transform big data into usable information in healthcare – descriptive analytics, predictive analytics, and prescriptive analytics. For more details and how organizations are using these types of data analytics and big data to ensure the success of MAB to optimize patient health outcomes, see Chapter 9 of the MAB Handbook.


4.      Health Information Technology Systems (HITS)

     MAB supports providers and healthcare teams as they work to improve the quality of patient care, outcomes, the health of communities, and organizational performance and to reduce healthcare costs. Now, through the advancements in health information technology systems (HITS), Dr. Sam's teams worked with their providers to further optimize MAB and create safer, higher quality, more coordinated, more efficient, less costly care, and secure care for everyone.

     HITS are the electronic systems that health care professionals and team members—and, increasingly, patients—use to store, share, and analyze health information. The systems make it possible for healthcare providers to more effectively and securely manage patient care and share patients’ health information between providers. It includes EHRs with computerized physician order entry (CPOE) and clinical decision support (CDS), pharmacy information management systems (PIMS), and medication/patient safety systems, to name a few. These HITS can support the optimization of MAB in numerous ways. Details in Chapter 9.


5.      Medication Management Apps—Linking Patients’ Devices to Better Engagement and Outcomes

     One of the purposes of medication management apps is to empower patients through nudging, providing daily motivational tips, and keeping them on track with reminders to take their medications at specific times as directed. Some key features to look for in an app include security to protect patient information, reminder alerts that can be programmed, the space and flexibility to put in various forms of medications (inhalers, liquids, pills), and availability for the smartphone or tablet being used. Additional features that may be helpful (usually for a fee) include the ability to track missed doses, alerts about side effects if too much medication is taken (especially for medications with strict dose limits), the ability to share information with healthcare providers and family caregivers, reminders for more complicated medication schedules, a searchable medication database, and online accessibility.

     With the number of apps and features growing, it can be tough to select an app that will help patients address their own Medication challenges. One new concept that Dr. Sam leveraged in one of his large pharmacies was the idea of an A.R.E.A.S. Genius Bar (MAB Bar), a concept derived from the Ochsner Health System’s Genius Bar (which got the concept from Apple). The MAB Bar was set up and staffed by a technician or clerk. Based on the consultation with the pharmacist, patients would be given a “script” with their primary Medication A.R.E.A.S. challenges. That would be given to the technician at the MAB Bar, who would then inform the patients about the mobile apps appropriate for them. The MAB Bar had wearable devices that were Bluetooth-enabled and linked to tools such as a blood glucose monitor, a wireless weight scale, or a wireless blood pressure monitor. The technician then involved patients in setting up the apps and trained them on how to use them. As Benjamin Franklin said, “Tell me and I forget, teach me and I may remember, involve me and I learn.” The value of these medication apps, coupled with wearable devices and optimized with training from the technician, may lead to greater patient engagement, better outcomes, and better health in the long run.


6.      A Solid Compliance Infrastructure

     The FDA is the US government agency charged with ensuring the safety and efficacy of the medicines available to Americans. The government’s control over medicines has grown significantly, and now medications are among the most regulated products in the country. As a result, organizations, health systems, and pharmacies are building, or have built, solid compliance infrastructures and controls to accomplish the following: comply with the significant number of state and federal regulations; monitor and respond to the frequent audits from the various agencies; minimize or eliminate the fines for noncompliance; prevent diversion, fraud, waste, and abuse and have a safe distribution plan; set up policies, procedures, and training programs to comply with the necessary regulations; and keep track of any changes to the laws and regulations.

     Organizations, health systems, and pharmacies that have effective compliance infrastructures and controls in place will minimize risk and contribute to the organizations’ focus and strategies like MAB. Dr. Sam worked with the Compliance department and leveraged the following to ensure his pharmacies were in compliance with key rules and regulations (not all inclusive): compliance training tools, internal controls and audits, pharmacy compliance audits, third-party provider audits, and regulatory agency audits.


7.      Laws, Policies, and Regulations that will support the MAB Rx Strategy

  •  The Drug Quality and Security Act: To protect the increasingly complex supply chain, the Drug Quality and Security Act was signed into law in 2013. Title II of the act, called the Drug Supply Chain Security Act, outlines steps to build an electronic, interoperable system to identify and trace certain prescription drugs as they are distributed in the United States. The law requires the FDA to develop standards, guidance documents, and pilot programs and to conduct public meetings, in addition to other efforts necessary to support efficient and effective implementation. This law will help the FDA protect consumers from exposure to harmful drugs.

  • The New Opioid Regulations & Guidelines: The FDA is deeply concerned about the growing epidemic of opioid abuse, dependence, and overdose. In response to this crisis, the agency has developed a comprehensive action plan to take steps toward reducing the impact of opioid abuse on American families and communities. It will work in cooperation with its sister agencies and stakeholders as it reexamines the risk-benefit paradigm, seeks improved treatment of both addiction and pain, and acquires new data for opioids.

The CDC has also created tools and materials to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain; to improve the safety and effectiveness of pain treatment; and to reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death.


8.      Cybersecurity

Pharmacies are just as vulnerable to physical attacks and cyberattacks as large businesses are. Pharmacies are attractive to thieves because of the drugs they stock and the confidential information they house that can aid identity theft. While pharmacies are not likely to become less of a magnet for thieves anytime soon, there are steps pharmacy owners can take to curb or prevent attacks, including: installing internal and external digital cameras, shredding documents that contain confidential information, reporting suspicious activities to the police, being vigilant against social engineering attacks, and quickly addressing issues with disgruntled employees. Pharmacies should also change their business patterns when possible and be aware of where the exits, entrances, and cameras are.


Dr. Sam’s teams were able to leverage the PBM, DUM, and the drug supply chain structures; utilize the HIT, apps, analytics, and big data capabilities; ensure solid compliance and cybersecurity infrastructures; and understand the laws, policies, and regulations impacting medication management to support providers and team members.

These infrastructures and capabilities that are sometimes minimized or overgeneralized. But when leveraged effectively, they can contribute to the successful implementation and the scalability of MAB across the continuum of care, make it easier for providers and team members to do the right thing when executing, and help ensure the sustainability of MAB in clinical practice on behalf of all patients on medications.


In Session 7 of this 10-Part Series, we will discuss the following in detail:

  • The building blocks of a high-performing and effective team

  • The importance of effective leadership to optimize the MAB Rx Strategy as a plan of action

  • How to transform teams into an interdependent and cohesive team capable of solving complex challenges and improving performance

  • Some of the key responsibilities of leaders during a project

  • How leaders can support the geographic expansion and reach of clinical MAB services

More information about the MAB Rx Strategy can be found at:

My hope and goal is to provide you with a prescription strategy that will make a difference in the lives of patients with multiple chronic conditions – the most frequent and expensive users of healthcare, contribute to making healthcare value a reality for all, and give you a competitive advantage in this new era of value-based healthcare!



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