It’s 11:30 on a Tuesday night in the emergency department of a local county hospital. The doctor pulls back the curtain on his next patient and frowns. He has seen this man before. He looks down at the chart and recognizes the name. He’d been in about eight weeks before with trouble breathing and chest pains. Gears click in doctor’s memory, as he recalls this patient. His medical work-up had shown nothing acutely wrong. He’d been encouraged to take his usual medications, and sent home with instructions to see his regular doctor as soon as possible to make sure his chronic diabetes and congestive heart failure were under good control.

The doctor pulls a stool across the floor and sits down bedside.

“Hi Brian, what seems to be the trouble?”

“My chest. I couldn’t breathe. And I can’t seem to concentrate. I just don’t want to do anything.” Brian’s voice is listless and low, and he looks fatigued.

“I see you were in a couple of months ago. Did you go and see your regular physician?”

Brian shrugs but doesn’t say anything. His eyes are fixed firmly on the floor.

The doctor pauses. He looks at Brian for a while. The man looks like he hasn’t taken care of himself. His clothes are wrinkled, and he’s lost some weight since his last visit to the emergency department. The doctor looks over Brian’s vitals and labs. He finds nothing concerning on physical exam. He asks, “Brian, has anyone ever talked to you about depression?”

In the case above, Brian is a fictional character, but the situation is not. The co-occurrence of mental health disorders with physical ailments is common. A Substance Abuse and Mental Health Services Administration (SAMHSA) report found that 68 percent of adults with mental disorders have medical conditions, and 29 percent of adults with medical conditions have mental disorders. The most common of these is depression. Many research studies have found high rates of comorbid depression with chronic and terminal medical conditions. In many cases, the medical conditions or treatments for the conditions can cause depression. In others, the depression itself can lead to health behaviors that cause or worsen medical illness, and even higher risk of death. For instance, persons with depression have higher rates of smoking cigarettes than the general public. This can lead to heart disease. But, depression itself can also cause changes in brain chemistry and platelets, which can worsen existing heart disease.

Common Conditions with Comorbid Depression

Comorbid depression in some medical conditions is common. According to the National Institute of Health, there is a close relationship between depression and other physical ailments:

• Alzheimer’s disease and other dementias
• Cancer
• Coronary artery disease
• Congestive heart failure
• Diabetes
• Epilepsy
• HIV/AIDS
• Multiple sclerosis
• Parkinson’s disease
• Rheumatoid arthritis
• Stroke
• Systemic lupus erythematosus

Depression also has a negative effect on treatment and outcomes for these diseases. A 2015 published research study showed those with comorbid depression had more negative outcomes for their primary ailment than those who only had the primary ailment. Research also shows a lower quality of life, lower compliance with medical treatments, and lower rates of exercise and healthy eating habits for patients with comorbid depression compared to those with the same physical ailment(s) who did not suffer from depression.

This comorbidity has consequences beyond the health of the patient. People with multiple medical conditions are a rapidly growing and extremely costly segment of the US population. Patients with behavioral health disorders spend more on treatment for general medical conditions. When compared to those without depression, overall health care spending for medical conditions is higher than those without, in addition to treatment for the depression itself.

Improving Care for Comorbid Behavioral Health Conditions

The first step is identifying patients with comorbid behavioral health conditions before they reach the dangerous and costly levels discussed above. The primary care setting may be the best place to first find depression. But how?

Magellan’s Screen and Engage program is an innovative, user-friendly application that primary care physicians (PCPs) can use to identify patients at risk for a mental illness. Using a Magellan-provided iPad, the patient answers questions about his or her health and well-being while waiting for an appointment. The screening tools are also available in Magellan’s Virtual Care Solutions. Magellan’s proprietary algorithms assess the results, identify potential behavioral health issues and suggest recommendations for treatment, and flag clinicians to engage the patients.

The benefits of the tool are clear. Given the limited amount of time that a PCP has for each appointment, he or she must focus the conversation on the primary reason for the visit. As such, there is little opportunity to probe for behavioral health concerns. By conducting the screening before the short appointment, the PCP has a chance to be notified of the screening results, and discuss them during the visit.

Screening for behavioral health conditions is just the first step. Step two is treating them. In general, depression is treated with either medications and/or cognitive behavioral (CBT) psychotherapy. CBT is a specific type of therapy that relies on identifying and changing ones thoughts that can lead to depression. Research shows that the combination of the two is better than either done separately. While it may be easy to receive anti-depressants from medical doctors, it is often difficult to find CBT.

Cobalt, Magellan’s computerized Cognitive Behavioral Therapy (CCBT) program, is a cost-effective solution to address common behavioral health conditions. Cobalt provides CCBT online or through a smartphone/tablet app. This makes face-to-face CBT—proven to work but often difficult to find providers, especially in rural areas and for working people—available anywhere, any time. It is also a more private approach to CBT. Patients can access treatment from their homes versus an office.

Computerized CBT has proven to be just as effective as in-person CBT. Magellan offers Cobalt modules for insomnia, depression, anxiety, substance use disorder and obsessive-compulsive disorder, treating more than 90 percent of behavioral health conditions seen in primary care and behavioral settings.

Tackling Comorbid Conditions for a Healthy Future

At Magellan, we have made it our mission to help individuals like Brian, whose case is all too common. Tackling comorbid behavioral health issues alongside common medical conditions is one way we do it. Investing in and using new technology, we can identify more people who need help and expand their access to effective, proven treatments.

On March 22, Magellan Rx Management released its seventh annual Medical Pharmacy Trend Report, which continues to be a leading source for payers and other industry stakeholders to analyze high-cost injectable drugs paid under the medical benefit. It’s clear that specialty spend on the medical benefit accounts for a significant expenditure for both members and payers alike and it is continuing to grow rapidly, particularly for commercial health plans. Ensuring a sound medical benefit drug management structure is in place is necessary to rein in costs in both the short- and long-term, particularly as new drugs come to market.

This year’s report highlights the member and payer impact of high-cost specialty drugs billed on the medical benefit. Often unrecognized, but a critical component of total drug spend, this segment of drug utilization is especially important considering that by 2018, it’s expected that 50 percent of total United States drug spend will be composed of specialty medications. Additionally, half of specialty drug spend is billed through the pharmacy benefit and half through the medical benefit, or “medical pharmacy.” Specifically, the report found:

• Commercial medical pharmacy spend increased by an average of 12 percent each year from 2011-2015, while Medicare Advantage remained relatively stable with only a 5 percent increase over the same five-year period.
• The majority of oncology drugs are still infused or injected and the largest portion of their costs are covered through the insured’s medical benefit. Oncology and supportive care agents represent nearly 50 percent of commercial medical benefit drug spend and nearly 60 percent for Medicare Advantage.
• The leading cause of blindness in senior populations is treated with injections that are exclusively covered through the medical benefit, and this was the highest trending category on the medical benefit in 2015 (30 percent for commercial and 39 percent for Medicare Advantage).
• On average, the 10 most expensive commercial medical benefit drugs averaged $421,220 annually per patient and affected two per 100,000 members. The 10 costliest Medicare medical benefit drugs averaged $268,780 and affected eight per 100,000 members.
• In total, taking into account coinsurance, copay and deductible, members using a medical benefit drug paid 3 percent of total medical pharmacy costs in commercial (97 percent for the payer) and 5 percent in Medicare Advantage  (95 percent for the payer). While the member percentage may seem small in comparison to payer percentage, many members have trouble affording their medications or reach their maximum out-of-pocket costs, oftentimes at thousands of dollars.

Key strategies for the effective management of medical benefit drug spend outlined in the report include:

• Clinically and operationally managing drugs billed with unclassified Healthcare Common Procedure Coding System codes;
• Improving claims system capabilities to capture and report National Drug Codes;
• Employing provider network strategies for commercial members to remove disparities in cost by outpatient site of service;
• Implementing benefit design strategies, and
• Bringing transparency of medical benefit drug costs and therapeutic options to members.

Building an effective medical benefit drug management strategy requires an in-depth knowledge of and expertise in this complex area, but it’s essential to help payers rein in costs and improve the quality of care for members.

Download the full report to learn more.

When I was selected to join the National Quality Forum’s Medicaid Innovation Accelerator Project Coordinating Committee, I thought about the background and experiences I would bring with me – both personally and professionally. As a trained pediatrician, my medical training focused largely on the care and treatment of young children. According to the Centers for Medicare & Medicaid Services (CMS), more than 45.2 million children were “ever-enrolled”¹ in Medicaid and the Children’s Health Insurance Program (CHIP) during fiscal year 2015. In addition, in the time since I was in practice, I’ve worked for several national healthcare companies, with a focus on population health, clinical delivery systems delivery and improvement.

Since joining Magellan as the company’s chief medical officer, I’ve worked with my colleagues to help continually looks for ways to reinvent how care is delivered. I am passionate about supporting the volume-to-value payment transformation, and Magellan has a key role to play because of the deep expertise we bring in behavioral health. Oftentimes, we don’t realize how specialized and important that expertise is, and how it impacts the overall quality of care for a patient, particularly with comorbid conditions. Magellan is also considered a trusted partner because we are an independent company and not part of a big health plan. In addition, we also bring a breadth of experience in medical specialty, medical pharmacy and long-term services and supports (LTSS) which is not found in most other organizations.

NQF’s Medicaid Innovation Accelerator Project (IAP) Coordinating Committee is tasked with identifying and recommending measures in four priority areas to help support states’ efforts related to payment and delivery system reforms.

The four priority areas are:

• Reducing Substance Use Disorders (SUD)
• Improving Care for Medicaid Beneficiaries with Complex Care Needs and High Costs (BCN)
• Promoting Community Integration – Community-Based Long-Term Services and Supports (CI-LTSS)
• Supporting Physical and Mental Health Integration (PMH)

The challenges – and opportunities – are many. Medicaid behavioral health does not currently have standard benefit packages from state-to-state, and there are also not standard billing practices. Both of those elements make it much harder to develop metrics which are reliable, and more technical expertise is needed to ensure that the metrics selected can be broadly used. Ultimately, this committee will provide guidance on performance measures for areas which are unique to Medicaid, including patients with complex health needs, LTSS needs and those with behavioral health and substance use/opioid disorders. The states will then have a list of standardized measures for use in Medicaid performance program evaluation.

All of the committee’s meetings are open to the public. The IAP will issue its draft report in July, and its final report at the end of September. I look forward to working with my committee colleagues as we work to draft these important metrics related to state’s efforts regarding payment and delivery system reforms.

¹These enrollment data are unduplicated counts of children who were enrolled in Medicaid and CHIP at any point in FFY 2015. A child who was enrolled in more than one program (e.g., Separate CHIP and Medicaid) at different times during the FFY is only counted in the program in which he or she was last enrolled.

April marks Autism Awareness Month, which focuses on increasing awareness and understanding of autism spectrum disorders (ASD). People with ASD may learn, communicate, and behave in ways that are different from others. Learn more about ASD below, and click on our tip sheets to find additional resources, including ways that you can help support others around you who may be impacted by ASD.

1. In the United States, 1 in 68 children is diagnosed with autism. Boys are 4.5 times more likely to be identified with ASD than girls.^[1]
2. Signs and symptoms of autism often start between 12 and 18 months of age. Sometimes a child will develop normally until the second year of life, then develop autism. ^[2]
3. Some people have had concerns that autism is caused by childhood vaccinations. However, extensive research over the past twenty years has shown there is no link between vaccinations, or the ingredients in vaccinations, and ASD. ^[3]
4. Children with ASD are prone to wandering or bolting from a safe, supervised place. This common behavior can cause great stress for families. ^[4]
5. People with ASD often suffer from other medical conditions which may include allergies, asthma, epilepsy, digestive disorders, obesity, persistent viral infections, sleeping disorders, and more. ^[5]
6. While many children with autism also have intellectual disabilities, almost half (about 44 percent) have average to above average intellectual ability. ^[6]
7. Although there is no cure for ASD, there are early intervention services to help children from birth to three years old learn to talk, walk, and interact socially with others. ^[7]
8. Many children with ASD are not diagnosed as early as they could be. The American Academy of Pediatrics recommends autism screening for all children twice before 24 months. ^[8]
9. Children with special needs, including ASD, may be eligible for treatment services under state and federal laws including the Individuals with Disabilities Education Act (IDEA). ^[7]
10. Autism itself does not affect life expectancy. However, studies show that the mortality risk among people with autism is double that of the general population, largely due to accidents. ^[9]

There are many resources to turn to if you are looking to learn more about Autism spectrum disorder.  Begin your search here:

Understanding Autism Spectrum Disorder (ASD)

How to Support Parents of Children with Autism

Resources for Autism Spectrum Disorder (ASD)

Sources

1. Centers for Disease Control and Prevention: Prevalence and Characteristics of Autism Spectrum Disorder Among Children
2. Autism Speaks: FAQ
3. Center for Disease Control and Prevention: Vaccines Do Not Cause Autism
4. Autism Speaks: Autism Wandering
5. National Autism Association: Autism Fact Sheet
6. Center for Disease Control and Prevention: Data & Statistics
7. Center for Disease Control and Prevention: Facts About ASD
8. American Academy of Pediatrics: Autism
9. Autism Speaks: Mortality and Cause of Death in Autism Spectrum Disorders

Learn more about ways to keep specialty spend, an important — and quickly growing — area of pharmacy spend, from Matt Ward, Magellan Rx Management’s general manager of the employer segment. Ward’s op-ed on the subject was recently published in WorldatWork’s magazine. WorldatWork is a nonprofit human resources association and compensation authority for professionals and organizations focused on compensation, benefits and total rewards.

Read more here: Six Ways to Keep Specialty Spend Under Control 

Between January 30 and February 1, Magellan hosted its Magellan Open Vision Exchange (MOVE) conference in Scottsdale, Ariz. Our annual gathering of healthcare insiders, experts and leaders provides opportunities for key members of the industry to talk openly about the future of healthcare. You can read part one of our review of the 2017 event here.

Building and Planning for the Future

Day two keynote speaker, Salim Ismail, chair of ExO Works, best-selling author of Exponential Organizations and former executive director of Singularity University, gave a fantastic overview of the exponential business model and how it applies to healthcare. Pointing to a wide variety of other industries, Ismail showed that disruption is powerful, creating both problems and opportunities. If a company fails to respond, it can quickly become overwhelmed — case in point, the photographic industry’s reaction to digital cameras. When the public embraced digital imaging, the market for film and film development disappeared; however, a whole new slew of problems arose allowing opportunity to flourish. In this case, the large number of images created by the average person needed new solutions, namely how to store and organize their digital pictures.

Ismail explained that there was a doubling pattern of exponential growth in a basket of many technologies. He also pointed out that humans are, in fact, not very good at accepting exponential growth. Our brains do not track exponential growth well, preferring scalable efficiency. Ismail gave advice on how companies (in healthcare and beyond) can prepare themselves to not just deal with exponential change but to lead it. Michael Guyette, president and CEO of Blue Cross and Blue Shield of Minnesota (BCBSMN), gave some key insights into how that spirit of disruption and innovation can look in the healthcare world. Guyette relayed how BCBSMN had created a unique program focused on innovation and diversification that has resulted in ways they can improve the health of communities they serve. “You need to have focus. Otherwise, you’re just going to go all over the place with innovation,” Guyette said. “But we as leaders need to make sure that we embrace our legacy while we start to reach out for the change of the future.”

Big Data Leading to More Personalized Care

One particularly interesting discussion centered on the rise of big data. While the concept of data-driven healthcare may seem impersonal at first glance, several voices argued that it can actually lead to more personalized care. For example, Michael Neidorff, chairman, president & CEO, Centene Corporation, brought up software that track genetic and genomic patterns. This data can be used to map cancer at the individual level, allowing for personalized care. Similarly, the ability to collect and process personal health data was brought up by Seth Dobrin, vice president and chief data officer at IBM Analytics, as a powerful and personal disruption of the health care industry.

Brian Flanigan, principal at Deloitte Consulting, brought up the fact that healthcare is in an affordability crisis. 76 percent of consumers rate the healthcare system as poor or average and costs are rising to unaffordable levels. Flanigan pointed to the use of innovation and data to provide the high-level, personalized services that consumers demand at more affordable prices. Using data and new technology, Flanigan pointed out, will literally allow us to do more for less.

Discussion with Peers and Experts

When we first developed the Magellan Open Vision Exchange, we wanted to avoid the typical corporate conference format and create a genuine exchange of ideas and experiences between healthcare peers and insiders. Once again, we were thrilled with the level of dialogue, questions and answers that we heard from our speakers and panelists.

Magellan’s collection of HEDIS (Healthcare Effectiveness Data and Information Set) quality measures for 2017 has entered the final phase of data collection. You’ve probably heard of the acronym HEDIS – but what does it stand for and what does it mean to you? The Healthcare Effectiveness Data and Information Set – HEDIS — was created by the National Committee for Quality Assurance (NCQA) to measure the clinical quality performance of health plans.  This is accomplished through the collection and analysis of data documenting the clinical care received by individual plan members from providers, influenced through activities and programs delivered by the health plans.  The data is aggregated and reported collectively to reflect the ‘collective’ or population-based care received by the plan’s membership.  These reports have become a major component of quality rating systems that measure the clinical quality performance of health plans by Centers for Medicare & Medicaid Services, states offering Medicaid and other entities. Right now, Magellan has entered the final phase of data collection for HEDIS quality measures for 2017.

There are 91 HEDIS 2017 measures, but it’s important to note that the number may vary from year to year as new measures are added to the set and some are retired. The measures cover many aspects of healthcare including preventive care such as screening tests (e.g., mammograms) and immunizations, management of physical and mental health conditions, access and availability of care, patient experience, utilization and relative resource use.  Data is reported individually for each product and line of business

Measure data is collected is a variety of ways.  Claims are the major source of data, but specific measures may also allow plans to survey members or to access member medical records for additional data not captured in claims.  This type of data collection (combined claims and chart data) is called hybrid.  The final phase of data collection for health plans choosing to do hybrid runs from January through May and is often called MRR for medical record retrieval, or simply ‘chart chase.’  Final HEDIS data covering services rendered in 2016 and prior will be submitted to NCQA by June 15, 2017.  Final health plan ratings for all lines of business are published on the NCQA website by October 2017.

For health plans, HEDIS ratings can be very important. The scores on measures can help them understand quality of care being delivered to their members in some of the most common chronic and acute illnesses.  Higher scores can help compete more effectively in various markets. HEDIS score reporting are often required in public markets as well, where the results are often reported to the states, or occasionally counties, in which the plans reside.

Behavioral health and pharmacy are well represented in the HEDIS measure set. Behavioral health has multiple measures that include ensuring continuity of care, appropriate psychotropic medication management/adherence, and initiation and engagement of drug and alcohol abuse treatment.  Pharmacy measures focus on medication management of acute and chronic physical and mental illness, appropriate medications in the elderly, and management of polypharmacy.  Specialty measures are directed toward inappropriate imaging.

So, what is the value of HEDIS to Magellan?  Aside from being a collection and reporting contract requirement for many of our customers and our own health plan, HEDIS gives Magellan valuable information about the populations we serve.

By following the behavioral health data, we collect, for example, we can identify gaps in network performance in patient follow-up patterns, management of drug and alcohol abuse, and prescribing and adherence to medications.  This allows us to design and implement interventions that can improve outcomes and reduce cost of care.

The same type of analysis/intervention applies to physical health conditions.  Analysis of HEDIS data helps identify gaps in care, particularly preventive care, in such important and chronic populations as patients with diabetes mellitus, patients with cardiovascular disease, and patients with lung disease.  We can also identify and address at-risk pediatric populations who fail to complete preventive care such as immunizations, dental and well-child care.

As the healthcare industry moves more and more toward value-based purchasing, all providers, insurers and their vendors are necessarily increasingly focused on the quality of care that is delivered.  The impact of this should be better outcomes for our members.

Find more articles about NCQA here

Medicine continues to evolve quickly, with new treatments and trials coming to market every month. As a doctor in practice, staying up-to-date on the newest innovations and school of thought can be overwhelming, particularly for rare diseases such as Duchenne muscular dystrophy or spinal muscular atrophy. What’s the role of a pharmacy benefit manager in cases like these?

As part of its value-based approach to pharmacy benefit management (PBM), Magellan Rx Management sees itself as an idea connector and conversation starter. Recently, a discussion forum connected doctors with two key opinion leaders to discuss the complexities and effective management strategies for Duchenne muscular dystrophy (DMD) and Spinal muscular atrophy (SMA).

• Duchenne muscular dystrophy is a genetic disorder characterized by progressive muscle degeneration and weakness. It is one of nine types of muscular dystrophy. DMD is caused by an absence of dystrophin, a protein that helps keep muscle cells intact. Symptom onset is in early childhood, usually between ages three to five. The disease primarily affects boys, but in rare cases it can affect girls.* According to the UCLA Duchenne Muscular Dystrophy Research Center, DMD affects one in every 3,500 male births.

• Spinal muscular atrophy is a genetic disease affecting the part of the nervous system that controls voluntary muscle movement. SMA involves the loss of nerve cells called motor neuronsin the spinal cord and is classified as a motor neuron disease. The age at which SMA symptoms begin roughly correlates with the degree to which motor function is affected: The earlier the age of onset, the greater the impact on motor function.* For SMA, the disease affects one in every 6,000-10,000 births, according to the Orphanet Journal of Rare Diseases.

The physician KOLs provided their expertise and insight on a wide range of topics including review of the clinical evidence, appropriate patient selection, and a discussion of the treatment landscape.  Additionally, effective clinical polices, practical dosing considerations, and emerging therapeutics were explored in this robust webinar. Importantly, doctors who took part in this discussion were given the opportunity to ask the KOLs questions about DMD and SMA – providing an opportunity for open dialogue and discussion about these complex issues.

*Information supplied by www.mda.org