Primary Components of Pharmacy Management Consultants (PMC):
Drug Utilization Review (DUR) Services
PMC plans the agenda and supports the monthly DUR Board Meetings under the advisement of the Oklahoma Health Care Authority (OHCA) and the DUR Board members. All DUR Board correspondence is developed and handled by PMC. An annual report prepared by PMC for the Centers of Medicare and Medicaid Services (CMS) describes the nature and scope of the prospective and retrospective DUR programs, summarizes the interventions used in all reviews and the education program of Board activities, and identifies the DUR program’s impact on quality of care as well as any cost savings generated by the program.
PMC assists OHCA staff with the development, implementation and maintenance of an on-line prospective DUR system. Clinical reviews and criteria reports are provided by PMC to OHCA and the DUR Board. Total savings from the Prospective DUR program was estimated to be $4.4 million for Federal Fiscal Year 2009.
PMC prepares monthly retrospective drug reviews for OHCA and the DUR Board. These monthly DUR reports include criteria-based reviews, patient management and population-based reviews.
Prior Authorization (PA) Services
PMC evaluates medication prior authorization (PA) requests and provides the results of approval, denial and/or more information requested to the dispensing pharmacy within 24 hours from the time the completed request was received by PMC. Clinical pharmacists are used to evaluate PA requests. Pharmacists respond via phone, fax or mail to providers and patients when questions arise pertaining to the PA process. PMC evaluated over 140,000 PA requests for Federal Fiscal Year 2009.
Pharmacy Help Desk
A call center is provided to help health care providers resolve technical and programmatic issues related to pharmacy coverage and prescription claims adjudication for Oklahoma SoonerCare members. The call center is open seven days a week except for holidays.
PMC develops and designs outreach programs to educate practitioners on common drug therapy problems with the aim of improving prescribing and/or dispensing practices. Educational training (experiential learning) is provided to pharmacy students, managed care clinical pharmacist residents and College of Pharmacy faculty. Additionally, graduate research assistants benefit from working on Oklahoma SoonerCare pharmacy program projects of interest to OHCA.
Recent Poster Presentations
Tidmore L, Lambert T, Keast S, Nesser N, Shropshire D. Implementation of focus groups in a collaborative assessment of medication utilization in the foster care system.
Keast S, Holderread B, Owora A, Cothran T, Skrepnek G. Socio-demographic and clinical correlates of treated versus untreated members with Hepatitis C in a state medicaid program.
Keast S, Holderread B, Cothran T, Skrepnek G. Effect of a novel prior authorization and management program on HCV treatment adherence and cost.
Keast S, Holderread B, Owora A, Cothran T, Skrepnek G. Association between viral clearance and clinical and sociodemographic factors within adult medicaid members treated for Hepatitis C.
Tidmore L, Holderread B, Adams M, Nesser N, Keast S. Patient factors associated with nonadherence of oral hypoglycemics in an Oklahoma Medicaid population.
Keast S, Owora A, Nesser N, Farmer K. Impact of opioid classifications and use on overall Medicaid expenditures among adults (over 21 years) enrollees in Oklahoma.
Pham TT, Skrepnek GH, Bond C, Alfieri T, Cothran TJ, Keast SL. Prescription opioid deaths in a state medicaid population 2012-2014.
Pham TT, Skrepnek GH, Bond C, Alfieri T, Cothran TJ, Keast SL. Epidemiology of opioid use in a state medicaid program.
Bulkley C, Traver J, Holderread B, Cothran TJ, Nesser N, Pham T, Keast S. Academic detailing for attention-deficit/hyperactivity disorder (ADHD) in Oklahoma Medicaid.
Thompson TC, Keast SL, Pham TT, Johnson PN, Cothran TJ, Lambert TL, Skrepnek GH. Health-service utilization and referrals among pediatric ambulatory care cases of asthma in the U.S. from 2006-2014.
Tidmore L, Lambert T, Shropshire D, Nesser N, Keast S. Review of psychotropic medication and mental health service use in individuals in foster care versus non-foster in a state medicaid population.
Prescription Drug Management Initiatives
PMC has ongoing initiatives that provide OHCA with a comprehensive ambulatory pharmacy management program, optimizing pharmaceutical therapies to SoonerCare members and ensuring cost-effective utilization of State resources. PMC implements and maintains the following initiatives for OHCA:
- State Maximum Allowable Cost (SMAC) Initiative This initiative includes evaluating the appropriateness of the HCFA Federal Upper Limit (FUL) and establishes the SMAC level reimbursement for generic medications.
- The Product Based Prior Authorization (PBPA) Initiative This program identifies therapeutic categories where medications could be grouped based on clinical efficacy, side effects and the cost of each medication. PMC provides analysis and production of economic data supporting the proposed additions to the PBPA program in compliance with any mandated statutory format. Support of this program is affected through the Pharmacy Help Desk via the prior authorization process.
- Provider Education and Profiling Initiative This initiative includes enhancing current provider education activities, quarterly provider newsletters and retrospective patient profiles, and includes communication of optimum therapy information, recommended treatment protocols and clinical updates of the literature.
- Therapy Management Initiative This initiative utilizes individual case management techniques for those Medicaid members consistently using a large number or high dollar amount of pharmacy services. Medication profiles are reviewed for therapeutic duplication, drug interactions, drug-disease interactions, contraindications, appropriate dosing and other measures of therapeutic appropriateness using principles of evidence-based medicine.