PH and PAH: Care Coordination From the Payer Perspective

Insight from the managed care perspective on how care coordination can benefit patients with PH or PAH.


Derek van Amerongen, MD, MS, FACOG: In terms of prescribing medications, especially in complex situations such as PH [pulmonary hypertension] and PAH [pulmonary arterial hypertension], we have never required a specific specialist such as a cardiologist or a rheumatologist to make a diagnosis or to write a prescription. With the conglomeration of more and more health care professionals into health systems, we’re seeing more multidimensional, multifactorial teams. In many respects, we’re getting away from a lot of the siloed approaches to care that we used to have, where only cardiologists would see 1 group of patients and only rheumatologists would see another group.

This goes along with the fact that so many of these conditions are now understood to cross many different organ systems and many different specialties in terms of their physiology and the multidimensional approach that needs to be taken to treatment. Ultimately, what we want to do is make sure that all our members are plugged in to the right systems of care where they can access the expertise they need. That would include the ability—once they’ve had specialists’ insight and plan development if necessary and if available—to go back to their communities and have their care continued by community physicians in collaboration with those specialists who are typically at the academic or tertiary care center.

At Humana Inc, we’ve developed a very sophisticated system to help patients get the care they need, especially for something as complex and sophisticated as PH and PAH. We have a very large team of care coordinators, most of whom are health care professionals: nurses, social workers, and other people who are very experienced in this field. Their job is to identify members who are at risk for chronic and complex conditions. We use a very well-developed predictive model to do that, and then we assign a score to each of those members, which is refreshed on a monthly basis as we get new medical data or pharmacy data or other information. The nurses reach out to these members to perform an assessment and understand where they are in their condition and what help they need.

The care coordination that those nurses provide is critical. It focuses on member education, which is tremendously important because everyone in health care should understand that for the people in the community, the level of health literacy is quite problematic. We on this side of the table understand the terminology and the concepts we’re delivering to patients, but they may not understand those aspects and may not be able to take that information and use it in a way that will help them participate fully with the health care professional team.

We have become more aware in the last few years—and this is an area where Humana has done a lot of work—of the importance of social determinants of health. This is a very important concept that there are so many things that impact the delivery of health care and the outcomes in health care that have not been part of what we’ve traditionally thought of as medical care. Things such as transportation. If someone can’t get to the hospital or get to the PAH treatment center, it really doesn’t matter how good those physicians are because that person can never take advantage of that.

If people are concerned about housing, if they’re concerned about where their next meal is coming from, if they’re concerned about their children not living in a safe community, all those issues tend to push a person’s focus on medical care way down the list and lead to a lot of the issues with compliance and adherence that physicians have always been aware of but never really understood how to address.

We also want to be very focused on the fact that even people with insurance are going to have very significant challenges in terms of covering the cost of medical care, especially when you look at the very significant out-of-pocket costs that many people have. Benefit coordination, helping people deal with the claims they receive, making sure that they’re accessing all the resources as efficiently and with as low a cost as possible—those are all very important components in making sure that people not only get the care but also are being as compliant and adherent as possible.

We have a very large group of pharmacists who reach out to members who are on these expensive and complex specialty drugs on a monthly basis to make sure they understand how to take the drugs and that they’re addressing any potential issues. They provide any support that members might need and make sure the delivery of these drugs is going to be safe and timely, so the members have the drugs that they need.

For a complex condition like PAH or PH, it’s critical to make sure that we are coordinating pharmacy services, especially when members are perhaps receiving their drugs from multiple sources. One of the advantages we have at Humana is that we own our own PBM [pharmacy benefit manager], so we have visibility over both the medical and pharmacy benefit as opposed to a health plan that might have an external PBM, where the plan can see the medical side but has to go through an outside party to see the pharmacy side, the self-administered side.

One of the things we do with our vast data resources and our very large networks is make sure that we understand where our members receive their medications, even if they’re not through us. We coordinate that through the pharmacists reaching out to the members on a monthly basis to ask about compliance and issues they have; address any educational concerns; access any other resources they might need, such as testing or monitoring; and make sure that all the medications they receive are going to be delivered in a safe and timely way.

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