Quicker response times saving millions in pharmacy costs at SEHA, Abu Dhabi
With pharmaceuticals representing such a significant portion of SEHA’s overall budget, the cost of insurance denials was significant in 2015. SEHA looked to reduce denials as part of the government’s Pharmacy Benefits Management (PBM) initiative.
PBM seeks to introduce a key quality and cost auditing mechanism by integrating disparate government systems and smoothing the relationship between insurance payers and health care organizations when it comes to dispensing medication for patients.
SEHA dispenses 32,000 prescriptions daily, so there were concerns that PBM would be yet another process that would impact on patients’ waiting times.
The organization needed to connect four separate systems to achieve an integrated solution – the Cerner Millennium® electronic health record, Rhapsody’s Interface Engine, Health Authority of Abu Dhabi’s Shafafiya (HAAD), and systems from insurer Daman. Some of these systems had no testing environments.
There were also pharmacy-specific scenarios that all needed to be considered, including refills, partial fills, cancelled fills, patients not collecting their medications and regulations relating to narcotics and controlled medications.
On top of this, there were challenges regarding patients’ nationality and related requirements.
Fixing the issues
By joining together all the systems, SEHA, Cerner, Daman, and HAAD streamlined authorization processes, enabling the benefits of the PBM initiative to be realized.
As a result, the numerous complex scenarios encountered diminished, with testing now available for all possibilities and multiple hospitals trialling the same scenarios to ensure full testing had taken place.
This included creating a sandbox environment for Daman to enable it to be tested without affecting real patient data.
Additionally, the PBM solution came with a full bundle of retail pharmacy enhancements such as a new price checker, and denial report printout capabilities were developed, as well as a new verification box to view full diagnosis details at the point of dispensing the medications.
In terms of timescale, a two-phase approach was adopted, with PBM being rolled out gradually based on health plans and the locations of pharmacies.
Between 2013 to December 2016, overall denials of pharmaceuticals across the SEHA organization fell from 34 percent to less than 10 percent. At the clinic that went live first with PBM, basic plan denials dropped sharply from 32 percent to 0.17 percent.
In all, the amount saved from the fall in insurance denials amounted to AED 33.5 million.
SEHA’s Malaffi applications – based on Cerner Millennium – include fully integrated patient accounting capabilities. Between May 2016 and April 2017, approximately 160,000 prior authorizations were processed electronically through the PBM solution.
This helped to reduce the response time for prior authorizations to less than three minutes on 92 percent of occasions.