Disease management program PDF

UNIVERSITY OF BOTSWANA
SCHOOL OF PHARMACY
MANAGED CARE ROTATION -PHA 327
REPORT
FACILITY: ASSOCIATED FUND ADMINISTRATORS
Mr. Mompati Letsweletse
201100183
Rotation period 21-25 June 2021
Submission date: 26-07-2021

TABLE OF CONTENTS
1.0 OBJECTIVES.............................................................................................................................................................2
2.0 INTRODUCTION......................................................................................................................................................2
3.0. DISEASE MANAGEMENT PROGRAM (DMP)........................................................................................................2
3.1 COMPONETNTS AND ACTIVITIES OF DMP......................................................................................................3
3.2 DMP key elements..............................................................................................................................................3
3.3 Activities undertaken in DMP............................................................................................................................3
4.0 PHARMACEUTICAL BENEFIT MANAGEMENT.....................................................................................................4
4.1 key Components of PBM....................................................................................................................................4
4.2 Activities undertaken in PBM............................................................................................................................5
5. PERSONAL EXPERIENCE SUCCESS AND CHALLENGES.........................................................................................6
RECOMMENDATION.....................................................................................................................................................6
6. CONCLUSION.............................................................................................................................................................6
REFERENCES.................................................................................................................................................................7
APPENDIX....................................................................................................................................................................8
1. AFA managed care organogram.............................................................................................................................8
2 (Managed care checklist).........................................................................................................................................9
3.0 DETAILED students assigned work.....................................................................................................................11
1 | P a g e

1.0 OBJECTIVES
 The role of managed care at AFA Botswana
 The activities undertaken at AFA Botswana
 The role of different departments at AFA managed care
 Personal experience, success and challenges encountered
2.0 INTRODUCTION
AFA was founded in 1990 as a Fund Administration specializing in medical aid administration
for both government and private institutions. Since then, the company made huge impact toward
providing high-level health management services. The success of this area of AFA’s business is
facilitated by the Managed Care program. In the early 2000s, while the country was experiencing
the severe effects of HIV/AIDS, the demand for a tool to avoid misuse of funds and regulate
funds arose managed care organization was born out of this necessity. This is accomplished
through the use of risk management systems, which identify the causes of loss, analyze, control,
and finance the risk, and finally ensure quality control. Managed care activities and services have
since grown in size, with 16 employees providing the following services: pharmaceutical benefit,
disease management program, hospital services management benefit underwriting for the
schemes they administer It is made up of a multidisciplinary team of pharmacists and pharmacy
technicians, nurses, doctors, and information technology personnel. The purpose of this paper is
to present the report for the experiential attachment at Associated Fund Administrators (AFA)
Botswana (Managed care), as guided by the objectives listed below.
3.0. DISEASE MANAGEMENT PROGRAM (DMP)
Disease management programs at AFA managed care is a structured treatment plans that aim to
help people better manage their chronic disease and to maintain and improve quality of life.
DMP department exist to help manage chronic patient and reduce risk often posed by these
conditions .DMPs are run with the general goal of improving medical treatment in the long term..
People with chronic illnesses are more likely to use health-care services, such as hospital and
2 | P a g e

physician visits, as well as prescription drugs As a result, health-care costs rise, putting a strain
on both individuals and the medical-aid scheme.
3.1 COMPONETNTS AND ACTIVITIES OF DMP
Activities undertaken under this program by the pharmacist include reviewing chronic
applications to ensure that the plans are clinically appropriate, cost effective, delivered the most
appropriate channel hence preventing unintended side effects and fund misuse. Pharmacist
interact with other health professionals to ensure that the patients are holistically managed. They
also stall chronic disease progression hence avoiding complications which lead to
hospitalizations. They perform pre-authorization of chronic benefit management of non-
communicable diseases, full disease management of HIV and reviews x-formulary (open
formulary) chronic medicines. Pre authorizations for chronic disease applications and chronic
benefit management programs. Counselling chronic patient on adherence to improve clinical
outcomes.
3.2 DMP KEY ELEMENTS
A fully functional system to manage patients; AID for AIDS (to manage HIV patients) and the
iMED system for other chronic illnesses systems in place to manage patients and simplify the
work
Guidelines for Evidence-Based Practice; Guidelines are used to motivate for inclusion of
products in the formulary, and also helps the pharmacist to educate other professional on what to
use that would benefit the patient guidelines mostly used are from reputable countries
Models of collaborative practice;Made up of different clinicians which work hand in hand to
ensure that the patients gets the best service from different professionals working together
Patient self-management education; Patients are encouraged and taught to become part of the
treatment, this is done by monitoring patient s response to the prescribed regimen
Process and outcomes measurement; Clinical parameters are used to mainly monitor the
response.
3.3 ACTIVITIES UNDERTAKEN IN DMP
Some of the activities that were assigned to the student are listed below.
3 | P a g e

Review one request for a chronic ex-formulary item. The request was for a patient with
uncontrolled Diabetes Mellitus to be given Empagliflozin (Jardiance). The following are the
comparative advantages of Empagliflozin: lower a1c: lower blood sugar, lower risk of
cardiovascular death for adults who also have heart disease, weight loss-In studies of adults with
type 2 diabetes, people lost 2–3% of their body weight, on average, lower blood pressure.
Jardiance, when used alone or in combination with metformin, helped some people lower their
systolic blood pressure and is thus recommended (Tikkanen et al., 2014). Furthermore, because
the majority of chronic patients on it have cardiovascular co-morbidities, it should be included as
a standard diabetic drug. The other activity was to consider Rivaroxaban (Xarelto) for possible
inclusion in the formulary. The main goal of analyzing the requests was to find convincing
evidence-based information demonstrating that adding the medicine to the chronic basket has a
significant benefit not just for one patient but for all patients with comparable illnesses. Factors
taken into account when advocating for the possible inclusion of one drug in the basket include:
Costs, side effects, monitoring parameters involved. For more detailed activity refer to appendix
4.0 PHARMACEUTICAL BENEFIT MANAGEMENT
Pharmaceutical benefit management services are aimed to help prescribers, pharmacists, and
other healthcare professionals influence prescribing patterns in order to maximize medicine
effectiveness and contain drug expenditures. Auditing claims, coding of pharmaceuticals (using
nappi codes generated in South Africa by MediKredit to identify the medicines in the system),
and pricing are among the activities carried out. MMAP® (Maximum Medical Aid Price) codes
are used to link all the related generic medicine. ATC coding classifies items at therapeutic level
while ICD 10 coding is used for diagnosis of disease conditions.
Other activities include re-imbursement strategies such as differential and generic referencing
mark-up. In the case of generic reference pricing, reimbursement is made at the price of a generic
if one exists; however, in the case of differential mark up, reimbursement is made at a certain
percentage if no generic exists. Pricing strategies employs the use of Single exit Price (SEP).
Wholesaler’s buys the medicines from South African manufacturers using SEP and they are
allowed to add a logistic fee of 10%, the retailers are allowed to add 52% mark up to generics
and 35% to the brand
4 | P a g e

4.1 KEY COMPONENTS OF PBM
 Medicine benefit plans;
Benefit plan Explanation
Acute medicines benefit. OTC benefit for which the limit is P1000.00
Non-dispensing Doctor for which the limit is P750.00. The limit is
meant minimize the risk of abuse by customers and for the non-
dispensing doctor the limit is set to minimize medicine errors that can
result from doctors prescribing and also dispensing again. As such this
encourages the practice of doctors prescribing and pharmacists
dispensing.
chronic medicines benefit Psychiatric and HIV benefit
pharmaceutical and
Related Substances
benefit
Appliances Benefits; only pay for appliances that have been
scientifically proven to be useful at home. Aero chambers and
glucometers are two examples. Appliances such as blood pressure
meters are not reimbursed because they are not suitable for self-use at
home and can endanger the patient's life.
Medical assistive devices benefit; those that attempt to compensate for
the function of a specific organ. Catheters and stoma bags, for
example.
4.2 ACTIVITIES UNDERTAKEN IN PBM
Some of the activities that were assigned to the student are listed below.
Drug utilization review: Student audited claims using iMED system .The purpose of a claims
audit is to determine the suitability of patients who are taking the same medicine for the second
time after taking it for less than 14 days the first time. The type of medication, age, and reason
for taking the medication were all taken into account. Claims for chronic conditions such as
hypertension were typically denied because most medications are given as a one-month supply
and cannot be completed in less than 14 days. Prior authorization: This was done for medicines
5 | P a g e

that were not on the formulary in order for them to be paid for specific patients. Doctors typically
send motivation letters outlining the patient's condition in order for them to be considered.
Because medical aids do not cover pregnancy supplements, the student was assigned to evaluate
a request for Preg- omega plus® for a 7-week pregnant. The importance of supplements during
pregnancy, the cost effectiveness of prenatal vitamins, and other accessible vitamins for prenatal
supplementation were some of the aspects considered when considering the request. The student
rejected the request because there are other cost-effective prenatal supplements, and the literature
suggests that the most important vitamins for prenatal supplementation are vitamin c, iron and
folic acid as outlines by (Peña-Rosas & Viteri, 2009)
5. PERSONAL EXPERIENCE SUCCESS AND CHALLENGES
The learner completed the experiential attachment and met the expectations of both the school
and the site. The learner recognized the importance of pharmacists in managed care in ensuring
that members receive quality pharmaceutical services. The time frame for the attachment was too
short, so most of the activities had to be completed in a hurry, and some of the staff members
were unavailable due to covid 19 isolation, so the student did not have the opportunity to interact
with every member of the staff to fully understand their role.
RECOMMENDATION
The experiential attachment at AFA was informative; as part of the recommendation, it is
suggested that managed care collaborate with medical school health science students for
updating guidelines and comparing available treatment regimens; this will aid not only in
developing guidelines but also instilling unity among health professionals.
Doctor and pharmacy hopping is a challenge for both service providers and managed care
because patients will receive the same treatment from different service providers, resulting in the
service provider not being paid because it appears to be duplicate; therefore, it is recommended
that AFA managed care provide a platform where service providers can see if the patient has
been to the doctor and which treatment they received This will allow staff who perform audits
and check duplicate claims to focus on other tasks.
6. CONCLUSION
6 | P a g e

Managed care has been shown to provide enormous benefits by lowering the cost of care, resulting in
a significant reduction in national health expenditure. Managed care that enrolled patients receive
high-quality care
REFERENCES
Peña-Rosas, J. P., & Viteri, F. E. (2009). Effects and safety of preventive oral iron or iron+folic
acid supplementation for women during pregnancy. Cochrane Database of Systematic Reviews.
https://doi.org/10.1002/14651858.cd004736.pub3
Tikkanen, I., Narko, K., Zeller, C., Green, A., Salsali, A., Broedl, U. C., & Woerle, H. J. (2014).
Empagliflozin Reduces Blood Pressure in Patients With Type 2 Diabetes and Hypertension.
Diabetes Care, 38(3), 420–428. https://doi.org/10.2337/dc14-1096
7 | P a g e

APPENDIX
1. AFA MANAGED CARE ORGANOGRAM
8 | P a g e

2 (MANAGED CARE CHECKLIST)
1. Disease Management Program (DMP)
Sourced from the Disease Management Association of America
COMPONENT YES NO
POPULATION IDENTIFICATION PROCESS: i.e., have a process of how patients are
enrolled and which specific diseases the patients should have.
EVIDENCE BASED PRACTICE GUIDELINES: i.e., national treatment guidelines,
Mims
COLLABORATIVE PRACTICE MODELS: i.e., multidisciplinary team of health
workers like pharmacist, physicians and nurses
PATIENT SELF MANAGEMENT EDUCATION: i.e., individuals are better educated on
how to manage and control their condition. Additional support to enrollees for them to stick
to their medical regimen eg Adherence Counseling, call centers, and appointment reminder
systems.
PROCESS AND OUTCOMES MEASUREMENT; A method for the measurement of
outcomes, including health care service use, expenditures, and patient satisfaction.
ROUTINE REPORTING AND FEEDBACK BETWEEN PATIENTS, PROVIDERS,
AND HEALTH PLANS; Routine reporting and feedback between patients, physicians, and
other providers on the care team
HAVE A FULLY FUNCTIONAL SYSTEM TO MANAGE PATIENTS
Review to see if the information found on the chronic benefit application form is fully filled
COMPONENT Pt 1 Pt 2 Pt 3 Pt 4
Principal member details; full name, medical scheme, member number
Patient details; full name, date of birth, phone number
Buddy details
9 | P a g e

Medicine supplier; pharmacy or dispensing doctor, medical aid practice
number
Member and / patients’ signature;
Details of the doctor providing medical care; full name, medical aid
practice number, email address, BHPC registration number.
Clinical data; weight, height, BP, blood sugar
Risk factors
Allergies i.e of Penicillin, Sulfonamides
Medical history; diagnosis (ICD 10), medication, strength, directions,
period in use, period required.
Motivation (if any)
Acknowledgement by examining Doctor
2. Pharmacy Benefit Management (PBM)
COMPONENT YES NO
Process for Reimbursement of prices; how much money will be paid and
from which benefit,
Conducts Medicines Utilization Review;
Prior Authorization Process: ensure the appropriate use of prescription drugs
to prevent improper prescribing or the improper use of certain drugs.
Claims processing;
Controls prices: i.e., Single Exit Price to regulate how much more or less the
prices can be increased or reduced.
Formulary coverage: have a list of which medicines are covered and which
ones are not.
Process and outcomes measurement; A method for the measurement of
outcomes, including health care service use, expenditures, and patient
satisfaction.
HAVE A FULLY FUNCTIONAL SYSTEM TO MANAGE PATIENTS
10 | P a g e

3.0 DETAILED STUDENTS ASSIGNED WORK
Case 1
A patient, a 48-year-old woman, was diagnosed with osteoporosis ten years ago and has
undergone several treatments. Doctor switched to Fosamax 10mg (Alendronic acid) daily for 18
months before switching to Zolendronic acid a year ago due to its market introduction. When
making a choice, the following questions were considered: medical history for this patient?
Current clinical status? The type of treatment has patient received in the past? Consistency with
approved indications? Alternative regimens for the patient’s stage of the disease? Do the
alternatives offer any advantage for this particular patient? Comparison Cost comparison with
alternative regimen per year. Despite being on this regimen, the patient was never pain-free and
had to be on NSAIDS all of the time. Patient did not experience any pains or complaints since
the infusion. In postmenopausal women, zolendronic acid is licensed for the prevention and
treatment of osteoporosis (Lewiecki, 2009). It's also licensed to help men with osteoporosis gain
bone mass and to prevent new clinical fractures in people who have recently undergone a low-
trauma hip fracture. The regimen is also easy to take as it is only administered once a year. As a
result, it is recommended that the drug be included in chronic basket for osteoporosis, as it is
especially indicated for postmenopausal women. The American Association of Clinical
Endocrinologists (AACE) published guidelines in 2010 (Reid, 2006).
Do the alternatives offer any advantage for this particular patient? Comparison
11 | P a g e

Efficacy Tolerability(s/e
profile)
Pricing
per year
Route
of
admin
Convenience Pharmacological
class
Zolendronic
Acid
Good,
demonstrated
efficacy in
reducing
vertebral and
non-vertebral
fracture risk
Generally
tolerable but
can cause
osteonecrosis of
jaw
P3746.57 IVI Once a year
dosing
Biphosphonate
Alendronat
e
Similar,
demonstrated
efficacy in
reducing
vertebral and
non-vertebral
fracture risk
Generally
tolerable but
can cause
osteonecrosis of
jaw
P12, 600 PO Taken once
weekly 2hrs
before meals
Biphosphonate
Bonviva Similar,
demonstrated
efficacy in
reducing
vertebral and
non-vertebral
fracture risk
Generally
tolerable but
can cause
osteonecrosis of
jaw
P5,600
IVI/ P25
000 PO
IVI/PO Taken once a
month PO or
3 times a yr
IVI
Biphosphonate
Fosamax Similar,
demonstrated
efficacy in
reducing
vertebral and
non-vertebral
fracture risk
Generally
tolerable but
can cause
osteonecrosis of
jaw
P15,600 PO Taken once a
week on the
same day
each week
Biphosphonate
Evista Lower,
cannot be
standard first
line. Should
not be
continued or
initiated after
age 60
Risk reduction
for Ca Breast
P4600 PO Cannot be
started after
age 60
SERMS
Rocaltrol Lower,
Largely
inhibit bone
resorption
but not
Severe
erythmatous
skin disorders
P6600 PO Strict
adherence to
diet.
Minerals& Vit. D
12 | P a g e

exclusively.
Protos Lower, MONITOR
RENAL
FUNCTION
P2800 PO Not available
in the market
Dual action bone
agents
Case 2
The learner reviewed and evaluated a treatment change application for a 53-year-old female who
was diagnosed with HIV 8 years ago and had been on Lamivudine/Zidovudine (AZT) and
Nevirapine. The laboratory parameters were performed CD44 count (385cells/mm3), viral load
(<25 copies/ml), Crcl 57.20 umol/l and EGFR >90ml/mg. The Hemoglobin profile was noted as
follows as per laboratory findings mean corpuscular volume MCV 116.1(83-101 femtoliter),
Hematocrit 38.70(40-50g/dl) and MCH mean corpuscular hemoglobin (MCH) 40.20(27-32
pictograms) .As per hemoglobin profile the doctor concluded that the patient had macrocytic
anemia. The possible explanation to this is because AZT can be toxic to the bone marrow where
blood cells are made resulting in anemia. The recommended new treatment was Acriptega
(Tenofovir 200mg/ lamivudine 300mg/Dolutegravir 50mg) and the reason given by the doctor
were that the patient had macrocytic anemia due to zidovudine This application was approved
because TLD has fewer side effects, taken only once daily which simplifies treatment regimen
promoting patient adherence. For the patient, a pathological monitoring strategy was devised,
with viral load testing at 3 months and then every 6 months, CD4 testing every 12 months, and
creatinine clearance testing at 3 months and then every 6 months (Wubetu & Mebratu, 2018)
13 | P a g e