MassHealth
As the health care consulting division of UMass Medical School, Commonwealth Medicine works closely with state agencies — such as the Massachusetts Medicaid program, known as MassHealth — to contain the rising costs of medication, amid increasing member enrollment and rising pharmacy claims.
By managing pharmacy benefits for MassHealth, Commonwealth Medicine’s Center for Health Policy and Research has helped Massachusetts avoid more than $1 billion in prescription drug costs since 2001. The expert pharmacy team in the Center for Health Policy and Research has designed a three-pronged strategy to continue realizing savings for the MassHealth program: drug utilization review, program and benefit design, and quality improvement and measurement.
Drug Utilization Review
Our Center for Health Policy and Research team provides MassHealth with comprehensive drug utilization review services. In addition to handling prior authorization requests, we use prospective drug utilization review to ensure that pharmacists are aware of safety issues of particular medications. By examining claims after prescriptions are dispensed through our retrospective drug utilization review, we help identify fraud and abuse.
Program and Benefit Design
Our program and benefit design expertise ensures that MassHealth members receive pharmacy benefits for drugs that are cost-effective and medically appropriate — and comply with federal and state Medicaid regulations.
To achieve this, we developed the MassHealth Drug List, which identifies more than 3,000 preferred drugs for pre-defined medical treatments based on clinical efficacy, safety, and cost effectiveness. We continue to update it as new therapeutic classes are evaluated and as new drugs come to market.
We also use the Pharmacy Online Processing System, a software system that provides real-time submission and approval of MassHealth pharmacy claims, as the prescription is entered at the subscriber’s local pharmacy. The system checks for up to 350 different conditions, such as member eligibility and prescription drug interactions. It also supports the federal drug rebate program and data analysis, as well as invoice generation, payment reconciliation, and dispute resolution.
Quality Improvement and Measurement
Our Center for Health Policy and Research pharmacy team works to ensure the ongoing quality of the MassHealth pharmacy program — to see that it supports clinical, financial, and operational objectives and is maintained within federal and state legislation, regulation, and policy, as appropriate. Our staff draws upon a wide range of methods:
- Analysis of drug use patterns
- Analysis of prescribing and fulfillment patterns
- Analysis of utilization management programs