General Overview
This initiative integrates the ACS SmartPA system with the ACS PDCSx2 system to provide enhanced claims processing capabilities for a Medicaid Pharmacy Program. The SmartPA system is a set of tools capable of managing cost containment options and provides efficient pharmacy benefit administration. This program uses a clinical rules system in conjunction with drug data—and medical data, when available—to help determine the appropriateness of dispensing certain medications to participants. It provides enhancements to the existing prior authorization and claims screening processes.
The initiative integrates four major components of the SmartPA system with the PDCSx2 system:
- SmartPA Clinical Rules System (Hercules)
- SmartPA POS System
- SmartFusion System
- SmartPA Database Systems
SmartPA Clinical Rules System (Hercules)
The SmartPA Rules system allows users to define and implement rules for evaluating drug utilization. When integrated with the PDCSx2 system, the SmartPA systems will use these pre-defined clinical and fiscal edits to apply Drug List criteria to each requested drug use and to communicate the evaluation’s results to PDCSx2 system and its users.
Each rule consists of one or more functions, or group of functions, that collectively evaluate the requested and/or historical drug use. The system uses functions to determine if particular conditions exist. The functions examine those aspects of the participant’s care, especially pharmacotherapy, that have the greatest impact on quality, cost, and effectiveness. Each function uses supplied parameters to assess a specific aspect of care, whether it involves drug claim, diagnostic, procedure, encounter, or participant data.
Functions evaluate:
- Participant variables, like: age and gender
- Disease variables (the presence or absence of user-defined diseases, when available)
- Procedure variables (the presence or absence of user-defined procedures, when available)
- Pharmacotherapy variables, like: drug class, specific drugs, dosage, duration, sequencing of therapy
- Provider variables, like: number of providers, provider-specific results
- Encounter variables, like: number and costs of admissions, office visits, ER visits
As part of the implementation of the SmartPA system’s integration with the PDCSx2 system supporting the Medicaid program’s pharmacy claim processing, the SmartPA Clinical Rules system will be adapted to provide support for the functional requirements outlined in the document, COR511 – Drug List Parameterization 10012004.doc. The ACS clinical team will work with the Medicaid clinical team to specify, create, and test the Medicaid rules in the SmartPA rules system.
SmartPA POS System
This initiative will integrate the SmartPA POS system with PDCSx2, providing the link between the processing system and the SmartPA rules engine. In the integrated system, drug use authorization requests are adjudicated online. At the pharmacy, the pharmacist submits a claim for the participant’s prescription to the PDCSx2 system. The system performs numerous front-end edits and, if the claim has passed the edits, transmits the claim to SmartPA for additional editing.
SmartPA applies a series of evidence-based clinical rules, within the pharmacy point of sale (POS) process, to up to thirteen (13) months of participant-specific medical (if available) and drug history. This enables SmartPA to approve appropriate prescription drug utilization on a real time basis while denying inappropriate medications.
The automated system will eliminate the need for a phone call for the majority of PA transactions – prescriptions that meet predetermined clinical rules are approved within seconds when the pharmacist submits the participant’s claim to the PDCSx2/SmartPA systems.
SmartPA POS Process Flow
SmartFusion System
This initiative will integrate the SmartFusion system with the PDCSx2 Prior Authorization (PA) subsystem, providing the link between the processing system and the SmartPA rules engine. As requests for PAs or overrides are entered into the PA subsystem, the DUR program’s pharmacist reviewer can submit the requested drug use to the SmartFusion system for review against the rules.
Upon screening the request against the pre-defined criteria and claim history, the SmartFusion system responds to the request, providing the reviewer with: a preliminary recommendation—approve, deny, or not applicable; a user-actionable, enumeration of the criteria applied to the request and their outcomes; and, a summary of the participant’s paid claim history.
When it recommends denying the requested drug use, the system will identify the criteria that were not met and allow the reviewer to resubmit the request, verifying that the criteria were met as evidenced by information provided external to the system; e.g., the PA request form.
The reviewer can use or ignore the recommendation. If the reviewer uses the recommendation, the SmartFusion system provides PDCSx2 with PA-related data.
SmartPA Database Systems
This initiative will integrate the SmartPA and PDCSx2 systems at the data level. Both initially and at regular intervals thereafter, the PDCSx2 system will provide the SmartPA database systems with patient, provider, prescriber, and claims data. The SmartPA systems use the data to support the Medicaid rules history requirements, to display descriptive information in the SmartFusion interface, and for reporting.
In addition to integrating data managed by the PDCSx2 system, this initiative will integrate medical data managed by the Medicaid systems with the SmartPA database systems. At the time this document is written, the availability of the medical data is not known. It is assumed that the medical data will not be integrated at the time the systems initially go live.
SmartPA – PDCSx2 POS Systems Integration
Real-time data exchanges between PDCSx2 and SmartPA includes PA requests, PA responses, and notifications. PDCSx2 sends PA requests for B1 (billing) and B3 (rebill) transactions regardless if the drug contains rules in SmartPA. A PA response from SmartPA is returned to PDCSx2 for each PA request. In addition to prior authorization requests, PDCSx2 sends paid claims, reversals and adjustments to the SmartPA system. These notification transactions are used to update the Smart PA databases.
SmartPA sends one of four responses for each PA request:
- PA Approved ‘A’
- PA Not Required ‘B’
- PA Denied ‘D’
- SmartPA Error ‘E’
The PDCSx2 interface to the SmartPA system will return the following transaction status when the transaction time exceeds a tunable, timeout threshold:
- Interface Pgm Time Out ‘F’ – (PDCSx2 will post an exception code log the error)
POS Systems Interfaces Diagram
Approvals generated by SmartPA are not stored on the PDCSx2 database as Prior Authorizations. This is subject to change based on further discussion regarding billing considerations. All exception codes and dispositions are returned for each line on the claim.
SmartFusion – PDCSx2 PA Subsystem Integration
Integrated as a component within PDCSx2, the SmartFusion application provides an interactive user session that displays information generated by and/or contained in the SmartPA rules system and database in response to requests from the PDCSx2 system. To provide maximum functionality of SmartPA, DUR Program users have the ability to interact with information from SmartPA through PDCSx2.
Once the SmartPA rules system reviews the requested drug use against the participant’s history and the pre-defined criteria, the system displays the determination indicating that the requested drug use either meets, or does not meet, or is not subject to, the clinical requirements. An overall decision is displayed by SmartFusion indicating if the drug requested is approved, denied or no Prior Authorization is required.
Web services are called by EA Server. PDCSx2 will make calls to EA Server which will, in turn, make calls to web services and return the data/result to the client PC.
Probabilistic PERT Analysis
The optimistic, most likely, and pessimistic times for each of the activities in this project are displayed in Table 1, below. The times were estimated based upon a combination of times seen from similar implementations in the past, and knowledge of the efficiency of the members of the project team.
Table 1: Project Activities and Their Optimistic, Most Likely, and Pessimistic Times
The results of the PERT analysis in Table 2 shows that there are two critical paths. The project duration is estimated to be 264.83 days. Since the project is schedule to begin on June 1, 2007, that would place the completion date at February 20, 2008.
Table 2: Results of PERT Analysis
Table 3 identifies the two critical paths for this project: A-I-K-P-Q-R-S-U-V and A-I-K-P-Q-R-U-V. While both critical paths have the same completion time, Critical Path 1 has a larger standard deviation, which indicates that there is less certainty about the time for Path 1.
Table 3: Project Critical Paths
The network diagram for the implementation is shown in Figure 1, below. The critical paths and their associated critical activities are shown in red. For each node in the diagram, the number in the upper left-hand quadrant of the node represents the earliest start time of that activity. Likewise, the upper right-hand quadrant displays the earliest finish time, the lower left-hand quadrant shows the latest start time, and the lower right-hand quadrant shows the latest finish time for the activity.
Figure 1: Activity Analysis for Project
In Figure 2, a Gantt chart for the project is shown. The chart depicts the overlap of start times for the various activities in the project and their relative dependencies upon each other.
Figure 2: Gantt Chart for Project
Project Cost Analysis
This project requires the work of clinical pharmacists, technical programmers, business analysts, application testers, and technical writers. Normal times and normal costs were estimated based upon a previous project implementation that was similar in scope. Crash times and crash costs were estimated by reassigning the appropriate internal resources to this project.
Table 4: Normal and Crash Time and Cost for Project
The results of the normal cost analysis are shown in Table 5. The project is estimated to be completed in 259 days at a cost of $490,800. Since the project is schedule to begin on June 1, 2007, that would place the completion date at February 14, 2008.
Table 5: Results of Normal Cost Analysis
The results of the crashing cost analysis are shown in Table 6. The project is estimated to be completed in 212 days at a cost of $588,480. Since the project is schedule to begin on June 1, 2007, that would place the completion date at December 28, 2007.
Table 6: Results of Crashing Cost Analysis
Conclusion
