Consumer Education

This standard provides:

The organization implements safeguards for any communication with potential consumers and clients to ensure that marketing and sales activities performed by the organization do not misrepresent them.  (Mandatory)

This standard essentially replicates the requirements of Pharm. Core. 21, the general consumer education accuracy requirement.  The only difference of import, in fact, is that this is a mandatory standard, while Pharm. Core 21 is not.  Thus, the only significance of this standard is that it essentially makes Pharm. Core 21, and particularly subsections (a) and (b), a mandatory standard.

Note that this may not apply to your organization if your clients do not delegate consumer communication responsibilities to your organization.  If that is the case, simply upload the attestation to that effect that you've already uploaded to AccreditNet under CSCD 1 here, again with an explanatory note indicating that this standard is not applicable.

The documentation required for this is a combination of:

1. a P&P that sets up the materials-monitoring program,
2. sample marketing materials, and
3. evidence of the implementation of your materials monitoring program (e.g., document review and approval forms, committee minutes showing review and approval of materials)

We recommend that your materials approval process be interdepartmental, as required by Pharm. Core 21(c).
Here are some more thoughts on this standard in this short video.

As I noted in the February 7 blog, the new URAC Pharmacy Benefit Management (“PBM”) accreditation standards are going through a beta process with a handful of brave applicants. Since that posting, however, we’ve got our hands on the official “Draft for Beta Testing” version. This version has a few significant changes from the “Draft for Public Comment” version released last year.
In this and the next few blogs, I’ll do a high-level analysis of the Beta Testing version, with brief commentary on changes from the Public Comment version.

Definitions

The PBM standards have a lot of concepts not included in the other accreditation standards. As a result, the “Definitions” section is substantially different than you’ll find in other Program Guides. Terms like “Automated review”, “Drug therapy management”, and “Generic substitution” are new. In addition, some terms that have appeared in other Program Guides take on new meanings in these standards, such as “Certification” and “Non-certification” have new, PBM-specific meanings. A close review of this section is, therefore, a must for anyone seeking to safely navigate these standards.

Module 1: Core

Naturally, as this is a clinical accreditation program, all applicants will be required to achieve a “passing score” on the Core module. Of course, as I’ve noted in a number of earlier blogs, this Core module (v.2.0) is changed from v. 1.0 and has some more rigorous standards than before (especially around patient safety).
Of particular interest to URAC during the beta testing period will be applicants’ compliance level with a couple of the Core standards:

• Core 3: The organization: (a) Maintains and complies with written policies and procedures that govern core business processes of its operations related to the scope of the accreditation; (b) Maintains a master list of all such policies and procedures; (c) Reviews clinical policies and procedures no less than annually and non-clinical at least once every three years, and revises as necessary; and (d) Includes the following on all policies and procedures: (i) Effective dates, review dates, including the date of the most recent revision; and (ii) Identification of approval authority.
• Core 10(c): “The organization designates at least one senior clinical staff person who has . . .Post-graduate experience in patient care.”

CDH, CDH, CDH.

How often in the last month have you come across yet another article proclaiming the rise of Consumer Driven Healthcare (CDH)? For me, it's been a bunch:

URAC Awards BlueCross Consumer Education Accreditation

Grades to Transform U.S. Healthcare, Secretary Says

Report: IT Necessary for Consumer-Driven Health Plans

And so on.

Unless one is careful about reading these reports, one might conclude that CDH is either already the new dominant mode of healthcare financing, or that it will be soon. Every once in a while, though, a countervailing view pokes through:

Consumer-Driven Health Care is a False Promise

Hmm, talk about a bucket of cold water.

So, what is happening out there in CDH-Land? A lot, as it turns out, but in the context of a lot of uncertainty. Health plans, payers, providers, and regulators and moving frantically toward IT systems that can gather and analyze health data on an increasingly fine-grained level with growing sophistication. Medical management companies are able to drill down and dissect claims, prescription, and other data with increasing speed and subtlety.

But it's not just about IT -- it's also about consumer education. URAC's new Consumer Education and Support (CES) accreditation program is starting to catch on, establishing national standards that will guide managed care companies on how to talk to consumers in the new CDH environment. Government entities, both as regulators and as purchasers, are wading in to the CDH arena, too.

All this is happening, though, in the face of the very real possibility that, at the end of the day, most people won't want to direct their healthcare treatment and financing decisions. Some early reports suggest that, given the choice, most folks still don't want to sift through the data to make informed decisions about their payers and providers.

About 6 months ago, I sat down to lunch with a long-time friend of mine, who now is the regional CEO for one of the largest health plans in the nation. I've always admired him for the clarity of his vision, and, after we caught up on family news, I started to pick his brain about trends in healthcare, including CDH. His company, like many of its competitors, is taking a two-track approach, pursuing CDH on one track while sticking with more traditional managed care offerings on the other. After explaining why it makes sense, both in terms of market forces and IT strategy, he explained, "Tom, I give this 2-3 years to shake out. By then we'll know whether consumers really want to get involved in these kinds of choices. I don't know how it will play out, but we'll be ready to move either way, once we can figure this out."

He also explained that the IT investment seems to have other dividends, so even if CDH doesn't pan out, much of the IT investment will turn out to be worth it. This is primarily true because medical management gets better with more sophisticated IT systems, and the industry is just starting to see some serious cost savings and health benefits in upgrading medical management.

So, where does that leave us?

Most of our clients who can are taking the approach my friend's company is: act as though CDH is likely to be a part of the future of U.S. healthcare, and leverage the system improvements so that their benefits last even if CDH goes the way of other fads, like 8-track tapes. Hedging bets is a pretty good strategy, it appears, especially if the cost of doing so is pretty small.