Care Management

The primary focus of CVS Caremark is on pharmacy cost management, but we also explore and invest in new ways to improve care and reduce costs more broadly. Expanding the care management portfolio helps support clients and plan members who face the challenges of costly chronic, rare and complex conditions.

Paying close attention to what clients say about the challenges they face, we combine those insights with the data collected through our services.

These insights and knowledge provide a foundation for the solutions we develop for and offer to clients. They are designed to complement and amplify a client’s existing care management programs. And, because each plan is unique, these solutions are designed to be configurable. Working with clients, we identify gaps and opportunities and develop solutions to fit their needs and desired results.

Data-driven individualized care

Members receive more personalized care and guidance using our deep data and analytic expertise. Care for each member is tied to the complexity of care, communication preferences and risk profile. A member-level view is developed using pharmacy and behavioral data from our services and operations.

The member-level view is supported by connected technology, including an electronic health record system that enables a continuum of care. To achieve the greatest efficacy, algorithms identify the best type of intervention for each individual and the right channel and time to deliver the message. Ongoing review of outcomes leads to optimizing the system for increasingly better results.

Managing chronic conditions

Chronic conditions, one of the most consistent challenges members face, affect six out of 10 adults and account for 90 percenthttps://www.cdc.gov/chronicdisease/about/costs/index.htm of annual health care spending in the United States. Forty percent of Americans have two or more chronic conditions, further complicating care management.https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm

Prescription therapy is key to managing many of these conditions, but successful management can require much more: lifestyle changes, tests and screenings, lab work and dietary changes. Many patients struggle to adhere to recommended regimens. Results can lead to poor outcomes and potentially avoidable, costly adverse events. It’s estimated that 30 percent of emergency visits and 40 percent of hospital readmissions are avoidable.Modern Healthcare. pharmaceutical-journal.com, 2019.

Transform Diabetes Care

An estimated 34 million Americans have diabetes. Comorbidities are common and make management even more complicated for members. To support these members, we designed a comprehensive solution to address members with diabetes. This customized experience identifies and prioritizes tailored interventions and 80% of members with A1C >9 saw improvement in their A1CCVS Health Analytics, 2022. Data from 2021. Actual results may vary. 1.) Two approaches were employed to derive a rate card that can tie closure of care gaps to Medical Cost Savings (MCS): (A) Estimated the value of closing a care gap statistically based on its observed impact on improving A1C and used values from medical literature to estimate how improvement in A1C translates to dollars of MCS; and (B) Used literature to estimate the value of closing care gaps that aren’t expected to directly drive improvements in A1C outcomes. Relative rates were then scaled such that the rate card times incremental gaps closed is equal to a conservative estimate of MCS for enrolled members. Transform Diabetes Care is more than a baseline diabetes offering, with 3:1 return on investment.** Transform Diabetes Care is more than a baseline diabetes offering.

Pharmacy Advisor

Pharmacy Advisor provides targeted adherence support to members, which can make a difference with improving outcomes and lowering overall costs. The program uses robust predictive analytics to identify members in need of support and provides one-on-one connections. Incorporating prescription claims, demographic data, engagement history and member feedback, predictive algorithms identify and activate the right interventions at the right time through the right channel.

Health Advisor

Health Advisor helps make it easier for members with chronic conditions to make better care decisions that will improve outcomes and lower costs. The program provides highly individualized support, based on ongoing review and analysis of medical claims, lab and pharmacy data, demographic data, plan benefits and other data sources. This real-time view of the member powers the analytic engine to identify and prioritize individualized communications known as next best actions.

Stages of a patient's journey

Site of care recommendations for diagnostics and procedures	Manage acute events	Reduce ER utilization	Health screenings and vaccinations	Medication optimization

	Site of care recommendations for diagnostics and procedures
	Manage acute events
	Reduce ER utilization
	Health screenings and vaccinations
	Medication optimization

Pharmacists are alerted when a member is at higher risk of a worsening condition. Pharmacists proactively engage with such members with the goal of prompting meaningful face-to-face conversations that explore the member’s entire situation to uncover adherence obstacles and follow up on therapy drop-offs. Then robust data is used at key points in the member’s experience to identify and activate messaging and connections using the right channel at the right time. Interventions are ongoing and pharmacists use notes from previous conversations to follow up and influence member behavior.

Health Advisor CVS Health Analytics, 2019. Based on a randomized controlled trial. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. Client-specific modeling available upon request.

Rare and Complex Nurse Care Management

Rare conditions, such as rheumatoid arthritis, multiple sclerosis, and Crohn’s disease, affect only 1 to 3 percent of members, but these individuals account for a disproportionate share of overall care costs. While the specialty medications used to treat rare conditions are costly, a substantial portion of the costs incurred reflect medical spend — for hospitalizations, ER visits and outpatient care.

These patients present a particular challenge to payors. Rare conditions are chronic and progressive. Comorbidities are common. Care regimens can be complicated — many of these patients see several specialists, manage multiple prescription therapies, and may be attempting to make recommended lifestyle or behavioral changes to better control their condition.

Rare and complex conditions are spiking your health care costsCVS Health Analytics, 2021. Data source is Accordant Data Warehouse, 2019 Client Program Value Outcomes. All data sharing complies with applicable law, our information firewall and any applicable contractual limitations. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. Client-specific modeling available upon request.

AccordantCare Rare

AccordantCare Rare has been proven to help reduce medical spend and improve quality of life for members with rare conditions by helping them avoid complications, costly ER visits and hospitalizations. It is a comprehensive, whole-person care management solution that focuses on high-touch and advanced care coordination. While supporting over 100,000 patients a year, we customize our approach to meet each population’s specific needs, coordinating care across the continuum, and ensuring members have continuous, wrap-around support.

Proven ResultsCVS Health Analytics, 2020. Based on Accordant client evaluations conducted in Q1‐Q2 2019, and Accordant Opportunity Analysis savings assumptions.

AccordantCare Rare has been providing support and care for patients with rare conditions for 25 years and has earned the National Committee for Quality Assurance (NCQA) accreditation in Population Health and Case Management.

AccordantCare Oncology

AccordantCare Oncology focuses on a significant contributor to cancer care costs by helping to improve clinical outcomes and control costs for members who are in active chemotherapy treatment and on select higher toxicity chemotherapy agents. Chemotherapy and its range of potential side effects can be particularly challenging for patients. AccordantCare Oncology proactively helps to mitigate risks to prevent or manage side effects. 

AccordantCare Oncology helps reduce ER use, hospitalizations

Quality Optimizer: Care Management Targeting Quality Measures

The Centers for Medicare and Medicaid Services (CMS) use rating systems to help consumers compare health services on quality and service. These systems provide benchmarks for plans to improve their performance and can strongly affect a plan’s overall success. Higher ratings relate to better service and quality of care while also deterring risk of sanctions or CMS penalties. A plan with a star rating of 4 or above, on a 5-star scale, also receives a quality bonus payment (QBP).https://www.cms.gov/medicarehealth-plansmedicareadvtgspecratestatsratebooks-and-supporting-data/2021

Star ratings, developed by CMS, and Healthcare Effectiveness Data and Information Set (HEDIS) measures, developed by NCQA, focus on quality determinants. These could include the management of chronic conditions; preventive care such as screenings, tests and vaccines as well as member experience and satisfaction.

Our care management solutions

influence 8 clinical quality metrics that account for 24% of the Part C star ratingCenters for Medicare & Medicaid Services Medicare 2020 Part C & D Star Rating Technical Notes. 36% of the Part D star ratingCenters for Medicare & Medicaid Services Medicare 2020 Part C & D Star Rating Technical Notes.

deliver results +2% annual increase in adherenceCVS Health Analytics, 2020. Adherence results are based on CVS Caremark data, measuring optimal adherence to Oral Antidiabetic, RAS Antagonists, and Statin Medications. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. Client‐specific modeling available upon request. 2-5%guaranteed improvement in Part C star measures*** 5%increase in breast cancer screenings, diabetes eye exams, flu shotsCVS Health Enterprise Analytics, 2020.

24% of the Part C star rating12

36% of the Part D star rating13

CVS Health care management programs offer plans a configurable collection of services, initiatives and tools that can drive performance on quality measures. Our teams work with clients to learn about their goals and population and together can select the appropriate services to help reach performance goals, supporting their Medicare members whether they use CVS Health locations or not.

Want to learn more about how we can help lower costs and manage member care? Ask Us