Key research takeaway: A recent Prime Therapeutics (Prime) study, presented at the Academy of Managed Care Pharmacy (AMCP) annual meeting, examined how often requests for high-cost therapies were referred to case management within an enhanced utilization management program and identified which patients might benefit most from additional support.  

What Prime has to say: “Patients receiving high-cost therapies often have complex clinical needs and can therefore stand to benefit most substantially from targeted case management interventions,” said Emily Divona, PharmD, M.S., co-author of the study and clinical account director for specialty clinical strategy at Prime. “In settings where resources are limited, identification of patient populations who are most likely to experience meaningful impact from case management services ensures optimal allocation of finite resources.” 

“Embedding case management referral within an enhanced utilization management program enables earlier identification of high-risk patients and allows them to be connected to supportive case management services sooner, improving access to resources and support throughout their treatment journey,” added Erin Ventura, PharmD, co-author of the study and clinical account manager for specialty clinical strategy at Prime.  

Further analysis: The study found that about 7% of requests were referred to case management, most often due to identification of a recent hospital stay or emergency department visit. 

Implications: Referrals were more common for certain complex therapies. Adjusting referral criteria could improve patient outcomes but may also require proportional adjustment to case management staff to maintain high-quality care and support. 

Prime’s approach: Prime supports case management for patients on high cost therapies through programs such as its Care Specialists and condition specific specialty management programs, which provide nurse  and pharmacist led case management, adherence support and coordination of care. 

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