Utilization Management: Interview with Amber Casteel and Sheila Arquette

Amber Casteel, Manager of BlueCare Authorization Services for Blue Cross Blue Shield Tennessee, and Sheila Arquette, RPH, Executive Director for the National Association of Specialty Pharmacy, will partake in a panel discussion at this year’s 10th Annual Managed Markets and Account Management Strategies Conference. The panel, “Evaluating Current Utilization Management Strategies,” will cover everything from the impact of common utilization trends of manufacturers to analytics that ensure the best utilization of care strategies. Read below for a preview of what will be covered at the program!

Can you please describe your job function and responsibilities? How did you get to this point in your career?

Amber Casteel: I currently oversee a Utilization Management (UM) program consisting of more than 100 clinical and nonclinical staff for a Tennessee Medicaid health plan covering 650,000 lives. I monitor the overall UM program for effectiveness while looking for ways to increase efficiency. I’m responsible for ensuring the UM program meets all NCQA and contractual requirements and that members receive medically necessary and cost-effective care within their Medicaid benefit structure. I also provide internal and external customer education, consultation and problem resolution. I worked as a nurse in the hospital setting for several years before learning about managed care nursing. I went to work at a health plan in order to have “normal hours.” Little did I know, the ability to impact lives is far more reaching in a health plan setting than the hospital setting. I began as a prior authorization nurse and worked my way up in various roles that provided me experience in utilization management, transition of care and population health management for a variety of Commercial, Medicaid and CHIP plans. This diverse experience provided me with the opportunity to become the senior manager for our Medicaid utilization management program.

Sheila Arquette: As the Executive Director for NASP I am responsible for the direction, management and oversight of the entire association. We are focused on fostering education, certification, advocacy and connectivity amongst our multi-stakeholder membership to improve clinical outcomes, cost efficacy and patient satisfaction. My responsibilities include providing the strategic vision and operational infrastructure required to ensure the seamless operation of the association. Previously, I was an active and engaged NASP volunteer and, in 2016, received the NASP Distinguished Service Award and was elected to the BOD. When Rebecca Shanahan became NASP President in 2017, she quickly recognized the need to bring on additional staff to support all the great things she had planned. She valued my previous health plan/PBM/SP experience, and I was offered the position.

What are some common utilization management strategies? Why are these UM strategies popular right now?

AC: Common strategies include prior authorization (PA) review, retrospective claims reviews and utilizing experienced vendors for more specialty type prior authorization reviews. Some of the less common strategies can include provider network strategies, such as gold carded providers or a preferred provider network, to decrease PA requirements while increasing quality measures and/or outcome-based payment initiatives. Ways to conduct UM can vary from medical necessity reviews received via phone, fax and web to claims data mining. The avenues in which to conduct UM are evolving as technology advances. The cost of healthcare continues to greatly increase across the U.S. despite efforts to reduce costs and utilization. UM is a great way to ensure that all members receive the highest possible levels of cost-effective health care, thereby lowering overall healthcare cost. Also, through the evaluation of each member’s needs, UM is able to offer the most appropriate programs to meet physical, behavioral health (BH) and long-term needs ranging from preventive initiatives to intensive case management.

SA: Prior authorization, step therapy and quantity restrictions are common UM strategies. Employers, prescribers, patients and payers are all looking for assurances that medications are being used appropriately. These strategies help to ensure the right patient is receiving the right drug at the right time.

How does prior authorization fit into utilization management?

AC: Prior authorization requirements reduce fraud, waste and abuse while ensuring the services being performed are medically necessary. A prior authorization review focuses on the clinical assessment of the member’s physical health, BH needs and the practitioner’s plan of treatment, including the appropriateness of care, procedure and setting. This allows the member and practitioner an opportunity to review alternative methods of treatment. The reviews are performed on an individualized basis for each member. Elements such as the member’s age, co-morbidities, complications, progress with treatment, psychosocial situation and home environment are considered.

SA: Prior authorization is the mainstay of utilization management.

Can you describe some of the areas that excite you about the future of utilization management?

AC: I’m excited about new approaches to utilization management, such as value-based payment initiatives and ways to utilize preferred provider networks. Ways to enhance the UM process with new technologies, such as web-based technology, including click to chat and electronic health records, and data mining excited me as well.

SA: Personalized and precision medicine and the need to tailor prior authorization for an individual patient and disease state will provide opportunity to not only ensure the medication prescribed is appropriate for the patient based on their genetic make-up, but also will provide clinical opportunities for UM staff to help prescribers select the most clinically appropriate and cost-effective alternatives if necessary. It will also demonstrate the value the pharmacists and pharmacy support staff bring to the health care delivery system.

What is something you hope attendees walk away from the panel knowing? What do you believe is the most important take-away?

AC: I hope attendees learn that there are other approaches to UM than the traditional prior authorization process and, therefore, use data and new technologies to drive UM processes instead of doing UM “the same way we have always done.”

SA: I hope attendees will walk away knowing the reason payers utilize these strategies and how all stakeholders can work together to ensure the process has value and is not just serving as a barrier to patients receiving care. We need to work together to refine the process to ensure it is delivering value and not just an onerous process that serves to add to the total cost of care without a true ROI.

Join us at the 10th Annual Managed Markets and Account Management Strategies Conference on September 12-13 in San Antonio, TX to learn more about utilization management and prior authorization. Download the full agenda today to learn about other topics and sessions the program will cover and don’t forget to reserve your spot!