The Problem

Increased Complexity in Healthcare

In any given month, 48% of Americans take a prescription drug and 11% take five or more. Prescription use in the U.S. is increasing as the number of medication therapies rises, the population ages, and chronic diseases become more prevalent. The pervasive and rising use of medications is increasing the complexity of medication management for healthcare organizations and making adherence to medication regimens more difficult for patients.

Imprecise Use of Medication → ADEs

Given the extensive and increasing use of medication, the potential for adverse drug events (ADEs) and for patient medication non-adherence presents a critical patient safety and public health challenge. The Alliance for Human Research Protection reports that 2.5 to 4 million serious, disabling or fatal ADEs occur on an annual basis. In 2009, the New England Healthcare Institute estimated that medication non-adherence is responsible for $290 billion in otherwise avoidable medical spending annually in the U.S. alone. ADEs contribute an additional $3.5 billion to healthcare costs on a yearly basis, according to the Institute of Medicine.

Need for Personalization, Medication Risk Mitigation™

Research suggests that a majority of ADEs are preventable. The current tools for medication safety produce inconsistent results and are widely viewed as ineffective. Personalized and precision-based methods are absent in prevailing trial-and-error approaches to medication selection. A provider’s ability to deliver optimal patient care is limited by insufficient data at the point of prescribing.

Industry Dynamics

The shift to value-based healthcare has increasingly placed healthcare organizations at financial risk related to imprecise medication usage, providing new incentives to reduce costs and improve quality. Rising healthcare costs and strained budgets have driven government agencies to expand the role of value-based capitated payment models, shifting incentives toward quality and value. In these at-risk models, providers are incentivized to deliver efficient care: lowering costs and improving care quality, safety, and the patient experience. As a result of this transition, data on patient-specific disease states and co-morbidities, clinical and quality outcomes, resource utilization and individualized patient information have become increasingly relevant to healthcare delivery. Accurate coding of medical procedures and diagnoses is increasingly complex and is required for proper reimbursement and regulatory compliance. In at-risk value-based care models, coding-based risk scoring is a significant factor in determining premium reimbursement rates and payments in many government-sponsored healthcare programs. In addition, government agencies regularly audit healthcare organizations to validate coding practices.


 

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