McKesson InterQual 2015 sets new standard for peer-reviewed evidence-based clinical content

McKesson Health Solutions unveiled InterQual 2015, the latest edition of the company’s flagship decision support solution. This release introduces 55 new and enhanced evidence-based clinical content areas and extensive updates—including the industry’s first admissions criteria to include comorbidities, criteria for 29 new specialty drugs and 33 new molecular diagnostic tests plus support for gene panels, and much more—ensuring payers and providers have the latest guidance reflecting the most current, best evidence for improved decisions across the continuum of care.

“There is tremendous variation in care and cost in healthcare, and the shift to value-based models is increasing the focus on cost and outcomes,” said Jackie Mitus, MD, Senior Vice President and General Manager of Decision Management for McKesson Health Solutions. “With InterQual 2015, we’re helping ensure payers and providers have the evidence-based content they need for the challenges they face today—such as the increase in patients with comorbidities—so they can ensure the most appropriate decisions and highest quality care.”

Medically complex patients are on the rise, with more than 141 million Americans now suffering from comorbid conditions. Over 40% of heart failure patients have five or more chronic conditions. COPD is another leading cause of adult hospitalizations, where comorbidities are a common or contributing cause. Moreover, 29% of those with a medical disorder have a comorbid mental health condition. McKesson first addressed comorbidities in 1978 as part of InterQual’s Continued Stay Criteria and has continued to enhance comorbidities criteria since. InterQual 2015 introduces comorbidity assessments in the admissions criteria, starting with Heart Failure and COPD. And of particular importance are the behavioral health comorbids now included. Now medically complex patients who should be admitted can be more effectively evaluated at the primary review level. InterQual 2015’s Acute Adult Level of Care Criteria helps promote care quality and minimize the administrative delays, costs, and inefficiencies of medical director reviews for patients who should be admitted but might not meet criteria for the primary condition alone.

Spending on specialty pharmaceuticals is expected to hit 50% of drug costs for commercially insured lives by 2018, up from just 20% in 2009. With the addition of 29 new specialty drugs, including new and costly orals, InterQual 2015’s Specialty Rx Criteria now covers 88% of the top 25 medical benefit specialty drugs. This gives payers and providers an objective resource that supports medically appropriate decisions regarding the use of drugs such as Harvoni, Sovaldi, and Olysio. These new orals cost between $66,000 and $94,000 for a 12-week hepatitis C regimen and $132,000 to $188,000 for a 24-week treatment plan.

Costly panel tests are becoming a prominent part of a $4.5 billion molecular diagnostics market expected to grow 8.7% annually through 2020. Among those most used is a Multi-Gene Panel for Inherited Breast Cancer, one of the 33 new tests covered in InterQual 2015’s Molecular Diagnostics (MDx) Criteria update. Now care managers can rely on InterQual to provide reliable guidance based on the medical evidence and clinical utility associated with these increasingly popular panel tests.

Health reform, value-based reimbursement, and consumerization are shifting healthcare delivery from inpatient to outpatient settings that favor high-quality services in convenient locations. Responding to this shift, InterQual 2015’s Home Care Criteria has been transformed into a question and answer format, which helps care managers conduct reviews faster. For example, reviewers can conduct a single review with all skilled disciplines, instead of having to use a separate view for each service requested. And they can view which service or set of services the medical evidence recommends after each medical review.

These are just some of the many new areas, enhanced content, and usability improvements that highlight this year’s InterQual release. Other usability enhancements include improvements to InterQual’s CareEnhance Review Manager and InterQual Mobile for iOS and Android, both of which foster efficient medical reviews using InterQual criteria.

InterQual 2015’s evidence-based criteria help improve clinical decision-making across the continuum of care. The InterQual clinical development team synthesizes the most current, best evidence into a fully referenced decision support tool that is reviewed and updated annually. InterQual’s development process, honed over nearly 40 years, is founded on rigorous review of the literature, and includes extensive peer review by practicing clinical experts across the United States.

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CareEnhance Review Manager, evidence-based content, InterQual 2015, McKesson


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