Pharmacy Management in a Post-Affordable Care Act Market

Ellyn Hosch, CIO, Prime Therapeutics

The majority of my career has been in health care— an industry known to be miles behind the curve when it comes to technological innovation, but where I see the greatest opportunity to drive change and improve results.

It’s a rare moment in any career when your direct work is part of something extremely important for the industry, perhaps even a society. When that does happen, it’s exhilarating to know that what you’re doing is vital to the future. At this point in my career, that is precisely where I find myself, leading IT efforts in an organization involved in the implementation of the drastically-needed and ever-changing world of health care in the U.S.

At its core, health care reform was introduced as a means to improve access, cost and quality. Technology has already played a key role in the implementation of the public health exchanges and in navigating a very broken system. However, it’s important to remember that we cannot correct the system overnight. Things are moving in the right direction, but it will require much more work.

It will take collaboration and connectivity across the board. All players in the health care system need to work together to improve and revise their pieces of the puzzle. As a pharmacy benefit manager with a unique, integrated model, Prime Therapeutics (Prime) is in a position to enhance programs using technology that integrates data to truly impact health. We are responsible for helping more than 25 million people get the medicine they need to feel better and live well, so it’s imperative that our systems–which process prescription claims, dispense medicines, and much more–seamlessly support our operation.

“All players in the health care system need to work together to improve and revise their pieces of the puzzle”

As the most sweeping U.S. health reform in more than 50 years alters the industry, I believe technology must play a central role in reshaping the system for the future.

Enabling Better Outcomes and Lower Costs through Integration

To get there, we’ve developed an analytics platform that uses integrated data to make the whole health care system smarter. GuidedHealth helps find and address potential health-and cost-related issues before they become major problems for both patients and health care payers.

The platform applies evidence-based clinical rules to medical and pharmacy claims data to generate actionable drug therapy opportunities. The information is then summarized in a Health Guide at the individual patient level and distributed to doctors, patients and health plan care management staff through a number of channels–including electronic provider portals.

We’re currently collaborating directly with our Blue Plan clients and vendors to deliver these reports to health care professionals enrolled in a pay-for-performance network. Web-based portals prompt doctors to work with patients regarding specific drug therapy management opportunities.

Examples include but are not limited to the following:

• Identifying opportunities to manage pharmacy underutilization. This would include the identification of high-risk patients based on specific chronic conditions that are either not adhering to prescribed drug therapy or need additional drug therapy. The drug therapy opportunity would not only alert the doctor to the adherence issue, it would provide a historical set of data such as the proportion of days covered along with claim history for an individual patient.

• Identifying patients with a history of overutilization. This would include utilization patterns that point to potential misuse or abuse of controlled substances, patterns of off-label indications, use of multiple medications and/or excessive duration of therapy.

• Identifying patients with potential safety concerns such as direct medical contraindications to drug therapy.

• Identifying opportunities for patients to save money by providing generic and/or preferred drug alternatives.

In addition to providing intelligent, timely guidance when and where it’s needed for patients and doctors, GuidedHealth offers tremendous savings opportunities to health plan sponsors. This platform has the potential to save 60 cents to $1 per member per month–a huge opportunity when we are only continuing to see health care costs rise.

This integrated solution is picking up steam. Our clients have seen its value and now more than 600 million medical and pharmacy claims are funneled through GuidedHealth each quarter resulting in the identification of nearly 250,000 unique drug therapy opportunities in the same time frame.

Though those numbers are impressive, what we are most excited about is the opportunity to enhance the delivery of critical drug therapy information at the point of care in near real-time— something we believe is imperative to improving outcomes and lowering costs. Giving doctors a holistic view of their patients’ drug therapy and medical information while still engaged with them during an office visit saves time, cost and inconvenience for the doctor, the pharmacy, and the health plan, but more importantly, for the patients themselves.

This sharing of data helps improve care coordination, which will help result in better patient care. And ultimately, that is what all of us in the health care industry is aiming for.

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