Nathan Holman, Vice President of Information Technology at RxBenefits, explains how the company is using data analytics, AI and machine learning to reduce the costs of pharmacy benefits in the healthcare industry in the United States. United.
What does RxBenefits offer?
RxBenefits is the industry’s first and only Pharmacy Benefit Optimizer (PBO). Most employers pay far too much for pharmaceutical benefits while enjoying suboptimal clinical management and customer service. In fact, over 60% of employers say their spending on prescription drugs is expensive and unsustainable.
Our priority is to help self-insured employers maximize the value they and their members receive from their investment in pharmacy. Our pharmacy experts work on behalf of employers, regardless of their medical carrier or PBM, to reduce their purchasing costs, eliminate unnecessary expenses, protect the health and safety of their employees, and increase employee satisfaction. Our model cuts pharmaceutical spending by more than 25% in the first year, on average, and isolates the plan against future trend drivers, like high-cost specialty drugs.
How does RxBenefits use data?
Our PBO model leverages advanced business intelligence and data modeling capabilities, which are derived from our proprietary analysis platform, RxAnalyzer, to identify risk areas and trending factors in a company’s claim data – such as chronic health conditions and high use of pharmacies – and to forecast costs the trajectory and impact of the program. By applying clinical expertise to this data, we are able to recommend hyper-targeted strategies to help the employer resolve any potential issues.
We have also started to integrate AI / machine learning and predictive analytics into a new technology platform called ONE.RxB. This platform, along with our other capabilities, will allow us to analyze a wider range of employer trends, patient demographics, prescribing patterns and more, as well as model that data, report important information and share recommendations to employers in real time – responding to a growing industry need for better access to data information.
By improving our data analysis capabilities, we will provide employers with more in-depth information on trends in employee health and the tools to make more informed decisions about their pharmacy benefits.
How important is data analytics in the pharmacy benefits industry?
Without data, an employer’s benefit plan is a black box. The pharmacy benefits industry is currently very opaque, with many employers stranded with misaligned pharmacy contract terms or a complete lack of pharmacy contract.
It is essential for employers to have transparent contractual conditions as well as full visibility into the performance of their plan in order to improve the health of their employee population at a lower cost. The application of data analysis is essential to achieve this visibility.
When data analytics is applied to drug benefits, employers can better assess their drug benefit options, gain insight into their plan’s performance and usage, uncover potential risks, and make better decisions about their drug benefit programs. benefits. They can also analyze the cost and impact on employees of any decision before it is made.
Can you give us an example?
Using information derived from our proprietary data analysis platform, RxAnalyzer, we predict the cost savings and member impact of each strategy recommended for our clients. With this knowledge, they are empowered to make the best decisions for their plan and members.
They can create compelling benefits for current and future employees, optimize their well-being, and reduce overall prescription drug costs. In fact, most employers are able to reduce their pharmaceutical spending by more than 25% on average in the first year and protect themselves against future factors of increased spending, such as increased cost and usage. specialized drugs.
What key trends are emerging in the pharmaceutical services industry?
There are several trends, some of the main ones to watch out for are:
Specialty to cut. We continue to see more and more innovative specialty drug therapies come onto the market every year, and the use of these drugs is increasing. Only 1% of prescription claims now account for about 50% to 60% of an employer’s plan costs, much of it attributable to high-cost specialty drugs. In order to mitigate the impact on employers, we are seeing an increase in the number of employers exploring specialized exclusion programs.
Unfortunately, this practice can negatively impact members, who may be left behind with no way to get their needed medications and employers still foot the bill. There are, however, alternatives to the specialty exclusion which protect both employers and their members. As specialty drugs continue to increase in both cost and use, employers must re-evaluate their pharmacy benefit strategy and bring in an independent pharmacy expert who will act in their best interests. and their members.
Increase in hospital costs: Hospitals’ revenues fell dramatically last year, and they are expected to lose another $ 122 billion this year. Meanwhile, their drug spending and use continues to rise. In fact, 70% of a hospital’s plan members take prescriptions each year, which is 25% higher than the typical commercial plan.
On top of that, 1 in 6 hospital plan members take a more expensive drug. Hospitals play a dual role as a health care provider and employer and as their employees expect rich benefits, so it is important for them to carefully design a drug plan that balances access. and cost while ensuring an optimal service experience. This includes promoting the hospital’s internal pharmacy, ensuring proper prescription and use of drugs, implementing processes to eliminate unnecessary spending on high-cost brand and specialty drugs, and access to Manufacturer Assistance Programs (MCAPs) and 340B drug price discounts, if eligible and available.
As these trends continue to emerge over the next several years, partnering with an independent advocate who regularly and proactively reviews your benefit plan can ensure employers are always receiving the best rates, discounts, and contract terms.
Do you think “virtual pharmacies” will be a standard way for people to get their prescriptions in the future?
Virtual pharmacies gained momentum during COVID-19 as patients needed more convenient healthcare offers. For example, last year Amazon announced a remote retail pharmacy solution that will accept insurance and be part of the PBM pharmacy networks, leveraging PillPack, an online pharmacy that fills prescriptions by mail.
Costco also recently announced a new online pharmacy, and many traditional “brick and mortar” drugstores now offer this option as well. It is likely that other options like this will continue to be available.
However, virtual pharmacies are just another option available to employees and members to fill their prescriptions for brand-name and generic drugs. There is often main differences between a virtual and in-person pharmacy, and the advantages of either option. Employers should help educate their members about the pros, cons and differences of each type of offer before making any changes to their drug plans.