Reprinted from DRUG BENEFIT NEWS, biweekly news, proven cost management strategies and unique data for health plans, PBMs, pharma companies and employers.
By Lauren Flynn Kelly, Editor
February 8, 2013 Volume 14 Issue 3
As both stand-alone and insurer-owned PBMs gear up for the 2014 selling season, the big two PBMs tell DBN that they’re expanding their research into consumer behavior to offer data-driven products to existing and potential clients that will ultimately improve adherence and patient outcomes. Express Scripts Holding Co. has built a platform based on engendering healthy decisions, while CVS Caremark Corp. says it is placing “lots of focus within the organization around adherence.”
Building on the behavioral science and “consumerology” approach that was such a big part of the Express Scripts business model prior to the company’s 2012 acquisition of Medco Health Solutions, Inc., the former has adopted a new philosophy it calls Health Decision Science. “I think about it as a lens that allows us to focus on what’s causing our clients to have issues around the affordability of their benefits, as well as health and safety issues of the people that our clients are responsible for,” explains Glen Stettin, M.D., senior vice president of clinical research and new solutions.
“The fact of the matter is that there are lots of opportunities to make a decision, and bad decisions or poor decisions or uninformed decisions can really cause a problem in terms of both health and financial outcomes,” continues Stettin. Thanks to the combination of the two PBMs, Stettin says Express Scripts is able to draw on “rich, actionable data” and is applying data science to that information to explain why people are making these decisions and what to do about it. “You’ll see that come through in our portfolio of solutions, whether they’re around trying to influence people’s drug choices or around the pharmacy network and home delivery.”
Here’s how some existing products have been enhanced for 2013 based on the merger and this new Health Decision Science approach:
· ScreenRx. Built by Express Scripts on the notion that a letter to a physician or a phone call to a patient isn’t going to work for everybody, ScreenRx uses predictive modeling to identify patients who are at the highest risk of falling off their medication regimen and tailors interventions based on certain factors (DBN 5/25/12, p. 1). “We recognize that what drives nonadherence in diabetes is different than what drives nonadherence in HIV, so there are some things that are similar, but there are different nuances about what’s the right thing to do based on the particular disease,” explains Stettin. In addition to gaining pharmacy data from Medco, Express Scripts has absorbed medical data for 25 million lives from Medco’s RationalMed program (see below), which Stettin says helps inform and make the predictive models even better and more precise. Another gain from the Medco acquisition is the use of its Therapeutic Resource Centers, organized by chronic condition and staffed with pharmacists who specialize and deal only with patients who have that condition.
· RationalMed. Health plans, employers and other clients who choose this safety and health product supply Express Scripts with medical data that the company integrates with pharmacy data. The goal is to “build a longitudinal record that allows us to look for safety issues and prevent errors that were otherwise undetectable when you don’t look at the data together,” says Stettin. One goal is to have as many legacy Express Scripts clients as possible participate in RationalMed so that the PBM can expand its data set, he adds.
· Express Alliance. This also was an Express Scripts offering prior to the merger that utilizes actionable data to improve coordination of care, but now “has some pretty interesting capabilities that were from the Medco organization,” says Stettin. For instance, the additional medical data contributes to predictive models that identify patients with gaps in care and aid in the creation of a “health action plan” through which patients are assigned a nurse case manager or care manager. In addition, the company has established a hotline that hooks up the care coordinators with its specialist pharmacists.
Stettin adds that Express Scripts continues to see client interest in narrower networks and narrower drug lists in both the traditional and specialty pharmacy spaces.
During CVS Caremark’s Dec. 13 Analyst Day, President and CEO Larry Merlo alluded to “next-generation” PBM programs that infuse “behavioral economics and predictive analytics.” Anita Allemand, Pharm.D., vice president of product innovation and management, explains that the company is building on the success of its Pharmacy Advisor program to augment pharmacy data with “rich data sources.” The pilot program is aimed at identifying what separates one patient from another when it comes to adherence. While Allemand says she can’t share the details of those alternative data sources just yet, the goal is to have a “360-degree view of that patient who has an adherence issue.”
“There’s data that shows that [for some patients,] no matter what you do, you will not be adherent, and there’s some data that says for some people you don’t need to have intense outreach because they are the types of people that will always be adherent,” explains Allemand. “Those two ends of the spectrum are fairly easy to identify, but what is in the middle is what I think is pretty groundbreaking: the people that we don’t know about, and what’s the right outreach for them.” Allemand adds that tailoring outreach methods to different patients may be more effective than frequency of the intervention. “We’re learning that if you reach out to someone three times, they’re frankly frustrated and they don’t want to hear from you again,” she says. As a result, the company is focusing more on how to design the content and the message that goes out to them.
Integrated Data Has Predictive Power
She adds that using pharmacy data alone has “great predictive power because it’s very rich and it’s real time,” but it can achieve adherence rates in the 60% range, while combining that data with other sources “can really get to that predictive power in the 80s, which is fairly transformative.” Through Pharmacy Advisor, which targets specific disease states through either face-to-face or telephonic interventions, CVS Caremark knows a patient’s age, gender, plan design information, condition severity, etc. But what it would like to do, with patients’ consent, is track what kinds of questions the patients asked when they called a call center, what lifestyle challenges they may have that prevent them from picking up prescriptions, or even their purchasing patterns such as what over-the-counter products they like to buy. “Ultimately that will all be embedded in our data warehouse by member and it will add to the pharmacy data so we can then very accurately predict past behavior, which relates to how someone will behave in the future,” asserts Allemand.
Meanwhile, other solutions that have already been piloted or offered in a limited capacity are now being rolled out more broadly. They include:
· The use of electronic prior authorization (EPA) and smart prior authorization, or smart edits. “Today lots of products have prior authorization. A member might go into the pharmacy and get a hard stop and be told that that product may not be covered, so these are two things that we’re rolling out to decrease disruption,” explains Allemand. Through EPA, physicians have the ability at the point of prescribing to understand the benefit design and go through prior authorization criteria immediately so that the prescription is processed seamlessly. Meanwhile, health plan clients enrolled in smart prior authorization supply medical data so that the patient’s diagnosis is already on file to ensure an automatic approval.
· Value Formulary. This two-tier formulary approach places generics on the first tier, and selected traditional brand products on the second tier in classes where multiple generics are not available. Specialty products would also fall on the second tier. CVS Caremark estimates that plan sponsors can save almost 12% by selecting this more aggressive formulary option, and accelerate generic dispensing rates that you would typically expect to achieve in 2015 as soon as this year.
· Limited networks. CVS Caremark now has four “off-the-shelf” network offerings, ranging from a full open network to a tiered approach. The most aggressive option is the Exclusive Choice Network, which is comprised of CVS/pharmacy and Wal-Mart Stores, Inc. locations. All of these options existed before, but the Exclusive Choice Network was enhanced for 2013, to ensure adequate coverage in areas where clients such as Blues plans have a more regional presence.
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