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Real-Time Data Plays Key Role in Population Health for PBMs

Pharmacy benefit managers (PBMs) and payers are turning to real-time data in an effort to control costs, ensure medication adherence, and improve population health management.

PBMs, real-time data, and population health management

Source: Xtelligent Media

By Jennifer Bresnick

- Real-time data access is a core component of industry efforts to improve price transparency, ensure medication adherence, and support ongoing efforts to improve population health.

At an educational session held during HIMSS19, top executives from some of the nation’s largest pharmacy benefit managers (PBMs), e-prescription enablers. and payers stressed the importance of enabling intelligent analytics and seamless access to data to control spending and meet federal goals for patient empowerment.

“The amount of progress we’ve made around information management in healthcare is stunning,” said Surescripts CEO Tom Skelton, who moderated the event.  “But we have an extraordinarily long way to go.” 

“Price transparency is intimately tied to medication adherence and access to care.  We have an extraordinary challenge in front of us to ensure that all consumers get the care they deserve at an affordable price.”

Medication non-adherence is an incredibly costly population health issue, he added, sapping around $300 billion a year from the healthcare industry.

READ MORE: Data Exchange, Integration Shortfalls Stymie Population Health

 Approximately 40 percent of patients who abandon treatment do so because of the administrative challenges of securing their prescriptions, while another 10 percent simply cannot afford to pay for their therapies.

The PBM and payer industries are changing rapidly, Skelton said before introducing leaders from two organizations that have undertaken some of the most striking acquisitions in recent years: Cigna and CVS Health.

“The market is really dynamic right now,” agreed Dr. Steve Miller, Chief Medical Officer at Cigna.  The payer announced the completion of its acquisition of ExpressScripts at the end of 2018.  “A lot of things are changing in the way patients interact with the healthcare system.”

“But we view the pharmacy as a constant: it’s the gateway into the health system for most patients.  They may go to the hospital once a year, or the doctor twice a year, but they go to the pharmacy once a month.  If we make the pharmacy the front door for patient engagement, education, and care management, we can do really great things in terms of population health.”

Dr. Troyan Brennan, Executive VP and Chief Medical Officer at CVS Health, the new owners of Aetna, also said his company is focusing on engaging consumers at the pharmacy.

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“We have the advantage of our physical pharmacy locations to reach patients on a face-to-face basis,” he said.  “And we also think the pharmacy is a great place to build on relationships and control population health costs.”

Improving those experiences to safeguard patient access to therapies will be a major ongoing challenge for PBMs, payers, pharmacies, and care providers, said Miller, a kidney transplant specialist by training.

“We’ve created a really horrible experience for patients from start to finish,” he said.  “You go to see me as a doctor, and I’m sitting there with my eyes down making love to a keyboard.  I barely have time to acknowledge you, and when I finally get off the stool and come to examine you, you get a brief once-over and then it’s time to go.”

“The system is giving us the results we’ve created, and they’re not good.  We keep hearing how other industries have liberalized the use of their data to create better experiences – we have to do.  We’ve got to totally reengineer the experience so that we can achieve better outcomes and include the human touch again.”

Data is at the core of that mission, said Brennan.

READ MORE: How to Choose a Population Health Management Company

“Information is the key to empowerment.  And it’s important to remember that empowerment is a two-way street.  We are responsible for making sure you have the data you need to make decisions as a consumer, but you’re responsible for understanding it and using it to make that decision,” he said. 

“There are expectations on both sides that we have to meet, and we haven’t been providing enough data – or the right data – to help everyone with their obligations.”

Miller, Brennan, and Skelton all cautioned against indiscriminately dumping data into the laps of any stakeholders, noting that alert fatigue isn’t just a provider issue. 

“Most doctors have experienced getting too much data that isn’t the data they wanted, and the same thing is true for patients,” said Miller.  “Curated data is the goal.  We have to look at human factors and start to understand what’s actually useful for supporting better decisions, whether you’re a prescriber or a patient.”

“Patients really want to know their choices when it comes to medications, and they want to know the prices associated with each of those options.  Giving them the information they need in the way they want it delivered is really hard, but it’s possible if we innovate and collaborate.”

Miller shared that his company can geofence physician offices, allowing Cigna to send alerts to participating patients as soon as they cress the threshold of the clinic. 

“If you turn on your locator, we can send your smartphone a list of questions that you should consider asking about your medications.  Is there a generic alternative?  What will it cost?  That’s giving patients data they want when they want it and how they want it.”

Skelton agreed that data has to be timely and immediately useful for supporting informed decisions.

“Everyone has to be able to act on the information,” he said.  “The issue is actionable intelligence, not just more data thrown at the problem.”

“We know that the right data, in real-time, can influence decision-making.  Surescripts has found that when a provider is shown an alternative medication that doesn’t require a prior authorization (PA), they will choose that drug 28 percent of the time.  That produces 158,000 person-hours per month in savings.  That’s huge for providers.”

Real-time access to pricing and prior authorization information can also support improved medication adherence, added Brennan.

“We need to make sure patients get on their medication and stay on it.  Data transparency and pricing transparency are only going to help that.  If we let people know there’s going to be a PA or that there’s a cheaper alternative, they can take action based on that information.”

“That means the patient is more likely to pick up their medication, and they’re probably going to take it.  That drives savings throughout the care process and can contribute to the better outcomes we’re all looking for.”

Miller agreed that data-driven tools such as real-time benefit checks can impact costs and behavioral patterns.  “If a provider can make the right decision the first time, that speeds up care for the patient and prevents all of the costs involved in subsequent attempts to solve the problem,” he said.

“We have such a complex pharmacy system in this country.  There are dozens of different formularies, and providers can’t remember what each payer says about particular dugs.  Computers can, so let’s use them.”

“We talk about the savings tied to improving adherence – that’s $300 billion.  But if we could get patients on products that their payers cover, that’s worth another $60 billion.  And if we can deliver those therapies through channels that consumers want to make sure they have a continuous supply, that could be another $40 billion.”

“That’s all down to getting the right information at the right time to the right people.  When we talk about how to use data intelligently, real-time benefits and electronic prior authorizations are incredibly important.”

Stakeholders across the care continuum will need to collaborate on creating and adopting the tools to bring these data assets to the point of care, said Skelton.

“Adoption of these strategies tends to take longer than people would like,” he said.  “It took ten years to get to 50 percent market penetration for electronic prescribing, for example.  We might be moving a little more quickly now that the comfort level has increased, but it’s still a challenge to educate and engage the right stakeholders.”

Adoption on the electronic health record vendor side is also a challenge, pointed out Miller. 

“There are so many legacy systems out there, and many of them don’t have the mechanisms in place to display this data in an actionable way,” he said.

“I don’t blame providers for not wanting to let go of something they’ve invested in, but it’s not much good to be able to give people data if they don’t have an EHR that can display it in a meaningful way.  You can’t have transparency if your tools aren’t programmed for it.”

Brennan expressed confidence, however, that these challenges will be overcome.

“It’s hard to look at our aging populations and how much they’re paying out-of-pocket for their care without being convinced that a major shift to risk-based population health is on the horizon,” Brennan said.

“I’m fairly certain that by 2030, there is going to be a substantial movement towards risk that will necessitate the adoption of data-driven tools and analytics.  The financial structures will increase the imperative to put people on the lowest cost medications and ensure that people will take those drugs.”

“Information has to flow freely.  Our ability to understand ways in which we need to intervene for patients is dependent on having as much information on them as possible.  I believe we’ll get to the point where the incentives for doing that will align and it will be second nature to providers to use this data to make more cost-effective decisions for everyone.”

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