Three minutes with Prime’s Nathan Downhour

Nathan Downhour, senior vice president of health care services, joined Prime in 2021, bringing nearly two decades of specialty pharmacy experience. He currently oversees all clinical and specialty programs, trend management and strategic partnerships. In addition, he was executive sponsor of the Prime and Magellan Rx pre-close integration efforts with a goal to redefine the integration between pharmacy and medical benefit management to create a new, differentiated model among pharmacy benefit managers (PBMs).

What’s something about Prime that more people should know? 
Delivery of specialty care to members is deeply personal to Prime. Some of us have been treated with specialty medications while many others have been a caregiver or relative or friend to someone who needs specialty medications. They often share stories about their experiences navigating this complicated path.

Those personal experiences affect us in our business decision-making. It’s part of what drives the North Star here at Prime — to be a people-centered partner, improving the experience for those we serve and transforming the health care landscape.

How is Prime helping clients and members benefit from treatment advances while managing costs?
The number one question I hear from our clients is “What is Prime doing to control specialty spend?” And they mean total specialty spend, across both pharmacy and medical benefits. We do that in many ways, but there are a few I’d highlight.

HighTouchRx® looks at both medical and pharmacy claims using integrated data and predictive modeling. It identifies big savings opportunities on high-cost medications. In a case study for our vial optimization category, one of our clients generated $500,000 in annual savings, or $0.03 PMPM.

Our NetResults formulary and UM programs deliver $10 to $25 PMPM savings and help optimize care.

GuidedHealth®, which offers a range of tools to help members and prescribers with medication regimens, can save up to $2 PMPM; it improves drug utilization, adherence and controls opioid use. Each of these programs also contributes to better clinical outcomes for members. Now, Magellan Rx gives us excellent new capabilities for managing medical specialty spend.

How does Prime’s approach to physicians differ from the big three PBMs?
It’s quite different. We recognize the clinical value of the integrated pharmacy model.

Dispensing specialty medications to patients in the same ecosystem can improve physician insights into patient adherence and toxicity management while reducing waste. Our IntegratedRx program does just that. It improves overall communication and coordination within the health care team. Others in the market have cut providers out of the equation by driving specialty prescriptions to their owned pharmacies, so physician and hospital-based specialty pharmacies aren’t able to provide these services directly to their patients.

Prime also has unique access to both medical and pharmacy claims due to our relationship with our Blue Plan clients. We use data mining and artificial intelligence to serve up actionable opportunities for providers to help improve the outcomes of their patients.

What’s next for our integration with physicians and how does that impact coordinated care?
We’ve heard from some of our Blue Plan clients that they don’t intend to pursue a robust physician employment strategy.

That means we need to partner with providers in other ways to create alignment. Coordinated care can be a broad topic. In the context of specialty pharmacy, it starts with enabling physician practices and health system-based specialty pharmacies to dispense specialty medications to the patients they serve in their clinics. We call this the integrated care model and it’s a core component of Prime’s specialty dispensing strategy.

If we’re going to improve affordability, patient experiences, and clinical outcomes in the specialty space we need to engage providers in our network strategy. But that needs to go well beyond dispensing. What’s next in our integration journey with physicians is an alignment model where we look to engage providers in sharing risk and sharing data. We need them to have some skin in the game so we can work collectively to drive results on the quadruple aim: lower costs, improved outcomes, great patient service and strong engagement with caregivers.

What trends do you foresee for the future in our industry or your area of responsibility?  
Specialty pharmacy is evolving very quickly! The landscape will look much different over the next few years. We know our strategy must address the current market, but we need to be agile to rapidly respond to new innovations and market events, which we will continue to see more.

For trends, we see cell and gene therapies that generate high one-time expenses up to $3 million per therapy. That demands creative ways to measure effectiveness and handle payments.

The rapidly changing environment for co-pay, accumulator, and specialty medication carve-out programs means member benefits and service programs may need to evolve in response.

The increase in biosimilars creates opportunities for cost optimization in the near term.

Everyone in the health care space will need to be extremely nimble both to react to market events and to proactively innovate.