Five Questions with Rachel Nelson

Delivering value and making Medicare easy to use: a conversation with Rachel Nelson, Vice President and General Manager of Federal Programs for Prime Therapeutics

May 13, 2020
Rachel NelsonRachel Nelson has worked within the Medicare Part D segment since it was first implemented in 2005. That’s 15 years of shaping and delivering Prime’s Medicare products and services. She provides strategic leadership for Prime’s Medicare program and manages the Medicare client engagement team to deliver the best outcomes for clients and members. She directs the development and implementation of Medicare program strategies, making sure efforts are aligned with client-specific strategic plans.

What are the biggest challenges Prime helps its Medicare clients face?

Affordability and access to medications for beneficiaries is top-of-mind for our Medicare team and clients.

  • Many ideas are proposed by various government officials, consultants and trade associations. We need to be able to project how these proposals could appear as changed regulations or guidelines – that can be a challenge.
  • Our program and clients need time to respond to regulatory changes. We proactively plan for the investments needed to meet those changes.
  • We need to deliver a competitive product that supports clients’ growth and retention. We compete with a number of national players, so our Medicare program needs to offer affordability, quality, choice and innovative products.

We will continue to focus on providing competitive offerings that support affordability and access. I also think that niche products will drive the continued evolution of our Medicare program, so I’ll be looking for strategic partnerships that help us achieve that.

What makes Prime a good Medicare partner?

Prime’s unique relationship with our clients enables us to form close partnerships that drive innovative solutions. Our dedicated Medicare experts have a deep understanding of this regulated segment, and offer solutions that support a high degree of compliance and quality of operations. We also put careful thought into leading the strategic planning for future business needs.

Can you share a story that shows how Prime made a difference in someone’s life?

Each year, we offer a comprehensive medication review (CMR) to Medicare members who have several chronic conditions. This is part of Medicare’s medication therapy management (MTM) program. During the CMR, members get to personally talk with a pharmacist. The member lists all the drugs they are taking and when. The pharmacist asks about any side effects they might be having, and works towards optimizing the member’s treatment plan.

During a recent CMR, the pharmacist noticed a potential drug-drug interaction. Two drugs the member was taking at the same time were impacting their effectiveness. And the member was reporting some uncomfortable reactions to the drugs. The pharmacist counseled the member to take one drug in the morning and one in the evening. The member was very grateful for the pharmacist’s help, and the direction to avoid this interaction by changing when she took her medications.

This drug review program provides support to members who take multiple drug therapies that cost thousands of dollars each year. CMS considers MTM the cornerstone of the Medicare Part D program. It’s easy to understand why. Through the years, we’ve had many powerful outcomes from our MTM program that have greatly improved the quality of life for members.

What keeps you working on Medicare?

I thrive on making Medicare less complicated. This makes such an impact on the lives we touch. Our Medicare members are among our most vulnerable. Many have several chronic conditions. It’s an absolute blessing to work toward improving health outcomes for these members.

Prime’s Medicare program provides value that gets passed through to our clients and ultimately members. A record 17 Prime-supported Medicare contracts earned a quality bonus payment based on the 2020 Star ratings recently released by the Centers for Medicare and Medicaid Services (CMS). These quality bonus payments will equate to hundreds of millions of dollars that our health plan clients will use to offer incremental benefits and/or reduce costs to their members. This is another example of how Prime supports making health care more affordable for Medicare members across the country.

Who are Prime’s Medicare clients?

Prime serves 20 Medicare clients in 21 states and covers more than 1.4 million Medicare lives. Prime’s Medicare program is centered around these key components:

  • Growth and retention
  • Affordability and access
  • Compliance
  • Quality management
  • Total drug management initiatives

Nationally, these are the statistics for Medicare membership¹

  • One-third of Medicare beneficiaries are functionally impaired; that means they need help on a daily basis with at last some of the activities of daily living
  • One-quarter of them have five or more chronic conditions
  • Medicare also covers the disabled, regardless of age — 15 percent are less than 65 years old
  • People are living longer — 12 percent of Medicare members are over 85
  • Only three percent live in long-term care facilities

  1. An Overview of Medicare, Feb 13, 2019. © 2020 Kaiser Family Foundation. Accessed at:

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