New tool brings more savings opportunities into focus

Our clients count on us for information and tools to help them provide sustainable access to quality health care. Prime’s work with integrated medical and pharmacy data has made a difference as it allows us to publish foundational research on condition-specific total cost of care. This research informs our product development and benefit designs.

And Prime is committed to ongoing innovation.

Last year, our work with Specialty Monitor, now known as Insights+ (powered by Artemetrx), began to give us access to health plan-specific data in an easily accessible format. It’s a whole new level of integrated information at our fingertips for the commercial business. Prime had integrated data experience and found a fit in the Insights+ platform. This gave us a solution to offer our Blue Plan clients in a way that could keep pace with industry changes. Insights+ helps us advise our clients on how to make smarter business decisions.

Contributing factors to health care upheaval

In science, we’ve seen tremendous advances in gene therapy, CAR-T and personalized and precision medicine. More therapies have been given breakthrough and orphan status by the FDA, and at the same time the effectiveness of new drugs is not always clear. Hundreds of drugs fill the pipeline. The market expects many of them to be priced at tens of thousands of dollars a year. Several are expected to be priced at hundreds of thousands a year (and possibly more!).

Specialty reached 50 percent of total drug spend (medical and pharmacy) in 2018. That number is heading to 60 percent by the year 2021.

Drug spend is approaching 30 percent of total health care costs, and more of those costs are spread across both medical and pharmacy benefits.

For many conditions, high cost drugs drive much of the total cost of care. Autoimmune is the highest cost drug category. Here, drugs make up 72 percent of total cost of care.

The current financial model is being pulled in many different directions. Industry dynamics do not suggest a clear path forward, which can be unnerving.

Insights+ keeps Prime’s focus on member-first, total drug management solutions.

Here’s a sample of what we can do together

Prime’s legacy of assessing integrated medical and pharmacy data matched up perfectly with the analytics platform of Insights+. The result is an innovative, interactive web-based tool with faster, easier access to clear data on:

• Trend and spend
• Site of care management
• Clinical management
• Reimbursement management
• Plan design

For example, in the area of drug trend, we know that medical drugs are 25 percent of total drug spend (and 40 percent of specialty drug spend). Insights+ can tell us whether a plan’s medical drug trend is greater than its pharmacy trend. If so, then a Prime analyst can show a health plan how focusing efforts on lowering costs for specialty drugs under the medical benefit (e.g., autoimmune) will have greatest impact on lowering trend.

For site of care, we know that a member getting an infusion drug at a hospital incurs costs that are often 200-500 percent more than a member getting an infusion drug at a doctor’s office. Insights+ can provide a plan-specific comparison of drug administration costs by channel, including outpatient hospital, doctors’ offices and home infusion. Then a Prime analyst can help identify the profile of a member (new starts) that can be considered as an opportunity to move to a lower cost channel with the least disruption (which drugs and which conditions).

In the reimbursement area, we know that physician office reimbursement rates vary widely across the country. It’s often a percentage of the wholesale acquisition cost (WAC) or list price of the drug. For specialty drugs that run into the hundreds of thousands of dollars, this may cause unreasonable profit taking. Insights+ can identify physician office reimbursement rates by drug and by state and identify outliers. Prime analysts can provide recommendations for new reimbursement guidelines. Often, disincentives can be written in to policies and contracts if high cost drugs are used.

Health plans can get more savings opportunities, faster

Insights+ gives our Blue Plans an option to access data to replace previously manual processes. Prime leads the industry in providing clients the ability to truly use their integrated data to make smarter business decisions. We don’t just have the data, we know what to do with it. We understand how to look at total drug spend across medical and pharmacy. We know how drug spend impacts total cost of care.

Insights+ provides a simplified view of complex data. It helps manage the financial side and improve the outcomes side. It finds trends over time that might not be evident from a book of business perspective. It gives us a new window into opportunities for case management to reduce spend of high-cost members and optimize outcomes for people with challenging conditions. From a quality perspective, it identifies inappropriate use and finds opportunities to improve care.

Something that every health plan needs today. An edge.