Prime highlights innovative strategies for payers and patients at PBMI National Conference
Prime showcases how leveraging data, technology and intelligence contains costs and improves the patient experience
March 19, 2020
Finding Bad Actors: Combatting Drug Fraud, Waste and Abuse Is More Than A “One Act Play”
Speaker: Anne Mack, Senior Director, Pharmacy Audit & Fraud, Waste and Abuse
Health care fraud continues going strong into the new decade. In 2020, there has been half a billion dollars in health care fraud charges due to nationwide fraudulent activity. “Bad actors” are looking at every step in the pharmacy claims cycle to exploit risks. Anne Mack shared how having a comprehensive approach – reaching beyond industry table stakes – can help see the complete picture of systemic fraud, waste and abuse.
Advanced analytical capabilities are critical to addressing drug misuse and abuse in the health care system and bringing about actional insights. Collaboration with health insurers is imperative to identifying potential fraud, waste and abuse, researching collected data, and obtaining evidence to determine actionable next steps to improve the safety of members and save money for the health care system. Mack shared case studies of member investigations, prescriber fraud schemes and pharmacy actions that lead to recovered payments and cost avoidance.
Mack left the audience with some lessons on how to execute a successful fraud, waste and abuse program:
- Existing practices should be reviewed for fraud opportunities
- Different data sources should be consolidated to provide a holistic view
- Internal and external partners should be engaged to prevent and detect fraud
- Solutions should innovate as new schemes emerge
From Information to Knowledge: How Prescribers are Using Benefit Optimization Tools to Make the Best Care Decisions
Speaker: John Mark Reimann, Principal Product Development
According to the Centers for Medicare & Medicaid Services (CMS) U.S. health care spending rose to $3.6 trillion in 2018, with American households contributing $1 trillion to that total. Consumers are facing significant, increasing out-of-pocket costs for expenses like prescription drugs. In fact, 17% of all spending on goods and services provided directly to patients is from prescription spending.
Currently, prescribers manually choose medications without access to patient-specific benefit information. Health care providers need accurate, streamlined information to make the best care decisions – clinically and financially – for their patients. Access to a real-time benefit check tool that’s a part of electronic health records (EHR) allows them to see a patient’s medication history, specific cost share and prior authorization requirements, giving prescribers an opportunity to optimize each patient’s benefit plan to the fullest.
To help add some needed transparency to these staggering costs, beginning in 2021, Medicare Part D (drug coverage) plans will be required to adopt at least one real-time benefit check tool that communicates with a prescriber’s EHR or ePrescribing system.
John Mark Reimann – partnering with real-time benefit check vendor Surescripts – unpacked the latest results from prescribers who are using data shared by PBMs and health plans to make prescription decisions that reduce out-of-pocket costs for patients and ultimately lower total cost of care.
Reimann argued that real change to the current system is necessary and will not be easy, but the adoption of real-time benefit check tools have the potential to deliver meaningful change. For example, in Prime’s real-time prescription benefit pilot, one of its Blue plan clients demonstrated better-than-expected drug savings made through appropriate medication switches at the point of prescribing.
“Prime’s real-time benefit tool delivers pharmacy and benefit data to providers and patients at the right place and at the right time,” said Reimann. “This innovative tool is one of many ways we leverage data and partner with vendors to deliver actionable information. This enhanced prescribing process enables the prescriber to see lower cost alternatives and allows the member to pick the lowest cost option and pharmacy of their choice.”
Applying real-time benefit knowledge to spur action improves efficiencies in EHR and clinic staff workflow by providing cost and coverage information in under two seconds and shaving electronic prior authorization approvals to within 60 seconds. And use of real-time benefit tools can drive patient savings, with average annual total savings per prescription of $500 when a lower-cost alternative medication is chosen.
The Journey of an Oncology Specialty Pharmacy Patient through the Lens of the Patient, PBM, Specialty Pharmacy and Patient Advocacy Organization
Speaker: Jen Mellum, Senior Director Customer Experience & Insights (panel with AllianceRx Walgreens Prime and Leukemia & Lymphoma Society)
The patient-focused panel was designed to address cancer care holistically and included representation from a PBM, specialty pharmacy and patient advocacy group. Prime’s Jen Mellum – who provided the PBM perspective – and fellow panelists discussed the complexities of navigating the cancer treatment journey from a patient perspective. Given the many emerging oncology treatment options, Prime’s role is to remove barriers to help ensure the right member receives the right treatment. For example, Prime is leading industry efforts to improve the flow of information to providers and members when they need it most, providing innovation and speeding care delivery.
Mellum, who leads customer experience for Prime, explained complex conditions are not “one-size-fits-all.” Mellum said, “Our job is to understand specific unmet needs for patients with complex conditions, and how those needs can vary by condition and classes of conditions – for example, blood cancers versus breast cancer – and whether patients are managing their “new normal” or still on the journey to get there.”
Understanding patient needs helps shape Prime’s human-centered design of condition-specific clinical programs that can reduce the time it takes for medication approval and increase the likelihood patients will receive covered treatments. And patient insights can help identify ways Prime can help members feel more confident and secure in their care team and treatment.
Prime’s dedicated team for each condition-specific management program includes a pharmacist and data analyst. As evidence of Prime’s unique care model, each program covers both pharmacy therapies and medical pharmacies administered by a health care professional.
Prime is a member of PBMI, an industry group that provides research and education on drug cost management. Prime also sponsors PBMI’s national conference, which drew about 400 health plan executives, employers, benefit managers and other stakeholders this year.
Visit PBMI’s website for more details on the conference.
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