Insights+ is the GPS that cut through the gridlock of rising costs
Patients can’t coordinate cross benefit therapy. That’s not their job.
October 7, 2020
Making smarter business decisions that lead to better outcomes
For many specialty conditions, drug costs comprise the majority of the total cost of care – 70 to 80 percent1 and even more. (Those drug costs may fall under the medical or pharmacy benefit, depending on the condition.)
How patients receive treatment for specialty conditions has evolved. Many specialty drugs used to be given as infusions taken over time, and had to be monitored by a health care professional. More treatments are now available in oral form or as a self injectable that patients can take at home. And many specialty conditions now have several treatment options.
Drug costs as a percentage of total care for some specialty conditions1
A single change can drive millions in savings
The value in findings from Insights+ is only achieved if changes are seen through to implementation. Prime collaborates with health plan clients to design and execute on changes that drive value. A roadmap for changes may include:
- Verifying contracted rates are billing correctly
- Comparing site of care use for savings opportunities
- Identifying high-cost patients with potential overuse opportunities for managed care pharmacy review
- Controlling for claims outside of network
- Adhering to negotiated fee schedules
- Benchmarking provider/physician fees for regional parity
The health plan controls which changes and savings opportunities to pursue. The health plan controls how any interventions are implemented.
Infused savings: Receiving infusions in a hospital outpatient facility can cost two to three times more than alternatives. Lower cost options include: the patient’s home, an independent infusion centers, or at the doctor’s office.
Moving patients from hospital outpatient facilities to their doctors’ offices for infusion services could generate an estimated savings of $1.41 per member per month. Once changes are implemented, the Insights+ platform can measure the impact. Insights+ provides an automated way to access data that previously had to be looked up manually.
Prime leads the industry in providing health plans the ability to use integrated data to make smarter business decisions. Insights+ has more than one thousand clinical rules to apply to:
- Finding outliers – claims that aren’t consistent with the product-approved use
- Seeking out drug duplication and overuse specific to the specialty space
- Miscoding that might can prevent insurance processing
- Incorrect billing
- Dosing inconsistent with drug labeling
Prime knows how to look at total drug spend across medical and pharmacy and understands how drug spend impacts the total cost of care.
Total drug management is the next big opportunity to make a difference in improving health care cost management. And it can be done while improving health outcomes. Prime’s partnership with health plans makes health care work better.
1. Prime and Blue Plan internal sources.
October 14, 2021
We combined integrated claims with diagnosis codes and UM data to uncover indication-specific…
September 14, 2021
Blue Cross and Blue Shield of Kansas (BCBSKS) began preparing for gene therapy…
July 23, 2021
Cell and gene therapies have been available for several years, but they are…