According to the results of this “Business Chemistry” test, my working style is primarily that of an Integrator.
So it’s no surprise that I’m a big fan of all-things-integration. And while “integration” risks being a buzzword in today’s digital health and employee benefits circles, I’d argue it’s worth every bit of the buzz (and possibly more) that it’s getting.
Here’s another—and I think better—way to consider integration: partnering effectively. The most successful integrations stem from the intent to partner deeply with other healthcare services for the benefit of the member.
Talking about integration this way makes an important distinction between integration and data interoperability, which is an enabler and accelerant for more effective partnerships across the healthcare ecosystem. But interoperability in and of itself does not ensure effective coordination around a member’s health.
In the digital health world, I see two axes of partnering that are critical to member experience. And by critical I mean: wonderful when done well, devastatingly disruptive when done poorly. The axes are:
Integrating data for a “whole member” view, especially medical and pharmacy data
Connecting the dots among point solutions
In this piece, I’ll focus on the first one: integrating member’s data, especially pharmacy and medical data, to have an impact on both pharmacy spend and total cost of care. I’ll discuss why it matters and then look at specific examples of the impact this integration can have.
Our ultimate goal with any member is to get “whole member” data. This includes pharmacy and medical claims data, SDoH data, lab data, and even discount network (like GoodRx) data. But the most critical line of sight exists between pharmacy and medical data, as looking across both gives us a (nearly) complete view of a member’s medications.
Typically, a member’s medication isn’t visible in one place. Up to one third of prescribed medication is billed under medical, not pharmacy, benefits.
Medications claimed under medical benefits include those administered in a hospital, clinic, or physician’s office. Many are specialty medications that require in-office administration, such as infusions. Other more standard medications, such as antibiotics or blood pressure medications, also hit the medical benefit if they are administered in a hospital or clinic.
When medications are claimed under medical benefits, there is an often dangerous lack of visibility from all sides. The medical benefit is unable to see what medications have been filled through the pharmacy benefit, and vice versa. The biggest danger: potential safety concerns about drug-drug interactions and drug-condition interactions. And this danger, when realized, incurs cost, often in the form of an ER visit.
In my view, the foundation for resolving these and other challenges, as well as realizing improved clinical outcomes and additional cost savings, is better data integration.
Our best integrations are achieved through strategic partnerships that integrate data and align incentives with the partner, the plan sponsor, and our members.
Through partnering with like-minded health plans and leading third-party administrators, especially through our strategic relationships with TPAs like Centivo, we are able to integrate medical data directly into our clinical ruleset and analytics engine. This enables critical line of sight into the diagnoses as well as prescribing actions across the care team - from the prescriber and her office staff to the pharmacist.
We’ve also established partnerships with navigators like Castlight that cut across many point solutions (see forthcoming Part 2 in this series for more on this).
When we are able to see across all of a member’s medications—what we like to call the ‘full medicine cabinet’—regardless of whether claimed on the medical or pharmacy benefit, our team can act as a bridge across fragmented medication regimens prescribed by different providers. This enables us to play a role in closing gaps in preventative care and ensuring check-ups take place to resolve any complications and track lack of progress sooner.
Our clinical interventions (see examples here) can drive up to 20% in indirect savings (i.e., savings on the medical side); that’s a huge lost opportunity when the medical and pharmacy experiences and benefits don’t integrate effectively. One example is diabetes patients on statins. For these members, increased statins adherence creates a savings of $220 per member per year. While that’s an attractive savings figure for a plan sponsor, especially in light of a large diabetes population, adherence-driven savings for more complex and less common diseases like autoimmune diseases (e.g., Rheumatoid Arthritis) can be in the thousands of dollars.
In both examples, the diagnostic information lives in the medical data, but adherence—or lack thereof—is visible on the pharmacy data. Using visibility into the medical data, we can intervene via the pharmacy benefit with medication-focused guidance to improve adherence, resulting in a lower cost of care for the plan sponsor. It’s a win-win for the member and their employer.
Let’s consider a few more examples, especially in context of our TPA partnerships:
In coordination with a TPA partner’s ER- and surgery-related solutions, we can perform post-ER / hospitalization medication review with a specific focus on opioid / pain management.
If a member visits an ER for a condition that is highly-manageable with medication (e.g. asthma), then can follow up to discuss maintenance medication adherence to avoid flare ups.
For members diagnosed with chronic conditions or high risk factors including diabetes, migraine, autoimmune disease, asthma/COPD, chronic kidney disease, and smoking, we can collaborate with the TPA to optimize medication use and improve outcomes.
If we identify a lower cost site of administration for specialty drugs on the medical benefit, then we can work with the TPA to shift the site of administration.
If we identify duplicate medical and pharmacy benefit billing, then we can resolve the redundancy.
Integrating across all medical and pharmacy data enables us to do our job better, but it also helps our partners and clients far beyond pharmacy savings too. This should be the nature of any good partnership: together we become better than our separate parts at impacting our clients’ and members’ experiences.
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