The member experience at most PBMs consists of brief inbound phone calls to resolve specific issues. Initiated by members, the interactions are transactional and reactive by nature, and the customer service representatives typically are under pressure to wrap up each conversation in three minutes and 30 seconds or less.
At WithMe Health, we flip that legacy member experience on its head.
Instead, we proactively engage our members with guidance along their entire medication journey. Our Medication Guides—pharmacists, pharmacy technicians, and customer service representatives—outreach to scores of members each day who are identified by our analytics engine as needing help with their medications. Our Guides may spend 10, 15, or even 20 minutes on each call and follow-up calls if that’s what it takes to close gaps in our members’ care.
Our experience shows this kind of outreach prompts members to make better choices about their medications and their health, resulting in better outcomes and ultimately lower pharmacy and medical spend.
To deliver on this experience, all of our Guides are trained and certified in our proprietary engagement model that we call “MEDS” — Meet, Evaluate, Decide, and Support.
The MEDS engagement model, which we launched in full force in 2020, provides a framework for our Medication Guides to build lasting relationships with our members and encourage healthy behaviors. We developed MEDS in partnership with a leading behavioral psychologist, who designed the model specifically for WithMe Health to build trusted relationships with our members and nudge them towards healthier choices.
At its core, the engagement model is comprised of four phases:
Meet members to build trust through empathy and establish clear goals
Evaluate the reality and history of the member’s situation
Decide which options available to the member are best, weighing pros and cons of each
Support members by making a concrete plan for their chosen option, including follow-ups by phone or through the app
Traditionally, PBMs use a number of reactive ‘sticks’ to enforce medication selection. These include tried-and-true utilization tools like copays and coinsurance, prior authorizations, restrictive drug formularies, and even threatening (or at the very least confusing) letters and emails. The goal of these tools is largely to direct a member’s medication selection towards those that are beneficial to the PBM--more volume to their mail order or specialty businesses, more rebate revenue, etc.--not always the member. And equally important, these tools add immense friction, confusion, and frustration for members and their doctors.
We think about this a bit differently by leading with carrots. The ‘carrot’ is all about proactively encouraging behavior change that is good for the plan sponsor and the member.
That’s where the MEDS model comes into play. We develop trusted relationships with our members to make positive change.
We meet the member with empathy to fully understand their situation. Our members report feeling not just heard but truly listened to, because we make space for our Guides to do so instead of putting the wrong pressures on our Guides to move too quickly through interactions. This approach enables our Guides to uncover all kinds of barriers to accessing or optimizing their medications, whether it’s cost issues or lifestyle factors. Our Guides do this by using the biopsychosocial model to uncover the full context of a member’s situation across biological, psychological, and social factors that may impact access to medication.
Using members’ claims and other health and engagement data, our analytics engine prioritizes members for proactive outreach from our Guides.
For example, we might find a member who appears not to be adherent to a medication based on a pattern of missed pharmacy fills. With this information, our Guide outreaches to the member to uncover barriers to staying adherent to their medication. From there, we can make informed recommendations and guide them towards options to stay adherent, whether that’s a lower cost alternative, more convenient delivery, or simply setting a reminder in our mobile app.
Even with the best recommendations and guidance, members have to be ready and motivated to change their behavior. Our Guides are taught to assess a member’s readiness to make a change with a simple scaling question.
As an example, if we are encouraging a member to be more active, we could ask: where do you fall on a scale of one to 10, with 10 being “Yes, I'm going to go walk around the block five times this week” And another one being, “Nope, I’m staying here on the couch.” ?
The actual number they cite doesn’t matter. What matters is their answer to the question of what would make them move from a 5 to a 6. To move up the scale, the answer might be, “Walking makes me feel more energetic,” which would encourage them to do more walking. On the other hand, they might say, “Walking makes me feel tired and drained, and I worry about falling.” That would be a barrier that we would have to discuss and work around.
As we implement this model, we continually look for metrics to determine its success.
One metric is simply whether our members pick up the phone and talk with our Guides – that’s how we define member engagement, along with app downloads. Our member engagement rate is 44%, an industry-leading figure.
A second metric is recommendation acceptance. We are seeing a positive response here too, with about 2/3 of recommendations accepted, again an extremely high rate.
Our third is net promoter score (NPS), which measures how likely the member is to recommend us to a friend or coworker. WithMe Health has an 85 NPS, which in the pharmacy benefit space is virtually unheard of. This figure is more common in the consumer industry: Apple and Tesla consistently achieve NPS scores of 90-95 NPS. Traditional PBMs have net promoter scores in the single digits.
A key goal of our engagement model, in addition to helping patients, is lowering health care costs for our clients. PBMs traditionally do this through negotiated rates and rebates from manufacturers – in other words, focusing on price. We also do that, of course. But our personalized medication guidance, enabled by the MEDS model, achieves additional savings on top of these traditional methods by going after utilization.
It’s a truism in healthcare that taking the right medications as directed can keep patients healthy, with fewer complications, fewer trips to the hospital, and ultimately fewer dollars spent.
By going beyond price to a real focus on utilization, we achieved 37% pharmacy spend savings for our 2021 clients. We estimate that 23% of this overall figure is due to medication guidance and its impact on utilization.
We’re happy with those results, especially given that we have only one year of full results under our belt. We know we can continue to drive up that figure too, as we bring online new clinical interventions in our overarching clinical program model, even though it’s already beyond what other PBMs are achieving.
As the program is currently structured, we are able to assist members in their present health condition. As we evolve our personalized medication guidance capabilities, including how the MEDS model is deployed and enabled by data, we will increasingly predict which members are about to become sick and require high-cost medications.
For instance, we can look at lab values and lifestyle factors to predict if someone is at high risk of diabetes. With this knowledge, we can intervene and help them stay healthy, avoiding illness and costly medicines to begin with.
Another important step going forward is to carefully set expectations with our clients, so their members are not surprised by the outreach. We want them to know this will be a high-touch model, and that’s what they’re paying for. But we also want them to know we can produce results.
We are advocates for our members. With the right technology and empathetic human-led guidance, we can lower pharmacy spend and help everyone lead their healthiest lives.
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