How to Boost Pharmacy Benefits Optimization



By Brandon Newman, CEO of Xevant

Pharmacy benefits is a complex environment and using the traditional, decades-old playbook to manage pharmacy benefits performance is daunting. There are 100,000+ drugs and drug formulations, 70,000+ pharmacies, 1M+ providers, and 100M+ patients all with perceived competing priorities. No big deal, right? In reality, with technological advances we can toss the old playbook of running and analyzing reports in favor of the new rules for boosting pharmacy benefits optimization by leveraging: 1) Big Data, 2) Analytics Automation, and 3) Alert-based Action. 

Data, Data, and more Data

Optimizing pharmacy benefits requires data, lots of data preferably received on a daily basis. The more sources of data the better. At a minimum, claims data received monthly is crucial to boosting pharmacy benefits performance. Other data sources include drug data, PBM contract data, demographic data, and benchmark data-rich with insights across all KPIs.

“Big Data” is a term being consistently thrown about by healthcare stakeholders in recent years. Although the term seems simple enough (large amounts of data), most experts suggest the real definition of the term goes well beyond the quantity of data: “Extremely large and diverse datasets that may be analyzed to reveal patterns, trends, and associations, that could lead to better decisions.”

Put this way, Big Data offers an opportunity to make an immediate and lasting impact on the cost and quality of pharmacy benefits by leveraging it to “reveal patterns, trends, and associations” that could result in “better decisions” to boost pharmacy benefits optimization. 

Why focus on AI when we haven’t embraced automation? 

“Artificial Intelligence” or AI is another buzzword floating around healthcare, but the term is a distraction to the real opportunity of fully leveraging analytics automation. The old PBM playbook suggests we task an army of trained experts to manually run and analyze reports to identify a few trends to present to clients. This is process is extremely inefficient, time-consuming, and expensive, and it rarely happens more than annually due to the difficulty and complexity of analyzing detailed reports for every client. 

Today we can leverage tech-enabled solutions to automate the extremely difficult task of analyzing hundreds of thousands of circumstances and trends every single day in order to identify the exact moment an opportunity to boost pharmacy benefits optimization presents itself…not 15 months later. This is equivalent to running an extremely comprehensive plan review comprised of thousands of reports, metrics, and analysis for every client and having it reviewed by the best financial and clinical experts…all on a daily basis. This is the new playbook, one with rules-driven by tech-enabled solutions.

Brandon Newman Xevant
Brandon Newman, CEO Xevant

“Artificial Intelligence” or AI is another buzzword floating around healthcare, but the term is a distraction to the real opportunity of fully leveraging analytics automation

Action now versus action later 

Whether improvement comes through lower cost, more appropriate utilization or other ways depends largely on our ability to use the data and inferred trends to make better decisions today. However, if we continue to make decisions a year after the opportunity presents itself then the benefits gained by making change pale in comparison to the benefits from acting immediately.

Consider the following results from a poll conducted by Geneia/National Alliance of Healthcare Purchaser Coalitions:

  • 97% of employers believe that advanced analytics is essential for making benefits and/or wellness program decisions and 90% said that near-real-time data is imperative to realizing costs savings

Nearly all employers surveyed feel that making benefits decisions to effectively manage their programs requires real-time use of massive amounts of data. However, they also struggle with the ever-growing massive amounts of data and their inability to quickly make informed decisions. Put another way, they can see the intended results of Big Data but are seeking automated analytics and alerts to effectively use it.

How to boost pharmacy benefits optimization?

All the necessary ingredients for a valuable transformational market change is at our fingertips that will enable us to more fully optimize pharmacy benefits through Big Data, Automation, and Alert-based action:  

  1. We have mountains of healthcare and pharmacy data at our fingertips that continue to accumulate at an accelerating pace.  

  2. We have access to comprehensive analytic automation tools that will enable a careful analysis of the vast sea of data on a daily basis to immediately identify trends and patterns in cost and utilization.

  3. We have near real-time alerts enabling pharmacy experts to make incredibly informed decisions that boost pharmacy benefits optimization on a daily basis resulting in the greatest opportunity to improve performance.

Despite the relatively complicated nature of Big Data, leveraging it within health benefits to achieve desired results is within our grasp. The big opportunity for pharmacy benefits is for employers, brokers, consultants, health plans, administrators, and PBMs to begin working together to expand our collective ability to deliver optimized pharmacy benefits performance by fully embracing Big Data, Automation, and Alerts.