Your company offers medical benefits, and it offers pharmacy benefits. But if you are not integrating these two components, you may be spending more than you need to, says Mark Haegele, director, sales and account management at HealthLink.
“Having both data sets boosts your ability to see the whole picture of your members and your costs,” says Haegele. “It really opens the door for new opportunities to control costs. If you just have the medical claims data, or just the pharmacy claims data, that only gives you part of the picture. But when you integrate that information and tie the pharmacy claim information into the medical claim information, then, all of a sudden you start to see the full story relative to specific members and, in particular, specific cost variances. And that really opens the door to do some pretty creative things with information, ultimately allowing you to control costs.”
Smart Business spoke with Haegele about steps an employer — particularly a self-insured employer — can take to manage health plan costs.
Why should employers integrate medical and pharmacy claims data?
Having that data under one umbrella can help improve care by creating a complete picture of a member’s health. Integration increases the identification rate for chronic conditions and care management programs as a result of improved access to key data.
It allows for better case management, increasing the likelihood that patients will receive the correct medication at the right time, avoid negative drug interactions and help members comply with prescribed therapies. In addition, patients with chronic diseases often do not get the help they need, resulting in more severe and costly complications, and higher rates of diseases and death.
How can an employer use integrated data to manage costs?
If you combine your pharmacy and medical data, you can then sort your data by members who have more than five prescriptions per year. You can further refine that information to determine from how many different physicians a member may be getting a single prescription.
For example, oxycodone is a very common concern in the marketplace, and an employer may have health plan members who are getting that prescription from five different providers. Without that integrated data, you wouldn’t know that. But by targeting controlled substances, you can identify those who are abusing the plan and then, in conjunction with your consultant or broker, notify those prescribing physicians so that they become aware of that situation.
Employers are often shocked to learn what is in the data. A plan member who is getting 15 or 16 prescriptions per month from 10 different doctors is clearly problematic, and identifying those people can help you control your costs.
What other action can an employer take using integrated data?
The second specific action that employers can take to control costs is to look at the use of antidepressants. This is a high-cost category, often in the top three most used prescriptions, which presents an opportunity.
Antidepressants are generally intended to get a person through a tough time, for example, as the result of a death or a highly stressful situation. Most are not really intended for chronic continuation for multiple years. When an employer has the data, it can identify those members who have been on antidepressants for more than a six-month period. Then you can introduce that member to a case manager, or into an employee assistance program, or refer that person to a psychiatrist for one-on-one therapy. Oftentimes, with three or four session — which are typically purchased by the employer anyway in an EAP — the member feels better and is able to get off of those drugs, reducing both usage and costs.
How can integrating medical and pharmacy data help employers assist members with chronic illnesses?
Employers can pull the data for members who have been diagnosed with one of five chronic illnesses — cardiovascular disease, hypertension, asthma, diabetes and COPD — then, with their consultant, identify whether those members are on a routine and taking their prescriptions for that specific illness. You can see if members are compliant, based on their refills, and can identify those who are not.
As an employer, you can then do a number of things to increase compliance within those categories. The employer can offer to pay for those drugs, because even though they are generally inexpensive, some members may not take them if they are living paycheck to paycheck. By simply paying for those drugs for its members, an employer could save the plan a lot of money.
You can also make a strategic decision as an employer, especially in a self-funded environment, to get members to work toward trying to achieve a better compliance rate. You can use your medical data to identify those members who have these diagnoses and couple that with your pharmacy data to identify those who are taking prescriptions.
Look at a 12-month period and how many scripts per month members are taking to identify any tailing-off patterns because refills have not been made. Maybe someone filled the first 90-day prescription, and the second one, but then never got it again.
What happened? How do you get the member back on track? Does the employer need to pay for the drugs? Do you need to assign a case manager to that member?
All of these things are fairly simple, straightforward specific actions that employers can take in their health plan to control costs and improve the health of their members.
Mark Haegele is director, sales and account management at HealthLink. Reach him at (314) 925-6310 or [email protected]