A textiles manufacturer was concerned that their medical costs had been climbing. They were not satisfied that their current medical plan carrier was doing enough to pinpoint cost drivers, or that they were doing enough to mitigate increases. They were willing to consider third-party solutions outside of what their medical plan carrier offered.
An intermediary was able to provide big data analytics on three years of their medical and pharmacy data. This review helped them narrow in on specific drivers of cost. Three areas required focused strategies.
1. Usage Patterns
Cost stratification of their members revealed that the top 5% were driving a disproportionately high percentage of their expenditure (66% versus national norms of 58%). An analysis revealed high numbers of back conditions, cardiac disorders and cancer. Many of these members also underwent surgical procedures and expensive therapies. The textile manufacturer was in a relatively rural area of Texas, and the limited provider community that treated most of their members was known to have some issues around quality of care and overutilization.
Strategy: This employer agreed to explore a second medical opinion vendor option that would offer a comprehensive medical review for claimants with complex or severe medical issues and provide medical recommendations based on their findings.
2. Asthma Management
A review of gaps in care for several key conditions revealed an unusually high prevalence of asthma in their population. A high level of gaps in care existed specifically for asthma (but notably not for some of the other conditions analyzed, such as diabetes, hypertension or coronary artery disease). Emergency room use for asthma was double that of predicted norms. Hospitalizations for asthma were higher than national benchmarks. Finally, analysis of pharmaceutical claims revealed inefficient (and potentially ineffective) prescription patterns for inhalers and other asthma medicines.
Strategy: The manufacturer determined that excellence in asthma management was a high priority for selecting a new vendor. Excellence specifically in asthma disease management intervention program that integrated pharmacy data for asthma was paramount. It agreed that a carve-out disease management option was not off the table.
3. Pharmaceutical Costs
A review of pharmaceutical claims revealed a cost and utilization upsurge of high-cost specialty pharmaceuticals. Overall prescriptions written had not changed, but the dollar spend had increased by 68%. The employer and the intermediary were both well aware of the recent industry focus on specialty pharmacy management (PBM). Looking at their particular numbers (and the list of high cost pharmacotherapeutics) prompted action.
Strategy: The employer agreed to carve out pharmacy benefits management from their medical carrier contract. Furthermore, third parties who offered high-touch, individualized outreach to claimants taking multiple drug classes was a priority.
Big data health analytics allow employer plan sponsors to pinpoint high cost patterns that point to focused solutions, such as:
- Cost stratification that can help identify trends in high dollar claimants.
- Identification of high risk and high gap in care individuals who have the greatest risk for high dollar spend in the next 12 months.
- High rates of surgeries per diagnostic conditions.
- Segment cohorts of members with high gaps in medical care.
- Greater than expected utilization of key, high cost specialty pharmaceuticals.
Increasingly, employers are interested in considering third-party vendors who can help them identify high risk, high cost and high complexity members and target solutions that work for their clinical situations.
Big data can be leveraged to target focused interventions that may make a difference in the lives of employees and their families by improving health outcomes. It is also one of the most powerful ways for employers to bend their medical cost trend.