Managing the cost of prescription drugs is a challenge for many health plan providers. Americans spent $325.8 billion on prescriptions last year. Historically, that spending has been mainly on treatments for common conditions like high cholesterol or diabetes. But high-cost specialty medications for chronic or rare conditions, like cancer or multiple sclerosis, are rising by up to 20 percent a year. They may account for more than half of all prescription costs by 2019.
Express Scripts, a $93.9 billion company that manages prescription benefits for government agencies, companies and unions, wants to help customers reign in those costs–and, it says, improve patient outcomes.
As the largest prescription benefits manager in the country, the 1.4 billion prescriptions it processes annually combine to produce 14 petabytes of data. Express Scripts feeds three of those petabytes into a Teradata analytics engine that helps physicians make effective prescription choices, says CIO Gary Wimberly.
Last year, the company launched an online portal called ExpressPAth, and paired it with a proprietary claims processing engine that manages both pharmacy and major medical benefits. That’s important: About half of all specialty drugs are processed under major medical insurance rather than under the patient’s pharmacy benefit.
These drugs are often administered in a clinical setting by a doctor, says Phil Walls, chief clinical and compliance officer of myMatrixx, another pharmacy benefit management service. “It looks like a medical bill as opposed to a prescription bill. This makes it difficult to track.”
Wimberly says Express Scripts is trying to sort out this big-data problem. The ExpressPAth portal provides real-time information on coverage and rules to assist in optimal prescription choices.
The portal uses Express Scripts’ proprietary rules for crunching pharmaceutical manufacturer’s guidance, claim adjudication data, clinical standards and prior authorization rules.
ExpressPAth then offers advice to doctors, such as recommending a more cost-effective or clinically appropriate drug, or identifying a lower-cost clinic that can provide recurring treatment. One health insurance provider, for example, saved $45,000–and its patient avoided extra treatment–when the portal noted that a drug had been prescribed for too long.
Customers save between 10 percent and 15 percent on medication claims filed under the medical benefit, says Wimberly. He declines to say how much the company spent or has made on the portal, but says it’s a growing source of revenue for Express Scripts. A nationwide rollout is planned in early 2014.
Building ExpressPAth, which took four years, was “extremely challenging,” he says, because it has to analyze complex data in real time and deliver concise information to individual healthcare professionals. The value, he says, is that it can help with decisions that can save money and improve care.
“That kind of tool didn’t exist anywhere else in the marketplace,” Wimberly says.
Stephanie Overby is regular contributor to CIO.com’s IT Outsourcing section. Follow everything from CIO.com on Twitter @CIOonline, Facebook, Google + and LinkedIn.