Utilization management is constantly evolving due, in part, to advancing technology and the intent to improve patient care and adherence to medications while reducing costs for all stakeholders. With an industry full of opportunities and challenges, knowing how and when to identify and act on them is crucial to optimizing outcomes.
With help from a few experts in the PBM space, we’ve collected and explored some of the most impactful utilization management trends that are emerging in the industry.
Real-Time Data That Enhances the Utilization Management Process
Arguably, one of the most significant advancements in utilization management is the ability to use real-time healthcare data analytics that provide a daily update of changes in the market. Benefits managers can construct and review reports that allow them to identify opportunities immediately and take action quickly.
Chris Robbins, CEO of Arxcel, explains, “With the increased costs and the complexity of the drugs that are being introduced, we need to be able to identify specific instances and trends for our clients. This includes the ability to immediately find potential problem areas and provide solutions. It’s a very real scenario with the COVID-19 outbreak. Employers were not prepared for this type of outbreak. With utilization management and timely data, we can identify trends for timely decisions now and prepare for the next time something like this happens.”
According to Robbins, the biggest benefits of real-time data include:
- Providing the opportunity to give clients time-sensitive information and recommendations without waiting for retrospective insight from a PBM
- Transparency into how close PBMs are performing to contract
- Assisting employers with welfare benefits as fiduciary responsibility is going to be more important
Active Engagement with Multiple Streams of Data Also Contributes to Utilization Management Enhancements
According to Ryan Rice, the Principal of Pharmacy Strategy at Prism Health Strategists and ,,ScripPoint, “Real-time and active engagement with multiple streams of patient data enhances the utilization management process to intelligently validate what’s actually happening in the patient’s medical and pharmacy history, then cross comparing with evidence-based, and clinically efficacious care pathways. All of which are designed to identify the most appropriate and prudent care pathways for the patient, then rapidly, and automatically communicating with all those within the care continuum.”
He expands further, saying that “Utilization management has historically meant implementation of binary, rules-based decision support, that more times than not benefits the PBM and/or carrier, or results in a contentious back and forth between the Patient, their Physician, the PBM/Carrier, and the Plan Sponsor.”
In Ryan’s expert opinion, “Technology must drive fast and evidence based decision support that independently advocates for the patient first, then the economics for the Plan Sponsor.”
It’s this need for instantaneous information that makes technology like Xevant’s all-in-one platform so important. Xevant offers an automated solution that allows benefits managers to analyze data and assimilate it into actionable, measurable, long-term strategies quickly and more effectively. PBM and health plan reporting that typically takes months can be collated instantaneously, allowing clients to quickly pivot where and when needed to save money and improve patient health.
The Transition to Novel Treatments
Another emerging trend in utilization management is the shift to the use of novel treatments. Historically, novel treatments have been avoided due to high costs, despite their tendency to ‘significantly help to advance patient care and public health.’
But, according to Nelly Rose, AVP of Clinical Pharmacy at Valued Pharmacy Services (VPS), that’s changing ,— “The biggest trend changing the future of utilization management is the shift from traditional therapies to novel treatments in specialty pharmaceuticals.”
She goes on to explain that the industry is seeing rapid increases in specialty drug spends, “In the past 5 years, the most commonly used specialty brand drugs experienced list price inflation of 57.1%. In contrast, list prices for generic specialty drugs declined by 35.1%. Over the past year alone, list prices increased 7.1% for specialty brand drugs and declined 20% for specialty generics.”
The use of novel treatments is specifically emerging in the areas of Oncology, Inflammatory conditions, Multiple Sclerosis, and HIV. And for even more rare conditions, Orphan drugs (higher cost) are becoming prevalent. Rose explains, “Their costs range from $100K-$1M/year, depending on the severity of the condition. Orphan drugs have had major growth in the industry due to financial incentives pharmaceutical manufacturers receive for R&D. Due to this, a lot of Orphan drugs have been used for off-label indications to make them more accessible on the market, therefore causing a major increase in pharmacy spend”.
In fact, according to Rose, this is a trend that will most likely become a staple, “In 2018, PBMI reported that specialty drug spend now represents 50% of total drug spend and forecasted it to reach 60% by 2021.”
The Role of the Physician Advisor
When looking at emerging trends in utilization management, it’s important to consider the review process. Originally, case managers armed with only screening criteria were the key decision-makers. However, according to P. Michelle Wyatt, Clinical Best Practice Director at XSOLIS, this changed when hospitals saw a need for clinicians to be able to support utilization management.
That’s when the physician advisor role was created. Wyatt states, “Physician advisors function as the arbiters of medical necessity and whether they are internal or external to the hospital, they play a crucial role in the review process.”
She goes on to say that as important as the review process is, it pales in comparison to the utilization of artificial intelligence (AI) in the industry, “Before now, we reviewed each patient in parts – specific diagnoses and conditions only – but now we can use analytics to help us understand the entirety of the patient.” She continues, “With this past focus on condition-specific diagnoses and determinations, we missed so much. Patients are complex – acute and chronic conditions all tie into one another – and as a case manager, I want to see all of that.”
Xevant: The Future of Utilization Management
While trends in utilization management will continue to morph as time goes on and more technological advancements are made, one thing is for certain – right now, real-time data analytics is changing the industry at its core. And that’s where Xevant is a game-changer.
Xevant can fully streamline PBM and health plan reporting with real-time insights from daily data feeds. This instantaneous information allows benefits managers to easily report on any opportunities for cost savings and improved patient care to their clients right away, instead of acting retrospectively.
“Artificial intelligence and technology give us the opportunity to better understand our patients and to manage care that meets their specific case.”- P. Michelle Wyatt, Clinical Best Practice Director at XSOLIS