As drug costs continue to climb, ensuring you have effective utilization management (UM) strategies in place is paramount to controlling drug spend, ensuring the efficient use of healthcare resources, and ensuring members can easily access the medication they need to stay on track with their health.
In a previous post, we looked at some emerging trends influencing the future of UM. I’d like to do a deeper dive into two of those trends: using UM to manage high-cost specialty drugs and the importance of real-time data, automation, and artificial intelligence (AI) in streamlining processes.
But first, let’s start with a quick refresher.
What is Utilization Management and Why is It Important?
UM helps ensure cost-effective and appropriate medication use. Core UM strategies include:
- Formulary design influences utilization and spending by controlling what prescriptions a payer will cover. Consider the formulary as the foundation. From there, you can layer on additional UM strategies and drive incremental savings.
- Prior authorization (PA) requires clinician review and approval of medication before use to promote safe, appropriate, and effective use.
- Step therapy requires members to try a preferred medication before a non-preferred one is approved.
- Quantity limits help ensure safe and appropriate dosing by controlling the amount of medication a member can be prescribed at one time.
UM also plays a crucial role in advancing value-based care by facilitating communication and collaboration among healthcare providers, optimizing medication use, and enhancing patient outcomes.
Two UM Trends Influencing the Future of UM
UM strategies continue to evolve between emerging technologies, new drugs entering the market, and innovative thinking on the part of PBMs, consultants, health plans, and payers. Two areas that continue to influence UM practices are specialty treatments and digital connectivity, automation, and AI.
1. Strategies to Manage the High Cost of Specialty Drugs
Despite only 2 percent of the U.S. population taking specialty medications, these high-cost treatments account for the greatest portion of drug spend. It’s easy to see why UM is crucial to controlling costs and reducing waste by ensuring effective treatment for each member.
Specialty drugs require unique management and administration, so it makes sense that they require unique UM strategies as well. Here are a few examples:
Site-of-care optimization helps ensure specialty medication is administered at the most cost-effective location. That could be in a doctor’s office, an outpatient setting, an ambulatory infusion center, or even the comfort of the patient’s own home. In-home infusion services, where specially trained infusion nurses go into a patient’s home to administer medication, are growing nationwide. They offer more convenience and lower costs – a win-win for payers and patients. Going forward, the site of care will increasingly become a factor in managing costs.
Dose optimization ensures money isn’t wasted on ineffective treatment. It assesses factors such as a patient’s age, weight, genetics, coexisting medical conditions, and response to treatment to determine the most effective and safest dosage regimen. What does this look like in action?
In addressing high blood pressure, dose optimization plays a crucial role in tailoring treatment to individual needs. For instance, a patient’s clinical profile and response to treatment may prompt their healthcare provider to employ a dose optimization strategy. This could involve several approaches, such as titration, where the dosage of the current medication is gradually increased to attain improved blood pressure control while monitoring for adverse effects. Alternatively, if the current medication proves ineffective or poorly tolerated, switching to an alternative medication from a different class may be considered. Additionally, combination therapy could be utilized by adding a second medication from a different drug class to enhance efficacy and achieve better blood pressure management. These personalized adjustments allow for lower doses of each medication, potentially reducing costs while optimizing the patient’s overall treatment outcome.
Vial optimization ensures payers and patients stop paying for medication they’re not using. This UM strategy limits waste by maximizing the use of multi-dose vials or packaging options to minimize waste and control costs. What does this mean? Consider the following scenario:
A specialty patient is prescribed a medication administered via a single-dose vial. Suppose this patient requires a specific medication dosage, but the vial contains more medication than they need for that single dose. There are strict guidelines that prohibit the sharing or storage of remaining medication for future use (due to concerns about contamination, stability, etc.). As a result, the patient would need to throw away any excess medication in the vial, leading to wasted medication and wasted money. By allowing multiple doses to be withdrawn from a single vial, multi-dose vials help minimize medication waste associated with unused or partially used vials. This waste reduction can lead to significant cost savings over time for both plan sponsor and patient.
2. Optimizing UM Processes with Connectivity, Automation, and AI
While UM strategies have many benefits, providers and patients often express frustration with the lengthy process and overall disruption involved. Lack of visibility to plan design at the point of prescribing paired with a historically cumbersome, manual process leads to critical treatment being delayed, potential rejections at the pharmacy counter, and unhappy members.
When we look at the future of UM, we’re already seeing how connectivity, automation, and AI are enhancing efforts and will continue to do so in years to come.
Electronic health records (EHR) have opened the door to greater connectivity with providers and the ability to share real-time information. When a provider has access to their patient’s treatment history, prescription plan design, medication lists, and more they can make more informed prescribing decisions.
EHR connectivity also increases efficiency and eases administrative burdens by removing many of the manual steps involved in programs such as PA. Providers can now initiate PA requests through their EHR portal. Pharmacy benefit managers and their clinicians can then automate certain elements of the review process and use AI to help ensure UM decisions are based on up-to-date and accurate clinical information. A recent analysis by McKinsey showed that AI-enabled PA could potentially automate 50 to 75 percent of manual tasks. Altogether, analytics, automation, and AI ensure UM programs operate efficiently, effectively, and responsively in an ever-evolving healthcare landscape.
While UM will continue to morph as time goes on and more technological advancements are made, one thing is for certain – real-time data analytics is changing the industry at its core. And that’s where Xevant can make all the difference in helping you prepare for the future of UM.
How can real-time data and automated analytics increase the value of your UM programs? Ask us.
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