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Excellus: 3 key pieces of data drive Rx savings


The healthcare environment challenges insurance industry stakeholders to drive clinically optimal treatments along with cost savings. Thanks to data analytics, Excellus BlueCross BlueShield in Rochester, New York, has been able to meet that challenge.

"Whether it is around clinical optimization, formulary management, benefit design, as well as pure clinical outcomes and strategies, we're using data," Mona Chitre, vice president of pharmacy management at Excellus, said Tuesday during a FierceHealthPayer webinar.

Chitre pointed to pharmacy claims as the data starting point because they offer a real-time view of both the population and individual patients. Excellus looks at pharmacy claims to uncover trends in utilization and compliance, as well as trends for a specific patient that could trigger a case management intervention.

Adding to its value, pharmacy claims data is valid, accurate and accessible--they show the quantity, the drug and the directions for use. But Chitre cautioned against just looking at the pharmacy data in a silo.

Excellus uses the pharmacy claims data and medical claims collaboratively and cohesively to look at the entire patient and population history. "We're going to always use the medical diagnosis as a double check," she said.

Integrated pharmacy and medical data is key to achieve savings, according to Chitre. Utilizing real-time pharmacy and medical data to do care management interventions can cut medical costs by about 6 percent. Moreover, integrating pharmacy and medical claims also can drive savings with regard to specialty drug management, she said.

The third type of data to reap healthcare savings is information in the published domain. For example, Excellus uses inclusion and exclusion criteria of clinical trials in its pharmacy and therapeutics reviews.

Those three pieces of data--pharmacy claims, medical claims and clinical data--guide all of the pharmacy decision-making, Chitre explained. They drive formulary, preferred product selections, tier structure, benefit designs and cost sharing. "The key to our best practice around saving money, driving clinical optimal programs all revolves around data," she said.

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