OptumRx, other PBMs use data to drive down drug costs

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With the simpler money-saving efficiencies already achieved, UnitedHealth subsidary OptumRx and fellow pharmacy benefit manager giants CVS Health and Express Scripts all have found that big data may be the key to cutting costs even further, Bloomberg reports.

Optum, for example, was able to save one client more than $70,000 in six months by changing acne treatment coverage policies based on insights gleaned from usage data; for another company, $110,000 was saved by taking action when data showed attention deficit hyperactivity disorder drugs were being overprescribed to adults.

Data can also help PBMs guide better patient care by identifying when it may be appropriate to switch a patient to a more effective treatment--such as when refill data show that an asthmatic patient is taking too many puffs on an inhaler.

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While OptumRx Chief Medical Office Sumit Dutta tells Bloomberg it is vital to vet such coverage decisions clinically beforehand, some patient groups have still pushed back against such cost-control tactics. In response, New York, Indiana and West Virginia have all passed laws this year to limit PBMs’ power over prescribing choices.

Health insurers, too, have begun to exert greater pressure on drug manufacturers to curb rising prices by spearheading contracts that tie clinical effectiveness to prices. Such agreements help align incentives between the two historically opposed stakeholders, Cigna CEO David Cordani has said.

Yet in one case a PBM and a payer have clashed: Anthem and Express Scripts are engaged in a legal battle over what the insurer claims are prescription drug savings the benefits manager failed to pass on. In addition, a recently filed class-action lawsuit takes issue with the two companies’ contract.

- read the article

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