Guaranteed Savings in Uncertain Times
Today more than ever, employers are juggling how they can best support their employees and keep them healthy. In addition, organizations are looking for saving opportunities to offset revenue losses and higher health care costs stemming from the COVID-19 pandemic. Medical Drug Management (MDM) is a comprehensive way to achieve each of those goals.
While most drugs are billed through the pharmacy benefit, costly specialty drugs frequently are administered in clinics, hospitals or doctors’ offices and billed through the medical benefit. MDM extends Express Scripts’ expertise and cost controls to that arena, helping plans use their health care dollars more efficiently while providing the highest level of care to their members.
Synergy From a Suite of Solutions
MDM can include utilization management, prepayment reviews of claims, edits to medical claims and site of care management. By themselves, each component is effective; when these capabilities are used together, plan sponsors pave the way to maximum savings.
- Utilization management ensures the safe and appropriate use of high-cost specialty drugs by employing prior authorization, step therapy and drug quantity guidelines.
- Claim prepayment reviews validate usage, dose and pricing for each drug that requires utilization management.
- Medical claim edits validate claims against clinical standards, improving patient safety, detecting errors and improving outcomes for a comprehensive list of drugs that do not require utilization management.
- Site of care management ensures patients utilize the most clinically appropriate and lowest-cost site of care, such as providing nurses for in-home infusions instead of utilizing a hospital.
Recently, Express Scripts’ MDM flagged a discrepancy that saved a health plan $81,000 in unnecessary spend in a single year for one patient. Using the prior authorization process, we approved a dose of 25 HCPC units for an infused medication to treat rheumatoid arthritis. The claim prepayment review allowed us to see that the provider was billing for 75 HCPC units, triple the quantity that had been prescribed. Thanks to the interconnectedness of these MDM components, the claims were repriced to match the dose.
Express Scripts’ MDM guarantees a 3:1 return on investment. On average, clients have experienced savings of $100 per member per year (PMPY) for commercial members and $93 PMPY for Medicare members. The program pays out annually in the unlikely event the guaranteed savings are not achieved.
In addition, MDM frees clients’ internal teams to focus more time on helping their members manage the challenges and pressures that have risen from the pandemic, such as home schooling, child-care issues, tending to elderly relatives and maintaining a work-life balance.
Our disjointed health care system made finding savings a challenge even before COVID-19. Now that plan sponsors are burdened with additional responsibilities to help their members manage the impacts of a pandemic and a recession, it’s more imperative than ever to identify solutions that can do the heavy lifting and guarantee results for all.