How to Always Improve Good Utilization Management

Utilization management protects plan sponsors financially while providing a seamless member and prescriber experience.
Advanced Utilization Management

For years, we’ve seen truly incredible pharmacological advancements, but, unfortunately, these improvements aren’t easily accessible to patients. In order to ensure access to these expensive drugs, plan sponsors need to manage utilization to ensure appropriate and optimized use that reduces waste. And, this isn’t just for drugs available today. According to the QuintilesIMS Institute report on U.S. Medicines Use and Spending, it will continue to compound with new high cost therapies in the drug pipeline since launches of innovative medicines are expected to average 40-45 per year through 2021.  Additionally, according to the National Business Group on Health, this remains top-of-mind for employers since 39 percent of them say that their top 2020 health care initiative is a focused strategy on high-cost claims.

Planning for these claims is difficult since patient populations shift overnight. No one can predict when a member will be diagnosed with a costly, complex chronic condition and new expensive therapies are coming to market at a rapid pace.

This is where utilization management can step in.

Utilization management ensures that less costly alternatives are prescribed first. This evaluation is done through a prior authorization (PA) process that checks that less expensive, clinically similar alternatives aren’t overlooked. This helps plan sponsors prevent waste and keep treatment affordable for members. And we know that it works: in 2019, clients that represent 58 million lives in total avoided $3.4 billion in costs—roughly 10-13 percent of total pharmacy spend, by being enrolled in the Express Scripts Advanced Utilization Management solution.

Here’s how Express Scripts is constantly innovating to optimize the solution for plan sponsors, while maintaining a positive experience for members:

  • Optimizing the Prior Authorization review process – Not all PAs require the same level of support, so coverage reviews are being optimized to ensure that resources are directed to the higher cost prescriptions, thus giving additional support to high cost medications and moving low costs medications through the PA process quicker.
  • Automatically updating PA lists when high cost products hit the market – This means that plan sponsors and members are automatically protected from high costs medications.
  • Giving providers greater visibility to members’ specific prescription benefits  – Express Scripts is constantly improving connectivity to providers’ Electronic Health Records (EHRs) so they know what medications are covered by the patient’s benefit and can prescribe a therapy that aligns. This streamlines the process for providers and patients alike to get the right, most affordable medication in their hands quicker.

While we know that constant improvement is necessary, we also know that each plan sponsor has individual needs, based on their member population. Advanced Utilization Management is built on various lists that provide plan sponsors the ability to mix and match to achieve their goals. These lists target areas like oncology medications, lifestyle medications, high cost therapies, etc.

There are a lot of uncertainties in the future, especially as it relates to drug pricing, but we know that with the right utilization management approach and continuous improvement, plan sponsors can manage costs and provide access for patients to the medications that they need.

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