Synergy between AI and digital platforms for PBMs; driving value-based programs

Both CVS Health and Express Scripts have recently expanded value-based care programs aimed at improving patient outcomes and reducing the high costs for treatments associated with oncology and cardiovascular disease, respectively. PBMs and payers believe that with seamless access to patient data, new technology such as artificial intelligence and predictive analytics will be critical in ensuring medication adherence to control spending and improve population health.


PBMs expand value-based programs

On Dec. 12, 2019, CVS launched the Transform Oncology Care program, that—with the help of genomic testing analysis—would introduce personalized treatment best suited to the patient’s condition from the beginning of the therapy. In collaboration with Tempus, a technology company focusing on precision medicine, patients can access broad-panel gene sequencing test, while providers can decide the most precise treatment regimen based on the test results, decreasing cancer progression and reducing treatment costs.

On July 30, 2019, CVS expanded the Transform Diabetes Care program with focus on early detection and prevention, and manage hypertension, a common comorbidity for diabetics. The expanded program grew from the success of the Transform Diabetes Care Program, which was able to achieve improved HbA1c levels by an average 1.2 percent in six months since it began in 2017. More than 50 percent of program members with uncontrolled diabetes moved to controlled status. The new program leverages CVS’s Health Engagement Engine analytics platform to identify potential members at-risk who could benefit from the program.

Express Scripts instituted the Cardiovascular Care Value program, expanding its value-based care program, SafeGuardRx Cholesterol Care Value. Through this program, Express Scripts not only will offer discounts and cost caps for PCSK9 inhibitors and select anticoagulants, but through predictive analytics using patient data on the SafeGuardRxSMplatform, will reach out to patients at risk, and are nonadherent to treatment, for an early intervention. In March 2020, Express Scripts opened its HIV Care Value program using the same SafeGuardRx platform. The platform with provide payers cost predictability, and control spend for health plans covering complete cost of pre-exposure prophylaxis treatment, patient support, and provider education.

Express Scripts manages therapy areas including diabetes, cancer, hepatitis C, and multiple sclerosis, among others. Its programs supported by SafeGuardRx that has delivered positive results. For instance, there was a 72 percent reduction in the use of inhalers among COPD and asthma patients, and 19 percent drop in drug spending for almost 800 plan sponsors.


Why do value-based programs demand high-end technology?

The panorama of PBM involvement in value-based programs draws attention on how the industry is shifting its attention toward prevention through early intervention to head off high costs associated with treatment of complex conditions such as cancer, diabetes, cardiovascular diseases, and auto-immune diseases. Moreover, recent mega-mergers between PBM and payers have brought together large volumes of patient data. As the care delivery model shifts more to preventive care than cure, payers are looking to artificial intelligence and predictive analytics to draw actionable analysis from their big data sources to customize management programs. These programs will then support providers to prescribe the most appropriate and effective treatment options to some of the costliest therapy classes for payers, including cancer, diabetes, inflammatory diseases, and high blood cholesterol. When applied with value-based payment strategies, these programs should deliver better medication adherence and improved compliance, reducing unnecessary costs.

For instance, using an advanced analytics platform, the CVS Transform Diabetes program identifies at-risk members, usually prediabetics, and reaches out to enroll them. Members receive digital scales and app-based yearly diabetes prevention coaching for continuous monitoring. Studies have shown that through better lifestyle management, medication adherence, and control of A1C, health can improve while costs can be significantly reduced.



PBMs will continue to invest in analytics to develop value-based programs given that payers are increasingly looking for ways to utilize real-time data to curb high cost associated with chronic conditions. Other PBMs may also join the larger PBMs to explore insights derived through analytics. OptumRx, for one, makes use of the behavioral economics principle (The Next Best Action) using medical and pharmacy claims where the best course of action for an individual is determined and ranked first in a suggestions list to increase member engagement in wellness programs.

PBMs play a crucial role in managing healthcare costs and driving value-based programs due to their growing influence. Teamed with data analytics and a large national footprint might make PBMs the strong engine for value-based programs.