Electronic Health Reporter

Guest post by Glen Stettin, M.D., senior vice president, clinical, research and new solutions, Express Scripts. 

In the United States, we spent $325 billion on prescription drugs last year. However, more than $500 billion in additional related spending was wasted on two problematic (and essentially opposite) patient behaviors:

1)      People who should take their medications but don’t. Patients who failed to adhere to their prescribed medication therapy cost the country $317.4 billion in avoidable hospitalizations and other medical costs last year.

2)      People who shouldn’t take medications but do. Prescription drug abuse is deadlier than cocaine and heroin combined. Each year, the U.S. loses between 3 percent and 10 percent of every healthcare dollar spent – as much as $224 billion last year – to fraudulent prescriptions. More importantly, prescription drug overdoses kill more than 15,000 people and result in 1.2 million emergency room visits each year.

Improving medication adherence and curbing prescription abuse are two of the greatest opportunities our country has to improve health and financial outcomes. Predictive analytics – truly actionable data – hold the key.

The Science behind Fixing Bad Health Decision-Making

At Express Scripts, we are passionate about solving poor health decisions. We use data to predict who may be at risk for making a bad health decision, why they might make that decision, and how to intervene with that person specifically to change that behavior. It’s an approach we call Health Decision Science:

Clinical Specialization: Our Therapeutic Resource Centers (TRCs) — entire pharmacies dedicated to one of 15 different therapeutic specialties, including cancer, diabetes and heart disease — are staffed by more than 1,500 specialist pharmacists and nurses focused on helping patients with needs in their specialty, and their doctors, make better health decisions for safer, more effective and more affordable treatment. Specialist pharmacists’ condition-specific training and experience provide them with a deep understanding of treatment of disease in their specialty, quickly identify obscure, yet critical concerns, and empowers them to address important questions to physicians that otherwise may not have been asked.

Behavioral Science: Through the advanced application of the behavioral sciences to healthcare, we seek to understand who is most at risk for making a bad health decision and why they make those decisions so we can pilot and implement a customized intervention.

Actionable Data: Serving more than 100 million Americans, Express Scripts manages an unprecedented amount of data. We process more than 1.4 billion prescriptions a year and warehouse more than 100 million life years of integrated medical and pharmacy claims. Advanced analysis of that data enables greater insights and stronger solutions from both a clinical and a behavioral perspective. We can make safety, savings and service opportunities readily apparent and actionable for more patients, caregivers and providers.

Putting the Health Decision Science to Work

Of course, medication non-adherence and prescription drug abuse are two very different problems. However, both are driven by patterns of behavior – intentional and unintentional – which makes applying Health Decision Science an effective approach to predicting, identifying and resolving both concerns.

Medication adherence is not an intentional behavior — 69 percent of problem is simple forgetfulness and procrastination. Also, many patients are unaware of their nonadherence or the impact it can have on their health.

To address this problem, Express Scripts created ScreenRx, which looks at more than 400 different factors related to each prescription that can tell us, within 98 percent accuracy levels, who is likely to stop taking their medication within the next year. That’s nearly nine times more accurate than what patients self-report. We can then intervene with a tailored solution to keep that patient on the path to better health and help them avoid unnecessary downstream medical expenses.

ScreenRx isolates the most likely reason why a patient is not taking their medication. If its forgetfulness or procrastination, we can send the patient daily reminders, 90-day fills or auto-renewals. If a patient is likely to have clinical concerns about the medication, our specialist pharmacists reach out for a consultation. If high cost is the primary concern, we can help the patient find payment assistance programs, lower cost medication alternatives and lower-cost pharmacy options such as home delivery.

To tackle the problem of prescription drug abuse, Express Scripts looks at more than 290 predictive indicators of fraud to identify potential cases of abuse. Because many prescription narcotics have limits on how much can be dispensed to a patient, we look at the data to find the ways people work around the system, such as the number of doctors visited, or the distance traveled to the physician or pharmacy.

When we identify patterns of abuse, we collaborate with a network of public and private organizations to assist the abuser, and work with the appropriate authorities to bring criminal charges to phantom pharmacies, pill mills, etc. In one year alone, this process enabled us to save the healthcare system an estimated $500 million.

When we focus the power of Health Decision Science on our country’s biggest problems, we gain earlier detection, tailored interventions and ultimately, better patient outcomes and lower healthcare costs.