Behavior-driven conditions are greatest contributors to health plan costs

• "9 Trends" Report Identifies What's On the Minds of Employers and Health Plans:
  • Helping Members Make Healthier Decisions
  • Using Social Media and Apps to Engage Members and Improve Behaviors
  • Developing New Ways to Comprehensively Manage Specialty Care
  • Improving Convenience and Adherence through Home Delivery

Poor health choices add billions in cost to the companies, unions, health plans and government agencies that provide pharmacy benefits to Americans. In response, benefit providers are investing as never before to help people make better decisions to improve health outcomes, save money and maintain robust benefits, according to a report issued today by Express Scripts (NASDAQ: ESRX).

According to the fifth annual "9 Leading Trends in Rx Plan Management," more than 75 percent of plan sponsors say behavior-driven conditions are the greatest contributors to plan costs. The report, which polled benefit managers from 318 organizations representing more than nine million covered lives, was conducted on behalf of Medco Health Solutions, which merged with Express Scripts earlier this year.

"This is a broad acknowledgement of how critical addressing behavior is to reducing healthcare costs," said Tim Wentworth, senior vice president and president, sales and account management, Express Scripts. "A vast majority of our clients are now focusing on improving the health behaviors of plan members. This is critical, especially at a time when rising healthcare costs, waste from medication nonadherence and suboptimal health outcomes are making it harder to provide a robust pharmacy benefit."

Concerns with member health behaviors have rekindled an interest in wellness programs. While only 58 percent of respondents report that they currently use a wellness plan, 81 percent say they intend to offer one in the next two years.

Integrated pharmacy/medical data is likely to play an increasing role in identifying members at risk, and coordinating efforts with disease management and wellness vendors. Express Scripts' RationalMed® program uses an integrated data system for proactive patient engagement and has been shown to improve patient outcomes, reduce hospitalizations and lower overall healthcare costs. At least three-quarters of respondents say they intend to employ integrated data programs to support their wellness initiatives within the next two years.

The gap between intended behavior and actual behavior costs plan sponsors, and the healthcare system overall, billions of dollars each year. Last year alone, nonadherence led to more than $317 billion of avoidable medical costs, according to the Express Scripts 2011 Drug Trend Report. Eliminating nonadherence could save enough money to cover the cost of healthcare for nearly 45 million uninsured Americans.

As part of its novel approach to addressing the growing issue of nonadherence, Express Scripts recently launched ScreenRx(SM), a solution that couples a proprietary predictive modeling tool with tailored interventions to increase adherence rates and improve individual patients' health.

While the study found activating healthy behaviors to be a primary area of focus, other insights include:

Plan Sponsors "Like" eCommunicating

The study shows that plan sponsors are rapidly adopting new media tools to better communicate with members. Seventy percent report that they currently use online tools and mobile apps to help members make more cost-effective healthcare decisions and 84 percent intend to use these programs in the next two years. Plan sponsors have turned to these newer, more personalized communication vehicles because traditional member communications, while widely used, are not considered as effective.    

Mail Order Delivers for Clients and Members

In each of the five national peer surveys, at least nine out of ten respondents agreed that home delivery has clear cost and convenience advantages over retail pharmacy. In more recent years, sponsors are increasingly likely to include clinical advantages to the list, and they are far more willing to implement mail-order programs.

The mail channel is perceived to have an advantage over retail in maximizing use of generics (55% to 9%), improving adherence (41% to 21%), reviewing prescriptions (41% to 23%), and dispensing safely (35% to 7%). The research also indicates that the broad spectrum of cost and care advantages appeals to plan sponsors and has led them to promoting home delivery.

Comprehensive Management Key to Addressing Rising Specialty Drug Costs

In the survey, 36 percent of plan sponsors cited "the rising utilization and cost of specialty medications" as the greatest concern in managing their prescription plan. Another 38 percent cited "overall drug costs." Since most of the increase in overall drug cost is being driven by specialty spend, it may well be that these two concerns are different expressions of the same idea.

As a general rule, the larger the plan, the greater the concern with the rising cost of specialty medications. Fifty-eight percent of plan sponsors with over 25,000 members cite rising specialty costs as their greatest concern, compared to just 24 percent of those with fewer than 5,000 members.

Further details on these and other emerging trends have been published in the 2012 edition of 9 Leading Trends in Rx Plan Management: Findings from a National Peer Study.