Merging pharmacy and medical claims data can generate a complete picture of health care usage and spending. At Clinical Pharmacy Services, we identify, analyze, and combine pharmacy and medical claims data using highly developed analytic evaluation processes and tools. One of these tools, Healthcare Explorer™, is a data warehouse and reporting system developed by our affiliate UHealthSolutions.
Improving pharmacy programs through data analysis
Using Healthcare Explorer, our pharmacy analytics staff drills down to the specific cost drivers in your program employing appropriate queries and innovative algorithms. Identifying areas with potential for improvement can make a difference in the cost of your pharmacy program, as well as health outcomes for patients.
Understanding what lies at the intersection of pharmacy and medical claims can provide you with the answers to key questions:
- Are patients receiving the standard of care?
- How often are generic and lower-cost drugs being used as a first-line therapy?
- Are medications being used off-label or inappropriately?
- Do physicians prescribe new or expensive drugs unnecessarily?
- Should new restrictions, such as prior authorizations or quantity limits, be placed on certain medications?
- Are there indications of fraud or abuse?
After reviewing the patterns that emerge from the data, we identify areas in which overall care management can be improved and expensive emergency care avoided. Then, we can help you determine the best course of action. For example, we can help you influence prescribing patterns through PrescriberEdu™, our customized academic detailing service. Or you may want to reach out to patients with a medication therapy management initiative. Our focus is improving health care outcomes — but these services can also help you contain costs.
Studying patterns to enhance program integrity
Our pharmacy analytics staff seeks out utilization trends and discrepancies in data, but our services are far more than basic fraud detection. We use the data to help you assess the current state of your pharmacy programs. Identifying patterns in the following areas can help enhance program integrity:
- Identify prescriber outliers
- Evaluate member outcomes
- Quantify hospitalization rates, including rates of emergency room visits
- Determine areas requiring prescriber outreach and/or education
- List medication classes where generic utilization can be increased
- Predict the effect of various formulary restrictions on cost savings
- Assess diagnosis data specific to the member population