WellNet in Thompson Publishing Guide

February 2009 | By Todd Leeuwenburgh, Editor, Thompson Publishing Group

Everyone’s heard that old saw: "20% of the population drives 80% of plan costs". If plan sponsors only knew exactly which plan participants are in that 20%, they could head off future acute conditions by managing high-risk conditions early on. But how should one identify those high-risk members?

It seems obvious: Ask plan participants, and analyze what prescription drugs they are taking, vendors and other experts tell the Employer’s Guide to Self-insuring Health Benefits ("Guide").

Bethesda, Md.-based WellNet Healthcare says prescription drug utilization data can identify those high-risk plan members. This will allow plans to understand their treatment needs, budget for those needs down the road, and adopt management strategies to change member behavior.

Predictive modeling software marketed by WellNet enables self-funded plans to use pharmacy benefit data to manage the plan as a whole. Based on the insights, plans may adopt strategies — such as chronic care management and wellness programs — to improve member health and manage utilization.

Many businesses use predictive modeling to build a picture of health risks, but only with medical data after the fact, company executives said. Claims processors and third-party administrators deliver data quarterly, but that’s often too late for the employer to take preventive action. Drug data enable the plan to micromanage care based on daily information.

Using Rx as the Leading Predictive Indicator
The advantage is that Rx data enables self-funded plans to manage benefits before expensive charges hit the system. And since drug claims come in faster than medical claims, companies can act more proactively. “It’s a window into the future,” WellNet Healthcare President Keith Lemer tells the Guide. The data analysis can also help the employer create personalized treatment plans and wellness initiatives.

WellNet executives say that drug data is 95% accurate at forecasting future risk. Analyzing drug utilization helps planning for the next three to five years, the company says. “Learning what’s driving costs in your health plan is not the same as shopping for vendors,” Lemer says.

Today’s Rx Data Reveals Tomorrow’s Risk
In a demonstration for the Guide, WellNet executives showed how the software sifts though a hypothetical 1,460-member self-funded plan to find the people who are most at risk. Without betraying patient privacy, the software found:
-Thirty-two employees who were at high risk of incurring major medical expenses soon. Those employees had an average of nine conditions.

-Two hundred and sixty-three employees were at medium risk. Those members had an average of five conditions each.

-That the total anticipated cost of high- plus medium-risk patients was $4.3 million to the plan, but it could go as high as $20 million.

The program revealed conditions that are most prevalent, and in this case they were: allergy/immunology, cardiovascular conditions, infections, and skin and respiratory problems. The software broke down these broad categories to more specific clinical conditions. For example, under cardiovascular, the software identified patients at high risk for high blood pressure, lipids, vascular disorders and congestive heart failure.

Software Lets You Tinker With the Plan
After the initial analysis, the software enables plan managers to plug in limited plan design changes and estimate outcomes. The design changes are mostly drug benefit tweaks like generic conversions, switches to OTC medications and mail order.

WellNet’s Plan Simulator gives plan sponsors a look at the impact of changes in drug plan design. It will predict savings from switching to generics and/or mail order.

Plan sponsors can also apply case management and other means to encourage treatment compliance, but the software will not predict impact in advance for these measures.

After 120 days with the design variation, the software measures results over time. It estimates what medical claims volume would have been without the intervention to claims volume since analysis and management strategies were applied.

The software highlights new prescriptions; those indicate a new diagnosis, and signal that it is the right time to reach out to the patient and maybe renew care management efforts on that person for the new diagnosis.

The approach builds on the self-funding plan’s access to data that insured plans don’t have. Insurers and PBMs do not share raw utilization data, because if inner workings remain secret, employers cannot question double digit cost increases, Lemer tells the Guide. WellNet’s program promises to fill in that transparency gap, he says.

Networking Software and Managing Health
Networking software takes the transparency further. “Point to Point Healthcare” offers online tools that connect employees to their utilization data, keeps track of health appointments, allows instant messaging with providers, and helps the employee create a network of providers he or she usually confers with.

Point to Point requires participation by the patient’s caregivers, by no means a given. Right now caregivers are invited to participate, but participation is voluntary.

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