Health Insurer Plans To Optimize Drug Treatment Using Data Analytics

New Jersey’s largest health insurer has partnered with a biopharma vendor to optimize drug treatment using medical and pharmacy claims data.  Horizon Healthcare Services will work with vendor Aetion to support case management strategies and develop value-based agreements with pharmas targeting specific patient populations.

Aetion is in the business of providing payers and biopharma companies the information they need to participate in value-based care efforts. It delivers evidence based on health data collected from health insurance claims, EMRs, patient-reported outcomes, patient registries and other sources.

The partners will analyze medical and pharmacy claims using data analytics tools to identify high-risk health insurance beneficiaries. Horizon will then develop formulary and drug adherence programs to improve outcomes.

These efforts will spring from the results of an earlier study in which Aetion analyzed Horizon’s population of type 2 diabetics and created a model to predict which were at high risk. By applying machine learning to medical and pharmacy claims data, the vendor was able to identify the optimal treatment pathway for this group.

Researchers concluded that Horizon would get the best results for this group by creating med adherence programs and moving to SGLT2 inhibitors as second-line therapy despite its being more expensive than other second-line drug classes.

Initially, Horizon is rolling out an initial intervention program targeting 1,500 members with type 2 diabetes, an effort which the insurer predicts could generate $5M in savings per year. The health plan is now conducting pharmacy case management programs for its members leveraging what it has learned. In addition, Horizon plans to strike value-based agreements with pharmas for its high-risk members who live with T2 diabetes.

Horizon is one of a growing number of health plans and provider organizations hoping to get more out of their pharma spending by better understanding the needs of patients with high-cost chronic illnesses.

For example, in January UPMC Health Plan and AstraZeneca agreed to a contract under which payment for the drugmaker’s heart medication Brilinta will be related to cardiovascular outcomes among a targeted subgroup of patients.

Another example comes from Geisinger, which struck a deal with Boehringer Ingelheim in which the two would develop a risk-prediction model for three of the most common adverse outcomes for T2 diabetes. The agreement was on behalf of Boehringer’s diabetes alliance with Eli Lilly and Company.

The more skilled health plans and providers become at risk-stratifying their populations, especially those with expensive chronic conditions like diabetes, the more common such agreements are likely to become.

Particularly given the rapid growth in drug costs we’ve seen in recent years, finding ways to get more out of patients’ medication management regimens is likely to remain critically important.  It will be interesting to see just how effective such approaches are at saving money on medications.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.