What You Should Know:

– Prescryptive Health, a leading healthcare technology company, today announced the National Community Pharmacists Association’s (NCPA) renewed endorsement of Prescryptive AI Pricing. 

– Prescryptive AI Pricing creates a dynamic and competitive cash pricing system, enabling independent pharmacies to thrive in the ever-evolving healthcare landscape. This AI-powered solution empowers independent pharmacies to optimize cash pricing and enhance their competitive edge.

NCPA Recognizes Value of AI for Pharmacies

NCPA first recommended Prescryptive AI Pricing in 2022, acknowledging its potential to revolutionize cash pricing strategies for independent pharmacies. This renewed endorsement underscores NCPA’s ongoing commitment to supporting its members with innovative solutions.

Data-Driven Profitability: AI Delivers Results

Prescryptive Health recently released compelling data highlighting the significant profitability improvements pharmacies experience with Prescryptive AI Pricing. Their analysis revealed an impressive gross profit margin of nearly 54% in 2023 for pharmacies utilizing the solution.

Independent Pharmacies in a Cash-Driven Landscape

The rise of high-deductible health plans has led to a significant increase in cash-paying customers at pharmacies. Traditional cash discount cards often result in financial losses for pharmacies. Prescryptive AI Pricing offers a powerful alternative.

AI-powered Cash Pricing Optimization

This innovative solution leverages a pharmacy’s own data and customizable parameters. Advanced analytics and actionable insights empower pharmacies to strategically position themselves within the cash pricing market.

“As the voice of the community pharmacist, we know the major headwinds that America’s community pharmacies are facing,” said Douglas Hoey, CEO of NCPA. “As our community pharmacies battle reimbursement challenges, our NCPA member pharmacies can use Prescryptive AI Pricing to remain competitive while also continuing to do what they do best: take care of their patients.”

What You Should Know: 

– Walgreens, a leading pharmacy chain, is making a significant push into the specialty pharmacy market with the launch of “Walgreens Specialty Pharmacy.” 

– The new $25B initiative expands access to care for patients with complex, chronic conditions while driving profitability for the company.

Walgreens Specialty Pharmacy: A Holistic Approach

Walgreens Specialty Pharmacy aims to break down barriers within the healthcare system. By leveraging Walgreens’ existing network of trusted pharmacists and strong community presence, the program offers convenient access to hard-to-find medications while providing critical adherence support. This comprehensive care model empowers payers to better manage specialty drug costs. 

Walgreens Specialty Pharmacy goes beyond medication dispensing; it offers a comprehensive suite of services designed to improve patient outcomes. This includes:

• Gene and Cell Therapy Services and Innovation Center: A dedicated center in Pittsburgh, PA, equipped to handle the complexities of gene and cell therapies, including supply chain management, logistics, and financial assistance.
• Central Specialty Pharmacies: Four central pharmacies with nationally recognized accreditations house expert pharmacists and care teams focused on dispensing complex medications and managing chronic or rare conditions.
• Extensive Network of Community Pharmacies: Walgreens boasts the most extensive network of community-based specialty pharmacies in the nation, conveniently located near medical centers to provide faster access to medications. These pharmacies also offer services like injection training, medication side effect management, and financial assistance coordination.
• Specialty-Trained Staff: Over 1,500 specialty-trained pharmacists, 5,000 patient advocacy team members, and dedicated Specialty360 teams create a comprehensive support system for patients across all specialty conditions and therapies.
• Wide Range of Medications: Access to a growing list of 240 limited distribution drugs, including exclusive options and medications in narrow networks.

Integrated Care for Patients Who Need It Most

Effective August 1st, 2024, AllianceRx Walgreens Pharmacy will transition to Walgreens Specialty Pharmacy. Existing patients will gain access to a wider range of resources, including disease-state experts, nutritionists, and care nurses. Additionally, patients can now view their entire prescription profile, including both specialty and retail medications, at Walgreens. Walgreens’ subsidiary, Shields Health Solutions, a leader in specialty pharmacy acceleration for health systems, will continue to support health system specialty pharmacies, complementing the expanded offerings of Walgreens Specialty Pharmacy.

“With approximately $24 billion in annual enterprise specialty revenue, Walgreens Specialty Pharmacy is the largest independent provider that offers the industry’s most robust specialty capabilities not vertically aligned with a pharmacy benefit manager,” said Rick Gates, chief pharmacy officer, Walgreens. “We have the flexibility to contract dynamically with any payer. We can partner directly with pharmaceutical manufacturers to facilitate products to market, including limited distribution drugs, and coordinate closely with providers to ensure patients experience a smooth start to treatment.”

What You Should Know:

– Eli Lilly and Company (Lilly) and Amazon Pharmacy today announced a strategic collaboration to improve patient access to GLP-1 medications for diabetes, obesity, and migraines.

– The partnership aims to improve access to these treatments and empower patients with the support they need to manage their chronic conditions.

Addressing a Growing Need

Millions of Americans struggle with diabetes, obesity, and related conditions.  Nearly one in three adults (approximately 98 million) have prediabetes, while 40 million have diabetes.  Additionally, over 40% of U.S. adults are considered obese. Treatments for these conditions hold promise, but access to newer medications can be limited.

LillyDirect and Amazon Pharmacy: A Convenient Solution

Through LillyDirect, a platform connecting patients with healthcare providers and pharmacies, patients can now receive select Lilly medications delivered directly to their homes via Amazon Pharmacy. This partnership offers several benefits:

• Fast and Free Delivery: Patients can receive their medications quickly and conveniently, with free two-day delivery for Prime members.
• 24/7 Clinical Pharmacist Support: Amazon Pharmacy’s team of clinical pharmacists provides patients with ongoing support, including medication review for accuracy, guidance on administration techniques, information on drug interactions and side effects, and cost considerations.
• Enhanced Medication Adherence: Pharmacists can also offer medication reminder tools to help patients stay on track with their treatment plans.

Multiple Options for Prescriptions

Physicians can send prescriptions to either LillyDirect Pharmacy Solutions or directly to Amazon Pharmacy. For a complete list of Lilly medications available through LillyDirect, visit https://lillydirect.lilly.com/medicines. For more information about Amazon Pharmacy and its medication offerings, visit their website at https://pharmacy.amazon.com/.

What You Should Know:

• Waltz Health, a digital health company developing smarter, technology-enabled ways to price, distribute and prescribe medications, today announced its entry into the Medicare market.
• The company will offer health plans that support Medicare beneficiaries customizable configurations of its proprietary Marketplace Search technology, which lowers prescription drug prices for members and improves their experience, while also providing health plans with critical insight into adherence trends.

Marketplace Search Revolutionizes Medicare Prescription Assistance

Waltz Health’s Marketplace Search is a customizable digital search engine leveraging AI technology, designed to optimize discounted drug pricing for various healthcare organizations such as health plans, PBMs, pharmacies, and self-insured employers, thereby enabling significant cost savings for their populations during prescription fills.

For health plans catering to Medicare beneficiaries, the utility of Marketplace Search varies based on individual requirements and member challenges. It serves as a robust and user-friendly tool empowering health plans to assist members in discovering savings on covered medications during coverage gaps, identifying cost-effective cash-pay alternatives for uncovered medications, and accessing patient-assistance programs tailored to the Medicare demographic.

The struggle with out-of-pocket drug expenses affects millions of Medicare beneficiaries annually, particularly underserved groups. Despite the availability of cash-pay options and patient assistance programs to alleviate member costs, these solutions are often obscure. Marketplace Search addresses this issue effectively, presenting a valuable platform that significantly benefits health plan members.

SCAN Health Plan, a prominent nonprofit Medicare Advantage provider, leads the way as the first payer to adopt a customized iteration of Marketplace Search specifically tailored for Medicare use cases.

Waltz Health’s bespoke tool serves as an online hub where eligible Medicare Part D members, entering a coverage gap, can explore prescriptions available at reduced cash-pay rates or through local pharmacy-based patient assistance programs. This marks the second distinct deployment of Waltz Health’s technology since its expansion into the payer, PBM, and self-insured employer sectors in September. While the initial deployment of Marketplace Search for Health Plan targets the commercially insured demographic, this subsequent deployment extends its reach to address the needs of Medicare beneficiaries.

Apart from its recent deployments within the health plan realm, Waltz Health has introduced unique iterations of Marketplace Search in four national pharmacy chains, spanning thousands of locations nationwide. These deployments have yielded average savings per prescription ranging from $5 to $10 more than alternative single prescription drug savings card solutions. Concurrently, the company is developing a specialty-drug solution for health plans aimed at enhancing transparency, reducing medication costs, elevating member experience, and ameliorating health outcomes for intricate specialty conditions, which constitute the fastest-growing segment of prescription spending in healthcare.

“Our tailored versions of Marketplace Search empower the members of Medicare Advantage plans with more choice and information when they’re searching for better prices on their prescription drugs, delivering savings for them and helping the plan with member retention,” said Waltz Health CEO and Co-founder Mark Thierer. “We’re honored to be working with such prestigious Medicare-focused health plan partners and look forward to helping them solve more unique use cases like coverage gaps.”

What You Should Know:

– Drug-drug interactions, a silent threat lurking in medication charts, can cause significant harm and even death. Yet, despite their prevalence, little is known about how doctors identify and manage these risks in real-time.

– A recent groundbreaking study sheds light on this crucial yet under-examined process, offering valuable insights to improve patient safety.

Unveiling the Decision-Making Maze

Led by Dr. Michael Weiner and Dr. Alissa Russ-Jara, the research team meticulously analyzed doctors’ thought processes while navigating potential drug interactions. Their work focused on “positive cases,” instances where doctors successfully identified and mitigated an interaction risk. This deep dive revealed 19 key cognitive cues doctors rely on, including:

• Severity Assessment: Doctors weigh the potential severity of the interaction, considering the type and duration of side effects, and the patient’s specific vulnerabilities.
• Patient-Centric Approach: Medical history, existing conditions, and the patient’s individual needs for each medication heavily influence decision-making.
• Seeking Alternatives: Exploring safer medication options, adjusting dosages, or even stopping one medication are all potential solutions doctors consider.
• Patient Education: Empowering patients to recognize warning signs of adverse reactions is a crucial part of risk mitigation.

Beyond Alerts: Designing for Real-World Decisions

The study goes beyond simply understanding doctor’s thinking; it offers concrete recommendations to improve electronic health record (EHR) systems, the primary source of drug interaction alerts. These recommendations include:

• Timely and Actionable Information: Alerts should clearly convey the time frame of potential interaction effects, enabling doctors to prioritize risks with immediate consequences.
• Side-by-Side Comparisons: Providing easy access to alternative medications within the alert itself, alongside relevant patient characteristics, can streamline informed decision-making.
• Smart Alert Displays: Leveraging data analytics to present tailored suggestions for alternative drugs based on the doctor’s specific evaluation criteria can significantly decrease cognitive load and improve efficiency.
• Patient-Focused Recommendations: Alerts should go beyond simply highlighting a risk; they should offer concrete suggestions for patient engagement and monitoring, empowering both doctors and patients to actively manage the situation.

A Roadmap for Safer Treatment

This study represents a significant step forward in the fight against drug-drug interactions. By demystifying doctors’ decision-making processes and offering practical solutions for EHR improvements, it paves the way for a future where these silent threats are effectively identified and mitigated, ultimately leading to safer, more informed treatment for all patients.

“Drug-drug interactions are very common, more common than a lot of people outside the healthcare system expect. In the U.S., these interactions lead to hundreds of thousands of hospitalizations in any given year at an enormous cost,” said study senior author Michael Weiner, M.D., MPH., of U.S. Department of Veterans Affairs, Regenstrief Institute and Indiana University School of Medicine. “Most of these drug interactions are preventable.

“This study was needed because we previously didn’t have a great understanding of how clinicians make decisions in assessing these interactions. No one had really taken apart the thinking process step-by-step to understand it from the beginning to the end. There’s a patient, there’s a drug and another drug. There is now a potential interaction. There’s been a decision about how to resolve it following an assessment and then a resolution process. Understanding all this is very important if we are hoping to design improvements to the medical system that enhance patient safety.”

What You Should Know:

– Prescriptions for the popular weight loss drug Wegovy showed a six-fold increase between December 2022 and June 2023, according to a recent analysis of prescribing trends by DrFirst.

– Prescriptions for Ozempic, the lower-dose version for treating diabetes, increased by 65% during the same period among doctors on the DrFirst prescribing network.

– DrFirst’s network includes over 350,000 prescribers across the U.S., including 260,000 doctors, who use their prescribing apps and solutions to transmit prescriptions.

Overall Semaglutide Prescriptions

There was a 150% increase in semaglutide prescriptions on DrFirst’s network in the last year, along with an 80% increase in prescriptions written per provider. Generic Medication: Ozempic and Wegovy have different names, dosages, and indications, but they are identical in terms of their molecular makeup, known as the generic medication semaglutide, and both are manufactured by Novo Nordisk. Semaglutide helps regulate the body’s secretion of hormones, such as insulin, while slowing stomach emptying and reducing hunger signals in the brain.

Prescribing Trends by Specialty

Primary care providers, including general and family practice, internal medicine, and obstetricians/gynecologists, were among the top prescribers of semaglutide. Endocrinologists wrote the most semaglutide prescriptions on DrFirst’s network.

Impact of Obesity and Diabetes Prevalence on Prescribing Trends

The CDC reports that approximately 42% of American adults are obese, and the prevalence of obesity is expected to rise globally, with about a quarter of the world’s population projected to be obese by 2035. Additionally, nearly 10% of Americans are estimated to have type 2 diabetes. The analysis indicates a notable change in prescribing trends following the availability of effective medications like semaglutide for patients with obesity and type 2 diabetes.

Prior to December 2022, there was a relatively steady rate of prescriptions for Ozempic and Wegovy, with a significant surge occurring in December 2022 and continuing in the present time. The data reveals an increase in the prescriptions of other oral diabetes medications during the same period, albeit to a lesser degree.

Early next year, the Centers for Medicare and Medicaid Services (CMS) will remove the application of retroactive DIR fees and move DIR fees to the point of sale instead. The major issues with the DIR fees, which are paid by pharmacies to pharmacy benefit managers, are the fact that they drive up the costs of prescriptions for patients and delay reimbursement of care to the pharmacies. 

Now, a brand new issue will arise in early 2024 – namely, pharmacies will be facing a DIR “cliff” where they will be required to pay double DIR fees: one large chunk retroactively at the end of 2023 and point-of-sale DIR fees beginning January 1, 2024.

The rapid evolution and advancement of artificial intelligence (AI) have recently positioned it as a groundbreaking tool for transforming healthcare. With its problem-solving capabilities, enhanced processes, and extensive knowledge base, AI possesses tremendous potential to revolutionize the industry. It even has the potential to be an advantage to pharmacies once the change in DIR fees is put into effect.

We recently spoke with pharmacy market expert and CEO at DocStation, Samm Anderegg, to learn more about how pharmacies can use AI to their advantage after the new rules surrounding DIR fees are implemented next year.

Why is AI adoption so critical for pharmacies once the DIR fee changes take effect?

Samm Anderegg, CEO at DocStation: I would argue that pharmacies, more than any other healthcare professionals, are being asked to do more with less. The forthcoming DIR cliff, happening January 1st will be yet another regulatory change demanding pharmacies to delve deeper and find ways to adapt. In this context, the adoption of new technology and automation is more critical than ever for pharmacies. We have to find ways to make our administrative processes more efficient to free up time to focus on revenue-generating activities.

Pharmacies can leverage AI to both automate workflows and unlock new revenue streams. Within our own organization, we are actively using AI to streamline our software development processes. We have implemented AI within our platform to help pharmacies generate claims automatically based on services rendered. For example, DocStations’ AI-powered Auto-Billing empowers pharmacies to efficiently bill to the medical benefit with maximum payout confidence, increasing revenue potential as well as reducing administrative burden by 80%.  

What are some AI best practices to improve the costs of prescriptions and increase pharmacy profits?

Samm Anderegg: I would challenge you on this question. My opinion, and that of others in the industry, is that the ship has sailed on the prescription side of the pharmacy business. Dispensing medications is basically a “loss leader” at this point, but a great way to drive clinical services revenue for pharmacies. 

Think about it. Pharmacies possess a loyal clientele, constantly seeking their guidance and relying on their expertise to maximize the benefits of their medications. That includes helping them find the most effective therapies at the lowest costs. 

What’s truly intriguing is the potential of harnessing AI for formulary optimization. Let’s say a patient is currently prescribed a non-preferred drug as per their pharmacy benefit. By utilizing formulary data provided by the plan, we can identify a therapeutic equivalent that offers the lowest co-pay or cost-share for the patient. This approach aligns everyone’s interests seamlessly. In this scenario, the pharmacy would be paid by the payer to make the formulary switch, the payer saves money on pharmacy spend, and the patient spends less out-of-pocket. That’s a slam dunk right there.

What are some of the barriers/challenges pharmacies will face when adopting AI solutions?

Samm Anderegg: I think healthcare as a whole faces challenges in adopting AI. The potential of this technology is limitless, with boundless use cases and applications waiting to be explored in the realms of healthcare and pharmacy. The biggest challenge, in my opinion, is implementing solutions in a way that actually makes things faster, easier, and better for providers and, ultimately, for patients. This comes down to workflow. 

For example, pharmacies may operate a prescription business using one core pharmacy management system. That’s an opportunity. Now, I can work with my vendor to implement automation and experience the benefit of AI-powered features that make my job easier. 

The challenge here for many technology companies in our industry is that the technology itself is dated. A lot of software runs locally on a server installed at the pharmacy. It’s harder to push updates than if it were, say, running on the cloud. It’s tough to find engineers and product people with knowledge of machine learning and artificial intelligence. And the ones that do understand AI and machine learning are being scooped up like crazy by OpenAI, Google, Microsoft, and Apple.

It’s going to be tough for pharmacies to keep track of all the technology advancements and navigate the jargon of companies’ marketing features that use AI. What it comes down to is this: Does this solution make my life easier? Does it grow my revenue? Do my staff enjoy using it?

Finding trusted peers and partners to help you navigate through all this will be critical.

What opportunities will AI offer the pharmaceutical industry to make further progress concerning PBMs and their DIR fees?

Samm Anderegg: There’s only so much we can do to combat shady PBM practices and DIR fees. But I can say this: We’ve been playing defense for far too long. We need to start playing offense and look to alternative revenue streams that unshackle pharmacies from PBMs and put us, the healthcare providers, back in the driver’s seat. 

I think that shift to offense starts with understanding what our differentiators are as providers. And particularly, as providers who are ubiquitous in rural and underserved communities across the country. Using AI, we can be in a position to work directly with payers and support pharmaceutical manufacturers on quality and cost initiatives that drive ROI for the entire healthcare system writ large.

About Samm Anderegg 

Samm Anderegg, PharmD, MS is Chief Executive Officer at DocStation. A pharmacist by training, Dr. Anderegg started his tech career in consulting. He has served as an advisor for leading national pharmacy associations and trade groups, building data standards for interoperability and quality measure reporting now used by the Centers for Medicare & Medicaid Services. With more than a decade of business and leadership inside and outside of healthcare, Samm leads a team of talented executives to guide strategy to achieve the overall vision of our company.

Large employers report that the biggest threat to self-funding medical coverage is the increasingly high cost of pharmacy claims. In their annual Health Benefits Priorities survey, MBGH found that employers consider pharmacy costs extremely problematic. Ninety-one percent of employers cited million-dollar treatments approved by the FDA, and 89% pointed to specialty drug spending as a top threat.  

Source: PSG 2023 Trends in Specialty Drug Benefits Report

Employers already pay too much for pharmacy; according to Kiplinger, drug costs will shoot up another 10% this year, the biggest increase in a decade. Employers are right to be concerned.

The problem is that controlling drug costs is complex, and the primary efforts to lower the costs have centered around unpopular programs like prior authorization and employee-centered apps. Neither addresses the fundamental problem behind high drug spending – prescribers.

The Commonwealth Fund pinpointed three main reasons why waste is built into the usual prescription process:

1. Physicians often don’t know the cost of medications; they simply prescribe them out of habit. Physicians say it takes too much time to figure out which drugs are within the formulary and which are lower priced. The process is frustrating for themselves, pharmacists, and patients.
2. Because of misaligned incentives with the PBM and the employer, rebated drugs on the formulary may cost more than an equivalent drug used to treat the same condition. In addition, the full discount of the rebate may not be going to the plan and the employee, raising costs for both. Price “spread,” which is the delta between what they spent on medicine and what they charged the self-insured employer, also adds cost. This spread delta grows as the drug cost goes up. 
3. Employers do not want to risk upsetting employees, so they allow low-value, high-cost drugs onto the formulary, which then get prescribed. Some of these drugs include:

1. “Me-too drugs”: Basically, the same drug formula as the original but with inconsequential differences to extend patent protection.
2. “Combination drugs”: Creating a new patent by combining two active ingredients into one pill.
3. “Brand-name drugs”: Using the brand version when a lower-priced version is available.

To date, employers have tried many strategies to control drug costs – mainly by placing the burden on their employees. They assume that by giving employees more information and more tools, they will get lower-cost prescriptions. But this tactic doesn’t necessarily guarantee savings. When offered health apps to find lower-priced drugs, few employees use them. These apps introduce the need to download, register, research, and essentially do their physician’s job – making prescribing decisions!

The net result is that employees feel overwhelmed with all the “help”: they simply want their doctors to prescribe lower-priced medications when they are available. 

Employee Experience: Role confusion.

“I feel bogged down researching alternative medications, figuring out how much they cost, determining which pharmacy has it, what each one charges, and on and on. Why am I doing the homework? Isn’t this why I am paying the people who went to med school? 

Employee experience: App frustration.

“I had a hard time with the prescription app. I am taking six medications, and it takes a lot of time to go through each one. Each medication has three or four different options, and I don’t really understand the choices. I decided not to use the app and just call the pharmacist.”

Employee experience: Information overload.

“I have health apps through my plan, and they all communicate A LOT. I’ve tried to turn off alerts. I can’t figure it out. The apps don’t communicate with each other or my health plan. There is too much coming at me. I am just one me. I want my plan to make this easier and bring my health information from all these disparate places together and manage it. Then, alert me once without trying to force me to do something. All these reminders! I feel bullied constantly. If my insurance and doctor could take something off my plate, that’s good for me! Just do it.”

Seventy-seven percent of patients said in a recent poll that they want their healthcare professional to prescribe the cheapest drug automatically (77.6%). Further, when asked if they would have a more favorable opinion of their health plan if it offered a lower-cost drug benefit, more than 80% said “Yes.”

Employees stress about how much health information they receive, and the number of health decisions placed upon them. The American Academy of Physician Associates (AAPA) poll identified a major pitfall in patient experience: care coordination feels like a second job for many. 

Despite this sentiment, technology in healthcare continues to overwhelm and overload consumers. Instead of making it easier to get and stay healthy, they must learn medicine and play doctor. But if the burden is to fall on the physicians, they need tools and tactics that integrate into their standard workflow.

Physician experience: Dr. Mohan on the difficulty of prescribing the lowest cost medication. 

“I see this daily. A patient will call, very upset, after going to the pharmacy and hearing how much the medication will cost. We do the research in our clinic to prescribe the lowest-cost option, but every person’s formulary is different. The pharmacy they go to matters. There are a lot of variables. We get on the phone with the pharmacy to test out the cost of each option. It’s slow going. Health insurers also offer apps and websites, but this often adds confusion to the process. There is a better way to prescribe than trial and error.”

Using HealthTech to Manage Pharmacy Costs

To solve wasteful prescribing problems, self-funded companies are turning to AI-driven solutions that engage prescribers directly, giving them the information and the choice to effortlessly switch their patients off higher-priced prescriptions and onto more affordable therapeutic equivalents.

The engagement process for employees is important to ensure they understand that the savings lower their out-of-pocket pharmacy costs. Prescribers are then engaged and recruited as partners to help lower drug costs for their patients instead of playing a guessing game about what drugs are covered for their patients.

When a prescriber-driven switch is approved, the employee is notified that their physician prescribed a lower-cost medication. Employees have the option to accept or reject the medication change though less than 1% opt out of the change. Data shows that employees working directly with their physician on medication choices have higher adoption rates than those using a 3rd party app.  

With excellent communication and frictionless engagement, employees readily see the value and appreciate the savings. Employers take control of the biggest threat to employer-provided medical coverage: high-cost pharmacy claims. Using technology to solve intractable problems is the best way to stabilize pharmacy budgets.

About Constance Sjoquist

Constance Sjoquist is a Senior Healthcare Analyst at RazorMetrics. Prior to joining RazorMetrics, Constance was Chief Transformation Officer at HLTH, where she helped create from the ground floor the largest and most important conference for health innovation. As one of the primary architects in shaping the voice and creating the agenda for a new conversation on how to improve health, Constance leveraged her cross-industry insights into a robust platform for market disruption and industry transformation. During her tenure, HLTH grew from just a concept to one of the leading industry events with over 7,500 senior leaders spanning every corner of health – payers, providers, pharma, employers, policy-makers, investors, startups, suppliers, retailers, analysts, and associations – and focused on creating the future of health.

What You Should Know: 

• Kalderos, a data infrastructure and analytics company, identified nearly $1B in inaccurate drug discount requests from 2016-Q1 2023 on its drug discount management platform.
• The report, titled “Mission Critical: Bringing drug discount stakeholders together so patients win,” outlines Kalderos’ vision for a new paradigm of cooperation among drug discount program stakeholders in which everyone benefits — particularly patients.

Rising Costs of Inaccurate Drug Discount Claims

As the Medicaid Drug Rebate Program (MDRP), 340B Drug Pricing Program and other similar programs expand, so do the volume and cost of duplicate discounts and other inaccurate drug discount claims. Across the healthcare industry, outdated technology, inadequate infrastructure and intractable data silos make it difficult to prevent these misapplied discounts, resulting in drug manufacturer overpayment. 

In response to this systemwide challenge, Kalderos’ MDRP Discount Monitoring solution analyzes and validates claims data while flagging potential duplicate discounts and other inaccurate claims. Between 2016 and Q1 2023, Kalderos’ MDRP Discount Monitoring solution identified nearly $1 billion in inaccurate discount requests. As Kalderos partners with an increasing number of drug manufacturers to process even bigger data sets, that number continues to grow.

Other findings in the report

• Kalderos identified an average of 5% potentially inaccurate discounts among drug manufacturers, mainly duplicate discounts between Medicaid (MDRP) and 340B (Some assessments identified more than 10% potentially inaccurate claims, some as low as 2%.)
• With Medicaid collecting more than $42 billion in drug manufacturer rebates in 2021, the resulting revenue leakage costs manufacturers billions of dollars each year
• Saw 5% ineligible rebates across commercial programs

“The findings in our third annual report are significant,” said Kalderos CEO Brent Dover. “We urge all stakeholders in drug discount programs to work together on building cooperation and trust. Full transparency and information are mission critical to attaining these goals and enabling our healthcare system to better serve patients.”

In IBM’s 2022 Cost of a Data Breach report, the company revealed that the global average cost of a data breach was $4.35 million. In the healthcare sector, however, that number skyrocketed to $10.1 million. Why is an attack on a healthcare organization so much more costly? While part of this comes down to the fact that healthcare organizations often have big budgets, and so might be able to pay big ransoms, the biggest part of the answer is consequences. In there, real lives are at stake. Downed systems don’t just mean a loss of profit, it means a loss of life. Faced while the choice of paying up or letting people die, the decision to pay a ransom is not a hard one, even if the asking price is very large indeed.

State of the Industry

The healthcare industry is a particularly attractive target for ransomware for two main reasons. First, irrespective of benefits, healthcare companies tend to be large businesses with large balance sheets. Total expenses for U.S. hospitals reached above one trillion dollars in 2022, indicating that on any given day, a massive amount of money is flowing in and out of hospitals nationwide. For cybercriminals, this means an easy target with an almost-guaranteed payout to some degree. 

Second, healthcare is an extremely vital industry for humankind. For many organizations in other verticals, ransomware may be a “pay up or go offline” situation. Devices may be taken offline and productivity may slow temporarily, but ransomware is a temporary setback- organizations may even take their time coming up with a way to circumvent payment. For healthcare, however, time is not on the side of the organization. The effects of a ransomware attack are far more useful for criminals when actual lives are on the line.

The deeper problem is that as long as healthcare organizations have to keep paying ransomware to save lives, criminals will keep attacking- it’s, unfortunately, part of the overall risk factor for these providers. 

A Different Breed of Risk

However, it’s not just the attractiveness of the target that keeps criminals attacking healthcare organizations- it’s also the risk profile of the average healthcare employee.

More than most other industries, we see extremely high mobility of staff within healthcare. Across many healthcare businesses, we see a substantial contingent of staff that are out in the field or is more mobile within their office space. Doctors and nurses are constantly on the move, even if they never actually leave the hospital. Many devices become mobile out of necessity. This creates a physical risk of device loss or theft, increasing the need for a strong, resilient connection and the ability to track or wipe a device should it be stolen. 

Additionally, healthcare data is extremely valuable to criminals. This isn’t simply because of the deeply personal nature of the data. It is because it’s a trove of extremely valuable Personal Identifiable Information (PII) point of view. This sort of personal information is just what cybercriminals need to get the answers to personal questions connecting bank accounts, site logins, and more. 

Finally, healthcare systems are often large and interconnected – if security is not ironclad, criminals can rapidly gain the ability to move from end-user laptops to departments like billing, to the pharmacy, to control systems – always finding the weakest link as long as a valuable target exists. This creates an endless game of ‘whack-a-mole’ for healthcare IT teams, where the objective is to simply become less of a target while routing out malware infections across a wide range of systems. 

Overall, with their large attack surface, interconnected systems and highly valuable data, devices in healthcare settings are a perfect target. They are also a perfect use case for a zero-trust network access approach to security. 

Reducing Risk

Risk is usually defined as the product the probability of a successful attack and the impact of the attack. Protecting your organization to minimize the chances of success is the cost common way people try to reduce risk, but it has its limits. No organization is ever going to be perfectly protected. This means that in most cases the best way to minimize risk is by being ready for an attack so that you can minimize its impact. This means that IT teams must find ways to get their organization to a point where it’s possible to recover without paying. This allows them to break the vicious cycle: as long as attacks lead to payments then payment will lead to more attacks. Breaking the cycle is crucial because if you can’t, then no matter how strong your defenses are, criminals will just find a different part of your business to attack. The ultimate goal is to get to a point where if your organization is ransomed it’s only a minor setback – you have the safeguards and backups to minimize the blowback. When you’re able to recover without paying then you win. Criminals aim to attack where the ROI is the greatest – if you reduce don’t need to pay then they’re more likely to move on. 

In the case of ransomware, minimizing impact means being able to restore your systems to the pre-attack state as quickly and efficiently as possible. Naturally, to do this you need to have backups, but you need more than that if you want a rapid response, especially when you have a mobile workforce. What you need is remote control of the devices and you need remote control tools that will survive a complete, clean slate reinstall of the systems. Surviving a reinstall is crucial because, in an ever-changing world of malware infections, it’s often impossible to be sure that you’ve successfully removed the infection without completely wiping the entire disc. The ability to bounce back in the face of an attack, what IT and Security people call “resilience”, is one of the most effective tools you can deploy to minimize the overall risk from ransomware attacks.

Importance of Forward-Planning

Reducing risk is impossible without a forward-planning, but with a little foresight, healthcare organizations can dramatically reduce the risk from ransomware attacks. The key to this is to balance existing cybersecurity techniques to help prevent attacks with cyber-resilience techniques to help IT teams bounce back. Everyone in healthcare knows that no matter how young and healthy you may be, health insurance is a necessity if you want to get healthy again when illness happens. Cyber-resilience is just the same; if you want to keep your systems healthy you don’t just need to practice good hygiene, you need to ensure that you can get prompt and effective treatment when an infection happens. That way your organization can spend less time and energy keeping PCs healthy and more time keeping the humans healthy!

About Nicko van Someren

Nicko van Someren serves as Chief Technology Officer at Absolute Software, where he oversees the direction and strategic vision of Absolute’s product architecture and security roadmap. He has more than two decades of experience leading, developing and bringing to market disruptive security technologies. Prior to his role at Absolute, Nicko served as Chief Security Officer and Chief Information Officer at nanopay, Inc, a financial services technology company. He has also served as Chief Technology Officer at the Linux Foundation, Good Technology (now a part of BlackBerry) and nCipher (now a part of Entrust Datacard) as well as the Chief Security Architect at Juniper Networks.

Nicko also serves as a board member and advisor for numerous startups and is a mentor for the Techstars accelerator program in Boulder, CO. He has a PhD from the University of Cambridge and fellowships from the Royal Academy of Engineering and British Computer Society.

What You Should Know:

• AmerisourceBergen (AB), a global healthcare company, has announced a strategic partnership with SteadyMD, a B2B telehealth infrastructure provider for the co-creation of a telehealth solution focused on Test to Treat opportunities. The solution is being offered as a pilot to independent community pharmacies across the US.
• In addition to the commercial partnership, AmerisourceBergen has also made a minority investment in SteadyMD through its venture fund AB Health Ventures.

Test to Treat Pilot

AmerisourceBergen’s telehealth solution is being developed to expand the number of Test to Treat services that independent pharmacies can offer to patients. The Test to Treat initiative was launched in 2022 to help provide quick and equitable access to COVID-19 testing and treatment in the early days of infection. The model is intended to provide a seamless patient experience and designed to reach high-risk, underserved populations.

With its telehealth solution, AmerisourceBergen is evaluating the long-term viability of the Test to Treat model for use cases, beyond COVID-19, to improve access to treatment. The pilot program has been launched across a group of 130 independent retail pharmacies, including members of the Good Neighbor Pharmacy network. Over a span of 12 weeks, pilot participants will utilize the SteadyMD platform to provide patients with a quick and accessible Test to Treat option within their pharmacy, at an affordable price. Patients can test for an illness or condition and then, if deemed necessary by a SteadyMD physician, consult with them on demand through the telehealth platform and receive a prescription for treatment.

Pharmacies participating in the telehealth pilot program can use the solution to help patients obtain COVID-19 oral antiviral therapies, as appropriate. AmerisourceBergen and SteadyMD will continuously evaluate opportunities to expand use cases during and after the program.

“The Test to Treat initiative is an important acknowledgement of the role of pharmacists and pharmacies as accessible healthcare providers and destinations,” said Jenni Zilka, Senior Vice President, Good Neighbor Pharmacy Field Programs & Services at AmerisourceBergen. “In order for pharmacies to continue making a sustainable impact on the communities they serve, we need to continue providing them the tools, resources, and authority to provide necessary clinical services, where appropriate. AmerisourceBergen’s exploration of a telehealth solution with SteadyMD to enhance the scope of the Test to Treat model is just one way we’re continuing to support the important role of the pharmacist in the healthcare ecosystem.”

To the observant onlooker, data is everywhere. From spending habits to hospital visits, humans are walking treasure troves of information. As technology has exponentially improved in the last 20 years, so has the collection of data. In 2010, a mere two zettabytes of data were created, captured, copied, or consumed. In 2020, estimates put that number at 79 zettabytes. 

Data collection goes hand-in-hand with the revolution of the Information Age — since the 1970s, unprecedented digital access to the details of everyday life has transformed the way we understand the world. Rather than relying on gut instincts and trial-and-error processes, experts can gather robust data and make more informed conclusions. 

Scientists can now chart changes to ecosystems in real time, doctors can predict their patients’ likelihood of developing certain conditions, and marketing execs can determine the success of an ad campaign before it is even launched. Such data-driven decisions are capable of reducing costs, improving daily experiences, and saving lives. 

From Collection to Analysis

Businesses often let data amass without devising a plan to use it, which translates into a massive lost opportunity. In 2020, a survey of 1,500 businesses revealed that 68 percent of data sits unused, collecting metaphorical dust. Seagate Technology, the data storage company that released the report, said barriers to data usage included the proliferation of data silos and the inability to break down collected data into actionable statistics.

That’s why it’s important for every organization to prioritize data analysis. The collection is only the first stop in a lengthier journey to effectively harness any available information related to the quotidian operations, client services, and long-term plans of a business. Leaders, especially those in the healthcare industry, would benefit from incorporating data-driven decisions into all their policies and practices going forward. 

Getting to that point requires supporting employees who are well-versed in data analytics and providing them access to key analytic programs. It may also include hiring a data scientist solely dedicated to decoding information that will improve an organization. 

Those ready to embrace data-driven decision-making should consider the following questions. Doing so can narrow the scope of a data project and result in more specific answers to pressing organizational concerns. 

What Issue(s) Can Data Illuminate?

A good leader knows their organization inside-out. They can tell when morale is low, a sector is underperforming, or an outside issue is slowing down business. One’s intuition on such matters can be a great springboard for targeting data but do not be surprised if it’s disproved in the end. Focus on one concern at a time, set a timeline for getting answers, and be willing to accept the unexpected.

Let’s imagine a doctor’s office in a working-class community where patients’ non-adherence to treatments is a common concern. Having providers ask patients outright why they are not taking prescribed medicine has yet to yield clear answers. Instead, the medical team decides to ask themselves: What factors might contribute to non-adherence in this situation?

They come up with a few ideas. Maybe the cost of prescriptions is too high, people don’t have time to visit the pharmacy between work shifts, or patients feel unsupported after their initial appointment. To determine an effective strategy to combat non-adherence, they’ll need to conduct a bit of research. 

How Can Such Data Be Collected and Processed? 

The office hires a data scientist to gather data on prescription costs, pharmacy hours,  average work shifts in the area, and patient’s perception of their care. Such information can be brought to light through a number of tools, like software programs, census and labor data, and anonymous surveys.

After doing so, the data scientist discovers that non-adherence most often occurs in zip codes furthest from the only pharmacy in town. The surveys reveal that many patients in the area don’t have regular access to transportation and are unaware of any delivery system available at the pharmacy. She presents her findings to the team.

Hundreds of companies provide similar analyses within the healthcare field, which offers data-driven solutions for pharmaceutical supply chains. These companies can extract a unifying narrative from large data sets, allowing their scientists to return to medical professionals with valuable insights about their staff, users, and operational capacity.

What Changes Might Result from Data Analysis?

More likely than not, data analysis will help identify areas of improvement within an organization. If so, it’s time for further action. In the case of the doctor’s office, the team may choose to send free delivery vouchers to all their patients, no questions asked. Then the data scientist can continue to track adherence rates and report back whether the vouchers made a significant difference. 

When embarking on a data project, decide what funds and resources should be allocated to it. That way, once the results are in, there is a way forward. Identifying a concern by using data is only useful if a solution is also identified and implemented.

The Potential of a Data-Driven World

As mentioned above, only one-third of data is currently leveraged by businesses around the globe. The remaining unleveraged data amounts to revenue loss, missed opportunities, and operational blind spots. 

The last thing to keep in mind as businesses make greater plans for data collection and analysis is privacy measures. Improving outcomes based on data cannot take precedence over privacy. In the healthcare sector, this primarily applies to patient data. Conduct due diligence when acquiring data-combing software, be transparent about research with staff and clients, and make sure to adhere to local and national policies. 

Data has the potential to streamline business practices and eliminate common setbacks. In the modern world, the raw information within our reach shows no signs of slowing down and effective business leaders know how to grasp it. 

About Joel Landau

Joel Landau, founder and chairman of The Allure Group, a network of six New York City-based nursing homes

What You Should Know:  

• Kaiser Foundation Hospitals and Geisinger Health are teaming up to launch Risant Health and a definitive agreement to make Geisinger the first health system to join Risant Health to expand access to value-based care in more communities across the country. Upon regulatory approval, Geisinger becomes part of the new organization through acquisition.
• Risant Health is a new nonprofit organization, created by Kaiser Foundation Hospitals, to expand and accelerate the adoption of value-based care in diverse, multi-payer, multi-provider, community-based health system environments.
• Jaewon Ryu, MD, JD, has been selected to serve as CEO of Risant Health. Dr. Ryu will transition from his current role as president and CEO at Geisinger Health as the transaction between Risant Health and Geisinger closes.

Risant Health’s Vision

Risant Health is a nonprofit affiliate of Kaiser Foundation Hospitals, which will be headquartered in the Washington, DC, metro area. Risant Health’s vision is to improve the health of millions of people by increasing access to value-based care and coverage and raising the bar for value-based approaches that prioritize patient quality outcomes. In addition to Geisinger, Risant Health will grow its impact by acquiring and connecting a portfolio of likeminded, nonprofit, value-oriented community-based health systems anchored in their respective communities.

Health systems acquired by Risant Health will   continue to operate as regional or community-based health systems serving and meeting the needs of their communities, providers and health plans while gaining expertise, resources, and support through Risant Health’s value-based platform. Risant Health will operate separately and distinctly from Kaiser Permanente’s core integrated care and coverage model while building upon Kaiser Permanente’s 80 years of expertise in value-based care.

Geisinger Acquisition Impact

Geisinger will maintain its name and mission, and will continue to work with other health plans, employed physicians, and independent providers. At the same time, Geisinger will build on its foundation by benefitting from Risant Health’s value-based platform that offers the best in value-based care practices and capabilities in areas such as care model design, pharmacy, consumer digital engagement, health plan product development, and purchasing. As the first health system to become part of Risant Health, Geisinger will participate in developing the organization’s strategy and operational model.

What You Should Know:

• Uber Health, Uber’s healthcare arm, today announced same-day prescription delivery on its HIPAA-supported, centralized platform.
• For the first time, those using Uber Health—including healthcare providers and health plans—will be able to manage prescription delivery from any pharmacy in their service area through the same platform they already use to coordinate transportation for patients. This launch enables providers to offer a full suite of care solutions that extend beyond the four walls of a clinic and is designed to improve patient experiences and health outcomes.

Enabling Health Systems to Give Patients Seamless and Direct Access to Prescriptions

Today’s news furthers Uber Health’s mission to optimize how patients access care. The platform allows connectivity to the key services providers require to address patient needs including prescription delivery, stress-free rides, and soon, the delivery of healthy food and over-the-counter medicine for those who need it most—including Medicare Advantage and Medicaid beneficiaries.

When Uber Health launched in 2018, the business focused primarily on streamlining non-emergency medical transportation (NEMT) options, enabling patient populations—especially underserved and vulnerable communities—to get to and from medical appointments. While transportation is an important social determinant of health, it’s only one piece of the patient care puzzle. For example, a patient discharged from a hospital regularly requires a ride home and to follow-up appointments, as well as new prescriptions. Launching prescription delivery powered by ScriptDrop on the Uber Health platform ensures organizations can fulfill their duty of care obligations to patients by arranging direct, same-day delivery of their prescriptions while tracking when they arrive, enabling them to fully “close the loop.”

The tracking of care delivery across multiple disciplines promises a paradigm shift in an industry where providers and health plans could lose sight of patients outside of a provider’s office. Imagine a patient with a chronic kidney disease diagnosis who regularly needs transportation to specialist appointments that result in prescription changes of critical medications. Rather than burdening the patient with homework, Uber Health furthers the patient care team’s ability to arrange these services directly and track that they occurred. Uber Health facilitates critical touchpoints that enable payers and providers to provide maximum quality care at minimum cost.

“At Uber Health, we are building solutions that address lessons we’ve learned from years at healthcare companies operating in value-based care contracts. Too much time has been spent ensuring patients had a ride to their follow-up appointment, had picked up the right prescriptions, or had access to food,” said Caitlin Donovan, Global Head of Uber Health. “That’s why I’m proud to add a scalable prescription delivery solution to our platform that empowers care teams to fully close the loop. From prescription delivery and NEMT today to healthy food and grocery delivery in the coming months, Uber Health remains committed to delivering a more connected care journey through a single, seamless platform.”Powered by an integration with ScriptDrop, prescription deliveries can be facilitated through any pharmacy registered with the NCPDP within delivery coverage areas. Importantly, Uber Health allows for access to delivery coverage areas that include pharmacies dispensing medications covered by the 340B program, helping health plans and providers reach low-income and uninsured patients.