A High-Touch Approach to Utilization Management

As part of the trend toward consumer-driven healthcare, plan members are expected to demand greater convenience and transparency in the costs of their medicines. As a result, online pharmacies, health plans, and other healthcare players increasingly are providing web tools that allow consumers to see the costs of specific medications.

Joe Murad

“We expect consumers to increase the adoption of these tools that allow them to get the medications they need at the lowest cost, with or without their provider’s support,” Joe Murad, president and CEO of WithMe Health, said in an interview with Formulary Watch.

This consumer-driven approach to pharmacy benefits will require integration with the prescriber and the pharmacist to help to close the loop with the member.

Navigating medications is incredibly complex, Murad said. “Members may need extra support to help them in that decision-making process to identify what’s best for them and their families. What matters most to healthcare consumers is personalized care, beginning with the provider relationships. That desire for personalized care extends well beyond the pharmacists and technicians to physicians and nurses as well. It’s a complex web that we’ve tried to solve for, simplifying it for both the member and the plan sponsor.”

WithMe provides PBM services, as well as medication guidance services. WithMe’s medication guidance services are automatically included as part of its PBM solution or they can be added as an overlay to a client’s existing PBM.

Murad said WithMe is fully transparent, and the rebates they receive are passed on to plan sponsors. The company charges an administrative fee for its services. “We have an all-in-one clinical program model that generates holistic interventions for those particular members rather than nickel and diming sponsors and members.

WithMe curates member profiles, bringing together data — including pharmacy claims, medical claims, patient reported outcome, health lab data — and analytics to identify which interventions are going to have the biggest impact on those particular members. Company executives predict that over the next year technology will play an even greater role in how utilization management tools are designed and administered.

For example, the continually improving quantity and quality of data in a members’ profile will allow organizations to better tailor utilization management programs. WithMe expects plan sponsors to adopt solutions that combine analytics and human-led engagement to do utilization management in a less disruptive manner for members.

Additionally, Medication Guides — pharmacists and pharmacy technicians — will engage with members to discuss their medication options. “We have a 44% member-engagement rate, and about two thirds of members take our recommendations,” Murad said.

This approach, WithMe executives have said, prompts members to make better choices about their medications and their health, resulting in better outcomes and ultimately lower pharmacy and medical spend.

Murad also noted that in addition to providing clinical interventions, pharmacists help members access patient assistance programs to take advantage of coupons and copay maximization. “We’re even integrating with a subsidiary of GoodRx around cash pay versus member cost share on the funded benefit.”

Murad said WithMe wants to be a PBM that earns the trust of members to help guide them to appropriate utilization.

“Most PBMs treat utilization management like a blunt instrument, sending a form letter, and the onus is on the patient to get prior authorization,” Murad said. “We proactively call that member and explain why both from a cost savings and a clinical viewpoint about an alternative, and then ask for permission to reach out to their provider.”

He said the organization is trying to strike a balance where the members’ incentive and the plan sponsors are aligned.

“This not a one and done interaction. We will follow up after a surgery or to check progress of Humira as a treatment for rheumatoid arthritis, for example. We are trying to build more of a an ongoing relationship around the more complex medication journeys with members.”