Flexible Solutions Deliver Impactful Results
From rising care costs to a changing regulatory landscape, hospitals and health systems are focused on balancing cost and care. With these challenges at the forefront of the industry, it is important to have a reliable partner with the flexibility to tailor custom solutions and the experience necessary to implement them. The WellDyne hospital and health system model embodies this need, allowing our clients the ability to enact timely, targeted changes in their plan administration.
Turning Challenges into Opportunities
A regional health system in Southern California with nearly 3,000 members wanted to grow in-house pharmacy utilization but had concerns about the undue stress members might experience with restricted options.
The health system sought a strategy that could increase 340B claim capture and lower ingredient cost without compromising medication adherence and member satisfaction. Our well-versed hospital and health system account team collaborated with clinical operations teams to develop solutions that addressed the client’s objectives without sacrificing patient care.
Balancing Cost and Care
Accessibility is a key component to keeping patients adherent to their medications. WellDyne worked with the health system to develop a soft approach to increase in-house pharmacy utilization without disrupting their members. Our solution was dynamic, applying outreach strategies across multiple channels, including:
- Utilizing benefit design strategies. As part of our approach, we developed copay tiering and a $0 drug list at the in-house pharmacy.
- Applying direct messaging at retail pharmacies. New alerts were created in the claims adjudication system to notify members of medications available for $0 at the in-house pharmacy.
- Targeting member outreach to change behavior. We crafted new communications to members filling $0 drugs at retail pharmacies with information about their savings opportunity and instructions on how to transfer prescriptions to the in-house pharmacy.
- Restricting specialty drugs to the in-house pharmacy. The claims adjudication system was hard coded to only allow specialty products to process at the in-house pharmacy. Additionally, we created a monthly audit report to ensure they are capturing all specialty.
Delivering Results
The multi-strategy solution steadily increased in-house pharmacy utilization while significantly shifting plan spend through the in-house pharmacies. Over time in-house pharmacy utilization went from 24% to 38%. Plan paid running through their pharmacies increased from 22% to 55%, largely due to the movement of specialty products.
The shift to in-house pharmacy utilization combined with strict prior authorization criteria – 40% denial rate – and various WellDyne clinical programs have resulted in a negative PMPM trend. Since implementing with WellDyne in 2017, the health system’s PMPM trend has dropped from $99.50 to $96.39.
WellDyne combined focused plan design changes with strategic member outreach to increase in-house utilization without disrupting their members. In an ever-changing industry, having a reliable partner is invaluable. Our approach to supporting hospitals and health systems allows us to put clients first and deliver impactful results solving their unique needs.
