Specialty drugs play a pivotal role in healthcare, yet their management often presents complexities and cost challenges for health plans. To address this challenge, Optum developed Specialty Fusion, a cross-benefit solution to streamline specialty drug management.
Recent client results illuminate the positive impact of optimizing specialty drug spend and improving coordination across benefits. We recently sat down with Brian Arendt, Director of Product Management at Optum Rx, to discuss these findings and their significance for health plans and providers.
Enhancing Specialty Drug Management with a Cross-Benefit Approach
As a starting point, Arendt emphasized the importance of understanding each client's needs in the specialty drug space and approaching the need together in a partnership with a customized strategy.
"When clients look for solutions like Specialty Fusion, they're primarily seeking opportunities to better manage their specialty drug spend," he said.
Specialty Fusion addresses this need by bridging the gap between pharmacy and medical benefits and managing specialty and oncology drugs comprehensively. Arendt highlighted that Optum's approach is to provide a utilization management solution that ensures efficiency by including all client policies and strategies from prior authorization through claim payment.
According to early findings from nearly 5,000 prior authorization requests, clients who have taken this cross-benefit management approach have benefitted from $12.5M in savings across Commercial, Medicare, and Medicaid markets — with Specialty Fusion on track to deliver nearly $7 per member per month (PMPM) in savings over 12 months.
A New Strategy: Treatment Recommendations and Actionable Insights
"Specialty Fusion is a provider-driven experience that facilitates the prior authorization process for specialty drugs," Arendt described. "It gathers information about the provider's intention, treatment recommendations, cost variations, and plan-specific details."
The real-time analysis of this data during prior authorization allows Specialty Fusion to deliver treatment recommendations on both benefits before the provider submits their request, increasing the likelihood of an auto-approval.
Beyond the immediate benefits to the provider and patient, capturing provider intent and behavior provides a comprehensive understanding of the utilization patterns, challenges, and opportunities for improvement in specialty drug management for the client.
Arendt mentioned, "Through the analysis of prior authorization activity, insights on drug utilization, denials, and conversions can be delivered." Solution data can identify missed opportunities where providers did not choose lower-cost treatment options, indicating potential areas for policy adjustments or utilization management strategies. These findings help health plans optimize specialty drug management processes and save costs.
Importantly, Specialty Fusion can track prior authorization data to actual claim activity and payments, demonstrating realized savings, which enables Optum to assess the program's true performance over time and refine its effectiveness, Arendt clarified.
For example, over a 12-month period, one client alone is projected to achieve cost savings of $6.1 million, equivalent to $4.90 PMPM. These savings are even more impressive when considering the high percentage of Medicare and Medicaid lives covered, which typically have fewer savings opportunities available.
Client Fit and Mindset
According to Arendt, organizations that want to maximize their results must be willing to embrace innovative approaches and seek better ways of managing specialty drug spending.
"Clients where we have the most success and the smoothest implementation have a leadership team and organizational structure that support a common, forward-thinking mindset around specialty drug management," emphasized Arendt.
Arendt reiterated the importance of approaching the entire process together in partnership, noting the full cost savings potential comes from working together to assess what is and isn’t working to ensure full optimization of the solution.
Realized Savings and Performance
By closely managing the utilization of specialty drugs and learning from comprehensive reporting, health plans can identify areas where cost reductions can be achieved without compromising quality of care.
Early findings from client data show the significant impact of a comprehensive, cross-benefit approach to specialty drug management. According to Arendt, Specialty Fusion provides a holistic, data-driven way for healthcare organizations to enhance cost-effectiveness, streamline processes, and improve coordination across benefits.
Disclaimer: Results not guaranteed. Individual plan results will vary.
