Experts at Evernorth Outcomes event stress the importance of an integrated data model to improve health and lower costs

Connection between pharmacy, medical and behavioral health benefits is key in improving care, and pharmacy insights have the power to drive the connection. That was one of the main takeaways of the closing session at the Evernorth Outcomes client event in Orlando, Florida, which was moderated by Bill Martin, chief commercial officer of Accredo, a division of Evernorth.

“The pharmacy benefit is the most utilized benefit — used 11 times on average per year,” Martin told the attendees. “Each one of those interactions gives us a lot of information on where patients are in their journey and what their needs are.” It also gives us insight into where the health care dollars are going, he added.

Evernorth chief innovation officer, Dr. Glen Stettin, echoed those thoughts. Dr. Stettin’s team is committed to using data to tackle health care’s biggest challenges. With more than 2 billion claims per year at their disposal, the team gets a lot of insight around what is driving the bulk of health care spend.

According to Dr. Stettin, cardiodiabesity, oncology and specialty conditions are seeing increased pharmacy spend. And these costs will only continue to rise, added Harold Carter, PharmD, chief pharma trade relations officer for Express Scripts, the pharmacy benefits management arm of Evernorth. According to Carter, more people are getting diagnosed across these three areas, and they are being diagnosed at younger ages than in years prior.  

Thinking about health care holistically, using data

Eva Borden, president of behavioral health at Evernorth, said that the health care industry as a whole needs to reimagine the notion of whole-person health and what it means.

“Cardiodiabesity isn’t happening in a vacuum. There’s a large percentage of people who are struggling with mental health as well,” Borden said, adding that where Evernorth comes in is using data to identify people at risk and helping them navigate to the right resources.

The dialogue shifted over to cancer treatment and the importance of coupling it with mental health support for the entire family and the patient. According to Borden, when an individual has cancer, spending just a little bit on behavioral health care for that person can save money and improve patient outcome, sharing that “people with cancer who do not get behavioral outpatient treatment are two times more likely to have avoidable emergency room visits.”

Borden recalled a young woman who had beat uterine cancer, but was skipping her annual physicals because she was afraid of being diagnosed again — emphasizing the need for helping people cope with their physical condition, as well as the effect it has on their mental state.

Bringing together quality care and affordability

Dr. Stettin spoke to a recent analysis from the Evernorth Research Institute, which looked at the utilization of immune checkpoint inhibitors. These are highly expensive in the treatment of cancer, costing about $150,000 per patient per year. For some people, these therapies can be a miracle in curing their cancer; but they don’t work for everyone.

The analysis found that, of the people using immune checkpoint inhibitors, only 70% had a genomic test done that would tell them whether this treatment would be effective. The other 30% were using this treatment method without any insight as to whether it was the right care for them, which could negatively impact patient outcomes, and results in wasted spend.

Site of care also makes an impact on both costs and patient outcomes, said Carter, who pointed to the fact that going to an infusion center instead of a hospital setting to receive chemotherapy by infusion does ensure patients still get the right care in a quality setting, only at the fraction of the cost. According to Carter, Evernorth’s main priority is to get people “the right drug at the right location” adding that bringing behavioral, pharmacy and medical together to prevent and treat cancer will mean long-term savings, better patient outcomes, and will create “ripple effects across the health care system.”

Behavioral health can have serious cost implications

According to Borden, behavioral health is a complicated factor of many physical conditions, but it is also a condition in and of itself. Health plans currently spend about 6% of the total cost of care on behavioral health medications — which is why many plan sponsors aren’t concerned with the costs, even though it contributes to nearly half of their overall pharmacy spend.

“You might not want to focus on that, but if you take that 6% and map it to people who are consuming [behavioral health drugs] and look at how much of your total pharmacy costs [they contribute to], you’ll see they are about 50% of your costs,” Borden said, explaining that when behavioral health is a comorbidity of another condition, the costs rise even higher.   

Borden also talked about the behavioral health care experience, comparing it to a common medical issue like breaking one’s ankle. She broke her ankle a few years ago and knew exactly what to do and what to expect. She went to urgent care, got an X-ray, and had to use crutches for some time. Unfortunately, this was not the case when Eva and her daughter were struggling with reactive attachment disorder a number of years ago.

“I didn’t know what treatment looks like,” she recalled. “Why do we leave such an important area to be a mystery for people to wander around in?” She stressed the importance of connecting care, using data to identify people early, and then helping them navigate this confusing system. Evernorth released research last year that shows among people newly diagnosed with a behavioral health condition, such as anxiety, depression, or substance use disorder, receiving behavioral outpatient care is associated with a reduction in costs up to $2,565 per person over 15 months and up to $3,321 per person over 27 months following a diagnosis.

The biggest opportunities ahead

The panel discussion ended with each panelist providing their point of view around what the biggest opportunities are in health care today. According to Carter, making room for expenses like biosimilars is going to be key, as is bringing capabilities together to better serve people.

As for Borden, she believes that we are in a mental health crisis in the United States, and we will see an accelerated use of benefits. “By connecting all the data within medical, pharmacy, and behavioral health, we have a unique opportunity to identify people early on, and engage them in the care that matches them to improve results.”

Dr. Stettin also left the audience with some great insights: “Pay attention to the drug pipeline and what’s coming,” he said. “The technology and the changes are coming fast. Look at your benefits and think in advance on how you want to handle these drugs as they come out.”