When Patients Move, So Should Their Health History

Jul 20, 2018

Through patient-centric Drug Utilization Review, Express Scripts can retain health history for patients, improving safety and reducing costs.

Supplier Diversity

Single-platform patient-matching technology gives Express Scripts the unique ability to identify and track patients’ complete health history every time a pharmacy claim is made.

Whether it’s a career move, change in income or retirement eligibility, life’s transitions often mean transitions in healthcare coverage. For Express Scripts clients and their members, starting a new job or coverage plan doesn’t mean starting over with a blank pharmacy record. That’s because Express Scripts is playing a unique and important role in defragmenting health information to maintain safety for our members.

Let’s consider this scenario: A member we’ll call Janice just started a new job and enrolled in new healthcare coverage. She developed an infection and filled the prescription her doctor gave her for an antibiotic. Even though her new pharmacy coverage may be administered by the same PBM, her prior health history isn’t integrated into her pharmacy profile. This can put Janice in danger. Without an up-to-date health history record, the pharmacy would not find out that Janice is currently on medication to treat muscle spasms. The likelihood of an adverse event is high when both drugs are taken, putting Janice at risk of additional health problems, another trip to the doctor or an emergency room visit.

Using patient-centric Drug Utilization Review (DUR), Express Scripts maintains full visibility into Janice’s clinical profile and alerts the pharmacy to the potentially serious interaction.

DUR is the process of evaluating a prescription against a member’s profile to make sure it is safe for the patient to take the drug. The process happens instantly, every time a pharmacy claim is made. With patient-centric DUR, Express Scripts is able to compare eligibility records and maintain a single patient identifier, even when a member switches plans. By operating proprietary, patient-matching technology on a single platform, our systems keep each patient's pharmacy history intact. 

Twelve standard modules review the claim for concerns relating to:

  • Drug­ age (of patient)
  • Drug – disease
  • Drug - drug interactions
  • Gender
  • Overutilization
  • Underutilization
  • Drug-allergies
  • Pregnancy
  • Additive toxicity
  • Drug name confusion
  • Therapy duplication
  • Prescriber consultation for combinations with limited medical use

This review encourages appropriate medication use and supports increased patient safety and decreased adverse events. It also reduces wasteful medical spending by helping to reduce emergency room utilization, hospitalizations, and urgent care visits through identification and correction of clinical safety and utilization concerns.

Other pharmacy benefit managers work across multiple platforms, making patient-centric DUR impossible. For those systems, a new member number means a new patient, technically speaking.

Patient-centric DUR also allows Express Scripts to catch and address early refills. If Janice tries to refill her prescription to treat muscle spasms too early, Express Scripts can alert the pharmacist instead of accepting and processing it as a first claim. This protects Janice from over-utilization.

Leader in Patient-centric Care

Since 2014, Express Scripts has processed all commercial, health plan and government claims under a single platform, with a single patient identifier. Yet, other PBMS have not caught up with our single-platform patient-matching technology.  As a patient-centric PBM, we are unique in the market and leading the way in providing a comprehensive review to ensure the highest level of patient safety.

Author Bio

Lab Staff
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