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Scott Whitmore, R.Ph.Director of Clinical Services

Milliman IntelliScriptBrookfield, Wisconsin

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Underwriting with Rx Histories:A Pharmacist’s Perspective

Texas Wide Underwriting ConferenceHouston, TexasMarch 19th, 2012

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Agenda

Rx data sources

Value of Rx histories

Limitations and challenges

Rx rules

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Prescription drug use in the U.S. continues to increase.

Spending In 2008, consumers spent $234 billion on prescription drugs Doubled from 1999

Utilization 48% of U.S. citizens used at least one prescription drug in the

past month (2005-2008) up from 44% from 10 years prior Cholesterol lowering drugs remain by far the most commonly

used prescription drug (2007-2008)

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Center for Disease Control and Prevention. Health, United States, 2010; Table 94

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Americans increasingly use multiple medications.

SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey

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Age, gender and race influence Rx use.

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SOURCE: CDC/NCHS, National Health & Nutrition Examination Survey (2007 – 2008)

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Rx history usage is increasing.

Life insurer survey results . . .

68% reported using Rx in 2008 . . . 41% in 2007

71% increased use of Rx

40% said Rx significantly contributed to the underwriting decision on more than 15% of cases

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Hank George Survey, November 2010 (99 companies reported)

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Rx histories have become a standard screening tool.

“At present nearly 80 percent of life carriers deploy pharmacy records in life underwriting….Virtually all others are at some stage of vetting this asset”.

- Hank George, FALU, CLU, FML

Making Progress in Life Underwriting. Resource. Feb 2012 ;12

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Top Reasons Reported for Using Rx Histories

1. Reduce anti-selection

2. Improve mortality results

3. Increase APS value by more selective ordering

4. Reduce turnaround time

5. Reduce APS use

6. Reduce underwriting costs

7. Facilitate automated underwriting

8. Increasing use of Rx histories by competitors

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Hank George Survey, November 2010

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How does it work?

1. Obtain the authorization

2. Submit the query

3. Review the results

Data Source

Data Source

Data Source

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Rx data come from multiple sources.

PBM

Retail Pharmacies

Pharmacy Benefit Managers (PBM) administer Rx benefits

Employers

Gov’t

Applicant

Health Plans

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IntelliScript Rx history metrics . . .

Results usually returned in 3 - 5 seconds

Hit rate varies by line of business / insurer

Average Hit rate: 75%

Key driver: Socioeconomic status of applicant pool

ConfidentiTWUCal for SAMPLECOMPANY

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Sample Prescription History

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Rx histories bring extensive information . . .

1) Indication2) Inherent risk (i.e. Red, Yellow Green)3) Condition severity4) Medication adherence5) Potential drug & lab interactions6) Black box warnings 7) Prescriber type8) Number of pharmacies

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What’s the value of an Rx rules engine?

Efficient / Consistent interpretation

Route important cases to underwriters

More selective APS ordering

Improved mortality

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RxRules interprets prescription history data.

Interpretation•Conditions•Severity•Actions / Decisions

Rx Data

Rule variables: Indication / Therapeutic class Drug combinations Red / Yellow / Green Fill timing Fill counts Dosage Physician specialty Gender / Age Other rules

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RxRules

RxRules

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Case Studies

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This is Frank, he's our LEAN champion streamlining paperless information flow

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Questions?

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Thank You

Scott Whitmore, R.Ph.Director of Clinical Services

Milliman IntelliScriptBrookfield, Wisconsin

(608) 345-7159scott.whitmore@milliman.com

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