Underwriting with Rx Histories:
A Pharmacist’s Perspective
Texas Wide Underwriting Conference
Houston, Texas
March 19th, 2012
Scott Whitmore, R.Ph.
Director of Clinical Services
Milliman IntelliScript
Brookfield, Wisconsin
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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)
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.
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
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
Hank George Survey, November 2010
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How does it work?
Data Source
Data Source
Data Source
1.
Obtain the authorization
2.
Submit the query
3.
Review the results
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Rx data come from multiple sources.
Health Plans
Pharmacy Benefit Managers (PBM)
administer Rx benefits
Applicant
PBM
Employers
Gov’t
Retail Pharmacies
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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
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Sample Prescription History
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Rx histories bring extensive information . . .
1)
Indication
2)
Inherent risk (i.e. Red, Yellow Green)
3)
Condition severity
4)
Medication adherence
5)
Potential drug & lab interactions
6)
Black box warnings
7)
Prescriber type
8)
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.
RxRules
Rx Data
Interpretation
• Conditions
• Severity
• Actions / Decisions
RxRules
Rule variables:
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Indication / Therapeutic class
Drug combinations
Red / Yellow / Green
Fill timing
Fill counts
Dosage
Physician specialty
Gender / Age
Other rules
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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 IntelliScript
Brookfield, Wisconsin
(608) 345-7159
scott.whitmore@milliman.com
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