Select Page

In this example learn how we helped a pharmacy benefit manager save $1.2m

 

Pharmacy Benefit Managers (PBMs) are an integral part of the US Healthcare landscape. Most Americans rely on PBMs to obtain prescription drugs at some point during the process, whether as part of a private healthcare plan, a self-insured employer plan or state-assisted health care. It is therefore crucial that PBMs run at optimal efficiency because if they don’t, the consequences can be far-reaching.

The Challenge

– To identify the bottlenecks in the PBM’s processes that were keeping them from meeting their SLAs

– To provide solutions to resolve the bottlenecks, reduce costs and increase efficiency

Patients may be forced to wait days until vital prescriptions are filled, costs escalate, and of course the PBM runs the risk of its contract not being renewed if it consistently fails to achieve the goals defined by their Service Level Agreement (SLA). In such a highly competitive market, inefficiency is at best, punitive, and at worst, fatal for PBMs.

Evidant Process Insight

Evidant can change all of this with their unique Process Insight Service that accurately identifies where the processes are breaking down – and why – to provide solutions to enable the PBM to radically improve efficiency, thus ensuring that SLAs  are met, and patients are not kept waiting unnecessarily.

So how does it all work? Here’s a recent example of a PBM who approached Evidant for help in the face of spiralling costs and increasing delays in processing claims.

Program

The very first step is to properly analyze the data. Evidant uses next-generation data transformation techniques to transform the raw data from the client’s workflow applications to enable efficient process mining. Once this has been achieved, Evidant can then map the data properly to give a clear overview of what is really happening within the company. In this instance, the aim was to define and analyze three things:

  1. Wait time (of workers between work activities)
  2. Work time (time spent by workers on each activity)
  3. Overall time (to process each case from beginning to end).

 

By accurately mapping the data and applying Process Analytics (Process Mining plus additional metric dimensions), Evidant was able to:

  • Identify the activities that were taking the longest
  • Identify where wait times (time between activities) were excessive (hours, even days)
  • Discover the areas that had the most opportunity for improvement: e.g. an activity that takes an average of 12 mins that can be reduced to 8 mins offers greater opportunity than an activity that takes 3 mins that could be reduced to 2 min

The final stage of the journey is to apply Evidant’s Process Insight (PI) which allowed the customer to:

  • Identify which workers were most efficient at completing their activities using the Evidant PI scoring system based on wait time, work time and total case time. The results show which workers and leaders are the highest performers and why.

Your best people train your team

As part of the solution, high-scoring workers were leveraged to train the lower-scoring workers, specifically targeting areas of weakness. Blockages further up the line that caused long wait times and therefore lower performance scores for certain workers were also addressed.

Activity Mining

‘A key part of the process is Activity Mining, which drills down below Process Mining even further to analyze each specific task that makes up an activity. Activity mining drills in at a granular level to understand the work habits that underlie how an activity is performed so improvements can be made where they are most needed and be most effective in terms of improving overall efficiency. Data is collected and transformed from workers’ PCs or tablets on a daily basis to enable the broad set of metrics available in Evidant PI’s Activity Mining module.

Evidant uncovered a number of areas where processes were failing, but one in particular was seriously affecting productivity. Scott Leslie, Evidant’s Chief Architect explains:

 

“The biggest thing that came to light for this PBM was that, in 25% of all cases, the initial decision was being reversed thereby sending the case back up the chain for re-assessment. Furthermore, this wasn’t just happening once per case – the average was well over two reversals per reversed case with many being reversed 10 times or more.

By identifying the problem and the workers and associates involved in these cases, reversals have had a steady downward trend from 25% and are now approaching the 15% goal of the organization.”

By using Evidant PI to address this problem alone, the PBM has stated that the savings generated have paid for the program in less than six months: case durations have decreased due to lowering wait times between activities; labor costs have been reduced thanks to reduced work times and improved processes. As a result, productivity has improved, and SLAs are being met. Indeed, the company was so impressed with the results that it has since undertaken three new process improvement initiatives with Evidant PI.

Are You Ready to Beat Your Competition?

Schedule a call with us to discuss your situation and goals.