Overview
Health plan IT leaders face a host of challenges with data integration. Systems and solutions for the modern health plan must be configured for efficient data exchange, and integration solutions need to avoid eating up IT budgets and staff time.
Nowhere is this more true than with pharmacy benefits carve-outs. In search of cost savings, self-funded employers are carving out pharmacy benefits by hiring their own pharmacy benefits managers (PBMs). This trend further erodes payers’ profitability: less revenue and additional administrative costs, driven by greater burden of already constrained teams. The Flume platform is built to help ensure seamless data integration with any PBM, making it easier for plans to manage eligibility data, pharmacy claims, copay accumulators and other vital information.
Pharmacy carve-outs
The “set and forget” days of data integration with a single PBM are long gone. Health plans now must deal with pharmacy carve-outs that require data exchange with any number of PBMs, each with their own formats and requirements that could challenge payers’ existing workflows. These are just a few of the challenges plans face as a result:
- New PBM choices are exploding as the market moves well beyond the Big 3, resulting in more integrations to establish and manage on behalf of employer clients.
- The potential of integrating a PBM for only a handful of employer clients increases fixed costs and challenges existing teams’ ability to implement.
- The PBM data exchange is highly consequential for member satisfaction; timeliness of eligibility data and accuracy of accumulator data is essential.
- The continual rise in drug prices, notably specialty pharmacy and expensive GLP-1 medications, might require new product designs that provide health solutions to complement or substitute expensive drug therapies.
When it comes to data integration, health plans always deal with complexity. The growth of pharmacy carve-outs takes this to a whole new level. Payers and third-party administrators are searching for solutions to make these integrations simpler and less costly.
Benefits of using Flume
Flume is the first data integration platform designed specifically for health plan administration. The solution systematizes the complex process involved in establishing connections with a variety of sources and destinations of administrative data that are required for members to use their health benefits, typically resulting in cost savings of 80% to 90% on integration setup and maintenance.
These advantages played out recently for two Flume clients:
- In a client’s data integration with a new specialty pharmacy, the setup was completed in just two days using Flume, resulting in an employer starting to realize significant cost savings while providing its employees with needed drug therapies.
- For a TPA client struggling to map pharmacy data from its PBM in the NCPDP standard format, Flume stepped in to liaise with the PBM and complete the integration in just three days (not including customer QA testing).
Key features
- Simplified process for custom business objects, allowing non-technical users to add and delete specific PBMs for specific groups, plans and products within the platform
- Enables pharmacy data trades between your systems and any PBM, from eligibility to pharmacy claims to accumulator data, conformed to essentially any standard or format
- Canonical structure (not point-to-point) for automated, secure bidirectional data exchange
- Ability to apply validation logic and send only incremental records or essential data, further enhancing data privacy protections
Expected outcomes
For health plan CIOs, CTOs or COOs, Flume can deliver significantly lower marginal integration costs and greater speed and simplicity with pharmacy carve-outs. And you can manage integrations within your existing charter as an IT leader, leading to budget protection for strategic priorities.
