CPAP Module 26, Section 4: From Data to Action
MODULE 26: DATA ANALYTICS & POPULATION HEALTH IN UTILIZATION MANAGEMENT

Section 4: From Data to Action

Data is only valuable when it leads to change. Explore how rigorous data analysis becomes the catalyst for new clinical programs, targeted provider education initiatives, and strategic adjustments to PA criteria.

SECTION 26.4

From Data to Action

Transforming Insights into Interventions: The Strategic Role of the Pharmacist.

26.4.1 The “Why”: The Imperative to Act

We have arrived at the culmination of our data journey. In the preceding sections, we learned to read the language of claims and PA data, to identify meaningful patterns within that data, and to measure the impact of our programs. But all of this work—every query written, every dashboard built, every report generated—is ultimately a prelude. Data that sits in a spreadsheet is an academic exercise; data that is not used to drive change is a wasted resource. The final, and most critical, step in the analytics cycle is action.

A Pharmacy Benefit Manager does not exist merely to observe and report on drug trends. It is hired by its clients to actively manage them. This is a profound distinction. It requires a fundamental shift from a passive, descriptive role to an active, prescriptive one. When data analysis uncovers a problem—be it an outlier provider, a dangerous prescribing trend, or an underperforming clinical program—the PBM has a fiduciary and clinical responsibility to intervene. The “Why” of this section is rooted in this core imperative: to close the loop between insight and intervention. Without action, data analytics is just an expensive hobby.

For the managed care pharmacist, this is where your value transcends the review of a single PA case and expands to population-level impact. Your clinical knowledge is the essential ingredient that transforms a statistical anomaly into a coherent clinical strategy. An analyst can tell you that a provider’s PA denial rate is high, but only a pharmacist can look at the specific denials and determine if the cause is a misunderstanding of complex oncology guidelines or a simple failure to submit the correct lab work. An analyst can flag a rising trend in the use of a new medication, but only a pharmacist can place that trend in the context of new clinical evidence, competitor drugs, and the existing formulary. In this section, we will explore the three primary pathways through which data is converted into meaningful action: the creation of new clinical programs, the deployment of targeted education, and the strategic refinement of the very PA criteria you work with every day. This is how you move from being a cog in the machine to one of its chief engineers.

Retail Pharmacist Analogy: The Quarterly Business Review

Imagine you are a proactive pharmacy manager who has spent the last quarter meticulously tracking data within your pharmacy. You’ve gone beyond just filling scripts and have started to analyze your business. At your quarterly review meeting with the pharmacy owner, you don’t just report basic numbers like prescription volume and profit. You present an action plan based on your analysis.

Your Presentation to the Owner:

  • The Data Insight (Trend): “I analyzed our dispensing data and found that our overall adherence rate for patients on statins is only 72% PDC. This represents a significant gap in care and, based on my calculations, about $15,000 in potential annual gross profit we are missing from unfilled maintenance refills.”
  • The Data Insight (Outlier): “Furthermore, I’ve identified that Dr. Smith, one of our top prescribers, almost exclusively writes for branded Crestor, even though generic rosuvastatin has been available for years. Our pharmacy spent an extra $25,000 in acquisition costs for his patients last year compared to what we would have spent on the generic.”
  • The Call to Action (The “So What?”): You don’t stop there. You slide to the next page of your presentation, titled “Q4 Action Plan.”

The Action Plan:

  1. Launch a New Clinical Program: “I propose we launch a ‘Healthy Heart Adherence Program.’ We will proactively identify patients with a PDC below 80%, enroll them in our medication synchronization service, and schedule them for a targeted MTM session to address any barriers. This will improve patient outcomes and capture that missed revenue.”
  2. Implement Targeted Provider Education: “I have prepared a one-page summary for Dr. Smith showing his prescribing data benchmarked against the other top 5 prescribers in our area, who have a 95% generic rosuvastatin prescribing rate. I will schedule a brief lunch meeting to review this with him and provide him with literature on the bioequivalence of the generic. This is an academic detail, not a confrontation.”
  3. Adjust Internal Systems & Protocols: “To prevent this from happening with new patients, I want to adjust our pharmacy software. From now on, any new prescription for a statin will automatically trigger a pop-up alert for the pharmacist to perform a ‘first fill counseling’ session, emphasizing the importance of adherence from day one.”

You have just taken raw data, identified problems, and translated them into a concrete, multi-pronged strategic plan. This is precisely the role a PBM’s clinical department plays on a massive scale. The data points to a problem, and the solution always involves a combination of new programs, targeted education, and systematic, rule-based changes.

26.4.2 The Three Pathways of Action: From Insight to Intervention

Once data analysis has successfully identified a significant trend, outlier, or performance gap, the strategic question becomes: “What is the most effective and efficient way to address this problem?” PBMs have a sophisticated toolkit of interventions, but they generally fall into three major pathways. The choice of pathway depends on the scale, severity, and root cause of the identified issue. A deep understanding of these pathways is essential for any pharmacist who wants to contribute to clinical strategy.

Data Analysis Core

Identifying trends, outliers, and program performance gaps.

1. New Clinical Programs

The solution for broad, population-wide issues that require a structured, multi-faceted approach with dedicated resources.

Examples:

  • Opioid Safety & Management Program
  • Diabetes Adherence Initiative
  • Site of Care Optimization for Infusible Drugs
2. Targeted Education

The solution for problems caused by knowledge gaps, where the targets (specific providers or members) are well-defined.

Examples:

  • Academic Detailing for Outlier Prescribers
  • Provider Report Cards and Benchmarking
  • Member Mailings about Generic Drugs
3. PA Criteria Adjustment

The solution for refining an existing UM program. It uses the program’s own data to create a continuous feedback loop for improvement.

Examples:

  • Tightening Criteria for High-Approval Drugs
  • Loosening Criteria for High-Denial Drugs
  • Adding New Criteria for a Pipeline Drug

26.4.3 Deep Dive: Launching New Clinical Programs

When data analysis reveals a complex, widespread problem affecting a large portion of the membership, a simple educational fax or a minor tweak to a PA criterion is insufficient. These situations call for the design and implementation of a full-scale clinical program. A clinical program is a structured, strategic initiative with a defined scope, dedicated staff (often including pharmacists), specific interventions, and clear goals for both clinical and financial outcomes. The decision to invest in a new program is a major one for a PBM and its client, and it is always justified by a compelling data-driven business case.

Masterclass Table: From Data Signal to Program Launch
Data Signal (The Problem) Clinical & Financial Rationale (The Business Case) Resulting Clinical Program The Pharmacist’s Central Role
Claims data shows an average daily MME of 85 across chronic opioid users, with 15% of members exceeding 120 MME/day. 5% have a dangerous overlap with a benzodiazepine. Clinical: High MME and BZD overlaps are strongly correlated with increased risk of overdose and death.
Financial: Opioid-related overdoses lead to extremely high-cost ER visits and hospitalizations.		 Opioid Safety Management Program You are the clinical engine. You review the PAs for high-dose opioids, perform academic detailing calls to prescribers to discuss tapering plans, and consult on complex pain management cases.
Medicare Star Ratings data shows the plan is underperforming on adherence (PDC scores) for statins (2 Stars) and diabetes medications (3 Stars). Clinical: Non-adherence leads to poor health outcomes (heart attacks, strokes, uncontrolled diabetes).
Financial: Poor Star Ratings result in lower CMS reimbursement payments, costing the plan millions of dollars.		 Targeted MTM Adherence Initiative You are the primary interventionist. Using the PBM’s data to identify the least adherent members, you conduct targeted medication reviews (TMRs) to resolve barriers to access and adherence.
Medical claims analysis reveals that 70% of the client’s spend on Remicade (infliximab) is being administered in the high-cost hospital outpatient department. Clinical: For stable patients, home infusion or an ambulatory infusion center are equally safe and often more convenient.
Financial: The cost of administering a drug can be 50-70% lower in a home or suite setting compared to a hospital.		 Site of Care Optimization Program You develop and review the PA criteria that directs new patients to a lower-cost site of care. You work with case managers and specialty pharmacies to ensure a safe and seamless transition for existing patients.

26.4.4 Deep Dive: Deploying Targeted Education Initiatives

Not every problem requires a new, resource-intensive program. Often, data analysis reveals that poor outcomes or high costs are not due to a lack of clinical options but a lack of knowledge or awareness. In these cases, the most efficient and effective intervention is highly targeted education. Instead of a broad, shotgun approach, data allows the PBM to pinpoint the exact providers, pharmacies, or members who need a specific piece of information and to deliver that information in a timely and impactful way. This is a subtle but powerful form of behavior modification.

The Golden Rule of Provider Outreach: Collaborate, Don’t Confront

Your experience in retail has taught you how frustrating and disruptive a poorly handled call from an insurance company can be. As a PBM pharmacist conducting outreach, you must never forget that lesson. The goal of academic detailing or any educational outreach is not to accuse a provider of “bad” prescribing. The goal is to present objective data, share evidence-based information, and position yourself as a clinical partner with a shared goal of improving patient care and affordability.

Wrong Approach: “Dr. Smith, you need to stop prescribing so much branded Crestor.” (Confrontational, accusatory)
Right Approach: “Hi Dr. Smith, I’m a clinical pharmacist with HealthPlan XYZ. I was reviewing some data reports for our quality initiatives and wanted to partner with you on a potential opportunity. Our data shows that a number of your patients are on branded Crestor. We just wanted to ensure you were aware that the A-rated generic rosuvastatin is on Tier 1 of the formulary, which could save your patients a significant amount of money at the pharmacy counter. Can I send you a one-page summary of the FDA’s bioequivalence data?” (Collaborative, data-driven, patient-centric)

Masterclass Table: The PBM’s Educational Toolkit
Intervention Tool Description Data Source Trigger Example Use Case
Provider Report Card (Benchmarking) A periodic, mailed report showing an individual provider their key prescribing metrics (e.g., brand vs. generic rates, cost PMPM, specialty drug use) benchmarked against their anonymous local peers in the same specialty. Pharmacy Claims, Medical Claims An endocrinologist receives a report showing their GLP-1 agonist prescribing rate is in the 95th percentile compared to their peers, prompting them to re-evaluate their prescribing habits for less severe patients.
Academic Detailing (Pharmacist-led Outreach) A one-on-one educational session (often telephonic) where a PBM pharmacist discusses evidence-based guidelines and formulary options with an outlier prescriber, using their own data as a conversation starter. Pharmacy Claims, PA Data A pharmacist calls a high-volume prescriber of brand-name NSAIDs to discuss the clinical appropriateness and cost-effectiveness of generic celecoxib or naproxen, based on the member’s specific formulary.
Targeted Member Mailings A letter or postcard sent directly to a specific subset of members identified through claims data, encouraging a specific action. Pharmacy Claims All members who filled a prescription for a branded drug that recently went generic receive a letter informing them of the new generic, explaining it is the same medicine, and detailing the potential copay savings.
Point-of-Sale (POS) Messaging Automated clinical messages that appear on the community pharmacist’s screen at the moment a claim is adjudicated, providing real-time guidance. Real-time Pharmacy Claim A claim for a non-preferred drug triggers a message: “Drug X is non-preferred. Preferred alternatives with $20 lower copay include Drug Y and Drug Z. Please contact prescriber to consider switching.” This empowers the dispensing pharmacist to initiate an intervention.

26.4.5 Deep Dive: Strategic PA Criteria Adjustments

Perhaps the most powerful and direct way that data leads to action is through the continuous, evidence-based refinement of prior authorization criteria. PA criteria should never be static, “set it and forget it” documents. They are dynamic clinical tools that must evolve in response to new clinical evidence, new drugs entering the market, and—most importantly—the data generated by the PA program itself. The PA system, when designed correctly, creates a powerful feedback loop: the criteria generate data (approvals, denials, denial reasons), and that data is then analyzed to improve the criteria. As a PA pharmacist, you are on the front lines of this process, and your insights are invaluable.

Masterclass Table: The PA Criteria Feedback Loop
PA Program Data Signal Clinical / Business Interpretation Strategic Action: Adjusting the Criteria
Extremely High Approval Rate (e.g., 99%) for Drug X The current criteria are not performing any meaningful utilization management. They are acting as a “rubber stamp,” creating administrative work for providers and the PBM without channeling utilization or saving money. The program has no ROI. Action: Tighten the criteria.
Example: If the current criteria for an oral oncology drug just requires a confirmed diagnosis, the revised criteria might add a requirement for failure of a previous line of therapy or the presence of a specific biomarker, aligning with NCCN guidelines.
Extremely Low Approval Rate (e.g., 10%) for Drug Y The criteria may be clinically misaligned with standard of care, out of date, or so confusing that providers cannot submit the correct information. This leads to high provider abrasion, potential access to care issues, and a high volume of time-consuming appeals. Action: Loosen or Clarify the criteria.
Example: If a criterion for a migraine drug requires “failure of 3 other agents,” but data shows 90% of requests are denied at this step, the PBM might re-evaluate the evidence and reduce the requirement to “failure of 2 agents,” or provide a clearer list of what qualifies as a failure.
High Denial Rate for a Single, Specific Reason This is a highly actionable signal. If 80% of denials for a new biologic are for “Step therapy with Drug Z not documented,” it indicates a widespread lack of awareness about this specific requirement. The problem is knowledge, not clinical appropriateness. Action: Education first, then potential criteria change.
The first step is to launch a targeted education campaign to providers (Pathway 2). If the denial rate remains high after 6 months, it may indicate the step-edit is not clinically practical, and the P&T committee may consider removing it.
Rapid, Uncontrolled Uptake of a New Pipeline Drug A new, high-cost drug hits the market and claims data shows its utilization is growing far faster than projected, often for off-label indications not supported by strong evidence. Action: Proactively Implement New Criteria.
The clinical team, including pharmacists, will rapidly review the evidence for the new drug and develop PA criteria that restrict its use to the FDA-approved indication and specific patient populations studied in the clinical trials. This is a reactive measure to control unforeseen costs.
The Pharmacist’s Role in the P&T Committee

The formal process for reviewing and adjusting PA criteria typically occurs within a P&T (Pharmacy & Therapeutics) Committee. This committee is usually composed of internal PBM pharmacists and physicians, as well as external academic and community-based physicians. The committee’s job is to review drug policies and PA criteria to ensure they are clinically sound, evidence-based, and meet the plan’s goals.

Your Contribution is Critical: As a PA reviewing pharmacist, you have a unique and vital perspective to bring to this process.

  • Qualitative Insights: You can provide real-world context that data alone cannot. You can tell the committee, “The reason we see so many appeals for this criterion is because the required lab test takes three weeks to come back, and providers are trying to start therapy sooner.”
  • Identifying Ambiguity: You are the best person to identify criteria that are poorly worded or ambiguous, leading to inconsistent application and provider confusion.
  • Championing Change: When you see a problematic criterion causing repeated issues, you can gather case examples and formally present a proposal for change to the P&T committee, using your on-the-ground experience to advocate for a more effective and efficient process.

Actively participating in or providing feedback to the P&T process is a key way for a PA pharmacist to have a strategic impact far beyond the individual cases they review.