The Granite List Live

Drugs and Data – How Analytics Truly Impact Claims Spend

October 27, 2021

Drugs and Data – How Analytics Truly Impact Claims Spend


Ryan Rice and Chris Ziemke from Prism Health Group represent a new breed of healthcare consultants, poised to impact the entire healthcare spectrum versus the traditional, siloed approach. They saw the needs in the pharmacy industry specifically to navigate the pharmacy benefit management space. Employers needed a better understanding of their pharmacy spending from an unbiased source. That's where Prism Health Group comes in. Listen to this episode, "Drugs and Data – How Analytics Truly Impact Claims Spend."

Here is the full transcript for this episode:

Announcer (00:09):

Welcome to another episode of The Granite List Live. Navigating a sea of benefits solutions is daunting at best, and new vendors emerge every week. Hosts Leigh Dill and Sally Pace bring brokers and employers a solid resource when it comes to uncovering what's new, what's needed, and what is happening now to allow for the best plan design possible. By staying on top of trends, brokers and employers can in turn stay on top of spending while improving employee engagement and outcomes. Ryan Rice and Chris Ziemke from Prism Health Group represent a new breed of healthcare consultants, poised to impact the entire healthcare spectrum versus the traditional siloed approach. They saw the needs in the pharmacy industry specifically to navigate the pharmacy benefit management space. Employers needed a better understanding of their pharmacy spending from an unbiased source. That's where Prism Health Group comes in. Listen to this episode of The Granite List Live: Drugs and Data - How Analytics Truly Impact Claims Spend.

Leigh Dill (01:10):

This is another episode of The Granite List Live, and we are thrilled to have Ryan and Chris from Prism Health Group here today to talk about the ins and outs of controlling pharmacy spend.

Ryan Rice (01:27):

Hi, I'm Ryan Rice. I serve as Principal and Practice Lead here for the Prism Health Group.

Chris Ziemke (01:34):

I'm Chris Ziemke Business Development Lead here at The Prism Health Group.

Sally Pace (01:38):

Ryan, Chris, we appreciate y'all being here today and we know that you are a new partnership. You've just come together to create a new group. Can you tell us a little bit more about what you found value in each other and what you're doing going forward?

Ryan Rice (01:53):

Yeah, absolutely. So we actually started out in this effort about three years ago. I founded the company in partnership with a few others and we were known as the Prism Health Strategists, and we started out really with this notion of, what is it that the marketplace is missing today? And the unanimous decision was is there's not a lot of independence. There's not this agnostic point of view specific to the pharmacy industry itself. There's lots of really talented and sharp brokers advisors out in the marketplace. And there are some larger shops that are out there. But what we found is that there is almost an obsession around coalitions, cooperatives, consortiums, and the like. And not to say those entities are bad per se, but what we found was, boy, there's a better way to do this. And the voice that we hear calling out for help are those of plan sponsors, TPAs health plans who are looking for an independent voice to help amplify their specific message and their strategy to the marketplace, and pharmacy, given our collective backgrounds, made the most sense.

Ryan Rice (03:00):

And that's how Prism Health Strategists was born. Fast forward about a year or so, the company was really picking up steam. We had gathered up a bevy of different client partners and then a group called ScripPoint approached us and it made lots of good sense. And so Prism acquired ScripPoint and became what you see here today as the Prism Health Group. So it's the combination of what we believe to be really smart folks and really solid technology to solve for helping folks really navigate the pharmacy benefit management space. It's a very complex space to have to navigate. And we have made it our mission to deploy innovation, really detailed analytics and expertise, but most importantly, the autonomy and that voice to those [inaudible 00:05:31].

Sally Pace (03:51):

What did ScripPoint add to Prism Health Strategies to make Prism Health Group?

Chris Ziemke (03:58):

I would say ScripPoint when I came on, when Ryan approached me about coming on to ScripPoint and Prism Health Strategies, to me, it was a no-brainer. From where I sat, leading a midsize TPA as their pharmacy director, what I would see in the marketplace, there wasn't a lot of brokers or consultants out that really knew the pharmacy space so to say. They knew a little bit just to be dangerous, but when it was coming to clients and talking to them about their pharmacy spend, they really didn't just focus primarily on pharmacy, which was a passion of mine. And really, it was a no-brainer for me to say, Ryan, I'd love to join up with you and provide that independent voice.

Chris Ziemke (04:42):

What ScripPoint added to the Prism Health Group was not only an additional book of business of client partners, but also a regional brokerage or consulting firm that kind of helps Ryan and the Prism team expand their reach more towards the West and the Northwest of the region. And really now as the Prism Health Group, we feel ourselves as a national presence. And that's kind of how we want to grow, from East Coast to West Coast, we're looking for clients, TPAs, hospitals, health systems that are kind of yearning or, or reaching or wanting to know and understand more about their pharmacy spend and receive that independent voice to kind of help with the market in where pharmacy spends going today.

Sally Pace (05:28):

Let's dive into that a little bit deeper. We talked about pharmacy spend. How is Prism helping plan sponsors and their partners manage, specifically, the Pharmacy spend?

Ryan Rice (05:38):

Really good question, Sally. You know, I think that when we look across the market, the landscape, and part of this missing component, it was this genuine sense of achieving performance transparency. And I'm a firm believer that you can't make a claim unless you can back it up with data. And claims data or data is the lifeblood of being able to make meaningful change because you have to know where you are to know where you're going to go or where you're going to travel to as a self-funded plan, as a hospital,  as a TPA, what have you. And so what our firm is very much committed to is that of having very clear and ready access to claims data. For nearly every one of the clients that we serve today, we've got real-time connectivity to that data. We're adjusting it on a daily basis.

Ryan Rice (06:28):

And so we're, we're putting a ton of emphasis on the ability to not only report and measure but then also being able to take near-immediate action. So we developed our own platform called Prism 360, which is a near real-time adjudication and claims data repository that really shows some pretty sleek and fancy-looking reports and all that good stuff. But most importantly, it helps coordinate with nurse case management staff. It helps coordinate high-cost claimants and then alerts out automatically so that you can take action immediately. Reporting and insights, 30 days, 60 days after the occurrence are meaningless. We can all talk and sulk about what we should have done when, darn it, let's go ahead and take the bull by the horn and have the ability to do something reasonable and meaningful with it in near real-time. And that's a very, very important aspect of being able to take control, meaningful control, of the spend itself.

Sally Pace (07:31):

Walk us through what that looks like. An employer group plugs in Prism Health Group. Are you looking at their claims real-time? Are they responsible for looking at it for themselves? Is it the PBM? How does that work once you implement your service?

Ryan Rice (07:47):

Really good question.

Sally Pace (07:51):

And what do you do once you find issues within the spend?

Ryan Rice (07:53):

Right. So technology in and of itself is great. It's like having a Ferrari, but if you don't know how to drive stick, well, it's kind of pointless, right? So what we like to say is not only do we manufacture the sports car, but we also know how to drive it pretty damn well. And so having that ability to not only ingest claims. And so when a new client comes on board with the Prism Health Group, the first thing that we are doing is going through a rigorous, implementation process where, first and foremost, we're identifying the different dynamics of the plan itself, plan design, what provisions are within that contract that govern the performance itself with the PBM. We're taking all of that into account and then also ingesting those claims directly from the PBM. And this is important. We actually apply our own source of average wholesale price to the analytics that we are performing.

Ryan Rice (08:47):

So, said differently, the independence or the agnostic point of view is really important. And that's something that separates the Prism Health Group from others. So when we are taking in those claims, we're not taking the PBM's word for it. We're actually applying our own independently sourced benchmarks of price and of value to ensure that the insights that we're able to then produce and advise our clients are based on independent data. And the best part about that is we're also providing access to the 360 environment directly to our clients. So they can also have real-time access to their data. It's their data. They should have every bit of right to it. And with the Prism Health Group, we provide that latitude and that ability to gain that kind of transparency they require.

Sally Pace (09:37):

So going forward, once you implement that, you reach out to the PBM, the client and say, this is not being adjudicated correctly. We need to fix it. [crosstalk 00:09:47] How does that work?

Ryan Rice (09:47):

Great question. So one of the core tenants of our services that we provide, or that we're doing an audit on a, dare say, on a real-time basis. So because we're collecting those claims transactions on a daily basis, we're able to see how that compares to the guarantees in the contract. So why that's important is we don't have to wait until the end of the year with the PBM to say, why did you miss your financial commitments? You can be doing that in near real-time. And in fact, we perform those audits on a quarterly basis, and then we actually help our clients as part of our service audit the PBM. So it's all included in that ability to not only measure, keep the PBM in check, but then do the negotiation with the PBM to make sure that you're getting all of the dollars that are in a sense owed to you.

Sally Pace (10:39):

Ryan, you said we don't take the PBMs word for it. So I can imagine there are some PBMs who quake in their boots when they hear that a consultant has been brought on to review an audit. But let me ask, conversely, are their PBMs that you have preferred relationships with, that you have exclusivities with? How does that work? Can you guys explain that?

Ryan Rice (11:04):

Yeah, really good question, Sally, and this is super important. We get asked this question a lot and the answer I always provide, we all talk about is we don't have a list. There is no magic list, and that's very much a deliberate action on our part because our independence is really based on this concept, this notion that I don't care who you're with, we're going to make that contract. We're going to make that partner of yours per perform what they said they were going to commit to. And so it's important for us not to be behind consortiums coalitions, cooperatives, and also align with PBMs. That's not to say that we don't have efficient ways of getting a group that may have to make a very quick decision and align with a different PBM. We do have a solid sense of what the market has to offer however.

Ryan Rice (11:56):

Today we work with 23 different PBMs with our different clients from across the industry. And I would say that we know which PBMs tend to agree to the requirements that we set forth in a procurement and or market check or audit. And we also know the ones that don't like to be so compliant. And so I would say that we don't have favorites, but we are very confident in which PBMs are likely to be more compliant and help those plan sponsors achieve performance transparency.

Chris Ziemke (12:28):

I would also add that if it really does depend on what the client wants or what they are ultimately trying to get out of their pharmacy plan. So I think another aspect that we do maybe a little bit differently is taking the time to sit down with the client alone and say, okay, client XYZ, what is it that you want out of your pharmacy plan?

Chris Ziemke (12:51):

What are you trying to achieve for your employees? And sometimes it may be a pass-through PBM. A lot of times, I think we have a couple clients that want to stay more on that traditional model. And I think that's what it's important that Ryan said that we work with every PBM out there and not just a select few, because you never know which client wants to have a certain model or a certain direction with their pharmacy plan.

Ryan Rice (13:15):

Yeah. You know, hospitals are a great example. We serve several hospital providers today where they have initiatives to provide uniqueness of giving access to their home hosts or domestic pharmacies within their own bricks and mortars. There are the right PBMs for entities like that. And there are some that aren't the greatest of fits and it just depends upon, as Chris said, who that client is and what they're trying to accomplish.

Leigh Dill (13:42):

I believe that's one thing that makes you unique compared to other offerings in the marketplace. But can you explain a little bit more about your value and why there is a need for a PBM only consultant?

Ryan Rice (13:56):

You know, we get asked this one a lot too. It's well, what the hell do I need a PBM consultant for? I've already got a really smart broker and you know, what, if that's the case then great, then there may not be a spot for us. But I would say that nine times out of 10, when we get brought in, we always start with a way for us to prove that there be a problem working underneath the surface. We consider this putting our money where our mouth is. I believe that we're one of the only consultants out there, independent or not, that actually put their fees at risk, meaning we are on a one-to-one basis, at least going to put everything you pay us, as a plan sponsor, on the line to make sure that we're delivering on those commitments.

Ryan Rice (14:37):

And I think that it really does serve to our core, our model of our grit, if you will, as part of our core values in that we wouldn't ask anyone to pay for something that we ourselves wouldn't pay for. I'm a big believer in that you got to eat your own dog food before you expect the broader [crosstalk 00:14:57] adoption and we live that every day. So the way in which we work with our client partners is personal because it has to be, we don't get paid unless you achieve those outcomes that we said you were going to set out to accomplish.

Sally Pace (15:18):

You mentioned a couple of clients already, the types of groups you work with. Can you delve into that a little bit further? Do you have a preference on the type of client you work with or who you typically look to for adding new business?

Chris Ziemke (15:24):

Yeah. Great question Sally. I think first and foremost, we work with every single type of client out there, whether you're a Taft Hartley group, a TPA, hospital health system, commercial group, government groups, we'll work with anyone. In fact, our book of business today is compiled of every single type of client that I just listed out there. I think where we're kind of finding our sweet spot is the TPA space. So, coming from a TPA myself, being in that position, it was always difficult for me to have a pulse on every single PBM that we work with. So you have preferred PBM relationships, but as a TPA, you work with every single type of PBM. And Ryan has said this a couple times TPAs tend to be the dumping ground for failed programs that want to be started either by PBMs or some brokers or consultants out there.

Chris Ziemke (16:22):

And so what we found with the Prism 360 platform is it really arms and gives the TPA, the power to make active and decisive decisions as it relates to pharmacy benefits. As Ryan mentioned earlier, being able to access real-time data, being able to take that data or some of the alert systems and work with a TPAs nurse case management team is an absolute powerful program. We've really found success. And maybe kind of back up a little bit from there, some of these regional TPAs, they don't have a pharmacy director or someone like myself that help manage those PBM programs. So we kind of see Prism 360 taking the space of that pharmacy director and our main giving the account managers themselves, the tools, the reporting, the access that they're able to go out to the brokers and the clients that they serve and say, "Hey, here's where your pharmacy spend is today. Here's where we think we can make some improvements over the next year and keep a pulse or a thumb as to how we're going to get from A to B."

Ryan Rice (17:34):

Yeah, I think that's right, Chris. And we really do welcome the challenge as well. So in an addition to the kinds of ongoing retainer-based relationships that we have with clients, it's our product, our RFP and procurement process, which we call partner alignment. So market checks and the audits that we perform. So we're also doing lots of project-based work as well. And some odd ones at that. We've even got some less than traditional business within the correction space. And we absolutely love working with those folks. Government entities are an area where we've done very well as well, anywhere someone is seeking that threshold, that purity of transparency and performance and insight into how things are performing. We're great fit for those kinds of folks.

Sally Pace (18:22):

How does somebody engage with you guys? You mentioned brokers or sometimes through brokers, is it ever direct with the employer? How does it work?

Ryan Rice (18:30):

There's a number of different ways. I mean, you can always just give us a phone call here and we'll definitely, we'll pick up, and we'll get you signed up lickity split. I would say that there are probably two or three different primary ways. As Chris had noted the presence we've developed in the TPA space is very unique because the TPAs we partner with all share a common goal. They want to provide insights and actionable data to their client partners that they serve so that they can be as forward and agnostic as well as doing things in the benefit of their clients. And so by providing technology, by providing our services and in that capacity through natural connectivity is a primary way.

Ryan Rice (19:14):

So TPA says, "Hey Bill, and Ted's Bait Shops, I know that you're struggling with X, Y, and Z on the pharmacy side. We have this group that works with us on a number of things. We really recommend that you take a look at them and look at getting into a long-term relationship." That's been one of a great way for us to generate partnership. I'd say another really powerful way is through advisors. I think of the bell curve of adoption. We're really good fits for those who are forward-thinking, who are early to adopt new concepts, and who know that the puck is going to be someplace else and we want to be where that's going to be.

Ryan Rice (19:53):

But if folks still using the rotary or flip telephones they may be more comfortable with the big houses that have been around for hundreds of years. So I think it's important to know that we are on that front side of that curve. And we see ourselves taking up relationships with client partners who see the value of being able to be at the front end of innovation as well as thought leadership. And broker relationships have been a great partner there for us in that they know they're not experts in pharmacies, like having someone who's really good at corporate tax to do your taxes. You're not going to Turbo Tax that one. Right?

Ryan Rice (20:35):

So it's a way for us to align with a broker in their respective book of business to help provide a deeper threshold of expertise that helps protect their book of business. But it also helps go out and predate or go after those clients, using pharmacy as a lever, to be able to say, "Hey, prospect, I can help you with these things. I bet you there's 20% savings in your pharmacy spend alone." So that's a great way in which we've been able to garner some that additional support.

Leigh Dill (21:05):

All right, talk to you soon. [crosstalk 00:21:08] great rest of the day.

Announcer (21:11):

Thank you for listening to this episode of The Granite List Live. Access our entire library by visiting your favorite podcast venue or subscribe in our site,


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