At CarelonRx, we use our ingenuity to bridge gaps between our members and personalized pharmacy care. One powerful tool we use is the Clinical Rules Engine (CRE), an automated data analysis platform. The CRE combs through members’ pharmacy, medical, and lab claims data to find gaps in care, ranging from missed prescription refills to untreated chronic health conditions. “The CRE’s main goals are to identify and close gaps in care to improve the lives of members and reduce costs,” says Product Manager Davena Gramke.
The CRE has been a key part of CarelonRx’s evidence-based approach since our launch as a pharmacy benefit manager (PBM). We include the technology in several solutions, including cost management programs, the Rx Care Nexus suite of digital pharmacy tools, and clinical quality measures such as Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare star ratings.
How the CRE Works
Users of CRE technology can create snippets of code logic, called rules. These rules are programmed to identify clinical care gaps and measure outcomes. With this data, we evaluate members’ experience, care quality, and costs. The CRE finds care gaps, such as whether:
- The member had a major medical event recently, like a heart attack.
- The member is not being treated appropriately for their condition.
- There is a more effective drug for the member’s diagnosis.
- A generic drug would reduce the member’s costs.
- The member is not refilling prescriptions on schedule.
- Carving in pharmacy may lower costs and improve communication among healthcare professionals.
According to Gramke, the CRE runs about 8,000 automated rules each month. To date, the platform has found more than 4 billion possible gaps in care for combined medical and pharmacy claims.1
When we see a gap, we engage affected members, their doctors, and other healthcare professionals as needed. We address gaps with actionable plans designed to improve members’ behavior. We support these plans through a variety of channels, including direct mail, phone calls, text messages, and fax. This outreach can improve health outcomes, lower costs, improve adherence, and prevent abuse. In 2020, for example, CRE gap closures offset more than $1.80 in per member per month (PMPM) medical costs and more than $0.61 in PMPM prescription costs.2