What pharmacy benefits administrators and the healthcare industry can learn from modern tech

Rick Bates RxSense.
Rick Bates

A pharmacy is many things to consumers: a point of connection and care, and often a focal point of their communities. According to MedRate 5.8 billion prescriptions were written and filled by pharmacists in 2018 — that’s a significant amount of disparate data points operating behind the scenes.

Pharmacy benefits administration is seeing a fundamental shift in the ecosystem. Traditional pharmacy benefit managers (PBMs) do not operate within one, central, unified database, often leaving data fragmented among insurance companies, employers, and other middlemen. Software built to improve pharmacy operations, adjudication efficiency, and data management is crucial for better and more personalized healthcare plans. The application of modern technology and consolidation of data, along with the optimization of old analog methods of storing information, improve patient outcomes and lead to an overall healthier world.

Two primary factors are modifying the status quo process:

  1. Many health insurance plans have shifted to high deductibles, and now nearly half of adults under 65 are responsible for paying for their own prescription drugs, because their insurance won’t cover them — sometimes until they spend thousands of dollars out of pocket first (an average of nearly $1600, more than doubling over a 10 year period, according to Kaiser research).
  2. The American population is aging and living longer (the number of Americans age and older will more than double over the next 40 years), which puts more pressure on the ecosystem and which causes drug utilization and associated drug spend to increase.

To combat these trends, there are two primary solutions that pharmacy benefits administrators can implement. This includes utilizing modern technology, and providing transparency including the cost of drugs with the goal of lower prices and associated spend.


Roughly 25% of US health care spending is estimated to be wasteful, with administrative complexity accounting for the highest share of spending at $265.6 billion per year, according to a study in the Journal of the American Medical Association. Using artificial intelligence and machine learning creates efficiencies that help lower the cost of healthcare, including medications to patients and employers. By breaking down and evaluating populations in smaller segments rather than by an average, AI can gather intelligence in the right order in which treatments should be administered and better formulate patient-focused health insurance plans. Furthermore, AI is able to personalize benefits, treatment hierarchies, and formularies. For example, by utilizing medical and pharmacy data, AI can help pinpoint patients that are “uncontrolled” (where disease is progressing or symptoms persist) and most at risk for hospitalization. With early detection and providing the right support and treatment before this patient progresses, AI can help prevent this hospitalization and get the patient back on the right track towards treatment goals.

Fortunately, there are modern technology solutions available now that are helping address these needs. One of them is RxIQ, RxSense’s industry-leading analytics platform, as it aggregates all of this data and provides automated reports to clients — including pharmacy benefit managers, regional health plans, health systems, third party administrators, new healthcare and pharmacy entrants, and healthcare technology companies — providing a 360-degree view of how their business is doing. These reports can include access to real-time pharmacy data and healthcare plan performance, and clinical or operational anomalies. RxIQ also allows for companies to easily make changes to healthcare plan options and benefit packages.

While AI can’t tackle health concerns such as COVID-19, aging, and hospitalizations, it can help track data and statistics over time to better predict beneficial treatment plans and minimize the impact of poor health in the long run. The machine learning component also allows AI healthcare systems to better predict future societal health patterns and improve overall wellness, ensuring a seamless care journey for each patient, from seeing a physician to visiting the pharmacy.

As AI grows in popularity and becomes fully integrated into the healthcare industry, we can more easily tackle challenges too big for a notoriously outdated, manual, and time-consuming system, to significantly reduce costs and create better care pathways for the future. Those not planning to integrate these innovative tools will be left behind.


There is a broad need in the healthcare industry for organizations to replace legacy systems with cloud-based services enabling on-demand access and analysis and increased efficiency. These legacy systems include Excel spreadsheets that require manual updates, and decades old operating systems on physical mainframe servers.

New cloud technology allows pharmacy benefit managers to access competitive drug prices, purchase pharmaceuticals, reimburse clients, and analyze it, all in real time. It also means that companies can decrease IT costs and spend less time managing data, while keeping sensitive patient information secure. Storing information in the cloud, when paired with security controls, improves any oversight. This is an incredibly important component when it comes to prescriptions and medication as it effectively decreases errors, which is critical given the nature of the data. As an example, RxSense has numerous security compliance certifications that are issued by independent accredited security auditors. This includes the highly-regarded HITRUST, ISO-27001 and SOC 1 and 2 certifications for security, and the ISO-22301 certification for business continuity.

With RxAgile, we’ve built a truly leading-edge platform that solves the problems of delivering pharmacy savings and benefit management with a more efficient and elegant solution. The cloud-based technology provides immediate speed, scale, and efficiency: as an example, businesses that previously took 6-12 months to set up pharmacy benefits on legacy systems can now do so in 6-12 weeks using RxAgile.

Our business exists to help employers provide exceptional benefits to employees. By leveraging modern cloud technology, AI, and machine learning, PBMs, health organizations and employers can make dramatic improvements in efficiency, transparency, and cost savings, and by extension, offer far greater value to the consumer.