Three Steps to Improving Member Health and Controlling Costs

According to the Centers for Disease Control and Prevention (CDC), six in 10 U.S. adults have a chronic disease and four in 10 have two or more. These include conditions from heart disease to diabetes and are the leading drivers of the nation’s $3.8 trillion in annual healthcare costs.[1] Helping people understand their condition and treatment can lead to better adherence to their medications, improved health outcomes and reduced healthcare costs.

Population health has become a commonly used term in the healthcare industry and while the end goal is always the same, to improve the health of a given population, what it entails can be different. To eliminate gaps in care, improve patient safety and medication adherence, and thus health outcomes and costs, the following three components should be in the mix:

Step 1: Identify – Elixir uses predictive analytics to identify members who would benefit from population health solutions based on specific criteria and factors. Our analytics platform utilizes over 600 data points to identify individual socio-economic risk factors, clinical risk factors, receptivity and preferred communication channel. As a pharmacy benefit manager, we can also view a member’s full prescription claims history and can see trends, such as non-adherence, drug-drug interactions, contraindications and comorbidities that should be addressed in order to optimize treatment.

Step 2: Engage – Once a member has been identified, our specially trained Care Navigators, which include clinical pharmacists, registered nurses and certified pharmacy technicians, reach out to them and/or their prescriber using a variety of communication channels to improve the potential for engagement.

Step 3: Educate – When the member and/or prescriber engage, our Care Navigators educate them on their condition and treatment, explaining any potential gaps in care. This can lead to improved adherence and safety, and a reduction in healthcare complications, leading to a lower total cost of care.

Elixir offers a mix of personalized population health solutions that utilize these three steps to empower members to improve their health while reducing unnecessary healthcare costs.

A Look at Our Population Health Solutions

  • Improving Adherence and Star Ratings through One-on-One Interactions - A Medication Therapy Management (MTM) program is required for Medicare Part D prescription plans in order to ensure members are taking their medications appropriately to optimize therapeutic outcomes. However, not all MTM programs offer personalized interactions with access to the member’s complete clinical profile.

    Elixir uses predictive analytics to detect instances of inappropriate drug therapy based on a number of factors or concerns. Our MTM-certified Care Navigators then conduct personalized comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) with the identified members.

    As the PBM, our Care Navigators have a holistic view of the member’s drug claims. Through our personalized CMRs, members receive advice on their medications, get answers to their questions, discuss side effects and cost saving opportunities, and any other social-determinant barrier to care. This personal interaction supports a true impact in closing care gaps, increasing adherence and improves Stars scores.

    Such a program can also be referred to as drug therapy management (DTM). Elixir is one of only four organizations URAC accredited for DTM.*
  • Safely Managing Pain - The misuse and abuse of opioids has become an epidemic in the U.S., yet these potent medications can be effective for pain management. We offer a population health solution to ensure appropriate pain management that utilizes retrospective reviews to identify potentially dangerous or long-term opioid utilization. Our Care Navigators educate at-risk members on the importance of naloxone therapy. They also provide outreach to the identified members’ prescribers to coordinate care and discuss various options to assist members with treating pain appropriately.
  • Going Beyond Utilization Management to Improve Health Outcomes and Costs – Diabetes is a major health problem in the U.S. and a significant source of prescription spend for many plan sponsors. Our Diabetes Management Solution is more than simple utilization management. Our Care Navigators educate identified members on improving adherence and changing behaviors. We also work with prescribers to close gaps in care, such as identifying diabetics who are missing a statin, due for an annual eye exam or due for essential lab work. Typical results after one year of implementation include a decrease in hospitalizations, an average 84% adherence rate for diabetic medications (benchmark is 80%) and an average reduction of 1.3% in HgA1c.**
  • Eliminating Gaps in Care with Personalized Coaching – Our Gaps in Care Solution identifies members who have a gap between their current therapy and the ideal treatment needed to achieve optimal clinical outcomes. We develop therapy care gap recommendations using current evidence-based clinical guidelines and provide them to the prescriber. Closure of these care gaps increases member safety and prevents adverse events.
  • Our Commitment to Member Care - We are continuing to add more population health solutions that focus on adherence and specific disease states as part of our ongoing commitment to member care.

By following the three key steps of identifying potentially at-risk members, engaging them using their preferred communication channel, and educating them on their condition and treatment, we are improving the whole-being health of members while managing the total cost of care.


[1] Centers for Disease Control and Prevention. Chronic Diseases in America.

*This accreditation is held under the legacy EnvisionRx name and programs.

**Results may vary depending on client mix and population.


Topics: Solutions & Best Practices