4 Major challenges facing health care industry

How we are working to solve big challenges in health care

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During a session at Optum Forum 2021, Dr. Sumit Dutta, chief medical officer of OptumRx, explained how ongoing innovations will help address four big challenges.

One area of consensus about the state of healthcare is that there is no shortage of challenges. This is especially true for pharmacy care services. Informed by ongoing conversations with clients, OptumRx has identified four key challenges facing plan sponsors, physicians, and consumers.

  1. A fragmented health system
  2. Plan affordability
  3. Growing burden on consumers
  4. A lack of health equity 

These challenges were the subject of a recent presentation made by Dr. Sumit Dutta, chief medical officer of OptumRx, at Optum Forum 2021, our annual gathering of healthcare change-makers. When asked which of these four challenges was most important to them, attendees selected fragmented health system, garnering 41% of the vote.

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  • Bar graph titled “Which of these challenges is most important to you?” Bar 1 is labeled “plan affordability” and is 32%. Bar 2 is labeled “fragmented health system” and is 41%. Bar 3 is “burden on consumers” and is 14%. Bar 4 is labeled “health equity” and is 11%.



1. Fixing fragmentation

The healthcare system is notoriously disjointed. Due to the complex and fragmented nature of the system, a patient could be prescribed a drug at a hospital or by another physician without their primary care physician ever being notified. “Fellow physicians have often reached out to thank me after OptumRx notified them that their patients were filling prescriptions for drugs that they were unaware of,” Dr. Dutta said during his presentation.

This lack of coordinated information has consequences for both payers and providers. Take, for example, specialty drugs. Due to their route of administration, these expensive medications can be billed under either the medical or pharmacy benefit. In addition to prices for the same drug differing across the medical and pharmacy benefits, drugs processed in one benefit may not be visible to the other benefit. This also raises the possibility that clinical gaps are missed. 

To help lessen fragmentation, Optum is bringing these formerly disparate parts of the healthcare system together. One example of this is Optum FusionTM, a first-of-its kind solution designed to drive better health outcomes and lower costs across all benefits. Optum Specialty Fusion provides physicians real-time insight into the best clinical and financially appropriate specialty treatment options at the point of care through a prior authorization tool. Moreover, Optum Specialty Fusion is market-leading because it incorporates unique real-time analytics capabilities. This gives providers transparency to treatment cost comparisons for a given drug under either benefit. This comprehensive approach can unlock significant savings for plan sponsors — up to $15 per member per month (PMPM) savings across both medical and pharmacy benefits.1

2. Maintaining affordability

Among session attendees, the issue of plan affordability was the second most cited concern. In fact, studies show that 90% of plan sponsors say high drug prices threaten affordable employee benefits. 

While examining the root causes impacting affordability, Dr. Dutta highlighted the recent growth in ultra-expensive orphan drugs. Originally intended to treat rare conditions, orphan drugs accounted for 44% of FDA approvals in 2019.2

To help counter this trend, the OptumRx Orphan Drug Program focuses on the use of orphan drugs. The program proactively identifies diseases with the greatest opportunity for clinical intervention and subsequent cost savings. The program engages providers to advise on clinically appropriate therapy changes as needed. It also supports members utilizing specific orphan drugs by providing a one-on-one coaching experience tailored to address their unique medical history and medication needs.

Looking further ahead at the trends shaping drug affordability, Dr. Dutta noted the emergence of gene therapies. These medicines have the potential to cure or provide long-term symptom alleviation of rare and often fatal monogenetic diseases. One such example is Zolgensma®, which was approved for certain patients with spinal muscular atrophy, a progressive disease attacking the motor neurons of babies and young children. The drug currently costs over $2 million.

While Zolgensma is one of only two gene therapies currently in the market, this will not always be the case. As result, Optum has created the Gene Therapy Risk Protection program to help plan sponsors manage the financial risk around gene therapies. Rather than face a claim for the full cost of a gene therapy, plan sponsors instead pay a flat PMPM fee for coverage of clinically appropriate gene therapies after a deductible has been met.

3. Relieving the burden on consumers

Much as the growing cost of medications is a concern to plan sponsors, consumers are increasingly bearing the brunt of high-cost medicines. Dr. Dutta noted that many consumers have acknowledged that they have skipped filling a prescription medication due to its cost.

To keep drugs affordable for patients, OptumRx has deployed a variety of strategies, including formulary design, pricing tools, patient assistance programs and off-benefit solutions. One innovative solution, PreCheck MyScript, helps members save $225 per prescription.4

In addition to alleviating cost burdens, OptumRx is also attacking the complexity members taking multiple medications face. Multidose packaging simplifies the user experience by presenting the member with a personalized roll of their medications presorted in packets, with clearly marked dates and times. These packets can contain vitamins and over-the-counter medications, as well.  Importantly, multidose packaging also leads to better adherence, with more than 90% adherence for consumers who utilize multi-dose packaging for their medications.5

4. Advancing health equity

The desire to address health inequity has long been part of the culture of OptumRx. In Kansas, a pharmacist observed members choosing between medications they needed and money for food, housing and other basic needs. This simple observation related to unequal access to care led to the development of a program in partnership with the State of Kansas. The program helps uninsured and underinsured people in the state obtain the medicines they need.

The COVID-19 pandemic has highlighted the problem of health inequity. Data indicates that COVID-19 has disproportionately impacted certain low income and ethnic groups. That is why we have redoubled our efforts to address health inequity. OptumRx uses analytics to create dashboards that monitor health equity. These insights allow us to find and address inequities in core pharmacy functions like driving adherence similarly for all groups. Another example is ensuring that our pharmacy networks do not create pharmacy deserts in certain communities. 

“We hire and promote a diverse and inclusive workforce, so all perspectives are appreciated,” Dr. Dutta said. “We make addressing health equity a routine part of our business.” 

The progress OptumRx has made on these four key challenges exemplifies how we are uniquely equipped to address the biggest challenges in healthcare. 

An annual gathering of healthcare industry thought leaders, this year’s Optum Forum is a 3-day virtual series held on Sept. 21, Oct. 5 and Oct. 26. The Optum Forum session featuring Dr. Dutta’s presentation is now available to view on-demand.  Register to access this and other engaging discussions at optumforum.com.



1.      Optum internal analysis. 2021. Actual savings will vary depending on client programs in place.

2.      U.S. Food and Drug Administration. Innovation in New Drug Approvals of 2019 Advances Patient Care Across a Broad Range of Diseases. Accessed Sept. 29, 2021.

3.      BioPharmaDive. First oral drug for spinal muscular atrophy approved by FDA. Accessed Sept. 29, 2021.

4.      Optum internal analysis 2021.

5.      Optum internal analysis of paid claims from Jan.–Dec. 2018.

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This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article.

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