New study shows $11-16 medical savings when Optum care management and Optum pharmacy are provided together with medical benefits.


Optum recently completed a study intended to assess the value of integrating medical and clinical benefits with OptumRx pharmacy benefits.

The study compared medical expenditures between two groups of customers:

  1. Those who had OptumRx integrated with medical benefit plan.
  2. Those who had an external pharmacy benefit manager with their medical plan.

All groups had the same carrier for medical coverage plus Optum care management programs. Due to the retrospective view of the study, the group with OptumRx integrated with medical/clinical included a range of synchronized model capabilities. To varying degrees, all of the plans being studied feature data, people, and technology used in a coordinated way across all channels.

Study results demonstrate up to a seven percent reduction in inpatient admissions and up to six percent reduction in ER visits, with an overall Per Member Per Month (PMPM) medical savings of $11-$16.

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[NOTE: At the request of OptumRx, Milliman validated the reasonability of the study methodology and assumptions. Please contact OptumRx for a complete copy of the Milliman review.]


Today, those who pay for and receive pharmacy benefits face complex challenges. These include more demand for medication, expensive specialty medicines, significant price inflation for many traditional medications, and more chronic illness than ever before.1, 2, 3, 4 These challenges have created an important opportunity for a next-generation pharmacy care services company like OptumRx.

Historically, cost management efforts of PBMs have been limited by a lack of data beyond prescription claims. At best they might have only sporadic access to medical and other data sources. PBM programs supported only by pharmacy claims data are subsequently forced to rely on inferred diagnosis and other assumptions as they attempt to drive any interventions.

Further, without the opportunity to leverage data in health care arenas beyond pharmacy, traditional PBMs tend not to attain broad and deep domain expertise. Such limited expertise in analytics and technology sets a low cap on the value they can deliver.

Finally, traditional PBMs can only interact with members only via traditional PBM encounters. This is a significant additional limitation. When fully integrated or synchronized, OptumRx has the power to look beyond pharmacy by leveraging data, analytics, technology, with our expertise and capabilities to help drive better care with a wider focus on total health care costs.

Many criteria can be used to evaluate a PBM’s value. This analysis examines the inherent value of integrating the OptumRx pharmacy management services with clinical and medical coverage. Specifically, we asked: “What medical cost savings can be measured when we compare our pharmacy care services approach to the traditional PBM approach?”  


This study extends and refines an ongoing series of internal studies. It features over 5 million participants from 80 clients, with a 12-month period ending in June 2015.

The analysis looked at the overall savings using a top-down approach to estimate the incremental overall value of integrating OptumRx pharmacy benefits and services with medical insurance coverage, as well as care management programs from Optum. The assumption is that integration of the unique pharmacy care services offered through OptumRx creates value by providing a faster and more complete view of a member’s care across all benefits. This allows Optum to identify gaps in care and other savings opportunities more quickly.

After adjusting for various factors to create valid comparable groups, we identified 80 large administrative services only (ASO) groups for the study. Common among all groups was health insurance coverage from the same carrier and clinical services from OptumHealth:

  • 40 groups had integrated pharmacy benefits with OptumRx
  • 40 groups used an external vendor for their PBM

This study focused exclusively on medical cost and utilization, since pharmacy costs were not available for the non-integrated groups.

study participants chart

Group Pairing Criteria

The analysis paired integrated and non-integrated groups and adjusted for factors such as retrospective risk, geographic cost, and plan specific factors such as cost sharing, plan design, provider network and wellness programs with United Healthcare and OptumHealth products.

Risk: Different groups of individuals will usually present differing levels of risk for future health care costs. The Symmetry® Episode Risk Group (ERG®) is a proprietary Optum risk assessment tool that predicts current and future health care usage for individuals and groups. The Society of Actuaries recognizes ERG as the most accurate risk assessment tools in the industry.1

We used ERG to create retrospective risk scores and calculated relative aggregate risk for each group that incorporated episodes-of-care methodology, medical and pharmacy claims information, and demographic variables.

Geographic Location: Inpatient, outpatient and physician costs can vary widely by location. To account for these differences we created an index for each ZIP code to reflect relative cost differences.  The index value was applied to all costs to reconcile the differences and create values that are more comparable.

Plan Factors: We use a proprietary actuarial index designed to summarize all the health and cost management solutions available to a client. These are grouped into seven cost management “levers,” including plan design, cost sharing, provider network, as well as clinical and wellness programs. Each solution lever receives an actuarial score based on its expected impact on medical costs. So for example, a plan design score of 1 is expected to yield 1% medical cost impact. When the scores for all the levers are combined, we have a single value, which captures how aggressively/progressively a plan is managing overall population spend.

In general, very large groups will tend to show many characteristics in common. However, we could not create an exact match between individual integrated and non-integrated groups across all metrics. The differences widened when pairings were aggregated to overall integrated and non-integrated groupings. Therefore, we made separate adjustments to aggregate PMPM costs for each factor.   

[NOTE: At the request of OptumRx, Milliman validated the reasonability of the study methodology and assumptions. Please contact OptumRx for a complete copy of the Milliman review.]


On average, the medical claims from groups with OptumRx demonstrated an overall medical savings of $11-$16 PMPM compared to the groups who did not have OptumRx. In each major spend category, costs were significantly lower, including inpatient hospital, outpatient hospital, and physician, with outpatient showing the highest value. The results also demonstrated lower inpatient hospital admission and Emergency Room (ER) visit rates.

overall savings chart

The study also evaluated utilization and cost for sub-categories within the major spending categories, including medical/surgical/ICU, outpatient surgery, radiology/diagnostic, and anesthesia. There were significant reductions in both utilization and cost in favor of the groups with OptumRx.

This graph illustrates reduced utilization rates for inpatient admissions and emergency room (ER) visits:

-6.4 and -5.3 ER visits

Evidence-Based Medicine (EBM)

We also measured compliance with nationally recognized Evidence-Based Medicine (EBM) guidelines. The purpose of EBM and practice guidelines is to provide a stronger scientific foundation for clinical work; to achieve consistency, efficiency, effectiveness, quality, and safety in medical care.2

EBM compliance was shown to be routinely higher for groups with OptumRx integrated pharmacy benefits. Shown below are summary results for select conditions:

highlighted conditions with increased evidence-based medicine compliance


Overall, the study yielded favorable findings in many areas – from aggregate medical PMPM to condition-specific compliance with EBM guidelines. Further research is underway to substantiate the extent to which each value driver contributed to the savings. What the analysis does show is a difference in outcomes that may be driven by the holistic view of medical and pharmacy benefit management in decision-making around UM/PDL/Clinical programs, as well as the following activities:

  • Medical, pharmacy, and clinical data are collected, integrated, analyzed, and referenced using a common clinical platform. This system generates over 130 billion evaluations per month – over 4 million evaluations per second.
  • Data velocity is much greater for clients with OptumRx integrated benefits. Daily data exchange results in faster, more timely, more actionable information.
  • Multi-disciplinary teams are in place to coordinate care for integrated clients. Each team consists of a health advocate, a nurse, and a pharmacist.
  • Members are educated to call their health advocate for any health need or pharmacy concerns. Since pharmacy is frequently the most used benefit, these additional calls represent additional touch points, for greater medication adherence and clinical engagement.
  • One of our key intervention tools is called next best action. Our multi-disciplinary teams are equipped with personalized insights into each member’s situation that generate “next best action health and savings offers” based on clinical research. These offers provide valuable influence for members, and include connecting them to other services, including wellness or behavioral support, disease and care management programs; identifying any potential safety or adherence issues; and promoting lower cost alternatives.

Through this approach, we capitalize on our ability to engage with our members and intervene to influence their next best health actions or set of personalized opportunities. This happens regardless of how or where the member came in contact with us.

The OptumRx relationship is key. Front-line clinical staff have real-time access to pharmacy claims information which cannot be duplicated when an external PBM solution is in place. This data helps generate a complete 360 degree view of the member, which fuels our ability to generate prioritized, relevant member-level opportunities across medical and pharmacy with the most current information.


One key area where perhaps intervention makes a material difference is in specialty pharmacy services. Domain specialist teams of nurses and pharmacists support patients with chronic and complex diseases like oncology, rheumatoid arthritis, multiple sclerosis, and HIV/AIDS utilizing the 360 degree view when available. In the future, when patients are engaged and educated, they  improve medication adherence, are able to better manage adverse effects, and benefit from  lower overall health care costs compared to non-integrated patients.3 In the future, Optum plans to expand on synchronized capabilities specifically within specialty management services.

Things to look for

  • We expect to release updated studies documenting specific specialty treatment outcomes in the coming months.
  • Since this study has been conducted, we are now employing a new method for prioritizing potential next-best actions. We’ll tell you more about this exciting capability in the upcoming months.


It’s clear that the time for impactful next-generation pharmacy services has arrived. These results demonstrate that OptumRx is best positioned to drive meaningful improvement in outcomes and value through the pharmacy benefit. OptumRx pharmacy care services with its synchronized approach leverages data and technology to build connections that result in more effective and responsible health care delivery to improve total medical costs.

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1. “More demand for medication.” CDC/NCHS, National Health and Nutrition Examination Survey. See Appendix I, National Health and Nutrition Examination Survey (NHANES). Table 79 Prescription drug use in the past 30 days, by sex, race and Hispanic origin, and age: United States, selected years 1988–1994 through 2009–2012. Accessed at:

 2. “More expensive specialty medicines.” The Pew Charitable Trusts Fact Sheet. Specialty Drugs and Health Care Costs. Nov 2015. Accessed at:

3. “Significant price inflation for many traditional medications.” Health and Public Policy Committee of the American College of Physicians. Stemming the Escalating Cost of Prescription Drugs: A Position Paper of the American College of Physicians. March 29, 2016. Annals of Internal Medicine.  2016;165(1):50-52. doi:10.7326/M15-2768. Available at:

 4. “More chronic illness.” National Health Council. About Chronic Diseases.  Rev: July 29, 2014. Accessed at:

5. Optum Solutions for Government. Symmetry® Episode Risk Group.® Accessed at: on 06.08.2016.

6. Health Affairs. The Promises And Pitfalls Of Evidence-Based Medicine. January 2005 vol. 24 no. 1 18-28. Accessed at: on 06.08.2016.

7. Annals of Internal Medicine. Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review. 4 December 2012, Vol 157, No. 11.