The new model of personalized care

Request More Information


For a long time, the limitations of predictive analytic technology used in call centers meant that it wasn’t all that predictive of the needs of an individual caller. Agents would often struggle to reconcile the static information on their screens with the dynamic, real-world concerns of the customer on the other end of the phone.

Things have changed. Leveraging ongoing advances in analytics technology, OptumRx has worked to build custom predictive models which are not only faster but also more predictive at an individual member level. A prime example is our recommendation engine called Next Best Action, which enables call center agents to make actionable, data-driven decisions in near real time. Next Best Action is a precision intervention model optimized to ensure that each member touch point can be maximized to deliver higher levels of patient engagement and reduce medical costs. Moreover, we are continuously refining our underlying model inputs to make sure the health care options presented to each caller are dynamic and better prioritized on an individual level.



male graphic Jack and female graphic Jill have the same symptoms lower back pain and Chronic Obstructive Pulmonary Disease

Here’s how Next Best Action works. When our members call their advocacy team for any reason, they interact with multi-disciplinary teams equipped with personalized insights into each member’s full health profile. After first addressing the member’s primary question or concern, the team uses this touch point to address other member-specific clinical and cost savings opportunities our system has identified. To achieve this personalized view, the Next Best Action model integrates individual attributes such as medical and pharmacy claims history, demographic information, and use of health/wellness programs, with an up-to-date, sophisticated set of clinical quality, best practice and economic rules.


The next best action model analyzes a wide variety of data

Jack and Jill have different options of plans of action that are unique to them

To understand Next Best Action at a more granular level, one needs to look at its component parts. At its base is data — a lot of data. Given the very nature of our business, OptumRx stands astride a multidirectional flow of data originating from many sources including payers, members, providers and drug manufacturers. Unique among PBMs, OptumRx has created a unified data infrastructure capable of capturing, structuring and analyzing this data, enabling us to better understand and engage customers.

Getting a more nuanced, personalized view of the caller requires mining and synchronizing more extensive and unique types of data. As a result, our model now accounts for geographic, psychographic and demographic variables specific to each patient. Geographic data may inform a patient’s options if a specific procedure is expensive or hard to obtain in their area. Likewise, the model incorporates psychographic data, which includes values, attitudes, interests and personality traits, in order to get a more complete view of the patient. Elsewhere, demographic information such as age, gender, income and marital status will also help determine the appropriate course of care.

Personalized patient data can determine their next best action
[Configure Slider]

Related articles

See all