Turning data into intelligence


Possibilities come together when data and analytics connect.


There is enormous clinical, financial and operational value in the vast amounts of data generated by the health care sector. However, up to 80% of that data is unstructured data, which makes it vastly more difficult to process and interpret.*

OptumIQ, a unique combination of data, analytics and health care expertise, has the capability to put these huge volumes of data to use.

Watch: Video interview with OptumRx vice president and chief analytics officer Andrea Marks,
who explains how OptumRx transforms data into results.

OptumRx uses OptumIQ to combine, refine, validate and continually enrich billions of data points covering over 250 million covered lives, including claims data and clinical data over 20 years of longitudinal experience. We filter that data through over 130 billion rules and algorithms that we apply well beyond just pharmacy, so we can impact cost and clinical outcomes at the client and individual level.

Here are three examples of how OptumRx is using the power of synchronized data with practical solutions that can solve today’s most pressing demands.

Next Best Action

Next Best Action is the way OptumRx can incorporate data beyond traditional health care sources to enhance consumer engagement. Geographic, psychographic, demographic and program interactions data helps Next Best Action apply predictive analytics to provide a personalized recommendation for each patient.

With applied expertise from clinicians, pharmacists and nurses, any time a member calls OptumRx, the Next Best Action intervention model displays customized cost saving or clinical enhancement suggestions based on that person’s unique profile.

For example, it may suggest replacing a branded drug with a generic alternative. It also alerts the representative to potential gaps in their treatment regimen that they may want to speak with a pharmacist about or highlight when a specialized disease management program could be helpful.

But even the best interventions can work only if people choose them. Critically, Next Best Action ranks each offer to maximize member engagement. The options are presented in an order customized to each caller for the most impact on an individual level. The accuracy of these predictions has resulted in members accepting the engagement option over 60% of the time.



OptumRx has been at the forefront of efforts to control the enormous opioid crisis. This top priority effort gets a boost from advanced data tools like machine learning and predictive modeling. The tools can identify patients whose utilization patterns place them at the highest risk of overdose and addiction.

OptumRx pharmacy and therapeutics (P&T)

The OptumRx pharmacy and therapeutics (P&T) committee is the independent group charged with deciding which drugs will appear on the drug formulary and how utilization will be managed. The leading external physicians and pharmacists on the P&T committee rely on OptumIQ to create unique, evidence-driven clinical management criteria and to quickly revise existing coverage and utilization management criteria.

Ocaliva™ (obeticholic acid) is used to treat a liver condition that can cause small bile ducts to become inflamed, damaged and ultimately destroyed. In September 2017, the U.S. Food and Drug Administration (FDA) discovered that, while a valuable option in the right individuals, when inappropriately dosed, Ocaliva can itself lead to moderate to severe decreases in liver function, increased risk of serious liver injury and even death.

OptumRx rapidly leveraged the analytical power of OptumIQ to determine that approximately 80% of its high-risk Ocaliva members were being inappropriately dosed, putting patient lives at risk.

In light of this compelling real-world evidence, the OptumRx P&T committee issued revised utilization management safety criteria for Ocaliva in November 2017. In February 2018, the FDA issued a new Boxed Warning to the Ocaliva drug label regarding the dangers of incorrect dosing in certain patients.

Robust data let OptumRx act months before the Boxed Warning, helping save lives and prevent other physical harm to members.


OptumRx vice president and chief analytics officer Andrea Marks recently clarified what OptumIQ can do:

OptumIQ allows us to translate vast amounts of data and information in a meaningful, actionable way. 

In order to garner true actionable insights, you need to get very personal with the data; you need to understand its nuances and how it’s behaving. When trying to evaluate how to engage with one person versus another, we leverage our insights and artificial intelligence. No two people are alike, and the data tells us just how and what matters in their health.

As we see the data story unfold, the opportunities for making changes, taking actions, or adopting new strategies become readily apparent.

A comprehensive set of data, analytics capabilities and applied expertise are critical to succeeding in the environments that matter most: better patient outcomes and lower overall costs.

Horizontal Rule

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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* HIT Consultant. Why Unstructured Data Holds the Key to Intelligent Healthcare Systems. March 31, 2015. Accessed May 6, 2019.