OptumIQ turns data into intelligence


Possibilities come together when data & analytics connect


While much of the health care industry is just waking up to the colossal challenge of creating truly integrated data systems, Optum is actively using OptumIQ: our unique combination of data, analytics and health care expertise.

One of the key characteristics of data in the health care space is its sheer volume. For example, it is estimated that some 30% of the world’s stored data is generated in the health care sector.1

In theory, this data potentially has enormous clinical, financial, and operational value. However, up to 80% of that data is unstructured data, which makes it vastly more difficult to process and interpret.1

OptumIQ is the key that unlocks the hidden value in these huge volumes of data.

Watch: Video interview with OptumRx vice president and chief analytics officer Andrea Marks. Andrea explains how OptumRx is transforming data into insight, insight into action and action 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 level, and even down to the individual person.

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

Next Best Action

With OptumIQ, OptumRx is harnessing curated data, leading analytics, and applied experience to amplify consumer engagement with Next Best Action. Going beyond traditional health care data, this impressive set of data integrates clinical data with non-clinical variables such as geographic, psychographic/demographic, and program interactions. Next Best Action applies in near real-time predictive analytics such as propensity to engage to provide a personalized recommendation.

With applied expertise from clinicians, pharmacists, and nurses, any time a member calls OptumRx, the Next Best Action intervention model will display 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 one of our pharmacists about; or highlight when one of our specialized disease management programs could be helpful to that individual.

But even the best interventions can only work if people choose them. Critically, Next Best Action ranks each offer to maximize member engagement. Even the order in which the options are presented to each caller will differ for the most impact on an individual level.


With OptumIQ, Next Best Action lets us position the options we predict members will choose first, which significantly increases the odds that they will choose them: In fact, we have seen 60% enrollment rates in condition management programs offered through pharmacy since we’ve implemented this methodology.


OptumRx has been at the forefront of efforts to control the enormous opioid crisis. It’s a top priority. OptumIQ provides advanced data tools like machine learning and predictive modeling that can identify patients whose utilization patterns place them at the highest risk of overdose and addiction. When these capabilities are fully implemented, they will allow us to perform robust monitoring of physician prescribing behaviors and pharmacy dispensing patterns in much more proactive and sophisticated ways. That means we will be able to intervene quicker and more aggressively when needed.

OptumRx pharmacy and therapeutics (P&T)

The OptumRx pharmacy and therapeutics (P&T) committee is the independent group charged to decide which drugs will appear on our drug formulary, and how the utilization of these drugs will be managed. OptumRx P&T consists of leading external physicians and pharmacists who rely on OptumIQ to create unique, evidence-driven clinical management criteria, as well as to quickly make revisions to existing coverage and utilization management (UM) criteria.

Ocaliva™ (obeticholic acid) was recently approved to treat a liver condition that can cause small bile ducts to become inflamed, damaged, and ultimately destroyed. In September of 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 was able to rapidly leverage the analytical power of OptumIQ to evaluate the potential risk to our own population. We found that approximately 80% of high risk Ocaliva patients 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 (UM) safety criteria for Ocaliva in November of 2017.

Months later, in February of 2018, the FDA issued a new Boxed Warning to the Ocaliva drug label regarding the dangers of incorrect dosing in certain patients.

We are convinced that our ability to act quickly in this situation – before the new Boxed Warning – helped to save lives and prevent other physical harm to our members. OptumIQ allowed us to make a data-driven decision much sooner than would have otherwise been the case.


Recently, we spoke with OptumRx vice president and chief analytics officer Andrea Marks to get her thoughts on the process and value of transforming data into insight. Andrea offered a simple, powerful image to clarify what OptumIQ can mean:

OptumIQ allows us to translate vast amounts of data and information in a meaningful, actionable way. We’re the data whisperers.

In order to garner true actionable insights, you need to get very personal with the data; understand its nuances and how it’s behaving. The data and information is trying to tell you a story – it is our role to give it a voice. 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.

Ultimately, we arrive at a place where the data can tell a story about what is actually going on at a person level, and within a given population. As we see the data story unfold, the opportunities for making changes, taking actions, or adopting new strategies become readily apparent – like it was there all along.

OptumRx is just beginning to exploit the potential of OptumIQ. This comprehensive set of data, analytics capabilities and applied expertise will be critical to managing the pace with change and 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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  1. NEJM Catalyst. Using It or Losing It? The Case for Data Scientists Inside Health Care. May 4, 2017. Accessed at: https://catalyst.nejm.org/case-data-scientists-inside-health-care/