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Develop Health’s Clinical Eligibility service addresses a critical need in healthcare: helping provider groups understand which drugs patients are eligible for based on their plan constraints. This understanding is vital to prevent unnecessary prior authorization cycles with PBMs, which can increase administrative burdens and negatively impact patient experiences.

The Challenge

Healthcare providers often face challenges in determining the most suitable medication for patients due to plan constraints. This lack of clarity can lead to multiple, time-consuming prior authorization cycles, resulting in delayed treatment and increased operational costs.

Our Solution: Drug Eligibility Endpoint

To address this, Develop Health offers a Drug Eligibility endpoint, an innovative solution designed to work alongside our Benefit Verification service. This endpoint takes patient coverage information, clinical data, and a list of drugs to output whether a patient is clinically eligible for each drug. The response includes a detailed tree structure for each drug, with annotations indicating eligibility based on clinical criteria.

Example: Saxenda Eligibility Criteria

The service evaluates various criteria like age, behavioral modification trial duration, BMI criteria, and additional criteria like concomitant behavioral modification and diet. Each criterion branches further to determine the final eligibility, providing clear insights into initial and continuing therapy eligibility.

Implementation Components

Our solution includes several key components:

  • Robust PA Policy Document Matching: Utilizes formulary data provider and patient coverage information to accurately find prior authorization policy documents.

  • PA Policy Document Parsing: Extracts clinical decision criteria from documents, structuring them into a tree format for each drug.

  • Eligibility Evaluation: Assesses patient’s eligibility based on clinical data against the structured criteria.

  • Endpoint for Information Submission and Response: Facilitates the submission of necessary data and provides structured responses.

  • User Interface for Visualization: Enables providers to visually review and understand the eligibility evaluation.

Application of the Data

With this data, clients can make informed decisions about drug eligibility and understand potential changes needed from the patient, such as willingness to participate in an exercise program.

Output Formats

The output is presented in a tree UI, suitable for scenarios requiring nuanced decision-making. The system provides clear yes/no answers for drug eligibility, indicating low-confidence areas where human fallback might be necessary.

Approach and Focus

In developing this feature, our focus is on addressing the most common scenarios and drug eligibility criteria. We aim to avoid being sidetracked by rare edge cases in the initial release, ensuring that the majority of cases are handled effectively and efficiently.

Conclusion

Clinical Eligibility at Develop Health represents a significant step forward in improving patient satisfaction and reducing operational expenses for healthcare providers. By structuring complex clinical decision criteria into an accessible format, we provide clear guidance on drug eligibility, simplifying the decision-making process and expediting patient treatment.