Decision volume is outpacing precision
By 2034, the payer market is projected to expand to more than $155 billion. But at the same time, rising costs, an aging population, and growing demand for services are expected to further squeeze payer organizations. Members, meanwhile, may want more cost-effective care options.
Care management, utilization management, and drug and medical benefits are growing in volume and complexity. Payer and pharmacy benefit manager (PBM) organizations need a more consistent way to apply trusted evidence and data standards across different teams and decision types to help them improve efficiency without losing defensibility of decisions.
“There are so many drugs coming to market, and these drugs are increasing in cost and complexity,” says Allison Combs, Head of Payer Product, Strategy and Innovation for Wolters Kluwer Health. “It creates this underbelly in payer decision-making of confronting how to solve for volume and for precision at the same time.”
Combs describes rising volume as the “push” driving payers to change, and the need for precision as the “pull.” Meeting both demands calls for a more consistent and governed approach to data, evidence, and decision support.
Real-world evidence needs a foundation
Real-world evidence (RWE) only strengthens decision-making when it's focused, governed, and purpose-built for payer workflows. Otherwise, it adds to the volume problem instead of solving it.
Payer interest in RWE is high, but so is hesitation:
- A small share of payers report regularly using RWE in decision-making.
- The majority say rigorous, unbiased data curation is a key factor in choosing evidence and value assessment tools.
- Common barriers include biased or incomplete data, inconsistent standards, and dilution after repeated data mining.
“Unless you have the really pristine data foundation layer at the bottom, everything on top of it is going to tumble down,” says Deborah Pasko, PharmD, MHA, Associate Director of Technology Product Management – Payer/PBM at Wolters Kluwer Health. Fragmented data can leave teams working from different versions of the truth, making decisions harder to defend.
How payer organizations build consistency
Across care, utilization, and benefits management, payers want to reduce fragmentation and improve efficiency. They also want to demonstrate impact on costs, quality, and member experience. None of this should come at the expense of the clinical nuance that helps keep decisions defensible and appropriately targeted to member needs. Prioritizing evidence infrastructure, data consistency, and governance can help reduce decision variability in a structured way.
Discover evidence-based solutions for payers and PBMs. To learn more about the pressures shaping payer decision-making and how teams are building decision consistency into member engagement and coverage decisions, read the whitepaper, Balancing volume and precision in payer decision-making.