Real-Time Drug Efficacy Visibility for Payers

Gain an immutable audit trail for every prescription and associated outcome, dramatically reducing areas of loss.

• Detect prescription fraud by tracking drug provenance and patient consent on an unchangeable ledger.
• Identify clinical waste by highlighting therapies with high rates of discontinuation or switch due to ineffectiveness.
• Quantifiable Impact: The NIH estimates billions are lost annually to healthcare fraud. A transparent ledger can help payers recover a significant portion by providing irrefutable proof of anomalous patterns.

Streamline the most burdensome administrative process by using a patient-owned health record. With patient consent, providers can instantly share verified diagnosis and treatment history, enabling near-instant authorization decisions.

• Reduce decision time from days to minutes.
• Lower administrative costs for both payers and providers.
• Improve member satisfaction by removing care delays. This turns a cost center into a competitive advantage in member retention.

Build a proprietary data asset on real-world drug performance. Anonymized, aggregated insights from your member population become a strategic tool for negotiating with pharmaceutical manufacturers.

• Leverage data in PBM and manufacturer negotiations to secure better pricing based on your population's specific outcomes.
• Identify unmet needs and partner with biotech firms on targeted solutions.
• This transforms data from a compliance burden into a core competitive differentiator.

Replaces manual, dispute-prone rebate processes with smart contracts that execute automatically based on verified patient outcomes. This eliminates reconciliation costs and ensures payers only pay for drugs that work as promised in real populations.

• Real Example: Aetna (CVS Health) has piloted blockchain to manage value-based agreements for specialty drugs, reducing administrative overhead by an estimated 30-40%.
• ROI Driver: Direct link between payment and proven efficacy protects margins and improves formulary decision-making.

Creates an immutable, shared ledger of prescription fills, patient diagnoses, and treatment outcomes. This single source of truth allows AI models to detect patterns indicative of fraud, off-label promotion, or ineffective prescribing in near real-time.

• The Pain Point: The US healthcare system loses an estimated $100B+ annually to fraud and waste.
• The Blockchain Fix: Early anomaly detection prevents payouts for non-compliant or ineffective treatments, directly protecting the bottom line.

Enables secure, patient-controlled sharing of verifiable health credentials and historical treatment data. This gives payers the evidence needed to approve or deny high-cost therapy requests instantly, without manual record chasing.

• Business Benefit: Reduces approval cycles from days to minutes, improving member satisfaction while ensuring compliance with clinical guidelines.
• Real-World Pioneer: Anthem (now Elevance Health) has explored blockchain-based platforms to give members control over their health data, streamlining access for providers and payers alike.

Tracks pharmaceuticals from manufacturer to pharmacy with granular serialization. For payers, this mitigates the cost and liability of counterfeit drugs entering the network and enables instantaneous, targeted recalls.

• The Pain Point: Counterfeit drugs cost the global industry over $200B annually and pose severe patient safety risks.
• The Blockchain Fix: Provenance tracking ensures plan dollars are spent on authentic products. In a recall, affected batches are identified in seconds versus weeks, minimizing member risk and claims expense.

Provides an immutable, timestamped record of all data access, contract executions, and coverage decisions. This automated audit trail dramatically reduces the cost and complexity of regulatory compliance (e.g., for CMS, HIPAA, SOX).

• Cost Savings: Reduces manual audit preparation labor by an estimated 50-70%.
• Business Enabler: Creates a defensible position for coverage decisions, demonstrating rigorous, data-driven processes to regulators and auditors.

Today, payers and providers spend millions reconciling disparate data from EHRs, labs, and pharmacies to assess a drug's real-world performance. A permissioned blockchain creates a single, immutable source of truth for treatment outcomes and patient-reported data. This eliminates manual reconciliation, reduces audit preparation time by up to 70%, and provides a verifiable audit trail for regulatory compliance (FDA, EMA).

Outcomes-based contracts are stalled by manual, disputable data collection. Smart contracts can automate payouts based on verifiable efficacy data recorded on-chain. For example, a contract for a diabetes drug could automatically trigger rebates to a payer if aggregate patient A1C levels don't improve by a predefined threshold within 6 months. This reduces administrative overhead and builds trust between manufacturers and payers.

Minimize risk and complexity. A successful pilot focuses on a single high-cost specialty drug (e.g., a novel oncology therapy) within one payer's network. Onboard 5-10 provider sites and a few hundred consenting patients. Track key efficacy metrics (e.g., tumor response, progression-free survival) and patient-reported outcomes. The goal is not a full rollout, but to prove data integrity, process efficiency, and a clear path to ROI within one quarter.

The pilot's business case is built on hard savings and risk mitigation:

• Reduced administrative cost: Cut manual data aggregation and dispute resolution by an estimated 30-40%.
• Faster contract cycles: Accelerate rebate and value-based payments, improving cash flow.
• Compliance risk reduction: Mitigate fines and litigation with an immutable audit trail.
• Strategic data asset: Create a new, high-integrity data product for market analysis and research.