Transcript Medical Benefit and Specialty Pharmacy

Specialty Pharmacy
Stakeholder Panel Discussion
Moderated by Mark Zitter
April 3, 2013
Our Fundamental Dilemma
New Drug Introductions Focus Payer Management
To what degree is each of the following categories a management priority?
Cancer
Multiple sclerosis
Diabetes - Type 2
Rheumatoid arthritis
1
High
priority
Payer Priority Percentile
Cancer, 1.0
Not at all a
priority
0
Diabetes - type-2, 1.0
Hepatitis C virus (HCV)
Cancer, 1.0
Diabetes - type-2, 0.9
Multiple sclerosis, 0.9
Hepatitis C virus (HCV)
Rheumatoid arthritis, 0.4
Multiple sclerosis, 0.1
Fall 2010
(n = 100)
Fall 2011
(n = 101)
Fall 2012
(n = 103)
Larger Payers in Particular Use Separate Specialty Benefit Designs
How does your most representative commercial benefit design
structure patient cost-sharing for specialty therapies?
Within the pharmacy
and/or medical benefit
cost-sharing structures,
even if predominantly on a
higher cost-sharing tier
As a separate benefit (not
just on a separate tier),
independent from the
pharmacy and medical
cost-sharing structures
10%
26%
90%
Percentage of Payers
Unsure n = 2
Payers n = 103
Covered lives n = 158.6 million
74%
Percentage of Lives
High Deductibles are Becoming the New Normal
An Increasing Percentage of Workers are Covered by High Deductible Plans
Source: Kaiser Family Foundation (2012), The Prevalence and Cost of Deductibles in Employer Sponsored Insurance:
A View from the 2012 Employer Health Benefit Survey, Available http: www.kff.org/insurance/snapshot/chcm110212oth.cfm
Care Delivery and Financial Risk are Becoming Integrated
Obamacare's Accountable Care Approach
Reaches 1 in 10 In U.S.
A rapidly emerging health care delivery system that
rewards doctors and hospitals for working together
to improve quality and rein in costs is serving
“roughly 10 percent of the U.S. population,”
according to a new report.
The new analysis from consulting firm Oliver Wyman
released Monday says the growth of accountable care
organizations, or ACOs, has reached up to 25 million
to 31 million patients, growing beyond the 2.4 million
patients.
Payers See SPPs as Helping, but Mostly for Pricing and Distribution
How valuable is each of the following services commonly offered by SPPs?
Not valuable at all (1) or Minimally valuable (2)
Considerably valuable (4) or Extremely valuable (5)
3%
Competitive pricing1%
Breadth of product availability / scope of
distribution arrangements with 4%
manufacturers
Patient compliance/adherence
measurements 8%
14%
17%
82%
3% 4.19
78%
4% 4.06
76%
19%
Mean
4.63
1%
*
94%
Reduced waste through dispensing as close
to the prescribed dose as possible 4% 11%
Reduced waste through proper inventory
management at the patient level (Utilization 4%
control)
Somewhat valuable (3)
We do not utilize this service
67%
Percentage of Payers
Payers n = 103
* ^ Significantly greater / lower than other services
3% 3.96
6% 3.81
Payers See Less SPP Value in the More Sophisticated Services
What are the reasons why you do not utilize specialty pharmacy services?
My organization already provides this service
Manufacturers in this category provide or make provisions to provide this service
We actively partner with another provider of this service, i.e., disease management firm
Contracting with the SPP for this service would not deliver a positive ROI
Creating prior authorization policies
(n = 27)
89%
Managing prior authorization policy
approval process (n = 22)
Consistency in care through clinical
guideline management (n = 20)
0%
86%
0%
74%
Capturing health outcomes measures
(n = 16)
75%
0%
6%
Percentage of Payers
7%
5%
5%
75%
Managing tests that help ensure
appropriate use (n = 19)
4%
9%
10%
5%
16%
11%
0%
25%
SPPs Influence Therapy Selection, But Less So Than Payers or GPOs
How influential is your practice’s relationship with each of the following stakeholders
when determining cancer therapy selection?
Asked of oncologists in an independent practice or independent hospital.
Oncologists
n = 62
Payers
3.81
Group purchasing organizations
Specialty pharmacy providers
n = 60
3.27
Practice committee
3.03
Independent hospital
Not
influential
at all (1)
n = 58
3.45
n = 59
2.85
Below
average
influence (2)
Average
influence (3)
n = 59
Above
average
influence (4)
Oncologists’ Average Influence
Extremely
influential
(5)
Eat or Be Eaten
• Not all stakeholders in the specialty pharmacy arena will thrive, or even survive
• Successful stakeholders will find new ways to manage costs while meeting
patient needs, in the era of greater integration of care delivery and financing
• One stakeholder’s excess cost is another’s income
• Current stakeholders that prove unable to add sufficient value will become the
victims of the “steak holders” and will be eaten
Specialty Pharmacy
Stakeholder Panel Discussion
Moderated by Mark Zitter
April 3, 2013
http://go.zitter.com/nasp
Specialty Key Stakeholders
Panel Discussion
Atheer A. Kaddis, Pharm.D.
Diplomat Specialty Pharmacy
Key Trends Impacting Specialty Pharmacy
• Expansion of specialty pharmacy to include both
pharmacy benefit and medical benefit
• The specialty pharmaceuticals pipeline
• Introduction of oral specialty pharmaceuticals
and biosimilars
• Impact of specialty pharmacy cost and utilization
trends on payors
• Expansion of specialty pharmacy providers
What Are We Doing to Respond?
• Gaining expertise and working with other
stakeholders to address specialty pharmacy
under medical benefit
• Growing partnerships with health systems and
physician organizations
• Gaining expertise and capabilities to support
increasingly complex pharmaceuticals and to be
positioned for limited distribution drugs
What Are We Doing to Respond?
• Developed unique partial fill programs,
formulary strategies, and medical management
strategies to assist payors
• Supporting retailers that are focused on specialty
pharmacy by providing support services while
retailers continue to dispense specialty drugs
• Preparing for ACOs and Health Insurance
Exchanges
Specialty Key Stakeholders
Panel Discussion
James R Lang, PharmD, MBA
Vice President, Pharmacy Services
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of Michigan
Provider Environment
• Physician Group Incentive
Program
– $120m annually
– Evidence-based measures
• Collaborative Quality
Initiatives
• Patient Centered Medical
Homes
– Largest in the country
– 3000 physicians
– 2 million members impacted
Blue Cross Blue Shield of Michigan
Provider Environment
• PCMH Neighborhood
– Specialists added
– Medication management a requirement
• Organized Systems of Care
(ACO)
– 38 up and running
• Hospital Incentive Contracts
• Provider Delivered Care
Management
– 400 practices
– Oncology – 1/1/14
18
PGIP: Catalyzing Health System Transformation in Partnership with Providers
2004
2005
2006
2007
2008
2009
2010
2011
2012
PGIP
PCMH
OSCs
Chronic Care
Model
Primary care
transformation
Organized Systems
of Care
• Transform care processes to effectively
manage chronic conditions
• Build PCMH infrastructure
• Strengthen doctor-patient relationship
• Build registry and reporting capabilities to manage
populations of patients
• Support PCPs and their team’s ability to
effectively manage care
• Support establishment of systems
of care that assume responsibility
and accountability for managing a
defined population of patients
across all locations of care
• Achieve savings in specified areas
• Reward physicians for improved performance and
efficiency
• Share savings
• Coordinate care across the continuum
for a defined patient population
• Establish linkages with community
services
1997
Implement first
Collaborative
Quality
Initiative (CQI)
Expand PGIP
to include
specialists
involved in
chronic care
Implement
PCMH and
quality/use
initiatives
Continue to
increase
number of
initiatives
Continue to
add new
specialties to
PGIP
Extend providerdelivered care
management with
links to BCBSM for
customer reporting
statewide
19
Provider Delivered Care Management
• Pilot began April 2010, ended March 31, 2012
• An extension of Michigan Primary Care Transformation
(MiPCT) program in collaboration with Medicare
• Five physician organizations
• 52 physician practices
• 258 PCPs
–
–
–
–
–
Metro Detroit
Ann Arbor
Flint
Battle Creek
Muskegon
• Addressed chronic conditions such as diabetes,
depression, etc.
20
Provider Delivered Care Management
• Expanded to 400 physician practices April 1st, 2012
• Nurse care managers hired and trained for each office
• Patient registry data (with specialty pharmacy markers)
sent to physician practices
• Physician organizations report positive impact on clinical
indicators
• Pharmacists eligible for some of the fee reimbursements
– Required to have relationship with the physician
• Expansion to oncology practices on January 1st, 2014
21
Aggregate Spend of Drugs in:
Medical Benefit and Specialty Pharmacy
Specialty drug costs are accelerating in all places of service
$400
Spend (in millions)
$350
$300
$250
$200
$150
$100
4Q08
4Q09
2Q10
Outpatient
4Q10
Physician
2Q11
4Q11
2Q12
Specialty Rx
Drugs administered under the medical benefit have been
shifting from doctor’s offices to more costly outpatient
facilities since 2008
Annual Trend:
Outpatient 20.2%
Physician 1.5%
Specialty Rx 7.9%
Channel Management
Specialty drug
spend
Medical
New cross-functional distribution
channel management abilities:
Outpatient
Specialty
Vendor
Inpatient
Mail-order
Vendor
Physicians
Retail
• Benefit design
• Claim editing
Pharmacy
• Expansion of vendor management
• Reimbursement enhancements to take
advantage of the most cost effective care
setting
• Physician Group Incentive Program
• Utilization Management (UM) programs:
• Prior authorization
• Off-label review
• Pipeline monitoring
• Provider services
• electronic Prescribing
• Medication adherence
DME
Home Infusion
Hemophilia
Provider
2323
Specialty Drug Management
Techniques Implemented
•
•
•
•
•
•
•
•
Prior Authorization
Step Therapy
Formulary Tiers
Quantity Limits
Off Label Limitations
Hemophilia limited network
Preferred Specialty Pharmacy
Physician Specialty Rx Dashboard / Data Set
– Oncology drugs to be added 2nd QTR 2013
•
•
•
•
•
24
Rebates
Referral efficiency reporting to physicians
Five and six tier benefit structures
Oncology Pathways Program
Pipeline Monitoring and Utilization Management Planning
Specialty Drug Management
• Developing
–
–
–
–
–
–
NDC level pricing (3rd QTR 2014)
NDC level quantity required (3rd QTR 2014)
Ambulatory Infusion Benefit (3rd QTR 2014)
Channel efficiency reporting to physicians
Global pmpm targets in place now for physician organization, including drug
Specific specialty drug pmpm targets under development
• Challenges
–
–
–
–
–
25
State and Federal mandates
Provider contracts
Fraud potential
Manufacturer Co-pay Cards
Physician Buy and Bill
Specialty Key Stakeholders
Panel Discussion
Jann Rigell, BS, Pharm
Express Scripts
Achieving Healthier Clinical and Financial Outcomes
Manage All Sides of Patient Care and Costs
Drug Choices
Pharmacy Choices
Health Choices
Ensure the Right Drug
Ensure the Right Pharmacy
Ensure the Right Care
 Guiding cost-effective and  Directing patients to the
appropriate prescribing
channel that offers
and utilization
 Clinical
 Drug
specialization
 Amount
 Personalized patient
 Duration
engagement
 Education and counseling
to better understand
conditions and drugs
 Regular adherence
monitoring
 Supportive services
Express Scripts Specialty Benefit Services
Practical Solutions in Key Decision Areas
Drug Choices
 Benefit design options
 Utilization management
 Medical benefit
management
Pharmacy Choices
 Network management
Health Choices
 Highly specialized
Therapeutic Resource
Centers® with CareLogic®
 Personalized patient
counseling and education
Yielding Healthier Outcomes
Improved Care for Patients
 Better adherence
 Better health outcomes
 Lower cost of care
Reduced Waste for Plan Sponsors
 Better management control
 Increased savings
 Lower specialty trend
Proven Results: Active Management Delivers Lower Trend
Plan sponsors who actively manage specialty
drugs reduce trend by half
Management Level
Unmanaged
Somewhat Managed
Tightly Managed
Programs Implemented
•Open specialty network
•No step therapy programs
•Exclusive specialty network
•One or no step therapy programs
•Exclusive specialty network
•Multiple step therapy programs
Trend
27.8%
16.7%
13.6%
Better Clinical Care From Accredo
Better Clinical Care
 CareLogic and TRCs
 Specialty-trained pharmacists and nurses
 Complete medication and medical profile
 Comprehensive therapy management
 Proactive outreach to 100% of patients
 Teachable moments maximized
Results in…
Better Adherence
Better Health Outcomes
Lower Costs
Pulmonary arterial
hypertension (PAH)
 17% higher than retail
 32% fewer hospitalizations
35% fewer ER visits
 $13,000 less medical
expense annually per
patient
Rheumatoid arthritis (RA)
 16% higher than retail
 9% fewer hospitalizations
13% fewer ER visits
 16% annual savings
on medical expenses
Multiple sclerosis (MS)
 32% higher than retail
 39% fewer hospitalizations
39% fewer ER visits
 31% annual savings
on medical expenses
Specialty Key Stakeholders
Panel Discussion
Sajid Syed, MS, RPh
ACRO Pharmaceutical Services
Who Is Acro?
• Acro Pharmaceutical Services is owned by Lincare
Holdings, a subsidiary of The Linde Group
• Revenue 2012 ~ $2 billion
• Over 11,000 employees
• 1100+ sales people
• Over 500 Nurses on Staff
• 30 closed door pharmacies across United States
– 26 infusion + 4 mail order + Acro Specialty Pharmacy (HUB)
– Over 85 RNs and 102 Pharmacists
32
Acro/Lincare Pharmacy Services
Lincare Pharmacy Locations
Boca Raton, FL
Little Rock, AR
Casper, WY
Livonia, MI
Charlotte, NC
Louisville, KY
Chesapeake, VA
Madison Heights, MI
Clinton, NY
Marietta, GA
Fayetteville, AR
Montgomery, AL
Flowood, MS
Orlando, FL
Fort Smith, AR
Pelham, AL
Grand Rapids, MI
Sharon Hill, PA (ACRO)
Huntsville, AL
Somerset, KY
Indianapolis, IN
Syracuse, NY
Jonesboro, AR
Tempe, AZ
Lexington, KY
Hammonton, NJ
Southhaven, MS*
Clearwater, FL*
Kansas City, MO*
Carlsbad, CA*
Staffing Includes: 102+ Pharmacists and 85+ Nurses
* Mail Order Pharmacy
33
Acro Business Model: The “Acro” Solution
Payers
Providers
Pharma
• Systematic
utilization
management
• Compliance &
Persistence Programs
• Designated
manufacturer
relations liaison
•Market Share Pull
Through Agreements
• Distribution through
the exclusive / preferred
SP for the key regional
payers
• Data Analytics



• One-stop efficient
specialty product
management
Continuity of care
Appropriate utilization
Optimal compliance and outcomes
34
Patients
• Dedicated specialty
pharmacy
• Integration &
alignment within the
provider-payerpharmacy team
Acro Provides Comprehensive Services






Dispensing and handling
-
24-48 hour turn-around with express carriers and local delivery
Clinical services and customer support
-
Benefit coordination
Clinical support 24 / 7 / 365
Formulary and utilization management
-
Policy development support
Pull-through strategies
Physician and provider communications
Prior Authorization Services
Compliance & Persistency programs
-
Confirmation and Follow up
Proactive Refill Notification
Live outreach
Specialty Therapy Management (STM) Compliance Program
Analytical services
–
–
Drug utilization (physician level)
Payer claims processing analysis
Consulting Services
–
–
–
Formulary Pull Through Strategies
Patient & Provider Outreach Coordination
Data & Service Agreements
35
NASP/AMCP Panel
Employer Perspective
April 2013
F. Randy Vogenberg, PhD, RPh
Principal, Institute for Integrated Healthcare
and
Managing Principal, Bentelligence
Influencers or Distribution Channels: Specialty Pharmacy
Manufacturers
Dispensers
-PBM w/ SP
-Chain Retail w/SP
-Independent SP
-MCO w/PBM-SP,
Other Rx Settings
Wholesaler &
Distributors
Patient
Payers
-Medicare /
Medicaid
-TPAs / ASOs
-MCOs / Health
Plans
Prescribers/
Administrator
Purchasers
-Employers
-Unions
-Municipalities
-MD Office
-Infusion Center
-Clinic
-Home
-HC
-Patient
2012 Annual Employer Survey on Specialty Pharmacy Benefits
• Total survey respondents:
– 68 large, self-insured employers
• Top industry types
– 34% Manufacturing
– 16% Government
– 13% Education
• Benefits Funding
─ 87% Self-insured
─ 13% Fully-insured
Copyright 2013 © MBGH & IIH
Employer level of understanding of specialty pharmacy benefits
2011
2012
Copyright 2013 © MBGH & IIH
Contracting and evaluating service providers
Importance of factors
when contracting with
service providers
Top outcomes
used to evaluate
service providers
1. Overall performance
1. Cost management
2. Cost of services
2. Overall performance
3. Medication adherence support
3. Patient management
4. Care management support
5. Trend management
Copyright 2013 © MBGH & IIH
Project Work Streams
Address market need
to understand
employer perspective
and claims experience
in the use of specialty
pharmacy drugs and
services.
Conduct employer
pilot programs to
test value-based
benefit design
concepts and
measure their
effectiveness.
Research and
develop innovative
value-based benefit
design coverage
approaches.
Work Stream 1
2011 to 2012
Work Stream 2
2012 to 2013
Work Stream 3
2012 to 2014
Work Stream 4
2012-2014
41
Copyright 2013 © MBGH & IIH
Deliver
education on
outcomes to all
key stakeholders,
including
reporting,
presentations
and publications.
New Drug Evaluation for Health Plan Decision Makers
Patient
Value
Proposition
Provider
of Health
Plan
Purchaser
• Value in eye of
decision maker
• Balancing clinical
& economic
issues to make a
value decision
• Requires
realigning
resources and
parallel efforts
(C) IIH, an Affiliate of Bentelligence. January 2013.