Transcript Document

What is so special about
Specialty?
PRESENTED BY:
Kim Foerster, Director, Managed Markets Sales, Diplomat Specialty Pharmacy
Jeremy Faulks, Retail Specialty Manager for Target Specialty Pharmacy
Learning objectives




Specialty Pharmacy Basics
Cost of Lick It, Stick It, Ship It Models
The Basics of Specialty Management
The Good + Bad of Co-Pay Assistance
Diplomat Case Study, July 2013 – January 2014.
2
Specialty pharmaceuticals
Difficult
Medication
Delivery
• Strict temperature control
• Distribution can be limited
• Restricted location for
administration
Complex
Treatment
• Personalized dosing or
administration
• Clinical management or
close monitoring required
Adapted from Blaser DA, et.al. How to Define Specialty Pharmaceuticals – A Systematic Review. Am J Pharm Benefits. 2010;2(6).371-380.
Diplomat Case Study, July 2013 – January 2014.
3
Specialty pharmacy market
The specialty market is not a level
playing field, as extreme variations
are seen in patient care
management, service, and
outcomes.6
1.
Cohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013.
4
Specialty pharmacy landscape
SP Model
Characteristics
PBM Owned
• Structured programs
• Higher use of technology for patient
outreach
• Strong buying power
• Ability to shift costs
• Specialty pharmacy is a piece of the
business
Plan Owned
• Ability to easily view all claims data
(medical + pharmacy)
Retail Owned
•
Independents
• More flexible – willingness to customize
• Specialty pharmacy is primary expertise
• Focused on patient care and service –
more high-touch
• Greater transparency
Community based care
5
Top 10 specialty drug classes
1
• Inflammatory Conditions – Rheumatoid Arthritis
2
• Multiple Sclerosis
3
• Cancer
4
• HIV
5
• Growth Deficiency
6
• CNS Disorders
7
• Respiratory Conditions – Cystic Fibrosis
8
• Anticoagulants
9
• Organ Transplant
10
• Pulmonary Hypertension
Express Scripts®. Drug Trend Report [Internet]. 2014 April [cited 2014 Apr 8]. Available from:
http://lab.express-scripts.com/drug-trend-report/table-of-contents.
6
Stakeholder concerns
PAYOR
PHARMA
PHYSICIAN
PATIENT
• Marketplace
trends
• UM programs
• Measured and
reportable clinical
outcomes
• Patient adherence
/ satisfaction
• Access to drugs
• Data
• Spend trends
• Adherence
• Biosimiliars
• Patient assistance
programs
• Therapy initiation
• Manufacturing
cost
• Administrative
work burden
• Patient
compliance
• Time for
appropriate care
• Buy and bill
• Administration
• Adverse event
management
• Disease
progression /
quality of life
• Cost
UM: Utilization Management
Cohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013.
7
Collaboration is the future of health care
Affordable Care Act (ACA)
 Requires collaboration on
quality initiatives with
reportable savings
 Physician Value-Based
Modifier coming in 2015 –
need to measure how
medication contributes to
quality
 Care coordination is priority
in six NQS (National Quality
Strategy) domains
Centers for Medicare & Medicaid
Services (CMS) Call Letter
“. . . ensure continuity of care and integration
of services through arrangements with
contracted providers.”

Demonstrate improved
outcomes and achieve patient
satisfaction through
advancement of good quality
health. Measured by five CMS
star rating categories:





Patient outcomes
Intermediate outcomes
Patient experience
Patient access to care
Process
8
Specialty care coordination – The basics
Adherence
Teamwork
Tolerance
Access
9
 Coordination of
benefits
 Physician
education on
guideline
updates
 Medical billing
 Side effect and
symptom
management
 Customized
communication
 Injection
training support
 Support group
enrollment
Clinical Management
 Case
management
coordination
Patient education +
empowerment
Care Collaboration
Best-in-class care
 Motivational
Interviewing
Techniques
 Drug regimen
assessment and
collection of
medication
history
 Adherence calls
 Proactive PA &
Rx renewal
support
10
Improving
adherence
“
Technology
Nurse Adherence
Calls
Prophylactic
Starter Kits
Compliance
Packaging
Patient
Training &
Education
11
Compliance & persistency
Adherence tools
Proactive side-effect
management
12
Cost of ineffective care
Category
Surplus
medication
Most Recent
Fill
Days
Name of
Supply
Drug
Dispensed
11/27/2012
84
10/25/2012
84
8/2/2012
84
10/8/2012
28
Quantity on Hand
Amount of
Surplus /
Waste
Member had 4 week supply of
6 week
Avonex medication on hand in early March
surplus
Enbrel Member did not set up first shipment 11 week
Sureclick
until early April
surplus
Member had 60 day supply of
Humira medication on hand as of early May
Member had a six week supply of
Aranesp medication on hand in mid January
24 week
surplus
10 week
surplus
Cost of surplus medications on-hand
Waste due to
member
stopping
therapy
9/17/2012
60
9/25/2012
84
6/6/2012
84
Member had 60 day supply of
waste of 60
Sensipar
medication on hand in May
days
Enbrel
Member had 60 day supply of
waste of 60
Sureclick medication on hand in early March
days
Enbrel
Member had 60 day supply of
waste of 60
Sureclick medication on hand in early April
days
AWP for
surplus/wasted
quantity
$7,045.20
$7,295.90
$15,767.78
$7,462.50
$37,571.38
$2,129.76
$5,306.00
$5,306.00
Cost of excess drugs dispensed and not used due to discontinuation
$12,741.76
TOTAL
$50,313.14
13
Co-pay assistance controversy
Traditional Drugs:
 Use of co-payment cards to
bypass plan formularies, step
edits and patient contribution
Specialty Therapies:
 Co-payment assistance
through foundation grants
allows continuation of
therapy
 Care collaboration =
Improved patient outcomes
14
The bridge to breast cancer patient care:
co-pay assistance
 Diagnosis: Metastatic
breast and bone cancer
 $1,927.23 co-pay is
roadblock to initiating
therapy
 Funding team was awarded
a Patient Advocate
Foundation grant on behalf
of patient
7-month case study
27%
Prescriber faxes
(average 3 per
month)
73%
Patient care phone
calls (average 8
per month)
*Physician discontinued therapy after 7 months due to anemia
anemia
Patient and prescriber communications, Diplomat Case Study, July 2013 – January 2014.
15
Higher cost-sharing leads to
greater prescription abandonment
Abandonment rate (%)
Oral Oncolytic Abandonment Rate at
Varying Cost-Sharing Amounts
(n=7,638)
(n=529)
Streeter SB, et al. Am J Manag Care. 2011;17(5 Spec No.):SP38-SP44).
(n=614)
(n=1727)
16
1% reduction in cost-sharing can increase
utilization of oral oncolytics up to 3.3%
Increase in utilization with each 1%
decrease in co-pay (%)
3.5
3.0
3.3%
2.7%
2.5
2.0
1.5
1.0
0.5
0.0
Oral Chemo <$1500 per
Treatment
Oral Chemo >$1500 per
Treatment
n=24,474 cancer patients, 20–69 years of age.
Milliman Inc., Parity for oral and intravenous/injected cancer drugs. January 25, 2010. Available at:
http://publications.milliman.com/research/health-rr/pdfs/parity-oral-intravenous-injected.pdf. Accessed March 3, 2013.
17
Bankruptcy rates for patients with cancer
Ramsey S, Blough R, Kirchoff A, et.al. Washington State Cancer Patients Found To Be At Greater Risk For Bankruptcy Than
People Without A Cancer Diagnosis. Health Affairs, May 2013;32(6):1143-1152.
18
Reporting: proof of collaborative value








Patient satisfaction
Medication adherence
Pharmacist interventions
Quality of life measures
Cost avoidance outcomes
Co-pay assistance summary
Patient communication summary
Specialty pipeline strategies
292 patients averaged 11.42 touches
3.16
Doctor - 28%
Insurance - 11%
7.04
1.22
Patient - 62%
Communications per patient, Diplomat Case Study, Q1 2013.
19
Questions
20