Transcript Emerging Opportunity Trends in Pharmacy Services

Trends and Opportunities
in Pharmacy Services
Meghan Swarthout, PharmD, MBA, BCPS
Nathan Thompson, RPH, MBA, MPH
Objectives
• Review trends in pharmacy purchasing, including
utilization of the 340B Program
• Describe various types of pharmacy services offered
in a health system
• Review various ways in which pharmacy services
can be leveraged to provide value within an
integrated health system
1
Johns Hopkins Home Care Group:
Aligning Home Based Services
2
Johns Hopkins Home Care Group:
Delivering the Promise of Medicine to Home
3
Outpatient Pharmacy Services:
Johns Hopkins Medicine
• To help patients and prescribers navigate
increasingly complex medication use system
an
• To avoid unplanned acute care encounters through
improved care coordination and patient management
programs tailored to meet individual patient needs
• To meet the challenges of new healthcare delivery
models and reimbursement structures
• To support patient care in the most appropriate, cost
effective, settings within Johns Hopkins Medicine
4
Outpatient Pharmacy Services:
Achieving the Triple Aim
Pharmacy Services
•
•
•
•
•
•
• EMR integration
Standard Specialty
• Advanced
compounding
• Shared patient
•
<1%
of
prescriptions
Standard
outcomes
dispensed
• Financial assistance
Community
• Specialized distribution • Population focused
Product dispensing
requirements
care
Basic compounding
• Compliance with
Vaccinations
regulations
Delivery service
• Disease management
Patient counseling
• Benefits investigation
Basic insurance
adjudication
Achieve the Triple Aim
• Population Health
• Patient engagement
• Improved patient
outcomes
• Patient Experience
• Convenient access
• Complete and
integrated care
• Reduce Costs
• Appropriate
medication spend
• Minimize
preventable
readmissions
5
Outpatient Pharmacy Services:
Patient and Family Centered Care
Johns Hopkins Pharmacy Patient Populations
6
Regardless of Source…
The Process is Complex
7
But in the End it is About the Cost
Group Purchasing
Organization (GPO)
Organization created to leverage the purchasing power of
a group to obtain preferred pricing
340B
Drug discount program for qualified institutions including
disproportionate share hospitals
Federal Supply
Schedule (FFS)
Large contracts through which federal customers can
acquire a multitude of products, including drugs
Wholesale Acquisition
Price (WAC)
Price paid by wholesaler for drugs purchased from the
manufacturer
Average Wholesale
Price (AWP)
Publicly available, national average of list prices charged
by wholesalers to pharmacies. Not defined in legislation.
“Sticker Price”, not actual price paid by purchasers.
Apexus 340B University, 2013
8
340B Overview
• Requires manufacturers to provide covered outpatient
drugs to eligible entities (a Medicaid requirement)
• Average savings of 25% to 50%
• Estimated $6 billion in drug purchases in 2014
• Enables covered entities to stretch scarce Federal
resources as far as possible, reaching more eligible
patients and providing more comprehensive services
HRSA 340B Drug Pricing Overview, September 2015. http://www.hrsa.gov/opa/stakeholderpres, 2012
9
340B History of 340B
• Created in 1992
• HRSA issued guidance for an individual to qualify as a
patient of a 340B covered entity
• 2010 Affordable Care Act broadens the definition of
“covered entity”; multiple contract pharmacies introduced
• 2016 “Mega-Reg” proposed
HRSA 340B Drug Pricing Overview, September 2015. http://www.hrsa.gov/opa/stakeholderpres012
10
Generating Savings with 340B
Adapted from Apexus, 2016
11
Eligible Entities:
HRSA Federal Grantees
Black Lung Clinics
Public Housing Primary Care Program
Comprehensive Hemophilia Treatment Center
Ryan White Clinics
Family Planning (Title X only)
Sexually Transmitted Disease Clinics
Federally Qualified Health Centers
Tribal/Urban Indian Health Centers
Federally Qualified Health Center
Look-Alike
Tuberculosis
Native Hawaiian Health Program
HRSA 340B Pricing Program Overview. http://www.hrsa.gov/opa/eligibilityandregistration
12
Eligible Entities:
Hospitals
• Disproportionate Share Hospitals
• Critical Access Hospitals
• Sole Community Hospitals
• Rural Referral Centers
• Freestanding Cancer Hospitals
• Children’s Hospitals
HRSA 340B Pricing Program Overview. http://www.hrsa.gov/opa/eligibilityandregistration
13
340B Implementation Options:
You Don’t Have to Pick Only One
•
•
•
Covered Entity Owned/In-House Pharmacy:
– 340B only used in Outpatient areas:
• Mixed use settings (Infusion, Outpatient Clinics)
• Retail Pharmacy
– Savings generated from increased margin
Contract Pharmacy:
– Way to expand access for patients and increase savings potential
– Pharmacy not owned by entity dispenses under contract relationship;
entity retains revenue minus a dispensing fee and purchases
replacement drug
Covered Entity:
– Maintains responsibility for 340B drug and program compliance
– Responsible for compliance with contract pharmacies
HRSA 340B Pricing Program Overview. http://www.hrsa.gov/opa/eligibilityandregistration
14
Trends in 340B Participation:
Program Eligibility
15
Trends in 340B Participation:
Contract Pharmacies
16
Trends in 340B Participation:
Program Integrity
• HRSA Guiding Principles
– Maximize Oversight Reach
– Manage Compliance Risks
• Covered Entity Responsibilities
– Ensure Program Integrity
– Maintain Adequate Records
HRSA 340B Pricing Program Overview. http://www.hrsa.gov/opa/eligibilityandregistration
17
Program Integrity:
Published Results
Year Posted
Posted Results
Programs with Findings
2012
51
32 (63%)
2013
94
73 (78%)
2014
99
80 (81%)
2015
178
134 (75%)
2016
14
5 (36%)
Adapted from HRSA 340B Program Integrity http://www.hrsa.gov/opa/programintegrity/index.html as of 2/25/2016
18
Trends in 340B Participation:
2015 The Busiest Year Ever
Month
Highlight
March
House Energy and Commerce Hearing
May
Draft Legislation
May
MedPAC 340B Report Issued
June
MedPAC comments suggest congress consider changes
July
GAO Report on 340B and Medicare Part B
July
Senator Grassley (R-IA) Requests Hearing
August
HRSA Proposed 340B Guidance Released
October
340B Raised in House and Senate hearings
November/December
MedPAC considers changes to payment for 340B Hospitals
Source: Melisa Lindamood
19
Trends in 340B Participation:
Happy New Year…Potential Topics in 2016
• Questions of Program Intent
• Shared Savings
• Patient Benefit
• Transparency
Source: Melisa Lindamood
20
Opportunities in 340B:
Work with Congressman
Hospitals
Address
Congressional District
Harbor Hospital
3001 S. Hanover Street
Brooklyn (21225)
Dutch Ruppersberger (MD-2)
Johns Hopkins Bayview Medical
Center
4940 Eastern Avenue
Baltimore (21224)
John Sarbanes (MD-3)
Prince George’s Hospital Center
3001 Hospital Drive
Cheverly (20785)
Donna Edwards (MD-4)
Shady Grove Adventist Hospital
9901 Medical Center Drive
Rockville (20850)
John Delany (MD-6)
Bon Secours Hospital
2000 West Baltimore Street
Baltimore (21223)
Elijah Cummings (MD-7)
Johns Hopkins Hospital
1800 Orleans Street
Baltimore (21287)
Elijah Cummings (MD-7)
Kernan Hospital
2200 Kernan Drive
Baltimore (21207)
Elijah Cummings (MD-7)
Source: Maryland Hospital Association
21
Opportunities in 340B:
Work with Congressman (cont’d)
Hospitals
Address
Congressional District
Maryland General Hospital
827 Linden Avenue
Baltimore (21201)
Elijah Cummings (MD-7)
Mercy Hospital
345 Saint Paul Place
Baltimore (21202)
Elijah Cummings (MD-7)
Union Memorial Hospital
201 E. University Parkway
Baltimore (21218)
Elijah Cummings (MD-7)
University of Maryland
22 S. Greene Street
Baltimore (21201)
Elijah Cummings (MD-7)
Sinai Hospital
2435 W. Belvedere Avenue
Baltimore (21215)
Elijah Cummings (MD-7)
Holy Cross Hospital
1500 Forest Glen Road
Silver Spring (20910)
Chris Van Hollen(MD-8)
Washington Adventist
7600 Carroll Avenue
Takoma Park (20912)
Chris Van Hollen(MD-8)
Source: Maryland Hospital Association
22
Opportunities in 340B:
It Takes a Village
• Executive Leadership
• Legal
• Internal Audit
• Compliance
• Finance
• Supply Chain
• Pharmacy
23
Trends in 340B Participation:
The Program is Changing, but not the Purpose
24
Navigating Medication Use Systems:
What type of Pharmacy do I even go to?
Community
Pharmacy
Mail Order
Pharmacy
Infusion
Pharmacy
Specialty
Pharmacy
Investigational
Drug Service
Acute illness
Medications
Chronic illness
medications
IV medications
given at home
or ambulatory
infusion center
Brand name,
high cost
medications
Investigational
medications
Source: Victoria T. Brown, Pharm.D., BCOP
25
The Business Model for Each Varies:
The Shift in the Market Space
26
Trends in Retail Pharmacy:
Generic Use Leads to Decreased Revenue
27
Trends in Retail Pharmacy:
While Revenues Drop, Costs Still Rise
28
The Results:
Independent Pharmacy Profitability
2013 NCPA Digest with Financials. http://www.ncpanet.org/pdf/digest/2013/2013digest_financials. Accessed 12/28/15.
Trends in Specialty Pharmacy:
The Look Quite Different
2012
2020
$87 Billion
3.1%
National
Health
Spending
$400 Billion
9.1%
National
Health
Spending
The Growth of Specialty Pharmacy: Current Trends and Future Opportunities.
UnitedHealth Center for Health Reform & Modernization. April 2014.
30
Defining “Specialty Pharmacy”
• Cost
– Monthly cost exceeding $600 – $10,000
– Threshold varies by payer
• Complexity
– Treatment of complex, chronic, and/or rare conditions
– Special storage, handling, and/or administration
requirements
– Ongoing monitoring for safety and efficacy
– REMS program requirements
31
Trends in Specialty Pharmacy:
Comparing Retail and Specialty Pharmacy
Average revenue per prescription revenue was $2,770 in 2014
Gross profits were more than 10 times that a typical retail
prescription
32
Trends in Specialty Pharmacy:
The Trend Will Continue…And Grow
33
Infusion Site of Care:
Implications of HSCRC Capitation
Ambulatory
Infusion Center
Hospital Clinic
Cost
Patient
Preference
Home
Safety
34
Evolution of the Pharmacist
• Education and Training
– Undergraduate
– Doctor of Pharmacy (4 years graduate)
– ±1-2 years post-graduate training
• Scope of Practice Expansion
– Vaccination
– Medication Therapy Management
– Behind the counter pharmacist managed drugs
35
Maryland Pharmacy Practice:
Collaborative Practice Agreements
• Allows for pharmacists to enter into Drug Therapy
Agreements (DTMAs) with physicians
– Modification, continuation and discontinuation of drug therapy
– Ordering of laboratory values
• 2015 Legislative Session
– Allows for DTMA with nurse practitioners
– Allows for initiation of drug therapy when agreement is with a
physician
– Therapy management contract with the patient does not need
annual renewal
36
Caring Across the Continuum:
And Avoiding Costs
Acute Care
Services
Ambulatory
Services
Community
Services
Treatment selection and modification, intensive
monitoring, and education (pre-discharge)
Treatment selection and modification,
monitoring, and education (post-discharge)
Monitoring (e.g., adherence, adverse events, changes
in condition), education, and referral for changes in
condition or development of new conditions
37
Pharmacy Services:
Avoiding Unnecessary Costs
Patient Case
Pharmacist Intervention
Cost Avoided
Patient on trifluridine/tipiracil
with labs prior to Cycle 2
showing ANC 0.5
Pharmacist recommendation
lead to holding therapy and
repeating labs in 1 week
Avoided potential hospital
admission for febrile
neutropenia and IV
antimicrobials
Paper script for
trifluridine/tipiracil with dose
calculated with wrong BSA
Pharmacist corrected BSA
resulting in 30% dose
reduction instead of 50% as
written
Avoided under-treatment of
metastatic colon cancer
patient
Patient with thrombocytopenia
with baseline platelets 30-50K
on CapeOx
Recommended stopping Advil
PM, Vitamin A and E due to
increased bleeding risk.
Recommended stopping folic
acid due to increased risk of
Xeloda toxicities
Avoided potential healthcare
utilization for bleeding
38
Discharge Prescription Services
• On average, 20-40% of patients never fill prescriptions when
they leave the hospital
• Patients face challenges with discharge prescriptions due to
insurance coverage issues
• Key operations
• Utilize high performing pharmacy technicians that are
integrated with inpatient team
• Patient choice in pharmacy selection is always maintained
• 340B eligibility for discharge prescriptions potentially at risk –
need to highlight these programs
39
Discharge Prescription Services:
Patient Satisfaction
Survey N=58
Low (1-2)
Neutral (3)
High (4-5)
Satisfaction
0%
10%
90%
More likely to take
meds at home
0%
14%
86%
Patient Comments:
•
•
•
•
Great interaction with the technicians. Very informative and cordial.
I really appreciate this service. It is a big help with my discharge!
When will this be available on all the units? It is great!
Thanks for all your help. I can tell you really care.
40
Discharge Prescription Services:
Special Needs Voucher Use
Pre-Program
Quarterly Average*
Quarter 1
(Q4 FY2013)
Quarter 2
(Q1 FY2014)
Quarter 3
(Q2 FY2014)
Quarter 4
(Q3 FY2014)
Annualized
Variance
$16,851
$18,854
$16,067
$13,429
$9,660
($29,215)
*Analysis conducted for ~100 medicine beds, cost of medications based on AWP
Factors Contributing To Voucher Cost Decrease:
– Prior authorization facilitation
– Focus on most affordable medication option based on patient’s pharmacy
benefit insurance
Goal:
– Create the most clinically appropriate, financially sustainable discharge
medication regimen
41
Enhancing Value in Patient Care:
Access: Insured, Underinsured, and Uninsured
Johns Hopkins Specialty Pharmacy Patient Out-of-Pocket-Cost for
ledipasvir/sofosbuvir, simeprevir, and sofosbuvir, CY14
Percent of Prescriptions
60%
50.4%
50%
45%
40%
•
More than $12 million in PAP/foundation
funding in 2014 for all patients
•
More than $20 million in 2015
30%
20%
10%
3.7%
0.9%
0%
0
$1-$50
$50-$250
over $250
Range of Copays (Dollars)
42
Outcomes for Pharmacist Home Visits:
Reducing Readmissions
The 30-day readmission rate associated with patients who received
pharmacist home visits was 54% lower than expected (4 v. 8.7). The
odds of a 30-day readmission in these patients compared to patients
who were offered and refused the service was 72% lower, adjusting for
severity based on the HSCRC 30day expected readmission ratio,
which was found to be statistically significant.
n
43
Readmission index
OR
0.46
0.28
95% CI (0.01 – 0.91)
95% CI (0.09 – 0.90)
p = 0.033
43
Improving Patient Outcomes:
Focus on Adherence
• Abandonment rate benchmarks?
• Drug trial discontinuation rates 1% to 4.3%
• “Real world” analysis average of 8.1%
44
Johns Hopkins Specialty Pharmacy:
Leading the Way Nationally
Johns Hopkins Specialty Pharmacy Patient Completion Rate, sofosbuvir
Those Not Excluded from Johns Hopkins Specialty Pharmacy Services, CY14
N=336
N=12
(3.6%)
Patients taking sofosbuvir
Did not complete
therapy
N=324
(96.4%)
Completed
therapy course
45
Conclusions
• Demonstrating value of 340B to lawmakers is
important for the sustainability of the program
• Consider strategic opportunities to build specialty
pharmacy disease state lines
• The clinical role of the pharmacist has evolved and
should be leveraged to improve patient outcomes and
reduce costs
46
Acknowledgements
•
•
•
•
•
•
•
•
•
•
•
•
•
Melisa Lindamood
Tim Warner, RPh, MBA
Vicki T. Brown, PharmD, BCOP
Jake Smith, PharmD, MBA
Kris Rusinko, PharmD, M.Ed.
Lori Dowdy, CPhT
Amy Shook, PharmD Candidate 2016
Andy Pulvermacher, PharmD
Jordan Rush, PharmD, MS
Joe Cesarz, PharmD, MS
Amy Nathanson, PharmD, AE-C, BCACP
Jennifer Katzianer, PharmD, BCACP
Tamara Reginald
47
Trends and Opportunities
in Pharmacy Services
Meghan Swarthout, PharmD, MBA, BCPS
Nathan Thompson, RPH, MBA, MPH