Transcript DoD Pharmacy Enterprise

Defense Health Agency
Optimal Pharmacy Care: DoD
Pharmacy Enterprise – Guiding
Integrated Pharmacy Benefit Delivery
Dr. George E. Jones, Jr. USAF, Retired
Chief, Pharmacy Ops, Defense Health Agency
Disclosures
∎ The presenter has no financial relationships to disclose.
∎ This continuing education activity is managed and accredited
by Professional Education Services Group in cooperation with
AMSUS.
∎ Neither PESG,AMSUS, nor any accrediting organization
support or endorse any product or service mentioned in this
activity.
∎ PESG and AMSUS staff has no financial interest to disclose.
∎ Commercial support was not received for this activity.
Learning Objectives:
At the conclusion of this activity, the participant will be able to:
∎ Describe the process evolution to an integrated pharmacy
benefit delivery enterprise for DoD
∎ Describe the membership and ops tempo of the Pharmacy
Work Group
∎ Describe key pharmacy enterprise targets for FY 17
Obtaining CME/CE Credit
If you would like to receive continuing education credit for this
activity, please visit:
http://amsus.cds.pesgce.com
Pre-Course Evaluation
1. DoD, facilitated by the Defense Health Agency, strives to
deliver a uniform pharmacy benefit as a pharmacy
enterprise. TRUE FALSE
2. The DoD Pharmacy Work Group membership includes the
Service Pharmacy Consultants, DHA Chief of Pharmacy Ops
and participation from other stakeholders as needed.
TRUE FALSE
3. Implementation of MHS GENSIS is a key pharmacy enterprise
initiative for 2017.
TRUE FALSE
DoD Pharmacy Enterprise
Mission
To direct the DoD Pharmacy
benefit in support of the
MHS’ mission through
effective planning,
programming, budgeting,
and execution of the DoD
Pharmacy operations.
Goal
Improving patient outcomes
while reducing overall
healthcare costs through the
delivery of optimal
pharmaceutical care.
Supported: MHS Strategy/Quadruple Aim.
Supporting: DHA–Facilitating Pharmacy Enterprise
Increased Readiness
Better Health
Ensuring that the total military
force is medically ready to
deploy and that the medical
force is ready to deliver health
care anytime, anywhere in
support of the full range of
military operations, including
humanitarian missions.
Reducing the generators of ill
health by encouraging healthy
behaviors and decreasing the
likelihood of illness through
focused prevention and the
development of increased
resilience.
Readiness
Lower Cost
Better Care
Providing a care experience
that is patient and family
centered, compassionate,
convenient, equitable, safe
and always of the highest
quality.
Creating value by focusing on
quality, eliminating waste, and
reducing unwarranted
variation; considering the total
cost of care over time, not just
the cost of an individual health
care activity.
“Medically Ready Force…Ready Medical Force”
MHS Pharmacy –
Integrated for Excellence
∎ DoD Pharmacy – Caring as an Enterprise
 Enabled by Defense Health Agency Pharmacy Operations
Division – guiding pharmacy shared service since Oct 2013
∎ Success Story! - DoD Pharmacy Enterprise
Delivered Savings/Process Improvements/Efficiencies
∎ The Key – Pharmacy Work Group
Army, Navy, Air Force, Coast Guard, DHA
Col John Spain / CAPT Thinh Ha / Col Melissa Howard /
CDR Aaron Middlekauff / Dr. George Jones
MHS Pharmacy –
Integrated for Excellence
∎ Advise DoD Health Affairs (HA) on policy development and
priority setting related to Pharmacy operations
∎ Create and implement a unified set of business rules to guide
and execute DoD policies for Pharmacy, with consideration for:
 Beneficiary Satisfaction
 Cost-effectiveness
 Evidence-based best practices
 Retail recapture
 Data-driven performance measures
∎ Align metrics/incentives across the enterprise to drive behaviors
∎ Provide clinical pharmacists credentialed to participate in direct
medical care (i.e., Patient Centered Medical Home (PCMH))
MHS Pharmacy –
Scope and Key Elements
∎ Managing global pharmacy benefit – 3 points of service (POS)
∎
∎
∎
∎
∎
for 9.4M beneficiaries located around the globe
Uniform Formulary (UF) process
Coordinate pharmacy efforts among Services and Veteran’s
Health Administration (VHA)
Coordinate patient care with Managed Care Support
contractors (MCSC) and other stakeholders
Develop and distribute data and analytics in support of
standardized metrics guiding enhanced benefit delivery
Support readiness posture
and deployed beneficiaries
MHS Beneficiary Stats –
Pharmacy Access Available to All
Retirees
& Family
Members
65+
16.4%
23.7%
Active
Duty
1.5M
2.2M
21.4%
2.0M
Retirees
& Family
Members
< 65
33.2%
3.1M
5%
0.5M
Other
Active
Duty
Family
Members
MHS Pharmacy Enterprise Stats
∎ 9.4 million beneficiaries FY16
 16.4% active duty
 82% use benefit in FY16 up from 66% in FY02
 7.7M utilizers in FY16 vs. 5.7M in FY02
 127M Rx in FY15 vs. 82M in FY02
∎ Points of Service
 Military Treatment Facility Pharmacies - 708
 Mail Order – 1
 Retail Network – 59,670
 Theater dispensing locations – 276
Pharmacy Spend 2016 – Reversed The Trend / Improved Access
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Pharmacy Costs
Mean cost per Beneficiary per Year
Rxs
Eligible Beneficiaries
65+
Cost
65+
24%
2.2M
65+
47%
~59M
76%
7.2M
50%
50%
~$3.9B ~$3.9B
53%
~66M
< 65
< 65
FY16 (estimated)
PMPY Cost Comparison
Data source: M2 & PDTS Data, FY16 (extrapolated
from data through 9/10/16)
$2914**
*Notes: MTF costs include estimated MTF dispensing
costs; retail costs are net of refund/rebates from
manufacturers, copays, dispensing fee, tax and other
payer costs; but do not include other contract costs;
mail order costs are net of copays and per Rx admin
fees, but do not include other contract costs
Medicare
Part D
$1745*
DoD
$544*
$1060**
$829*
Commercial
DoD
DoD
<65
65+
< 65
All Ages
* Including estimated retail refunds & estimated MTF
dispensing cost
**2015 Commercial and Medicare Part D costs from
ESI Drug Trend Report
Managing Utilization and Costs

Retail Refund Program
 Over $9B in total refunds (FY08-16)


Formulary Management plays a key role in negotiating with
manufacturers - $120M cost avoidance in FY16
Formulary Management Tools
 Medical necessity, prior authorizations, quantity limits, step
therapy, Basic Core Formulary, Preferred
 Maximize use of Home Delivery

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Cost Share/Co-Pay considerations
Encourage use of MTF and Home Delivery over retail for
maintenance medications – analytics / metrics support moves
Contract compliance / Generic use / Therapy Adherence
Monthly Compound Expense
600000000
500000000
400000000
May was estimated at
$195M based on 1-7 May
data, actual was $84M
following
300000000
100000000
Aug Estimate $8.5M, down
3M from July based on
adding selected FDA
approved ingredients to
screen of bulk powders
200000000
0
Sep-16
Aug-16
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Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-…
Apr-14
Mar-…
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
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Jul-13
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Enhanced MTF and
Mail Order Pharmacy Program
∎ Program to facilitate TRICARE beneficiaries to refill select
brand name maintenance drugs at MTF Pharmacy or TMOP
 Does not apply to Active Duty Service Members or beneficiaries with
Other Health Insurance
 Does not apply to beneficiaries living overseas (unless there is a retail
pharmacy network: e.g. Hawaii, Guam, Puerto Rico, and Alaska)
 Waivers are available for certain circumstances (nursing home
residents, emergency, or personal hardship). Beneficiaries must
contact Express Scripts directly to request the waiver
∎ Beneficiaries are allowed two 30-day “courtesy fills” at a retail
pharmacy until they are responsible for 100% of the cost
∎ Effective reduction of “Patient Cost” and “Govt Cost”
Implementation is great example of “Win-Win” result
Enhanced MTF & Mail Metrics (EM3) –
Tracking Results
∎ Identified Cohort of patients with at least one fill of branded
maintenance medications on Enhanced MTF & Mail (EMM)
list during the 5 month period prior to the pilot
∎ Cohort comprised of 429,918 beneficiaries in CONUS
∎ Developed a monthly report tracking ALL EMM medication
filled at ANY point of service (Mail, Retail, and MTF) by Cohort
∎ Report tabs track by month and age group (Under/Over 65):
 Unique Users of EMM medications by MTF (Prism Heavy-Catchment)
with enrollment category drill down
 Prescription count by drug with drill down to MTF, enrollment
category, and POS
∎ Enables granular monitoring of EMM medication movement
Enhanced MTF & Mail Metrics –
Tracking Results
Managing the Benefit:
Clinical Quality Initiatives
∎
Improved Outcomes & Quality
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Expand Pharmacist delivery of care in PCMH
Medication Therapy Management (MTM) Pilot (NDAA15)
Promote and measure medication adherence
DoD/VA continuity of care (focus on psychoactive therapy)
Vaccine program
Tri-Service Drug Take Back program
∎ Data transparency and sharing initiatives

Forward-facing Utilization Data

CDC (developing MOU to provide DoD adherence data to CDC for state-level reporting)

Exploring participation by DoD in States’ PDMPs (Prescription Drug Monitoring
Program)

Polypharmacy and CD-Mart reports (frontline clinician tools)
∎ Informatics
 Electronic health record data standardization working groups (New EHR)
 ePrescribing (improves clinical quality by reducing transcription errors)
Managing the Benefit: Clinical
∎ Patient Centered Medical Home (PCMH)
 Promote expanded inclusion of Pharmacists as either
∎
∎
∎
∎
embedded or supporting PCMH teams
 Medication therapy management/adherence
 Tri-Service workflow Clinical Pharmacy AIM page
 Promote standardization of practice
Smoking Cessation program and products
Polypharmacy and Warrior Transition Unit (WTU) medication
use monitoring
Coordination of infusion services with MCSCs
Specialty Pharmacy Services at MTFs / Mail Order / Network
Medication Therapy Management
(MTM) Pilot
∎ Congressionally directed pilot to determine feasibility and
desirability of including MTM as part of TRICARE benefit
∎ Two year pilot
 Sites: 3 location types (LT)
 LT 1: PCMH empaneled beneficiaries using an MTF pharmacy
 LT 2: Beneficiaries managed by retail providers but use an MTF pharmacy
 LT3: Beneficiaries managed entirely in the retail network
 Each Service (Army, Navy, Air Force) selected a site for LTs 1 & 2
 Outcomes metrics will include cost and efficacy
∎ Implementation beginning in last half of 2016
Managing the Benefit:
Adherence Initiatives
∎
∎
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∎
∎
•
•
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Facilitate access to real-time pharmacy metrics and patient level measures through CarePoint
Support healthcare initiatives by providing actionable, predictive, and longitudinal adherence data
Integrate Adjusted Clinical Groups (ACG) with Pharmacy Quality Alliance (PQA) metrics.
Leverage PQA and ACG to support Polypharmacy, MTM, and Adherence initiatives
Adapted PQA adherence algorithm for proportion days covered (PDC)
Pharmacy Quality Alliance (PQA)
Benchmark medication-use measures for
medication safety, adherence, and appropriateness
Quality improvement indicators
Free membership/licensure to government
organizations
–
–
•
In the process of acquiring licensure and all metrics
Implemented three adherence measures thus far
Standard measures used by CMS and Health
Insurance Marketplace
•
•
•
•
•
Adjusted Clinical Groups (ACG)
Available on CarePoint MHSPHP to patient level
Predictive measures for cost and risk
Several adherence measures – some disease
specific
Working with Dr. Carnahan to expand use for
clinicians
Integrating PQA measures with ACG measures
to enhance standardized reporting and
actionable measures
23
Managing the Benefit:
Data Guided War Fighter Support
∎ Prescription Medication Analysis & Reporting Tool
 Pre-deployment screening tool identifies high-risk Members
∎ Deployment Prescription Program (DPP)
 Facilitates mail order support to deployed members
 Peaked in 2009 at 42K, currently around 6K in 2016
∎ WTU/Medication Analysis & Reporting Tool
 Weekly Rx report/tool sent to all WTUs concentrated on psychotropics, narcotics,
and several high risk combinations of medications at all Points of Service
∎ Sole Provider/1-1-1/MTF Rx restriction Program
 PDTS leveraged as data source for restrictions
∎ Controlled Drug MART (CD-MART)
 Automated tool to assist providers in analyzing controlled prescription usage
within MTF 40 mile catchment area
 Includes utilization from all points of service
 Over 150 reports requested in FY16
Managing the Benefit: TRICARE Pharmacy
Network Vaccine Program (CY 2010 through CY2016 through Oct16)
∎ Access to vaccines at
45,413 retail network
pharmacies at $0 copay
(preventative services)
∎ Retail vaccinations
visible on PDTS & ALTHA
med list
∎ Over 3.5 M vaccines
administered at retail
pharmacies
Vaccine Type
Total (CY2010
thru CY2015)
Hepatitis A & B, A&B Combo
17,911
Human Papillomavirus
5,792
Influenza, H1N1
2,833,926
Measles, Mumps, Rubella &
Combinations
4,747
Meningococcal
13,789
Pneumococcal
186,906
Polio
Tetanus, Diphtheria, Pertussis &
Combinations
Tuberculosis
Zoster
Total
246
131,106
32
391,921
3,590,267
Enhancing the Benefit:
Enterprise Wide E-Prescribing (eRx)
∎ DHA initiative to enables civilian providers to electronically transmit
prescriptions to Military Treatment Facility (MTF) pharmacies

Aligns the MHS with the Meaningful Use requirements for electronic prescribing

Ensures MTFs can support the growing number of civilian providers who utilize
electronic prescribing as their only means of generating a prescription
∎ Benefits of electronic prescribing

Improves patient safety by reducing translation and transcription related errors

Enhances MTF access, pharmacy workflow and business processes
∎ Available at U.S. MTFs (including Guam & Puerto Rico) that currently
accept civilian prescriptions

Implementation completed January 2015

All interested MTF pharmacies can accept electronic prescriptions

Received over 2.1M prescriptions via eRx through January 2016
Collaboration - Improving Mental Health
Medication Transitions / Drug Safety
∎ Supporting Service members with mental health conditions in making medication
transitions to VA care

VA has issued a policy to ensure continuity of care by maintaining access to mental
health medications prescribed by DOD provider, regardless of whether the medication
is currently on the VA formulary

DOD has promulgated VA policy among DOD prescribers and pharmacies for awareness
∎ Enabling Safe Medication Disposal

DOD is committed to ensuring safe disposal of unwanted prescription drugs and to
reduce the opportunities for abuse, misuse, use for suicide and suicide attempts, and
accidental poisoning

Drug Enforcement Agency released Final Rule, Disposal of Controlled Substances, on
September 9, 2014

Rule allows DOD pharmacies to take back controlled medications for the purpose of
disposal
Congressionally Mandated Joint
Transition Drug List
• NLT June 1, 2016 SECDEF and SECVA establish a
joint transition drug list for DoD and VA
 Pharmaceutical agents critical for treatment transition of Service
member from DoD to VA in selected therapeutic categories;
 Agents for control of pain, sleep disorders, and psychiatric
conditions, including post-traumatic stress disorder; and
 Any other conditions determined appropriate by the Secretaries.
• NLT July 1, 2016 SECDEF and SECVA submit a
Report to Congress to include a copy of the Joint
Formulary - Done
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Success –
Joint Transition Drug List
∎ Integrated effort of DoD and VA
 Formulary Teams pulled / compared utilization data
 Developed initial list and identified differences
 Resolved to a consolidated list
∎ Briefed / Achieved concurrence - DoD P&T Committee / VA
P&T Committee
∎ Incorporated feedback from Psych / Pain Management SMEs
∎ Fully integrated Joint Transition Drug List finalized in Report to
Congress – Full compliance with Congressional mandate
Enables Smooth Transition Medication Management
29
Building on Success: DoD/VA
Continued Collaboration
∎ VHA working on repeating study of medication
continuation in transitioning Service members with a larger
sample size; planned completion during FY 17
∎ VHA maintains in-place policy supporting continued
therapy until clinical evaluation
∎ DoD and VHA formulary processes will monitor and
maintain Joint Transition Drug List
Drug Take Back – Implementing New
DEA Guidance
The DOD is committed to ensuring safe disposal of unwanted
prescription drugs and to reduce the opportunities for abuse, misuse,
use for suicide and suicide attempts, and accidental poisoning
∎ Drug Take Back Program DoD Instruction (DoDI) signed / DHA Interim
Procedures Memorandum - fully implemented during 2016
∎ Integrated Strategic Communication Plan Continues
 Uniform access to Communication Toolkits
 YouTube Drug Take Back Video - Sept 2016 release
 Sharps, Inc industry partner/vendor for bins and supplies
 All Services actively engaged
 MTF capability
 Supporting DEA/Law
Enforcement events
External Shared Opportunities –
Industry
∎ Exploration of New Partnership Opportunities
 Bid Processes (eBidding; Condition Sets, etc)
 Driving Patient Outcomes (tools, measures)
 Optimizing Investments
 cost, adherence, clinical integration, outcomes
∎ Performance/Outcome Based Contracting
∎ External Input - Web capabilities; Forums
∎ Focused Communication During Bid Cycles
 Flow through Contracting Officer
DoD Team Pharmacy – On to 2017!
Collaborative / Integrated / Consistent Excellence
∎ Essential – Sustain On-going Projects
∎ Projects Under Development for 2017 –
Founded on the goal of optimal patient care!
 Uniform Controlled Substance framework
 Specialty Pharmaceuticals
 Uniform Automation requirements / Integrated execution
 Drug Database Standardization
 Antibiotic Stewardship
 Medication Therapy Management pilot
 Expand Clinical focus
∎ Facilitate successful transition to MHS GENESIS
Post-Course Evaluation
1. DoD, facilitated by the Defense Health Agency, strives to
deliver a uniform pharmacy benefit as a pharmacy
enterprise. TRUE FALSE
2. The DoD Pharmacy Work Group membership includes the
Service Pharmacy Consultants, DHA Chief of Pharmacy Ops
and participation from other stakeholders as needed.
TRUE FALSE
3. Implementation of MHS GENSIS is a key pharmacy enterprise
initiative for 2017.
TRUE FALSE