Transcript OptumRx - National Labor and Management Conference

Health Care Connected: Next Generation Pharmacy
February 13, 2016
2015= Hepatitis C $$$$
2016 and Beyond: Strategies to
control Specialty Drug cost and
improve outcomes
Pharmacy impacts all health care costs
Pharmacy represents 20% of health care costs …
yet it can dramatically affect the other 80% of spend
Missed Opportunities
50%
of medications
20
50%
of patients
19%
are not taken
as prescribed2
Fragmented Experience & Care
%
 Generics
 Brands
 Specialty
81%
46%
leave doctor
not understanding
what they were told1
Increased Cost
35%
$54B
increase
in specialty
pharmacy costs
over last 5 years3
18%
1%
Use
Cost
1. AHIP Coverage, 2013; 2. Kaiser/HRET Survey of Employer Health Benefits, 2013;
3. IMS Health, National Sales Perspectives, Dec 2014; 4. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare. 2013
3
Clinical Solutions
Standard Toolkit
Innovation ‘Now’
• Standard Formulary Suite
• Transitional Care Readmission Prevention
• Utilization Management
• Tech-Enabled Diabetes Care Mgmt
• Concurrent DUR
• Outcomes-Driven PhRMA Contracting
• Retrospective DUR
• Multidimensional Specialty Care
Management
• Fraud Waste & Abuse Mgmt
• Adherence Monitoring & Intervention
• Care Gap Impact
• Prospective Pipeline Review,
Forecasting & P&T Deliberation
• Therapeutic Interchange
• SECURE Compound Mgmt Program &
Industry’s 1st & Only Credentialed
Compound Network
• High-Risk Meds in Elderly
• Patterns of Care Provider Profiling
• Provider Profiling
• Generic Inflation Solution Suite
• Medication Therapy Management
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Medical utilization management
CONTINUED MANAGEMENT OF THE MOST EXPENSIVE MEDICATIONS
Today
Tomorrow
• 28 drug policies - over 100 drugs
• Implementation of new drug polices
• Prior authorization with medical necessity
• Expansion of genetic testing and
lab value requirements
• Preferred products
• Redirect to lower-cost sites
• Clinical claim edits
• Administrative guide protocols
• Required specialty pharmacy sourcing
• Expansion of preferred products across
benefits
• Expansion of redirection to lower-cost sites
of services
• Expansion of utilization management
programs
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Expansion of medical necessity
NOTIFICATION /
PRIOR AUTHORIZATION
MEDICAL
NECESSITY
Coverage is based on
approved or proven uses of
the medication
Coverage is approved
if treatment
is deemed medically necessary
Drug


Diagnosis


Dose


Duration


Genetic Testing


Dose Titration

Evaluation of
Response

Treatment Guidelines

Preferred Product

Site of Service

Expanded clinical and cost effectiveness review
with medical necessity vs. traditional approach
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Improving
patient well being
Smart touch approach to patient care
BETTER CARE THROUGH DATA AND ANALYTICS
8
BriovaLive™
INCREASED COMFORT AND ADHERENCE THROUGH VIDEO CONSULTATIONS
9
BriovaLive™
Our video consult capability provides education
with a personalized touch
• Review medications & supplies •
•
• Assemble device (if needed)
•
• Injection training
•
• Storing procedures
Side effects
Drug interactions
Questions
Support & reassurance
7%
improvement in
adherence after
participating in a
video consultation.*
*Catamaran/BriovaRx study
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BriovaCommunity™
GREATER UNDERSTANDING THROUGH PERSONALIZED VIDEOS
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BriovaCommunity™
Tailored websites and videos to help members better
understand their conditions and live healthier lives
10%
Better persistency and
adherence for
Harvoni patients using
BriovaCommunity™*
Information on conditions and treatments
Tips on medication adherence and
side-effect management
Guidance on diet, meditation and other
lifestyle topics
Introduction to BriovaRx® care team members
Advice from expert physicians and clinicians
Testimonials from peers with similar illnesses
*internal analysis
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Specialty Drug Strategies for Fund Trustee Consideration
• Assure Current Plan Design and Administration is addressing :
- Priior Authorization
- Step Therapy
- Quantity Limits
- Site of Service
- Rebate transparency
• Leverage International Union PBM programs
- Preferred pricing
- Contract terms
- Service Model
• Explore Regional Labor Alliances
- Coalition pricing
- Audit rights
- Contract terms
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