Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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.