Presentation on theme: "What is so special about Specialty?"— Presentation transcript:
1 What is so special about Specialty? We want you to be seen as an expert – that will be what generates interest.As a reminder, your presentation should focus on the role of specialty pharmacies in supporting patient outcomes and employer cost management and the content should focus on what the employer should look at when choosing the right SPPRESENTED BY:Kim Foerster, Director, Managed Markets Sales, Diplomat Specialty PharmacyJeremy Faulks, Retail Specialty Manager for Target Specialty Pharmacy
2 Learning objectives Specialty Pharmacy Basics Cost of Lick It, Stick It, Ship It ModelsThe Basics of Specialty ManagementThe Good + Bad of Co-Pay AssistanceCenCal QBR 4Q13-1Q14 shows avg RX = $2,801Diplomat Case Study, July 2013 – January 2014.
3 Specialty pharmaceuticals Strict temperature controlDistribution can be limitedRestricted location for administrationDifficult Medication DeliveryPersonalized dosing or administrationClinical management or close monitoring requiredComplex TreatmentCenCal QBR 4Q13-1Q14 shows avg RX = $2,801Adapted from Blaser DA, et.al. How to Define Specialty Pharmaceuticals – A Systematic Review. Am J Pharm Benefits ;2(6)Diplomat Case Study, July 2013 – January 2014.
4 Specialty pharmacy market The specialty market is not a level playing field, as extreme variations are seen in patient care management, service, and outcomes.6Cohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013.
5 Specialty pharmacy landscape SP ModelCharacteristicsPBM OwnedStructured programsHigher use of technology for patient outreachStrong buying powerAbility to shift costsSpecialty pharmacy is a piece of the businessPlan OwnedAbility to easily view all claims data (medical + pharmacy)Retail OwnedCommunity based careIndependentsMore flexible – willingness to customizeSpecialty pharmacy is primary expertiseFocused on patient care and service – more high-touchGreater transparencyTalk about mergers/acquisitions and potential impacts on industry.
6 Top 10 specialty drug classes Inflammatory Conditions – Rheumatoid Arthritis2Multiple Sclerosis3Cancer4HIV5Growth Deficiency6CNS Disorders7Respiratory Conditions – Cystic Fibrosis8Anticoagulants9Organ Transplant10Pulmonary HypertensionNote HCV not on the Top 10 List yet – Sovaldi will change that for 2014Express Scripts®. Drug Trend Report [Internet] April [cited 2014 Apr 8]. Available from:
7 Stakeholder concerns PayOr Pharma Physician Patient Marketplace trends UM programsMeasured and reportable clinical outcomesPatient adherence / satisfactionAccess to drugsDataSpend trendsPharmaAdherenceBiosimiliarsPatient assistance programsTherapy initiationManufacturing costPhysicianAdministrative work burdenPatient complianceTime for appropriate careBuy and billPatientAdministrationAdverse event managementDisease progression / quality of lifeCostUM: Utilization ManagementCohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013.
8 Collaboration is the future of health care 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 outcomesIntermediate outcomesPatient experiencePatient access to careProcessAffordable Care Act (ACA)Requires collaboration on quality initiatives with reportable savingsPhysician Value-Based Modifier coming in 2015 – need to measure how medication contributes to qualityCare coordination is priority in six NQS (National Quality Strategy) domains1. Department of Health and Human Services. Centers for Medicare & Medicaid Services. 42 CFR Parts 409, 417, 422, 423, and 424 [CMS-4159-P] Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs. Pg. 388.8
9 Specialty care coordination – The basics TeamworkAccessToleranceAdherence
10 Best-in-class care Care Collaboration Patient education + empowerment Clinical ManagementCase management coordinationCoordination of benefitsPhysician education on guideline updatesMedical billingSide effect and symptom managementCustomized communicationInjection training supportSupport group enrollmentMotivational Interviewing TechniquesDrug regimen assessment and collection of medication historyAdherence callsProactive PA & Rx renewal support
13 Cost of ineffective care CategoryMost Recent FillDays Supply DispensedName of DrugQuantity on HandAmount of Surplus / WasteAWP for surplus/wasted quantitySurplus medication11/27/201284AvonexMember had 4 week supply of medication on hand in early March6 week surplus$7,045.2010/25/2012Enbrel SureclickMember did not set up first shipment until early April11 week surplus$7,295.908/2/2012HumiraMember had 60 day supply of medication on hand as of early May24 week surplus$15,767.7810/8/201228AranespMember had a six week supply of medication on hand in mid January10 week surplus$7,462.50Cost of surplus medications on-hand$37,571.38Waste due to member stopping therapy9/17/201260SensiparMember had 60 day supply of medication on hand in Maywaste of 60 days$2,129.769/25/2012Member had 60 day supply of medication on hand in early March$5,306.006/6/2012Member had 60 day supply of medication on hand in early AprilCost of excess drugs dispensed and not used due to discontinuation$12,741.76 TOTAL$50,313.14
14 Co-pay assistance controversy Traditional Drugs:Use of co-payment cards to bypass plan formularies, step edits and patient contributionSpecialty Therapies:Co-payment assistance through foundation grants allows continuation of therapyCare collaboration = Improved patient outcomes
15 The bridge to breast cancer patient care: co-pay assistance 27%73%Diagnosis: Metastatic breast and bone cancer$1, co-pay is roadblock to initiating therapyFunding team was awarded a Patient Advocate Foundation grant on behalf of patientPharmacist Calls- 1) patient asks about drinking Alkaline Water, pharmacist confirms no known interactions. (it can neutralize acid in your bloodstream, boost your metabolism and help your body absorb nutrients more effectively, it can also help slow bone loss & prevent disease); 2) Extreme fatigue asks if she can take drink more coffee—only need to avoid grapefruit juice; 3) Confirmed no interactions with Maxide or Exemestane with Afinitor.*Physician discontinued therapy after 7 months due to anemia anemiaPatient and prescriber communications, Diplomat Case Study, July 2013 – January 2014.
16 Higher cost-sharing leads to greater prescription abandonment Oral Oncolytic Abandonment Rate at Varying Cost-Sharing AmountsAbandonment rate (%)(n=7,638)(n=529)(n=614)(n=1727)Streeter SB, et al. Am J Manag Care. 2011;17(5 Spec No.):SP38-SP44).
17 Increase in utilization with each 1% decrease in co-pay (%) 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 (%)n=24,474 cancer patients, 20–69 years of age.Milliman Inc., Parity for oral and intravenous/injected cancer drugs. January 25, Available at: Accessed March 3, 2013.
18 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):
19 Reporting: proof of collaborative value Patient satisfactionMedication adherencePharmacist interventionsQuality of life measuresCost avoidance outcomesCo-pay assistance summaryPatient communication summarySpecialty pipeline strategies292 patients averaged touchesCommunications per patient Q1 2013Communications per patient, Diplomat Case Study, Q19