Presentation on theme: "What is so special about Specialty? PRESENTED BY: Kim Foerster, Director, Managed Markets Sales, Diplomat Specialty Pharmacy Jeremy Faulks, Retail Specialty."— Presentation transcript:
What is so special about Specialty? PRESENTED BY: Kim Foerster, Director, Managed Markets Sales, Diplomat Specialty Pharmacy Jeremy Faulks, Retail Specialty Manager for Target Specialty Pharmacy
2 Learning objectives Diplomat Case Study, July 2013 – January 2014. Specialty Pharmacy Basics Cost of Lick It, Stick It, Ship It Models The Basics of Specialty Management The Good + Bad of Co-Pay Assistance
3 Specialty pharmaceuticals Strict temperature control Distribution can be limited Restricted location for administration Difficult Medication Delivery Personalized dosing or administration Clinical management or close monitoring required Complex Treatment Adapted from Blaser DA, et.al. How to Define Specialty Pharmaceuticals – A Systematic Review. Am J Pharm Benefits. 2010;2(6).371-380. 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. 6 1.Cohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013.
5 SP ModelCharacteristics PBM Owned Structured programs Higher use of technology for patient outreach Strong buying power Ability to shift costs Specialty pharmacy is a piece of the business Plan Owned Ability to easily view all claims data (medical + pharmacy) Retail Owned Community based care Independents More flexible – willingness to customize Specialty pharmacy is primary expertise Focused on patient care and service – more high-touch Greater transparency Specialty pharmacy landscape
6 Top 10 specialty drug classes 1 Inflammatory Conditions – Rheumatoid Arthritis 2 Multiple Sclerosis 3 Cancer 4 HIV 5 Growth Deficiency 6 CNS Disorders 7 Respiratory Conditions – Cystic Fibrosis 8 Anticoagulants 9 Organ Transplant 10 Pulmonary Hypertension Express Scripts ®. Drug Trend Report [Internet]. 2014 April [cited 2014 Apr 8]. Available from: http://lab.express-scripts.com/drug-trend-report/table-of-contents. http://lab.express-scripts.com/drug-trend-report/table-of-contents
7 PAYOR Marketplace trends UM programs Measured and reportable clinical outcomes Patient adherence / satisfaction Access to drugs Data Spend trends PHARMA Adherence Biosimiliars Patient assistance programs Therapy initiation Manufacturing cost PHYSICIAN Administrative work burden Patient compliance Time for appropriate care Buy and bill PATIENT Administration Adverse event management Disease progression / quality of life Cost UM: Utilization Management Cohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013. Stakeholder concerns
8 Collaboration is the future of health care Affordable Care Act (ACA) Requires collaboration on quality initiatives with reportable savings Physician Value-Based Modifier coming in 2015 – need to measure how medication contributes to quality Care coordination is priority in six NQS (National Quality Strategy) domains 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 outcomes Intermediate outcomes Patient experience Patient access to care Process 8
9 Specialty care coordination – The basics Teamwork AccessTolerance Adherence
10 Best-in-class care Care CollaborationPatient education + empowerment Clinical Management Case management coordination Coordination of benefits Physician education on guideline updates Medical billing Side effect and symptom management Customized communication Injection training support Support group enrollment Motivational Interviewing Techniques Drug regimen assessment and collection of medication history Adherence calls Proactive PA & Rx renewal support
13 Cost of ineffective care Category Most Recent Fill Days Supply Dispensed Name of Drug Quantity on Hand Amount of Surplus / Waste AWP for surplus/wasted quantity Surplus medication 11/27/201284Avonex Member had 4 week supply of medication on hand in early March 6 week surplus$7,045.20 10/25/201284 Enbrel Sureclick Member did not set up first shipment until early April 11 week surplus$7,295.90 8/2/201284Humira Member had 60 day supply of medication on hand as of early May 24 week surplus$15,767.78 10/8/201228Aranesp Member had a six week supply of medication on hand in mid January 10 week surplus$7,462.50 Cost of surplus medications on-hand$37,571.38 Waste due to member stopping therapy 9/17/201260Sensipar Member had 60 day supply of medication on hand in May waste of 60 days$2,129.76 9/25/201284 Enbrel Sureclick Member had 60 day supply of medication on hand in early March waste of 60 days$5,306.00 6/6/201284 Enbrel Sureclick Member had 60 day supply of medication on hand in early April waste of 60 days$5,306.00 Cost 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 contribution Specialty Therapies: Co-payment assistance through foundation grants allows continuation of therapy Care collaboration = Improved patient outcomes
15 The bridge to breast cancer patient care: co-pay assistance Diagnosis: Metastatic breast and bone cancer $1,927.23 co-pay is roadblock to initiating therapy Funding team was awarded a Patient Advocate Foundation grant on behalf of patient *Physician discontinued therapy after 7 months due to anemia anemia Patient and prescriber communications, Diplomat Case Study, July 2013 – January 2014. 27% 73%
16 Higher cost-sharing leads to greater prescription abandonment Streeter SB, et al. Am J Manag Care. 2011;17(5 Spec No.):SP38-SP44). Oral Oncolytic Abandonment Rate at Varying Cost-Sharing Amounts Abandonment rate (%) (n=7,638)(n=529) (n=614) (n=1727)
17 1% reduction in cost-sharing can increase utilization of oral oncolytics up to 3.3% Milliman Inc., Parity for oral and intravenous/injected cancer drugs. January 25, 2010. Available at: http://publications.milliman.com/research/health-rr/pdfs/parity-oral-intravenous-injected.pdf. Accessed March 3, 2013. n=24,474 cancer patients, 20–69 years of age. Increase in utilization with each 1% decrease in co-pay (%)
18 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):1143-1152. Bankruptcy rates for patients with cancer
19 Patient satisfaction Medication adherence Pharmacist interventions Quality of life measures Cost avoidance outcomes Co-pay assistance summary Patient communication summary Specialty pipeline strategies Reporting: proof of collaborative value 292 patients averaged 11.42 touches Communications per patient, Diplomat Case Study, Q1 2013.