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What is so special about Specialty?

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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 SP PRESENTED BY: Kim Foerster, Director, Managed Markets Sales, Diplomat Specialty Pharmacy Jeremy Faulks, Retail Specialty Manager for Target Specialty Pharmacy

2 Learning objectives Specialty Pharmacy Basics
Cost of Lick It, Stick It, Ship It Models The Basics of Specialty Management The Good + Bad of Co-Pay Assistance CenCal QBR 4Q13-1Q14 shows avg RX = $2,801 Diplomat Case Study, July 2013 – January 2014.

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 CenCal QBR 4Q13-1Q14 shows avg RX = $2,801 Adapted 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.6 Cohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013.

5 Specialty pharmacy landscape
SP Model Characteristics 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 Talk about mergers/acquisitions and potential impacts on industry.

6 Top 10 specialty drug classes
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 Note HCV not on the Top 10 List yet – Sovaldi will change that for 2014 Express Scripts®. Drug Trend Report [Internet] April [cited 2014 Apr 8]. Available from:

7 Stakeholder concerns PayOr Pharma Physician Patient 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.

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 outcomes Intermediate outcomes Patient experience Patient access to care Process 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 1. 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
Teamwork Access Tolerance Adherence

10 Best-in-class care Care Collaboration Patient 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

11 Improving adherence “ Technology Prophylactic Starter Kits
Nurse Adherence Calls Prophylactic Starter Kits Compliance Packaging Patient Training & Education

12 Compliance & persistency
Adherence tools Proactive side-effect management

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 11/27/2012 84 Avonex Member had 4 week supply of medication on hand in early March 6 week surplus $7,045.20 10/25/2012 Enbrel Sureclick Member did not set up first shipment until early April 11 week surplus $7,295.90 8/2/2012 Humira Member had 60 day supply of medication on hand as of early May 24 week surplus $15,767.78 10/8/2012 28 Aranesp 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 9/17/2012 60 Sensipar Member had 60 day supply of medication on hand in May waste of 60 days $2,129.76 9/25/2012 Member had 60 day supply of medication on hand in early March $5,306.00 6/6/2012 Member had 60 day supply of medication on hand in early April 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
27% 73% Diagnosis: Metastatic breast and bone cancer $1, co-pay is roadblock to initiating therapy Funding team was awarded a Patient Advocate Foundation grant on behalf of patient Pharmacist 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 anemia Patient 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 Amounts Abandonment 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 satisfaction Medication adherence Pharmacist interventions Quality of life measures Cost avoidance outcomes Co-pay assistance summary Patient communication summary Specialty pipeline strategies 292 patients averaged touches Communications per patient Q1 2013 Communications per patient, Diplomat Case Study, Q 19

20 Questions


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