1. Changing Specialty Distribution to Clinical Management Models
Jonathan Gavras, MD, FCCP
Senior Vice President, Chief Medical Officer Prime Therapeutics

2. Disclosure Declaration
Dr. Gavras does not have a vested interest in or affiliation with a corporate organization offering financial support or grant monies for this CE activity.
Dr. Gavras does not have an affiliation with an organization that has a specific interest in the therapeutic areas under discussion.

3. Why need to change the playing field?
Increasing pressure to demonstrate value and address costs
Markets reaching tolerance threshold
Provider based reimbursement driving need for integrated solutions
Provider systems looking to manage total medical costs
Will find ways to keep revenue and spend within “their house”
Value-based reimbursement models progressing
Traditionally medical costs focused
Pharmacy costs usually excluded
Consumerism continues to drive the industry
Individual market remains major part of health care spend despite “whatever” legislation is present
Need to keep it simple: Members understand costs and experience… not reimbursement and procurement methodologies

4. Total Drug Cost of Rx and Medical
Source: Prime Therapeutics full service book of business

5. Specialty Will Soon be 50% of all Costs
Source: Prime Therapeutics commercial BoB 14 million lives integrated medical and Rx data

6. Managing pharmacy from an integrated approach
Effectively managing costs requires new strategies that consider the entire care spectrum.
These costs bridge both medical and specialty and include emerging technology*
4% of our members drive over half of total medical costs
TOTAL COST of CARE - $400 PMPM
Total Drug Spend - $130 PMPM
(32% of Total Costs)
1% of our members drive over 60% of total drug costs
Traditional Rx - $70 PMPM
(54% of Total Drug Costs)
Specialty Rx
$31 PMPM
(24% of Total Drug)
We are a clinical company that is using data to surface the most important information to you. We help you focus your efforts and dollars where it matters most. And, because we follow the trends and your market so closely, we are always developing and bringing you new approaches that work - tailored just for you.
Of those 1% of members, over 85% are on a specialty medication.
Medical Rx
$29 PMPM
(22% of Total Drug)
*Prime medical benchmark report, data on file

7. Prime Integrated Pharmacist Program
Opportunity
Identification
Therapeutic Opportunities
GuidedHealth®
Limited Use
CRE & CMM Reporting
Client Reports
Other Cost of Care Aggregator
Future
Referrals via Case Mgrs & Team Mtg
Channel Opportunities (AllianceRx Walgreens Prime, Walgreens, Site of Care)
Cost of Care
(formulary compliance, generics, high cost drugs, duplicative therapy, opioid)
Clinical Quality
(adherence, gaps, safety, readmits, ER )
Path Two
Intervention Platform /Workflow
Strategic Pharmacist Intervention
Reporting:
Quarterly Savings & Outcomes
Path One
Data File to Plan

8. Value Based Contracting
Current Prime Programs:
Leverages our integrated model
Proves the value of selected medicine(s) when taken appropriately
Need to better align payers, members and doctors to achieve desired health outcomes
Contracts in place
2018 pipeline
Condition
Criteria
Diabetes
Monitors frequency of lab testing
Multiple sclerosis
Total cost of care evaluation
Hepatitis C
Evaluation of cure rates
Cholesterol
Adherence
Condition
Criteria
Diabetes
Adherence component, long-term outcomes
Autoimmune
Indication-based contracting
Respiratory
Persistency & compliance
Cholesterol
PMPM guarantee

9. Goals of Prime CareCentered contracting model
Must impact overall health care outcomes
Cannot be focused entirely upon:
Adherence
Clinical efficacy
Must expand focus to:
Drive affordability
Lead to better overall clinical outcomes
Improve member access to care and experience with the health care system
Population Health
Experience of Care
Per Capita Cost
Triple Aim

10. Florida Blue value-based oncology programs
Measures that have evolved to ensure members get the most effective care with the best outcome
Drug Replacement (‘08)
Provider Administered Drug Program (‘09)
Evaluated Pathways (‘10)
Bundled Prostatectomy (‘11)
Designed with Baptist Health South Florida
Leveraged model to launch program with Moffitt (2013)
Evolved program design
Continuing to evolve program designs
Multiple oncology management programs
First oncology value-based (VB) reimbursement program (2011)
Launched largest commercial
VB program in Florida with
Florida cancer specialists (2016)
Drug costs and trend accounts for over 40% of the spend
Oncology drug costs not cited as a significant driver of savings at this time
Savings achieved largely through reduction in inpatient and ER utilization

11. Prime model Demonstrate value to members, payers and providers
Future Prime efforts more focused on partnering with collective combination of integrated delivery systems, payers and pharmaceutical industry to drive more comprehensive outcome improvements.
Will include:
Development of comprehensive clinical programs to:
Improve proper use of drug(s)
Manage high cost and complex cases
Defined (and measurable) clinical, utilization, quality and cost endpoints
Rigorous analytic and financial review
Utilize similar tools that support medical value based reimbursement models
Value based design with shared cost risk among participants