PBMI 2013 Presentation on Shift From FFS to Value


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My 2013 PBMI presentation on my thoughts about using data and consumer engagement to shift the pharamcy industry to a industry focused on value as part of the overall health reform efforts.

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PBMI 2013 Presentation on Shift From FFS to Value

  1. 1. Pharmacy – Data, COEs, PredictiveModels, and Consumer EngagementGeorge Van AntwerpVP, Product DevelopmentinVentiv Medical ManagementFebruary 2013
  2. 2. Caregiver PCP Patient Case Manager Pharmacy Pharmacist Pharma Health PBM Insurer Employer2
  3. 3. My Predictions For 2013 1. Reform will happen. 2. Big Data will be a focus. 3. Physicians grab power through “ACOs”. 4. mHealth will drive innovation and patient engagement. 5. Incentives and gamification will become the norm. 6. Home testing and remote monitoring will increase. 7. Pharmacies will address the PCP shortage. 8. Telemedicine will hit a tipping point. 9. Transparency will empower consumers. 10. Generics will no longer be a focus.3
  4. 4. Learning Objectives • Explain the pharmacy industry implications of the shift from Fee For Service to Outcomes Based Contracting • List examples of how leading edge companies are using technology and Big Data to embrace this change • Outline options for PBMs and pharmacies to take a more active role within the expanded care team with a focus on the Triple Aim of cost, quality, and consumer experience4
  5. 5. What Is Population Health Management?Source: Outcomes Guidelines Report Volume 5. (2010). Washington, DC: Care Continuum Alliance5
  6. 6. Adherence Is Our Foundation For Growing The Role Of Pharmacy • Adherence has been shown to drive lower medical costs1: – CHF savings $8,881 / year – Hypertension $4,337 / year – Diabetes $4,413 / year – Dyslipidemia $1,860 / year • Adherence has also been shown to reduce absenteeism by 7 days per year per patient with chronic diseases (~$1,700 in savings) 2 • Additionally, there is a significant gap between perceived adherence (which is high) and actual adherence (which is low) signaling a need for increased intervention3 1 – Health affairs article - http://www.cimit.org/images/events/ciw/Adherence-Health-Affairs.pdf 2 - http://www.drugstorenews.com/article/cvs-caremark-research-finds-link-between-medication-adherence-employee-productivity 3 – Gap in perceived versus actual adherence identified in 2011 Express Scripts Drug Trend Report6
  7. 7. Growth Requires Integration Of Medical And Rx Data Source: PBMI 2012 Specialty Drug Report, Prime Therapeutics 2012 Drug Trend Report7
  8. 8. The Value Of Pharmacy On Quality Is Increasingly Being Recognized Source: CVS Caremark 2012 Insights Report8
  9. 9. Evidence-based medicine Accountable Care Warning: Bundled Payments New Paradigm VBID Ahead Comparative Effectiveness9
  10. 10. Pay For Value Not Service “Fee-for-service payments drive up health care costs and potentially lower the value of care for two main reasons. First, they encourage wasteful use, especially of high-cost items and services. Second, they do nothing to align financial incentives between different providers.” Quote from http://www.americanprogress.org/issues/healthcare/report/2012/09/18/38320/alternatives-to- fee-for-service-payments-in-health-care/10
  11. 11. Employer Premiums Tied To Health Outcomes 12% of employers penalized or 30% of difference in premiums incented employees based on allowed by the ACA based on outcomes in 2011 according to “meeting employer defined Towers Watson health targets” http://www.towerswatson.com/united-states/press/5708 http://www.huffingtonpost.com/2012/06/29/health-plans-obese-smokers-supreme-court_n_1636139.html11
  12. 12. Outcomes Based Thinking Creates A New Way Of Looking At The Value Chain “Dr. Google” Population Physician mHealth Pharmacy Health Encounter P2P Mgmt Where did they go from information? Feeling Sick What information or apps did you prescribe? Cure Annual Exam How did you improve their PAM score? Remission Were they satisfied with their experience? Survivorship Did you pull in their caregiver? What are their goals? How will they judge improvement?12
  13. 13. People Aren’t A Disease I can’t wait to lower X my A1c by 2 points. That would be great! I hope I’m mobile enough to take my grandkids to Disney!13
  14. 14. Understanding Consumers Allows For Information To Be “Prescribed” Go to this website Watch this video Download this mobile app Join this community14
  15. 15. Not about access but about outcomes Shift from Rx costs to total costs Transition away from rebates Look at quality of life Physician and pharmacist collaboration De-emphasize eRx for PHR and EMR15
  16. 16. Lowest Most Trend Generics Lowest Best Error Rebates Rate16
  17. 17. 17
  18. 18. Pharmacists Can Influence Key ACO Metrics • Better Care for Individuals: – Patient/Caregiver Experience – Care Coordination/Transitions • Medication Reconciliation After Discharge from an Inpatient Facility (measure 10) – Patient Safety • Better Health for Populations: – Preventive Health • Influenza Immunization (measure 26) • Pneumococcal Vaccination (measure 27) • Cholesterol Management for Patients with Cardiovascular Conditions (measure 30) – At-risk population/Frail Elderly Health – Diabetes Mellitus: Aspirin Use (measure 39) – Heart Failure: Beta-Blockers Therapy (measure 49) – Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy (measure 50) – Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation (measure 51) – Coronary Artery Disease (CAD); appropriate drug therapy including antiplatelet therapy, beta-blocker therapy, ACE/ARB therapy, LDL-cholesterol lowering therapy (measures 52–55, 57) – Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy (measure 62) – Osteoporosis Management in Women Who had a Fracture (measure 64) – Monthly International Normalized Ratio (INR) for Beneficiaries on Warfarin (measure 65) http://amcp.org/WorkArea/DownloadAsset.aspx?id=972818
  19. 19. Counting Pills Is Not Enough19
  20. 20. http://hin.com/blog/2012/12/17/infographic-improving-primary-care-by-expanding-the-role-of-pharmacists/20
  21. 21. Examples Of True Outcomes Based Contracting In Pharmacy Are Limited • Merck – Cigna Diabetes • Rebif – Prime Therapeutics MS • Sanofi – Health Alliance Osteoporosis • Pfizer – Humana Alzheimers, pain, cardiovascular • Bayer – Denmark Levitra • J&J– UK Velcade21
  22. 22. Cigna-Merck Diabetes Contract • The two-part contract with Merck provided discounts if CIGNA customers with diabetes lowered their blood sugar levels, regardless of the medication they were taking, and also provided for additional discounts if people who were prescribed Merck’s drugs Januvia and Janumet took their medications according to their physicians’ instructions. Discounts will be shared in various ways with CIGNA employer clients. • Kang said that the idea of paying less for medications if they are successful is counter-intuitive and not at all like other performance-based contracts on the market today. What makes this unique approach so successful is that everyone’s incentives line up behind helping customers keep their diabetes under control. CIGNA’s costs are lowered, medication adherence increases, resulting in health benefits for individuals and improved productivity and lower health care costs for their employers. http://www.vbhealth.org/outcomes-based-contracting-2/cigna-merck-obctm-delivers-on-vbbd-dividends22
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  24. 24. Prime Therapeutics CareCentered Contracting • Through CareCentered Contracting, pharmaceutical companies agree to either refund the cost of the drug for patients whose medication does not work as expected, such as an osteoporosis patient who suffers a fracture, or cover the cost of treating such an event. The health outcomes and medication adherence of patients are not typically factors in pricing negotiations. • CareCentered Contracting includes these components in order to reduce uncertainty about the effectiveness of medications and possible side effects for members and increase accountability between pharmaceutical manufacturers and health plans. http://blog.primetherapeutics.com/blog/outcomes-based-contracting24
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  26. 26. Big Data!! Will It Mean Anything26
  27. 27. http://georgevanantwerp.com/2012/01/30/uping-the-rxante-an-adherence-predictive-model/ http://georgevanantwerp.com/2011/10/27/predicting-medication-adherence/ Express Scripts presentation from William Blair Growth Stock Conference 201227
  28. 28. Source: Strecher, Victor, Analysis of medication adherence data for HealthMedia, Inc., 2006.28
  29. 29. Of Course…Data Is Only Good If You Can Use It http://thefuturescompany.com/what-we-do/living-well/29
  30. 30. Programs Don’t Work If People Don’t Engage30
  31. 31. Do You Really Think That 99 Seconds Is Enough Time For A Patient To Understand Their Drug? http://www.thedoctorweighsin.com/what-physicians-spend-10-mins-of-every-conversation-doing-can-drive-or-diminish-patient-engagement/31
  32. 32. What Are Some Opportunities For Outcomes- Based Alignment? • PBMs contracting with retail pharmacies based on patient satisfaction or adherence • Employers contracting with PBMs based on improvements in overall medical spend • Linking mail order rates to the patient experience based on a metric like Net Promoter Score • Replacing rebate contracting with outcomes based contracting • Paying for gaps-in-care addressed at the POS • Linking employee engagement to lower health premiums32
  33. 33. 12/14/12 Morgan Stanley Presentation from Humana33
  34. 34. Pharmacy Focuses On A Narrow Set Of Star Measures Not The Broader Set34
  35. 35. www.nebgh.org/pdf/presentations/bruner072210.ppt35
  36. 36. Walgreens’ WellTransitions Program • Medication review – pharmacists review patients’ prescriptions upon admission to the hospital and at discharge; check for potential interactions and simplification of medication regimen • Bedside medication delivery – Walgreens pharmacy staff member delivers medication the patient will need to take after discharge to the patient’s room and offers medication education and instruction • Patient counseling – pharmacists provide medication counseling to both the patient and caregiver and work in close communication with the medical staff • Regularly-scheduled follow-up calls – pharmacists conduct regular calls to follow up on patient progress, discuss regimen and answer any questions or concerns • 24/7 pharmacist support – pharmacy staff is available to answer patient questions 24/7 either over the phone or online http://news.walgreens.com/article_display.cfm?article_id=564836
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  39. 39. www.omadahealth.com39
  40. 40. Shifting The Pharmacy / Pharmacist Role To Be Part Of The Expanded Care Team Is Critical40
  41. 41. Learning Objectives • Explain the pharmacy industry implications of the shift from Fee For Service to Outcomes Based Contracting – Mx and Rx integration of data – New metrics – MD collaboration • List examples of how leading edge companies are using technology and Big Data to embrace this change – Predictive adherence models – Pharma contracting around outcomes • Explore options for PBMs and pharmacies to take a more active role within the expanded care team with a focus on the Triple Aim of cost, quality, and consumer experience – Prevention – Engagement – Re-admissions – mHealth41
  42. 42. Thank You George Van Antwerp VP, Product Development inVentiv Medical Management george.vanantwerp@inventivMM.com www.georgevanantwerp.com @gvanantwerp42