What makes WEA Trust different? How can we all make a difference in the cost of healthcare?

1. How is WEA Trust
Reclaiming
Healthcare?
Tim Bartholow, MD
VP & Chief Medical Officer
Alan Lukazewski,
Director of Clinical Pharmacy

2. What does “reclaiming” mean?
• Talented, trusted team that serves our
members first
• Appropriate, affordable care
• Careful selection of physicians/systems
who reach for higher value

3. Why is the Trust different?
• We talk to the member
• We remove physicians who aren’t safe for
members
• We will deny care that is not appropriate or
unnecessarily uses too many resources

4. • We work with physicians to make care more
consistent and appropriate in areas like :
– Cardiology
– Orthopedics
– Gastroenterology
– Psychiatry
– Rheumatology
– Oncology
70% of
claims
Why is the Trust different?

5. • We seek bundles and warrantees
• We are all Wisconsin employees
• We are smarter, faster through
analytics
Why is the Trust different?

6. Reclaiming Healthcare: Quality
• Help keep people well
• If not well, be sure the patient receives
“appropriate” care
• Provide appropriate care with as little variation
as possible
• Shared decision making that empowers the
patient
• Anticipate future care needs

7. 0%
10%
20%
30%
40%
50%
60%
70%
80%
DistrictofColumbia
Utah
Connecticut
Nevada
NewJersey
RhodeIsland
Washington
NewMexico
Delaware
Colorado
Maine
Nebraska
Wisconsin
Georgia
Wyoming
Oregon
California
NewYork
NewHampshire
Missouri
Pennsylvania
Minnesota
SouthCarolina
Montana
Alaska
Kansas
Massachusetts
Michigan
Illinois
Idaho
WestVirginia
Arizona
NorthCarolina
Mississippi
Virginia
Florida
SouthDakota
Arkansas
Ohio
Indiana
Kentucky
Tennessee
NorthDakota
Texas
Alabama
Oklahoma
Louisiana
Iowa
Hawaii
Vermont
Proportion
of Evaluated
Hospitals
That Were
Penalized
Number of Hospitals By State That Will Be Penalized
(Source: Kaiser Health News,2014 on 2011 Data)

8. IHD with Angioplasty,
2 Groups 2 Hours From One Another,
Doctors with at Least 10 Episodes, DMV2
$36,009
$33,911 $33,508
$30,865
$29,853
$26,728
$25,221 $24,897 $24,890 $24,772
$21,863
$-
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
A A A A A A A B A B B
Doctor in Clinic A or B
StdCostperEpisode
0
0.5
1
1.5
2
2.5
3
HealthRisk,Retrospective
Std Cost per Episode
Health Risk

9. Reclaiming Healthcare: Affordability
• We are stewards of resources (with
physicians)
• Unless we buy differently, hospital
systems will not/cannot change
• Waste in health care is paid from
employee earnings

10. Pharmacy Focus: Quality & Affordability

11. Pharmacy Benefit Goals
• Deliver value
–High quality
• Based on best evidence for positive
outcomes AND reducing risk for harm from
medications
–Affordable benefit

12. Lowest Net Cost
• High-Cost Generic Program
• PBM program to reduce drug spend
• Work within Value Choice Drug Plan
• Preferred Drug List
– Formulary interchange program
• Substitute with effective lower cost equivalents
• High-touch member engagement

13. Specialty Drug Strategy: Cost and Safety
• Less than 2% of utilization
– 35% or more of total drug spend
• By 2018: more than 50%
• Average $4,200 per script
– 20% annual trend
• Price, Mix and Utilization
• PBM and Medical spend strategies
– Adhere to lowest cost therapies
– Avoid downstream medical costs from ADEs

14. Cost Focus: Specialty Drugs
• Case 1: Office-based infusion for asthma
– Proclaimed failure of inhaled asthma medications
– Intervention: Reviewed claims data to discover
<33% adherence over 6 months
– Outcome: Denial of expensive, inconvenient
infused product AND offered support for
adherence to lower cost therapy

15. Safety Focus: Specialty Drugs
• Case 2: Infantile spasms
– High cost therapy >$100,000/short-course
• New evidence for lower cost therapy
– Alternative associated with permanent vision loss in
30%
– Interventions: Advocate and collaborate
– Outcome: Avoided more toxic therapy
– Strategy: Revise prior authorization criteria to support
safer options