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2016 Forum: "Landscape Reality on the Ground" - Dr. Mora

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October 21, 2016

Published in: Healthcare
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2016 Forum: "Landscape Reality on the Ground" - Dr. Mora

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  3. 3. 3 Group Health • More than 1,000 physicians representing 60 specialties; 7,500 total staff • Dozens of Health Plan products including 90K Medicare Advantage Members • 9,000+ contracted network providers • $3.9 billion in annual revenue
  4. 4. 4 Pharmacy Costs Continue to Rise – All Lines of Business By 2018 Group Health will spend more on pharmaceuticals than inpatient costs
  5. 5. 5 2015 Commercial and Medicare Medication Trend Drivers
  6. 6. 6 Framework to Manage Pharmacy Drug Spend Leadership Focus • Investments in the science of evaluation • Redeploying resources to get scale at the unit level • Clinical leadership • Therapeutic equivalency equals competition • Partnering with Kaiser Permanente for purchasing and performance • The right information for the best conversation
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  8. 8. 8 Pharmacy and Therapeutics Committee • Responsible for making decisions on formulary placement and utilization management edits for drugs covered under the pharmacy and medical benefit • Value driven guiding principles  Evidence reviews and budget impact models prepared by Group Health Staff  Decisions based on best long-term interest of patients  Use evidence-based process to make value judgments about risk vs. benefit  Consider total system cost rather than only pharmaceutical cost • Committee membership  13 Physicians, 2 pharmacists, 1 consumer member  Primary Care and Specialist physician and pharmacy representation • Accountability  Reports to the Medical Policy Committee (Where larger value question is debated and addressed….)
  9. 9. 9 Highlight: Specialty Pharmacy Program 19© Qualis Health 2010 Specialty programs for patients taking medicines in the following drug categories: – Oral Oncology -- Biologics for Rheumatoid Arthritis or Crohn’s Disease – Hepatitis C -- HIV
  10. 10. 10 Highlight: Medication Adherence Strategies to improve adherence: Pharmacy services Targeted outreach Medication home delivery Low-cost therapy Refill synchronizationBenefit design 2015 WA Health Alliance Community Checkup Metrics Medical Group Performance State Summary Rating Rate Confidence Interval State Rate Confidence Interval Adherence for diabetes medications BETTER 70% (69%-72%) 65% (64%-66%) Adherence for hypertension medications (RAS antagonists) BETTER 84% (83%-84%) 78% (78%-79%) Adherence for cholesterol medications (statins) BETTER 80% (79%-81%) 74% (74%-75%)
  11. 11. 11 Formulary Management – Value and Dependencies Group Health’s formulary management framework ensures utilization of appropriate, high value, cost-effective medications Commercial State Exchange/IFSG Medicare % Formulary 95.2% 99.6% 97.0% GDR 88.8% - 90.8% 87.2% - 91.2% 91.6% PBM GDR 85.7% 86.2% 86.4% Percent formulary and generic dispense rate (GDR) 2015 by LOB
  12. 12. 12 Group Health THANKS

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