SlideShare a Scribd company logo
1
2
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
Pharmacy Costs Continue to Rise – All Lines of Business
By 2018 Group Health will spend more on
pharmaceuticals than inpatient costs
5
2015 Commercial and Medicare Medication Trend Drivers
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
7
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
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
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
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
Group Health
THANKS

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

  • 1. 1
  • 2. 2
  • 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 Pharmacy Costs Continue to Rise – All Lines of Business By 2018 Group Health will spend more on pharmaceuticals than inpatient costs
  • 5. 5 2015 Commercial and Medicare Medication Trend Drivers
  • 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
  • 7. 7
  • 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 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 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 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

Editor's Notes

  1. Leadership Focus
  2. In a survey covering prescription effectiveness, patient safety, and cost stewardship, we ranked number one in pharmaceutical management* of five health plans evaluated in the 2014 eValue8 report sponsored by the Washington Health Alliance. *Results were based upon performance in value-based formulary, generic prescribing and appropriate drug use, specialty pharmaceuticals, and quality and safety of outpatient prescribing. Opioids: Different opiates would be on different tiers.  The less expensive older generics, like hydrocodone/APAP and generic short release oxycodone would be tier 1 as would fentanyl patches.  Oxycontin and brand name long acting morphine drugs would be tier 2.  And then some of the newer, really potent, dangerous products like Subsys and Actiq (short acting fentanyl products that really only should be used for cancer pain) would be tier 3.  The tiering is really based on generic formulary, brand formulary and non-formulary.  However, there are some opiates in each tier that have prior authorization criteria on them that would have to be met before we would cover them at any tier level.  Oxycontin, fentanyl patches, Subsys and Actiq, and others all have prior auth criteria that make them really difficult to acquire under their GH benefit.  (Ok, Oxycontin isn’t that hard but it does have criteria.)  There are a number of products though like hydrocodone/APAP and some long and short acting morphine products as well as methadone and hydromorphone that don’t require the patient to meet any criteria. 
  3. Adherence metrics from 2015 WA Health Alliance Community Checkup (GPD providers) Targeted outreach GH implemented enterprise-wide IVR phone technology to outreach to patients who are late in filling a medication. The calls first ask the patient if they'd like to refill and then transfer them to their pharmacy. If the patient indicates they have reasons why they're not filling they go through a variety of barrier assessment questions. Based on their answers they can be transferred to a clinical pharmacist (for counseling on side effects, understanding the medication, and general adherence questions/issues), to the pharmacy where they fill, to pharmacy call center (if interested in changing to 90 day supply and/or using home delivery), or instructed to call provider. Group Health has specific targets for adherence:  For specific consumers, the target is that the patient needs to be 80% adherent, or in other words take 80% of their doses to be considered adherent to their medication.  In regard to health plan targets, our target is generally the 90th percentile for HEDIS or 5-Star performance on Medicare. We received 5-Star status from CMS on all three of the adherence measures. Reference: Drug non-adherence costs over $350 billion year. Nearly 75% of Americans do not always take medication as directed, adding $250 billion per year to U.S. healthcare costs.