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Pharmacy – Data, COEs, Predictive
Models, and Consumer Engagement

George Van Antwerp
VP, Product Development
inVentiv Medical Management
February 2013
Caregiver              PCP
                            Patient
       Case Manager                     Pharmacy


    Pharmacist                              Pharma


     Health                                   PBM
     Insurer


                           Employer




2
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
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 experience




4
What Is Population Health Management?




Source: Outcomes Guidelines Report Volume 5. (2010). Washington, DC: Care Continuum Alliance

5
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 Report




6
Growth Requires Integration Of
                                 Medical And Rx Data




    Source: PBMI 2012 Specialty Drug Report, Prime Therapeutics 2012 Drug Trend Report


7
The Value Of Pharmacy On Quality Is
             Increasingly Being Recognized




    Source: CVS Caremark 2012 Insights Report




8
Evidence-based medicine      Accountable Care




                     Warning:
     Bundled
    Payments       New Paradigm               VBID
                      Ahead


                Comparative Effectiveness



9
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
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.html


11
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
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
Understanding Consumers Allows For
       Information To Be “Prescribed”

                                   Go to this
                                    website



                                Watch this video



                                 Download this
                                  mobile app


                                   Join this
                                  community



14
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 EMR




15
Lowest     Most
      Trend    Generics




                Lowest
      Best
                 Error
     Rebates
                 Rate




16
17
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=9728

18
Counting Pills Is Not Enough




19
http://hin.com/blog/2012/12/17/infographic-improving-primary-care-by-expanding-the-role-of-pharmacists/

20
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 Velcade




21
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-dividends


22
23
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-contracting


24
25
Big Data!! Will It Mean Anything




26
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 2012

27
Source: Strecher, Victor, Analysis of medication adherence data for HealthMedia, Inc., 2006.

28
Of Course…Data Is Only Good If You Can Use It




     http://thefuturescompany.com/what-we-do/living-well/




29
Programs Don’t Work If People Don’t Engage




30
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
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
       premiums

32
12/14/12 Morgan Stanley Presentation from Humana
33
Pharmacy Focuses On A Narrow Set Of Star
          Measures Not The Broader Set




34
www.nebgh.org/pdf/presentations/bruner072210.ppt
35
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=5648



36
37
38
www.omadahealth.com

39
Shifting The Pharmacy / Pharmacist Role To Be Part
            Of The Expanded Care Team Is Critical




40
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
         –   mHealth

41
Thank You

             George Van Antwerp
          VP, Product Development
        inVentiv Medical Management
     george.vanantwerp@inventivMM.com
         www.georgevanantwerp.com
               @gvanantwerp




42

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PBMI 2013 Presentation on Shift From FFS to Value

  • 1. Pharmacy – Data, COEs, Predictive Models, and Consumer Engagement George Van Antwerp VP, Product Development inVentiv Medical Management February 2013
  • 2. Caregiver PCP Patient Case Manager Pharmacy Pharmacist Pharma Health PBM Insurer Employer 2
  • 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. 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 experience 4
  • 5. What Is Population Health Management? Source: Outcomes Guidelines Report Volume 5. (2010). Washington, DC: Care Continuum Alliance 5
  • 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 Report 6
  • 7. Growth Requires Integration Of Medical And Rx Data Source: PBMI 2012 Specialty Drug Report, Prime Therapeutics 2012 Drug Trend Report 7
  • 8. The Value Of Pharmacy On Quality Is Increasingly Being Recognized Source: CVS Caremark 2012 Insights Report 8
  • 9. Evidence-based medicine Accountable Care Warning: Bundled Payments New Paradigm VBID Ahead Comparative Effectiveness 9
  • 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. 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.html 11
  • 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. 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. Understanding Consumers Allows For Information To Be “Prescribed” Go to this website Watch this video Download this mobile app Join this community 14
  • 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 EMR 15
  • 16. Lowest Most Trend Generics Lowest Best Error Rebates Rate 16
  • 17. 17
  • 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=9728 18
  • 19. Counting Pills Is Not Enough 19
  • 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 Velcade 21
  • 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-dividends 22
  • 23. 23
  • 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-contracting 24
  • 25. 25
  • 26. Big Data!! Will It Mean Anything 26
  • 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 2012 27
  • 28. Source: Strecher, Victor, Analysis of medication adherence data for HealthMedia, Inc., 2006. 28
  • 29. Of Course…Data Is Only Good If You Can Use It http://thefuturescompany.com/what-we-do/living-well/ 29
  • 30. Programs Don’t Work If People Don’t Engage 30
  • 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. 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 premiums 32
  • 33. 12/14/12 Morgan Stanley Presentation from Humana 33
  • 34. Pharmacy Focuses On A Narrow Set Of Star Measures Not The Broader Set 34
  • 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=5648 36
  • 37. 37
  • 38. 38
  • 40. Shifting The Pharmacy / Pharmacist Role To Be Part Of The Expanded Care Team Is Critical 40
  • 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 – mHealth 41
  • 42. Thank You George Van Antwerp VP, Product Development inVentiv Medical Management george.vanantwerp@inventivMM.com www.georgevanantwerp.com @gvanantwerp 42