Reclaiming Healthcare means making healthcare in Wisconsin more affordable, higher in quality, and more user-friendly.

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?
1. Talented, trusted team that serves our
members first
2. Appropriate, affordable care
3. Careful selection of
physicians/systems who reach for
higher value

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

4. Why is the Trust different?
• We work with physicians to make care more
consistent and appropriate in areas like :
– Cardiology
– Orthopedics
– Gastroenterology
– Psychiatry
– Rheumatology
– Oncology
70% of
claims
(2 of 3)

5. Why is the Trust different?
• We seek bundles and warrantees
• We are all WI employees
• We are smarter, faster through
analytics
(3 of 3)

6. Reclaiming Healthcare - Quality
1. Help keep people well
2. If not well, be sure the patient receives
“appropriate” care
3. Provide appropriate care with as little
variation as possible
4. Shared decision making that empowers
the patient
5. 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. Variation in resource use is a
quality problem

9. 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

10. 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

11. Work With Specialties
• SMARTCare, $15.9M ACA grant builds electronic
yardstick for angioplasty appropriatenessCardiology
• Bundling and registryOrthopedics
• CancerlinQ for more consistent cancer care,
bundling investigationOncology
• Bundling for rheumatoid arthritis treated with
RemicadeRheumatology
• Conversations in telehealthPsychiatry
• Early conversations about ambulatory surgery
center useGastroenterology

12. How does Pharmacy Affect
Quality and Affordability?

13. Our pharmacy benefit goals
• Deliver value
– Affordable benefit
– Higher quality
• Based on best evidence for positive outcomes
AND reducing risk for harm from medications
• Bend down the cost curve

14. Pharmacy cost trends
• Generic inflation
– High-cost generic oxymoron
• PBM program to reduce drug spend
• Work within Value Choice Drug Plan
• Branded “Me Too” drugs
– Formulary interchange program
• Substitute with effective lower cost
equivalents
• High-touch member engagement

15. Cost Focus: Specialty Drugs
• Less than 4% of utilization
• More than 35% of drug spend
– By 2018: more than 50%
• Average $3,100 per script
• Large portion of R&D tax payer paid
• Why the high cost?
• Sovaldi $272million R&D cost
– >$85,000/ course of therapy

16. Specialty Pharmacy Strategy
Improve
pricing
• Move Medical
billing to
Pharmacy billing
• Network
negotiations
• Choose best-fit
specialty
pharmacy
Manage
utilization
• Strengthen
preauthorization
process
• Duration of
therapy
• Adherence
Manage
product mix
• Formulary
preferred agents
• More cost-
effective medical
outcomes
(analytics)
• Prevent or
mitigate adverse
drug events