What is so special about Specialty?

PRESENTED BY:

Kim Foerster, Director, Managed Markets Sales, Diplomat Specialty Pharmacy

Jeremy Faulks, Retail Specialty Manager for Target Specialty Pharmacy

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Learning objectives

Diplomat Case Study, July 2013 – January 2014.

Specialty Pharmacy Basics Cost of Lick It, Stick It, Ship It Models The Basics of Specialty Management The Good + Bad of Co-Pay Assistance

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Specialty pharmaceuticals

• Strict temperature control• Distribution can be limited• Restricted location for

administration

Difficult Medication

Delivery

• Personalized dosing or administration

• Clinical management or close monitoring required

Complex Treatment

Adapted from Blaser DA, et.al. How to Define Specialty Pharmaceuticals – A Systematic Review. Am J Pharm Benefits. 2010;2(6).371-380. Diplomat Case Study, July 2013 – January 2014.

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Specialty pharmacy market

The specialty market is not a level playing field, as extreme variations are seen in patient care management, service, and outcomes.6

1. Cohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013.

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SP Model Characteristics

PBM Owned • Structured programs• Higher use of technology for patient

outreach• Strong buying power• Ability to shift costs• Specialty pharmacy is a piece of the

business

Plan Owned • Ability to easily view all claims data (medical + pharmacy)

Retail Owned • Community based care

Independents • More flexible – willingness to customize• Specialty pharmacy is primary expertise • Focused on patient care and service –

more high-touch• Greater transparency

Specialty pharmacy landscape

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Top 10 specialty drug classes

1• Inflammatory Conditions – Rheumatoid Arthritis

2• Multiple Sclerosis

3• Cancer

4• HIV

5• Growth Deficiency

6• CNS Disorders

7• Respiratory Conditions – Cystic Fibrosis

8• Anticoagulants

9• Organ Transplant

10• Pulmonary Hypertension

Express Scripts®. Drug Trend Report [Internet]. 2014 April [cited 2014 Apr 8]. Available from: http://lab.express-scripts.com/drug-trend-report/table-of-contents.

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PAYOR

• Marketplace trends

• UM programs• Measured and

reportable clinical outcomes

• Patient adherence / satisfaction

• Access to drugs• Data• Spend trends

PHARMA

• Adherence• Biosimiliars• Patient assistance

programs• Therapy initiation• Manufacturing

cost

PHYSICIAN

• Administrative work burden

• Patient compliance

• Time for appropriate care

• Buy and bill

PATIENT

• Administration• Adverse event

management • Disease

progression / quality of life

• Cost

UM: Utilization ManagementCohen GM, Calla N, Moore TS. Evolution of a community pharmacist to a specialty pharmacist. Specialty Pharmacy Conference; 2013.

Stakeholder concerns

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Collaboration is the future of health care

Affordable Care Act (ACA)

Requires collaboration on quality initiatives with reportable savings

Physician Value-Based Modifier coming in 2015 – need to measure how medication contributes to quality

Care coordination is priority in six NQS (National Quality Strategy) domains

Centers for Medicare & Medicaid Services (CMS) Call Letter

“. . . ensure continuity of care and integration of services through arrangements with contracted providers.”

Demonstrate improved outcomes and achieve patient satisfaction through advancement of good quality health. Measured by five CMS star rating categories:

Patient outcomes Intermediate outcomes Patient experience Patient access to care Process

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Specialty care coordination – The basics

Teamwork

AccessTolerance

Adherence

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Case management coordination

Coordination of benefits

Physician education on guideline updates

Medical billing

Side effect and symptom management

Customized communication

Injection training support

Support group enrollment

Motivational Interviewing Techniques

Drug regimen assessment and collection of medication history

Adherence calls

Proactive PA & Rx renewal support

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Improving adherence“

Technology

Patient Training & Education

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Compliance & persistency

Adherence tools Proactive side-effect management

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Cost of ineffective care

CategoryMost Recent

Fill

Days Supply

Dispensed

Name of Drug

Quantity on HandAmount of Surplus /

Waste

AWP for surplus/wasted

quantity

Surplus medication

11/27/2012 84 AvonexMember had 4 week supply of

medication on hand in early March6 week surplus $7,045.20

10/25/2012 84Enbrel

SureclickMember did not set up first shipment

until early April11 week surplus $7,295.90

8/2/2012 84 HumiraMember had 60 day supply of

medication on hand as of early May24 week surplus $15,767.78

10/8/2012 28 Aranesp Member had a six week supply of

medication on hand in mid January10 week surplus $7,462.50

Cost of surplus medications on-hand $37,571.38

Waste due to member stopping therapy

9/17/2012 60 SensiparMember had 60 day supply of

medication on hand in Maywaste of 60

days $2,129.76

9/25/2012 84Enbrel

SureclickMember had 60 day supply of

medication on hand in early Marchwaste of 60

days $5,306.00

6/6/2012 84Enbrel

SureclickMember had 60 day supply of

medication on hand in early Aprilwaste of 60

days $5,306.00

Cost of excess drugs dispensed and not used due to discontinuation $12,741.76

 TOTAL $50,313.14

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Co-pay assistance controversy

Traditional Drugs: Use of co-payment cards to

bypass plan formularies, step edits and patient contribution

Specialty Therapies: Co-payment assistance

through foundation grants allows continuation of therapy

Care collaboration = Improved patient outcomes

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The bridge to breast cancer patient care: co-pay assistance

Diagnosis: Metastatic breast and bone cancer

$1,927.23 co-pay is roadblock to initiating therapy

Funding team was awarded a Patient Advocate Foundation grant on behalf of patient

*Physician discontinued therapy after 7 months due to anemia anemia

Patient and prescriber communications, Diplomat Case Study, July 2013 – January 2014.

7-month case study

Prescriber faxes (average 3 per month)

Patient care phone calls (average 8 per month)

27%

73%

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Higher cost-sharing leads to greater prescription abandonment

Streeter SB, et al. Am J Manag Care. 2011;17(5 Spec No.):SP38-SP44).

Oral Oncolytic Abandonment Rate at Varying Cost-Sharing Amounts

Aban

donm

ent r

ate

(%)

(n=7,638) (n=529) (n=614) (n=1727)

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1% reduction in cost-sharing can increase utilization of oral oncolytics up to 3.3%

Milliman Inc., Parity for oral and intravenous/injected cancer drugs. January 25, 2010. Available at: http://publications.milliman.com/research/health-rr/pdfs/parity-oral-intravenous-injected.pdf. Accessed March 3, 2013.

n=24,474 cancer patients, 20–69 years of age.

Oral Chemo <$1500 per Treatment

Oral Chemo >$1500 per Treatment

0.0

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2.5

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3.3%

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18Ramsey S, Blough R, Kirchoff A, et.al. Washington State Cancer Patients Found To Be At Greater Risk For Bankruptcy Than People Without A Cancer Diagnosis. Health Affairs, May 2013;32(6):1143-1152.

Bankruptcy rates for patients with cancer

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Patient satisfaction Medication adherence Pharmacist interventions Quality of life measures Cost avoidance outcomes Co-pay assistance summary Patient communication summary Specialty pipeline strategies

Reporting: proof of collaborative value

3.16

1.227.04

Doctor - 28%

Insurance - 11%

Patient - 62%

292 patients averaged 11.42 touches

Communications per patient, Diplomat Case Study, Q1 2013.

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Questions