It s all about the patient gaps in care for the specialty patie nt
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“It’s All About the Patient” Gaps in Care for the Specialty Patie nt. Diane Sullivan, Vice President Specialty Payer & Channel Group Pfizer Inc. April 3, 2013. In The Healthcare System, An Acknowledged “Quality Gap” Persists.

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“It’s All About the Patient” Gaps in Care for the Specialty Patie nt

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It s all about the patient gaps in care for the specialty patie nt

“It’s All About the Patient” Gaps in Care for the Specialty Patient

Diane Sullivan, Vice President

Specialty Payer & Channel Group

Pfizer Inc.

April 3, 2013


In the healthcare system an acknowledged quality gap persists

In The Healthcare System, An Acknowledged “Quality Gap” Persists

  • Patients are receiving only 54.9% of recommended care based on established evidence-based guidelines.

  • Adherence to the processes involved in care delivery ranged from 52.2% for screening to 58.5% for follow-up care.

  • More information and accountability for the quality of healthcare is being demanded by payers.

  • Consumers and governmental agencies are expecting health plans and providers to demonstrate the value of their services.

McGlynn EA, Asch SM, Adams J, et al. The Quality of Health Care Delivered to Adults in the United States. N Eng J Med. 2003;348:2635.


Adherence to quality indicators are below the recommended care received

Adherence to Quality Indicators are Below the Recommended Care Received

  • Adherence to quality indicators suggest significant opportunities for improvement in most modes of care delivery.

  • The highlighted areas reflect opportunities for Specialty Pharmacy professionals.

McGlynn EA, Asch SM, Adams J, et al. The Quality of Health Care Delivered to Adults in the United States. N Eng J Med. 2003;348:2635.


Gaps in care for specialty patients

Gaps in Care for Specialty Patients

  • Undiagnosed

  • Untreated

  • Poor Medication Adherence

  • Uneducated Patient


Specialty patients gaps in care

Specialty PatientsGaps in Care

Specialty Patient

  • Of the more than 2.2M U.S. RA population, ~700K have not been diagnosed or treated.5

  • Delay between symptom onset and DMARD prescription for individuals for RA is a problem across countries, with a median lag time ranging from 6.5 to 19 months.6

Gaps in Care

Hemophilia

  • A general lack of knowledge about and familiarity with the

  • genetic and clinical implications of the disorder among

  • affected patients.1

  • The potential for preventable morbidity and mortality related

  • to delayed diagnosis and treatment.1

Multiple

Sclerosis

  • In a study of 2,750 patients with multiple sclerosis, early

  • treatment resulted in greater benefits on disability

  • progression.2

  • Adherence for multiple sclerosis patients range from 40-80%,

  • reflecting additional room for improvement.3,4

Rheumatoid

Arthritis


References specialty patients gaps in care

ReferencesSpecialty Patients: Gaps in Care

  • Amy D. Shapiro, MD, et al. Knowledge and Therapeutic Gaps – A Public Health Problem in the Rare Coagulation Disorders Population. American Journal of Preventive Medicine ; 2011;41(6S4):S324 –S331

  • M. Trojan, MD, et al. Real Life Impact of Early Interferon Beta Therapy in Relapsing Multiple Sclerosis. American Neurological Association; 2009;66:513–520

  • Bruce JM, Hancock LM, Lynch SG. Objective adherence monitoring in multiple sclerosis: initial validation and association with self-report. MultScler. 2010;16(1):112–120.

  • Rio J, Porcel J, Tellez N, et al. Factors related with treatment adherence to interferon beta and glatiramer acetate therapy in multiple sclerosis. MultScler. 2005;11(3):306–309.

  • John J. Cush. Early Rheumatoid Arthritis Care.- Is There a Window for Opportunity? J Rheumatol 2007;34 Suppl 80:1-7.

  • Linda C. Li, et al. An Evidence-Informed, Integrated Framework for Rheumatoid Arthritis Care. Arthritis & Rheumatism. August 15, 2008;1171.


Today s specialty patient gaps in care key gap closure strategies

TODAY’S SPECIALTY PATIENT: GAPS IN CARE & KEY GAP-CLOSURE STRATEGIES

David Calabrese, R.Ph, MHP

VP, Chief Pharmacy Officer

Catamaran


Understanding today s specialty patient

UNDERSTANDING TODAY’S SPECIALTY PATIENT

  • Increasingly older patient demographic

  • Much more likely to be suffering from multiple chronic conditions

  • Not uncommon to be frequently in and out of the ED’s, hospitals & rehabilitative care

  • Functional status, productivity and quality of life significantly impacted by their condition(s)

  • Require much more in-depth & proactive level of risk assessment and intervention


Gap i inadequate data integration communication

GAP I: INADEQUATE DATA INTEGRATION & COMMUNICATION


Gap closure strategies

GAP CLOSURE STRATEGIES

  • Integrated data warehousing & analytics

    • Medical claims, pharmacy claims, lab data, CM data, etc…

  • More advanced & continuous risk scoring/stratification

  • Enhanced connectivity w/ providers & health systems

    • Real-time, automated Prior Authprocessing

      Value Proposition:

    • Improved allocation and targeting of clinical resources

    • More timely clinical alerts & provider intervention

    • Decreased admin burden for providers

    • Dcreased risk of primary non-adherence for pts

    • Enhanced outcomes evaluation (patient & drug)


Gap ii insufficient care management support

GAP II: INSUFFICIENT CARE MANAGEMENT SUPPORT

DRUG EDUCATION

CONTRACTING

WASTE MGMT

DISTRIBUTION MGMT

DOSE MONITORING

CALL CENTER SUPPORT

Missing Pieces:

More Integrated, Holistic & Patient-Centered Specialty Care

ADHERENCE MONITORING

INJECTION

TRAINING

PRIOR AUTHORIZATION

FORMULARY MGMT

REIMBURSEMENT SUPPORT

SIDE EFFECT MONITORING

DISEASE EDUCATION

PT

COUNSELING


Gap closure strategies1

GAP CLOSURE STRATEGIES

  • More routine MTM intervention for the specialty pt

  • Employment of periodic screenings for common comorbidities

  • More comprehensive efficacy & safety monitoring

    • Example: Multiple Sclerosis - EDSS scoring; MRI; exacerbations; admissions/readmissions; depression screening; etc…

  • Annual disease-specific QOL assessment

  • More “proactive” call center outreach/coaching

  • More contemporary patient engagement strategies

    • mobile; web; social media; gaming; motivational interviewing


Gap iii care transition support

GAP III: CARE TRANSITION SUPPORT


Gap closure strategies2

GAP CLOSURE STRATEGIES

  • Bi- (or tri-) directional sharing of critical data elements

    • Plan-specific hospital admissions data

    • Complete, up-to-date patient medication history

    • Notification of hospital discharges and discharge planning info

  • Pharmacist-driven MTM and med reconciliation w/ patient and/or caregiver w/i 48-72 hrs of discharge

  • Establishment of automated monitoring & provider (MD, CM) alerts if/when patient falls out of appropriate care

  • Periodic outreach/coaching


Bridging the gaps in patient care

Bridging the gaps in patient care

Dan Duffy

Chief Business Development Officer

Biologics, Inc.


A highly fragmented healthcare system

A highly fragmented healthcare system


Support the entire journey

Support the entire journey

  • Holistic patient management vs. silo approach

SP

SP

Specialty pharmacy

Source: National Business Group on Health and National Comprehensive Cancer Network


Bridging the gaps in care

Bridging the gaps in care


Specialty gaps in care

Specialty Gaps in Care

Jim Hopsicker, R.Ph., MBAVice President, Pharmacy ProgramsMVP Health Care


Who we are

Who We Are

30 Years Strong. Regional. Innovative. Not-for-Profit.

Nationally recognized, not-for-profit health insurer, with headquarters in upstate New York and regional offices throughout New York, Vermont and New Hampshire – serving the region formore than 30 years

Providing health insurance solutions for over 25,000 employers, serving more than 625,000 members throughout New York, Vermont and New Hampshire and covering more than 100,000 Medicare retirees nationally

Partnering with more than 500,000 doctors, specialists, and hospitals from coast to coast

Powered by the ideas and energy of more than 1,600 regional employees

Providing innovative, breakthrough products with integrated wellness solutions


Current issues

Current Issues

Definition

Gaps in care

Formulary management

State mandates

Pharmacy carve outs

Guidelines

Site of service

Trend / cost


Example formulary management

Example : Formulary Management

MS therapy

New orals to market

Meeting with Neurologists to evaluate current and impending product market

Evaluation of current formulary structure, clinical policies and current contracts

Evaluating hospitalizations due to MS as opportunity for improvement


Marketplace challenges

Marketplace Challenges

State Mandates

Oral chemo

Prohibition of tier 4

Infertility

Any willing provider

Pharmacy Carve out

Definition

Medical – brown bag

Home care coordination

Enteral therapy


Gaps in care

Gaps In Care

Use PBM and Specialty vendor

Adherence is key

Manage both medical and pharmacy specialty benefit for patient

Coordinate real-time with case management (ie: transplants, PAH, Factor, IVIG, oncology)

Work with patient to ensure they can get therapy


Gaps in care for the specialty patient gaps what gaps

Gaps in Care for the Specialty Patient…Gaps, What Gaps?!

Keith McGee, PharmD

Vice President, Business Development

US Bioservices


Us bioservices our perspective

US Bioservices: Our Perspective

  • Continuity of Care Program

    • - Speed to Therapy

    • - Drive Compliance and Adherence

    • - Reduce Administrative Burden


Us bioservices our approach

US Bioservices: Our Approach

Employee Engagement

Technology

Centers of Excellence


Gaps in patient care

Gaps in Patient Care

  • Patient Onboarding: new diagnosis & unfamiliar model for most patients

  • Highly Variable Experience

  • Complicated Prescribing Processes

    • eRx inadequacies / 8.5”x11” Referral Form(s)

    • Mandatory HUB, Optional HUB, Direct Referral to SP

  • Product Access

    • Payer Networks

    • Pharma Limited Distribution Networks

    • Site of Care

    • Benefit Design

      • Medical v. Pharmacy

      • Buy & Bill v. Assignment of Benefit

      • Networks (Specialty v. Retail v. Mail)

    • Medical Necessity (Prior Authorization/Step Edit)

    • Financial Assistance (copay cards / 501(c)(3) variability / PAP)


Gaps in patient care1

Gaps in Patient Care

  • Specialty Pharmacy Operations

    • Time to Fill (TAT)

    • Compliance and Persistency

    • Patient Contact and Engagement

    • Redundancy of work and services – leads to confusion

    • Communication and Transparency

    • Meaningful & Actionable Data Analytics

  • Goals:

    • Appropriate Utilization & Site of Care

    • Managing Costs – Clinical spend and administrative expense

    • Improving Outcomes

  • Future of Healthcare:

    • New Models = New Gaps

    • Need to successfully predict & mitigate the unintended consequences


It s all about the patient

“It’s all about the Patient”

Gaps in Care for the Specialty Patient

John Witkowski

Senior Vice President

CareMed Pharmaceutical Services


It s all about the patient1

It’s all about the Patient

  • Gaps

    • Hospital Discharges

    • Uncoordinated communication

      • Physicians, patients, payors and pharmacies

    • Varying software platforms & formats

      • EMRs, Pharmacy software, Portals

    • Access to Therapy

      • Limited Distribution Models

      • Limited Access Networks

      • Patient Workload


It s all about the patient2

It’s all about the Patient

  • Collaboration Opportunities

    • Multi-caregiver education/support programs

      • Pharmacists, Nurses, Physicians & Payors

    • Unified Platforms

      • Systems integrations

        • Disease Management Programs

        • EMR to Pharmacy software

        • Multi-Directional Databases

          • Real-time data sharing


It s all about the patient3

It’s all about the Patient

  • Services to improve adherence

    • Understanding Therapy

      • DMPs

        • Traditional

          • Pharmacist/Pharmacy Nurse administered

      • Support Groups

    • Ease of Access

      • Financial Assistance

        • Conditional Approvals

      • “Work-load distribution”

        • Patient involvement in Front-End vs Back-End processes

      • Transfers


It s all about the patient4

It’s all about the Patient

  • Best Practices

    • DMPs

      • Collaborative

        • Portals, Mobile

    • Transition Programs

      • Inpatient to Outpatient

        • Multi-Organization Teams

    • Ease of Access

      • Patient work-load distribution

        • Prior Auths, Benefit Verification, Co-pay Assistance, Refill Management, Provider communication. Etc - HCP

        • Patient Engagement


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