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

1. “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

2. 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.

3. 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.

4. Gaps in Care for Specialty Patients • Undiagnosed • Untreated • Poor Medication Adherence • Uneducated Patient

5. 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

6. 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.

7. TODAY’S SPECIALTY PATIENT: GAPS IN CARE & KEY GAP-CLOSURE STRATEGIES David Calabrese, R.Ph, MHP VP, Chief Pharmacy Officer Catamaran

8. 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

9. GAP I: INADEQUATE DATA INTEGRATION & COMMUNICATION

10. 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)

11. 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

12. 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

13. GAP III: CARE TRANSITION SUPPORT

14. 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

15. Bridging the gaps in patient care Dan Duffy Chief Business Development Officer Biologics, Inc.

16. A highly fragmented healthcare system

17. 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

18. Bridging the gaps in care

19. Specialty Gaps in Care Jim Hopsicker, R.Ph., MBAVice President, Pharmacy ProgramsMVP Health Care

20. 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

21. Current Issues Definition Gaps in care Formulary management State mandates Pharmacy carve outs Guidelines Site of service Trend / cost

22. 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

23. 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

24. 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

25. Gaps in Care for the Specialty Patient…Gaps, What Gaps?! Keith McGee, PharmD Vice President, Business Development US Bioservices

26. US Bioservices: Our Perspective • Continuity of Care Program • - Speed to Therapy • - Drive Compliance and Adherence • - Reduce Administrative Burden

27. US Bioservices: Our Approach Employee Engagement Technology Centers of Excellence

28. 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)

29. 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

30. “It’s all about the Patient” Gaps in Care for the Specialty Patient John Witkowski Senior Vice President CareMed Pharmaceutical Services

31. 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

32. 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

33. 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

34. 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