it s all about the patient gaps in care for the specialty patie nt
Skip this Video
Download Presentation
“It’s All About the Patient” Gaps in Care for the Specialty Patie nt

Loading in 2 Seconds...

play fullscreen
1 / 34

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

  • Uploaded on

“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.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about '“It’s All About the Patient” Gaps in Care for the Specialty Patie nt' - thea

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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


  • 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



  • 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



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


David Calabrese, R.Ph, MHP

VP, Chief Pharmacy Officer


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 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







Missing Pieces:

More Integrated, Holistic & Patient-Centered Specialty Care











gap closure strategies1
  • 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 closure strategies2
  • 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.

support the entire journey
Support the entire journey
  • Holistic patient management vs. silo approach



Specialty pharmacy

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

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


Gaps in care

Formulary management

State mandates

Pharmacy carve outs


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


Any willing provider

Pharmacy Carve out


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


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