Diane Sullivan, Vice President

Specialty Payer & Channel Group

Pfizer Inc.

April 3, 2013

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

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 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.

• Undiagnosed• Untreated• Poor Medication Adherence• Uneducated Patient

Gaps in Care for Specialty Patients

Hemophilia

Rheumatoid Arthritis

MultipleSclerosis

Specialty Patient Gaps in Care

Specialty PatientsGaps in Care

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

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

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

1. 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

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

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

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

5. John J. Cush. Early Rheumatoid Arthritis Care.- Is There a Window for Opportunity? J Rheumatol 2007;34 Suppl 80:1-7.6. Linda C. Li, et al. An Evidence-Informed, Integrated Framework for Rheumatoid Arthritis Care. Arthritis & Rheumatism. August

15, 2008;1171.

ReferencesSpecialty Patients: Gaps in Care

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

David Calabrese, R.Ph, MHPVP, Chief Pharmacy OfficerCatamaran

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 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 Auth processing

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

ADHERENCE

MONITORING

DISTRIBUTION MGMT

SIDE EFFECT MONITO

RING

CALL CENTE

R SUPPO

RT

WASTE MGMT

DRUG EDUCATI

ON

INJECTION TRAINING

PRIOR AUTHORIZATION

REIMBURSEMENT

SUPPORT

CONTRACTING

PT COUNSE

LING

DOSE MONITO

RING

DISEASE

EDUCATION

Missing Pieces:More Integrated, Holistic &

Patient-Centered Specialty Care

FORMULARY MGMT

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 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

Dan DuffyChief Business Development Officer

Biologics, Inc.

A highly fragmented healthcare system

Support the entire journey

• Holistic patient management vs. silo approach

Specialty pharmacy

SP

SP

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

Bridging the gaps in careGap Solution

Longitudinal patient relationship

Engage early & often to establish trustValidate goal of therapy (curative vs.

palliative)Educate & listen to patientCollaborate with all stakeholders

Proactive transitional care

Survivorship Palliative Hospice (end-of-life)

Specialty Gaps in Care

Jim Hopsicker, R.Ph., MBAVice President, Pharmacy Programs

MVP Health Care

Who We Are

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 for more 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

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

Current IssuesDefinitionGaps in careFormulary managementState mandatesPharmacy carve outsGuidelinesSite of serviceTrend / cost

Example : Formulary ManagementMS therapyNew orals to marketMeeting with Neurologists to evaluate current and impending product marketEvaluation of current formulary structure, clinical policies and current contractsEvaluating hospitalizations due to MS as opportunity for improvement

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

Use PBM and Specialty vendor Adherence is keyManage both medical and pharmacy specialty benefit for patientCoordinate 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?!

Keith McGee, PharmDVice President, Business Development

US Bioservices

US Bioservices: Our Perspective

Continuity of Care Program

- Speed to Therapy

- Drive Compliance and Adherence

- Reduce Administrative Burden

US Bioservices: Our Approach

Centers of Excellence Employee Engagement Technology

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 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”Gaps in Care for the Specialty Patient

John WitkowskiSenior Vice President

CareMed Pharmaceutical Services

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 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 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 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