Specialty Pharmacy and Pharmacy Distribution: Unwrapping a … · 2020. 3. 10. · PBM Pharmacy Benefit Manager Prescribers Physicians, Nurse Practitioners Pharmacies Retail and Home

© 2017 Express Scripts Holding Company. All Rights Reserved.

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Specialty Pharmacy and Pharmacy Distribution: Navigating a Complex Ecosystem

Lynne Nowak, MD VP Clinical and Provider Solutions, Express Scripts

March 4, 2017

2 © 2017 Express Scripts Holding Company. All Rights Reserved.

Welcome to the complex world of pharmacy care

Benefit Advisor Strategic Partner

PBM Pharmacy Benefit

Manager

Prescribers Physicians,

Nurse Practitioners

Pharmacies Retail and

Home Delivery

Pharma Drug

Companies

Health Plan Insurance Provider

Member/Patient Spouse and Dependents

Plan Sponsor Business, Union, Government, etc.


Healthcare costs are exploding

Our role is to help manage trend and control

costs while improving care.

Almost 50% of

Americans have at

least one chronic

condition

Specialty drug

spend is currently

30% of total

pharmacy costs and

is projected to be

49% by 2019

Inflammatory

conditions,

diabetes, multiple

sclerosis, and

cancer are top four

cost categories

Average list price

for brand drugs

rose 10.7% in

2016.

Rising pharmaceutical prices are not sustainable


Why is trend increasing?

Price Inflation Higher Utilization

Never before have we seen such high prices on medications that are used by so many

20

08

20

09

20

10

20

11

20

12

20

13

20

14

Brand Prescription Price Index

Generic Prescription Price Index

Consumer Price Index (BLS)

20

15

Source: Express Scripts research


Our business is complex

Manufacturer

Pharmacy

Patient

Pharmacy Benefit Manager

Rebate pass through

Third-Party Payer

Payer reimbursement

to PBM

Services Agreement Formulary Agreement

Prime Vendor Agreement Network Participation

Pharmacy payment for product Rx reimbursement

Formulary rebates Wholesaler payment for product

Services Contract Product shipment

Product Shipment

Service & data fees (Specialty)

Copayment/ Coinsurance Dispense Rx

Note: Chart illustrates flow for patient-administered, outpatient drugs in the U.S. It does not

represent every type of financial, product flow, or contractual relationship in the marketplace

Source: Fein, Adam J., The 2016 Economic Report on Retail, Mail and Specialty Pharmacies,

Drug Channels Institute, January 2016

Financial Flow

Contract Relationship

Product Movement

Drug Wholesaler


Pharmacy

Benefit

Management Home

Delivery

Pharmacy

Specialty

Pharmacy

Group

Purchasing

Organization

Specialty

Distribution

Clinical

Development

& Rx Hub

About us

85+ million members 3000+ clients 1.3 billion Rx’s per year

7 © 2017 Express Scripts Holding Company. All Rights Reserved. Source: Company Reports, Internal Analysis

PBM & Specialty Pharmacy Landscape

Independent

PBM - MCO

PBM - Retail

Various PBM and Specialty Pharmacy ownership models exist in industry

Proprietary & Confidential

Integrated / MCO-owned

Independent

Retail-owned

PBM Models Specialty Pharmacy Models

Retail

PBM



Manufacturer

Pharmacy

Patient


Rebate pass through

Third-Party Payer

Payer reimbursement

to PBM






Product Shipment







Financial Flow


Product Movement

Drug Wholesaler



Manufacturer

Pharmacy

Patient


Rebate pass through

Third-Party Payer

Payer reimbursement

to PBM






Product Shipment







Financial Flow


Product Movement

Drug Wholesaler


What is a Pharmacy Benefit Manager (PBM)?


Our clients represent all of healthcare

Plan Sponsors (Employers, Health Plans)

Managed Plans (Medicare, Medicaid, Exchanges)

Government Plans (Department of Defense, States)

Pharma Manufacturers

Providers (Physicians, Hospital Systems, ACOs)


Formulary Development Starts with Clinical Evaluation

• Efficacy

• Side-effect profile/toxicity

• Outcome data quality

• Indications

• Drug interactions

• Special populations


Formulary Development Process Clin

ical D

eci

sion

Busin

ess D

ecisio

n

Formulary

Recommendation

Value Assessment

Committee

Therapeutic Assessment

Committee

National P&T

Committee

Express Scripts

Formulary Client Decisions


Formulary management: Lowest cost, broad access

National Preferred Formulary Value of Exclusions

$4.9B TOTAL SAVINGS



Manufacturer

Pharmacy

Patient


Rebate pass through

Third-Party Payer

Payer reimbursement

to PBM






Product Shipment







Financial Flow


Product Movement

Drug Wholesaler



Manufacturer

Pharmacy

Patient


Rebate pass through

Third-Party Payer

Payer reimbursement

to PBM






Product Shipment







Financial Flow


Product Movement

Drug Wholesaler


Express Scripts Home Delivery Pharmacy

11-19% Higher adherence rates

6X longer patient counseling time

compared with retail

116M prescriptions delivered

annually


Express Scripts’ unique model of specialized pharmacy care Disease-Specific

Focus

Education and

Experience

Individualized

Health Action

Plan

Behavioral and

Communication

Expertise

21 Therapeutic Resource Centers


Advanced clinical solutions enhance TRC specialized care and member engagement

PATIENT-FOCUSED, SPECIALIZED CARE

Care Coordination

Coordinating care

with your case managers

for patients with chronic

and complex conditions

Safety

Engages providers

to address patient-specific

safety risks identified via

real-time analysis of medical,

lab and pharmacy data

Adherence

Identifies and addresses

adherence risk

with predictive modeling

and patient-tailored

interventions


Inflammatory

Conditions

Oncology Multiple

Sclerosis

Pulmonary

Hypertension

Specialization and focus through scale Accredo’s Therapeutic Resource Centers®

Unique clinical protocols

maximize safety, effectiveness and

affordability

One-on-one counseling

from specialty pharmacists and nurses

Proactive copay assistance1

and enhanced member service

Widest access to limited & exclusive distribution drugs

in the industry

14 Specialized areas

of focus, including:

$463M in copay

assistance for 2016

94% of specialty

drugs on the market

500pharmacists

550 field nurses

1. For eligible therapy classes and drugs

2. When an Accredo pharmacist recommended intervention and the MD accepted


Understanding the challenge of specialty

1% of patients use

specialty medications,

but drive 38% of

total healthcare

spend

Specialty drug spend

continues to rise

to 40% in 2016,

projected to be 50% by 2018

Inflammatory

conditions, multiple

sclerosis, and cancer

are driving a specialty

cost boom.

FDA approved 33 new specialty

medications in 2015,

exceeding traditional

approvals for the 5th

year in a row.

1% 38%


60% 40%

Drug Trend Report: Specialty landscape

2016 Drug Spend Specialty Spend by

Billing Location

53% 47%

Traditional Specialty Pharmacy Medical


Specialty continues its rapid rise

RANK SPECIALTY

THERAPY CLASS

2016

PMPY SPEND

TREND

UTILIZATION UNIT COST TOTAL

1 Inflammatory conditions $118.21 11.4% 15.1% 26.4%

2 Cancer $60.70 11.9% 9.6% 21.5%

3 Multiple sclerosis $58.63 -1.3% 7.4% 6.1%

4 HIV $39.92 5.5% 16.2% 21.7%

5 Hepatitis C $25.26 -27.3% -6.7% -34.0%

6 Cystic fibrosis $9.51 12.7% 26.0% 38.8%

7 Growth deficiency $7.82 0.1% 4.5% 4.6%

8 Pulmonary hypertension $7.26 15.0% 8.8% 23.8%

9 Hemophilia $6.24 9.8% -2.7% 7.1%

10 Sleep disorders $5.51 6.6% 13.5% 20.1%

COMPONENTS OF TREND FOR THE TOP 10 SPECIALTY THERAPY CLASSES

RANKED BY 2016 PMPY SPEND


$60

$80

$100

$120

$140

$160

$180

$200 2X

Specialty’s top spender

Topped spend in specialty drugs for the

seventh year in a row

If trend continues, inflammatory drugs will

nearly double in spend by ’18

Actual

Projected

Inflammatory Spend

‘15 ‘16 ‘17 ‘18

Inflammatory is #1 in spend for

commercial business and top 5

in all other lines of business

1. Source: 2015 Drug Trend Report


Inflammatory quick facts and challenges

1.Express Scrips Drug Trend Report, 2015

All other cited facts based on Express Scripts and Accredo 2015 data.

$3,035.95 average cost per prescription1

Rheumatoid Arthritis patients are

7x more likely to reduce work hours and

6x more likely to incur medical charges

43.7% of patients are nonadherent1


A patient’s success story

• RA patient concerned with stability of Humira® Pen after being

unrefrigerated for a short time

• Specialist pharmacist reviewed medication information and

confirmed medication was OK to use

• Achieved: waste avoidance and patient education

Rheumatoid Arthritis and Inflammatory TRC T

RC

DIF

FE

RE

NC

E

FEATURES OF

OUR UNIQUE

CLINICAL MODEL

• Easy-open bottle caps

• Thorough gap-in-care intervention outreach

• Activities of daily living screenings

• Extensive patient training and education

• Proactive therapy-effectiveness assessments

• Motivational partnerships

RA&I-specific care and counseling helps patients achieve

THE BEST POSSIBLE OUTCOMES

78% Overall adherence

$1,935 Payer savings per RA patient

in medical costs annually

4.5x More time with a clinician

compared to retail


Additional Support Connecting Patients with Resources

I can hardly afford the copays to see my doctor, let alone pay my other bills.

I am no longer able to stand up long enough to cook, and I have no help at home.

I feel so lonely since we moved to another state.

“

“

“

Disease-Specific Resources

Clinical Staff Training and Referrals

Counseling and Emotional Support

Community Resources

Psychosocial Assessment

Financial Resources

Crisis Intervention

Accredo

connects

patients with

community and

manufacturer

support

resources



Manufacturer

Pharmacy

Patient


Rebate pass through

Third-Party Payer

Payer reimbursement

to PBM






Product Shipment







Financial Flow


Product Movement

Drug Wholesaler



Manufacturer

Pharmacy

Patient


Rebate pass through

Third-Party Payer

Payer reimbursement

to PBM






Product Shipment







Financial Flow


Product Movement

Drug Wholesaler


Specialty drug distribution

1) Copyright © 2016 by the Center for Healthcare Supply Chain Research

Line weighting denotes volume

Manufacturers Patients

Specialty

Pharmacies

Physician Offices/

Clinics

Traditional

Wholesale

Distributors

Specialty

Distributors

Hospital

Pharmacies

Home Care

Providers

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Specialty distributors handle ~ 33% of specialty sales volume and primarily serve physician clinics and home care providers


Specialty pharmaceutical manufacturers choose their distribution model carefully

Copyright © 2016 by the Center for Healthcare Supply Chain Research 31

Optimize patient and provider access

Provide clinical and educational support

Support patients with adverse events

Ensure maximum patient and provider reimbursement

Help obtain financial assistance for patients

Minimize supply chain costs

Maximize supply chain efficiencies

Ensure product integrity

Reduce the risk of counterfeiting or tampering

Meet regulatory requirements


Express Scripts optimizes specialty medication access for patients and prescribers

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• Specialty Pharmacy

• Custom Adherence Programs

• Therapeutic Resource Centers

• Customized Data Reporting

• Specialty Distribution

• Third-Party Logistics

• Inventory Management

• Extensive Pharmaceutical/ Biopharmaceutical Contract Access

• Drug Purchasing & Supply Chain Monitoring

• Inventory Control & Management Solutions


How do Express Scripts’ specialty medication offerings inter-relate?

Exclusive/Limited

Drug Distribution

Contract Priced

Products


CuraScript SD provides therapeutic agents to medical professionals across the broad expanse of healthcare providers

.

Alternate Sites of Care

Hospital (Acute Care)

Community Physicians/

Clinics

Specialty Pharmacies

Closed-door Pharmacies


UBC: comprehensive, end-to-end pharma services

Development Commercialization Pharmacy

Bring Drugs

to Market

Ensure Patient Safety,

Access & Adherence

Product

Delivery


Actionable, data-driven physician engagement

Real-time clinical and benefit information in the EHR and at the point-of-care

• Patient Medication Benefit Check

• Electronic Prior Authorization

• Direct digital messaging

• RxChange/RxCancel

• Telehealth integration

Prescriber utilization and quality performance management

• Physician profiling and peer benchmarking analysis

• Physician network assessment tools

• Academic Detailing with targeted physician outreach for member-specific, actionable interventions

Supporting value-based care with healthcare systems and ACO partners

• Clinical consultants focused on population health management

• Data analytics to help prioritize resources and target interventions

• Predictive modeling to identify at-risk members and populations

Building solutions with physicians for physicians

• Medical Advisory Board

• Specialty physician focus groups

• Academic Detailing team feedback

• Accredo specialty physician consultants and physician concierge programs

• Physician Call Center feedback, surveys

Innovative solutions

Meaningful interventions

Collaborative partnerships


My contact info:

Lynne Nowak, MD Vice President, Clinical and Provider Solutions

Express Scripts, Inc

[email protected]

Office: 314-684-5639

Cell: 618-210-3874


Documents

Specialty Pharmacy and Pharmacy Distribution: Unwrapping a … · 2020. 3. 10. · PBM Pharmacy Benefit Manager Prescribers Physicians, Nurse Practitioners Pharmacies Retail and Home