A Comprehensive Survey of Managed Care Organization (MCO) Medication Adherence Intervention Programs Part I: Patient and Intervention Targeting

A Comprehensive Survey of Managed Care Organization (MCO) Medication Adherence Intervention Programs Part I: Patient and Intervention Targeting August 2014 1 of 14

Executive Summary Additional annual healthcare costs due to non-adherence per patient ($) Medication non-adherence Medication non-adherence is a complex and costly problem 1/3 of Americans do not take their medications as prescribed. 1 $290 billion in avoidable US costs each year. 2 8,000 6,000 4,000 2,000 CHF Hypertension Diabetes Hyperlipidemia 1. Haynes, R.B.NCPIE Prescription Month, October 1989 2. "Thinking Outside the Pillbox A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease." New England Healthcare Institute, 1 Aug. 2009. Web. 30 July 2014. <http://www.nehi.net/writable/publication_files/file/pa_is sue_brief_final.pdf>. Medication adherence programs Managed Care Organizations (MCOs) use medication adherence intervention programs to uplift their patients adherence. Study: 30 MCOS were interviewed about their current medication adherence programs and future plans. 0 Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending. Health Affairs. Jan 2011; 30:191-99. Note: Medication adherence impact on annual medical spending for dyslipidemia, diabetes, hypertension, and congestive heart failure patients is calculated using 2005-2008 claims data. Identify interviewees Conduct interviews Analyze outcomes Small MCOs (<200,000 members) and large MCOs ( 200,000 members) Conducted 30 phonebased interviews over a 10-week period in Spring 2014 Interviewed 19 small MCOs and 11 large MCOs Quantitative data analyzed before and after stratification into small and large MCOs Survey research This survey research outlines the current trends in MCO medication adherence programs as well as identifies the key differences between small and large MCOs The paper is divided into 2 parts which outline the 3 major components of these programs. Part I: Patient and intervention targeting 1.Which patients will get interventions? 2.When do patients get interventions? Part 2: Intervention techniques 3.What are the interventions and how are they executed?

Landscape of medication adherence programs (Outline of survey) 1 Which patients will get interventions? Part I: Patient and intervention targeting 2 - Disease segmentation When do patients get interventions? - How patients are selected for interventions - Use of predictive analytics for medication adherence 3 What are the interventions and how are they executed? Part II: Intervention techniques - Intervention channels - Where interventions are conducted - Effectiveness measurements 3 of 14

Part I: Patient and Intervention Targeting 1 Which patients will get interventions? 2 When do patients get interventions? 4 of 14

1 Which patients will get interventions? Summary of findings Targeted disease states (pgs. 6 & 7) MCOs target chronic cardiovascular diseases as a top priority for intervention programs. MCOs intervene with these patients, because: Patients suffering with cardiovascular diseases are often associated with a high-risk of medication non-adherence. Medicare Part D sponsors are required to target beneficiaries suffering from multiple chronic diseases. Cardiovascular diseases (hypertension, heart failure, diabetes, and hyperlipidemia) count towards this requirement. Most MCOs plan to expand their intervention programs to target more disease states. Most notably Asthma, Depression, and COPD. 5 of 14

1 Most MCOs target cardiovascular disease states To which of the following diseases do your current intervention programs apply? Respondents having medication adherence intervention programs in specific diseases (%) Certified Disabled Rheumatoid Arthritis Multiple Sclerosis Vaccinations Schizophrenia Bipolar Disorder Lower Back Pain Prenatal Counseling Migraine Cancer Osteoporosis Antiretrovirals Depression COPD Asthma Myocardial Infarction Heart Failure Hyperlipidemia Hypertension Diabetes 7% 10% 17% 20% 17% 30% 30% 50% Most intervention programs target cardiovascular disease states 90% 9 9 0% 20% 40% 60% 80% 100% 6 of 14

1 MCOs are planning to expand to other diseases Are there any disease states you are considering to expand to in the future? Subject Breakdown of respondents Respondents planning to expand to more disease states All MCOs 65% Expansion of disease states % of all small MCOs 7 % of all large MCOs 50% 0% 20% 40% 60% 80% The most popular disease states for expansion are COPD, asthma, and depression 7 of 14

2 When do patients get interventions? Summary of findings How patients are selected to receive interventions (pg. 9) MCOs use three common methods to select patients for interventions: triggers, predictive analytics, and retrospective adherence measures. For MCOs that use triggers, Late to fill are the most common events used to trigger interventions. For the few MCOs that use predictive analytics, prioritizing the patients who are at-risk of becoming non-adherent is the most common method to select patients for interventions. For MCOs that use retrospective adherence measures, MPR (medication possession ratio) is the most common metric to classify a patient as non-adherent. Predictive analytics (pgs. 10 & 11) Most MCOs are interested in expanding their current medication adherence programs. Predictive analytics allow MCOs to tailor their adherence programs to specific goals and ultimately influence patient behavior. While very few MCOs currently use predictive analytics, a large number plan on incorporating a platform that will personalize interventions and more effectively reduce total medical costs. 8 of 14

2 MCO methods to start interventions How are patients selected to receive interventions through your intervention programs? Triggers Below are three common methods MCOs use to select patients for interventions Predictive analytics Retrospective adherence measures 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 30% First fill 3 New diagnosis 80% Late to fill 3 Script coming due 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 7% Predictive Analytics - priortizing patients at-risk for nonadherence 80% 60% 40% 20% 0% 40% Retrospective adherence measures Most MCOs intervene with patients who have an MPR (Medication Possession Ratio) below 80% for a certain amount of months. Most MCOs use some combination of methods to determine when patients get interventions. For example, many MCOs intervene with patients who are late to fill their prescriptions (triggers) and/or have an MPR below 80% in the last 6 months (retrospective adherence measures). MCOs also select patients for interventions using patient questionnaires such as Morisky medication adherence scale, scheduled targeting, and intervening with every patient of a given condition. 9 of 14

2 MCO plans to expand current programs Do you plan on expanding your medication adherence intervention programs? Subject Description Respondents planning to expand programs Expansion of adherence programs Includes adding intervention types, more frequent interventions, etc. 75% 0% 20% 40% 60% 80% Do you use predictive analytics to identify patients who will be non-adherent in the future? Subject Predictive analytics Description MCOs currently using predictive analytics MCOs planning to use predictive analytics in the future Respondents 7% 60% 0% 20% 40% 60% 80% 10 of 14

2 Ideal predictive analytics platforms How they work Enhanced predictive analytics platforms: Identify interventions most likely to engage patients and influence their behavior Avoid wasteful spending on interventions with patients who will not need them Use flexible machine learning technology that continually learns Medical claims Pharmacy claims Laboratory results Intervention data Patient demographics Predictive analytics platform Capabilities Predict patients medication adherence for each medication Predict most effective and costefficient interventions for each patient Prioritize patients for interventions Evaluate interventions and identify key areas for improvement Since these platforms are dynamic and self-learning, they can rapidly adapt to new intervention techniques. This enables more rapid cycle innovation and deployment of new intervention approaches in a rigorous data-driven manner. 11 of 14

Summary of findings 1 Which patients will get interventions? MCOs target chronic cardiovascular diseases as a top priority. Most MCOs are interested in expanding to other disease states including asthma, depression, and COPD. 2 When do patients get interventions? The three most common methods to select patients for interventions are triggers, predictive analytics, and retrospective adherence measures. Predictive analytics While very few MCOs currently use predictive analytics to predict a patient s medication adherence, many are planning to incorporate more enhanced platforms. These enhanced platforms identify interventions that will most likely engage patients and avoid wasteful spending on interventions with patients who will not need them. 12 of 14

Part II: Intervention Techniques Sneak peek 3 What are the interventions and how are they executed? A. Intervention channels Most commonly used intervention channels and types of messaging. B. Where interventions are conducted Whether interventions are conducted in-house and/or outsourced. C. Effectiveness measurements Most commonly used metrics to evaluate programs. Thank you for reading Part I: Patient and Intervention Targeting 13 of 14

Authors Affiliations and methodological issues About AllazoHealth AllazoHealth is a predictive analytics firm focused on anticipating patients behaviors and predicting how to change those behaviors. Its AllazoEngine technology incorporates partial or complete population data to forecast individual patients adherence to each of their medications, anticipate how medication adherence interventions will influence those patients, and target the right interventions to the right patients at the right time. Allazo provides its services to PBMs, health insurers, ACOs and providers both a stand-alone analytics solution and a full-service medication adherence solution. www.allazohealth.com For further information contact clifford.jones@allazohealth.com (888) 464-2776 ext. 705 charles.boothe@allazohealth.com (888) 464-2776 ext. 707 Collaborators: Clifford Jones Ian Sullivan Upal Basu Roy, Ph.D., MPH Michael Boice David Coutts, Ph.D. Stefanie Mazlish, MBA Aishwarya Nagarian, Pharm.D., MBA Slanix Paul Alex, Pharm.D. Sudarshan Phani, Ph.D. Kalee Shah Aneesh Sheth, Ph.D. Kamilia Sip, Ph.D. Tracey Van Kempen. About The Solution Lab The Solution Lab is a non-profit consulting organization based in New York. It staffs top tier graduate (PhD, MD, and MBA) students and professionals on interdisciplinary teams for short term management consulting projects in the Pharma/biotech/healthcare space. www.thesolutionlab.org For further information contact stefanie.mazlish@thesolutionlab.org Methodological issues The questionnaire only recorded data from MCOs who agreed to participate in the survey. This is a potential source of non-response bias. Some of the questions (including graphs on pages 9 & 10) were added midway through the interview process. These graphs represent a reduced sample space. Not all MCOs agreed to answer each question. 14 of 14