Tips, Tricks and Traps Practical Insights into 340B Assessing the Opportunity in Ambulatory and Specialty Pharmacy Kevin Scheckelhoff, RPh, MBA Asst. Vice President 340B Solutions, McKesson Chris Shain, PharmD, BCPS Asst. Vice President 340B Solutions, McKesson Brent Brumagin, MBA, MHA, PMP 340B Program Manager Vanderbilt University Medical Center July 14, 2015 Partnering for Better Health
Agenda Welcome and introductions Objective Q&A 2 Partnering for Better Health
Guest Speakers Chris S. Shain Pharm.D., BCPS Assistant VP, 340B Solutions McKesson Kevin Scheckelhoff RPh, MBA Assistant VP, 340B Solutions McKesson Brent Brumagin MBA, MHA, PMP 340B Program Manager Vanderbilt University 3 Partnering for Better Health
Objective Outline key 340B program attributes and strategies Discuss key market trends influencing DSH hospitals and other 340B entities Gain insight into developing sound business plans for ambulatory and specialty pharmacy 4 Partnering for Better Health
Hospital-Based Ambulatory Pharmacy: Trends and Forecasts 50% 25% 50% Health systems will have a relationship with retail clinics Health systems will conduct their own specialty pharmacy services for at least three specialty medications Health systems will have a business plan to expand pharmacists services for ambulatory patients Zellmer WA, ed. Pharmacy Forecast 2015 2019: Strategic Planning Advice for Pharmacy Departments in Hospitals and Health Systems, December 2014. www.ashpfoundation.org/pharmacyforecast 5 Partnering for Better Health
Ambulatory Pharmacy: 340B Considerations 1 340B regulation remains in play what is your risk tolerance? 2 What is your organization s ambulatory and specialty care strategy? 3 How much of your opportunity is 340B-dependent? 4 Narrow provider networks, limited-access drugs, competing commercial providers and declining reimbursement? 5 How do contract pharmacy options fit? 6 Partnering for Better Health
Ambulatory Pharmacy: Traditional vs. Specialty Definition: Products that treat a complex condition and meet at least four of the following characteristics: 1. Generated by a physician specialist 2. Injectable 3. Requires specialized handling, shipping and storage 4. Unique or limited distribution model 5. High cost 6. Requires extensive patient counseling/training and monitoring 7. Requires additional reimbursement assistance 7 Partnering for Better Health
Is There an Opportunity (Traditional)? Forecasting strategies: Evaluate patient-care areas Evaluate prescriptions generated Separate traditional and specialty Global prescription count Attrition rate 340B eligible vs. non-eligible Capture rates based on proposed model 8 Partnering for Better Health
Is There an Opportunity (Specialty)? Forecasting strategies: Use a different data profile than traditional prescriptions Evaluate specialty prescriptions Prior authorization process Drug-specific utilization based on average dose/quantity Attrition rate and strategies to impact 340B eligible vs. non-eligible Capture rates based on model and network constraints 9 Partnering for Better Health
Business Planning Approach Forecasting the cost of operations: Use independent and small chain as a comparison Hard to find specialty operations benchmarks Build pro-forma scenarios Three-year modeling Be thoughtful on staffing especially with specialty Include all software and capital assets Calculate net with all associated costs and use same basis to evaluate impact of 340B program 10 Partnering for Better Health
Key Business Planning Takeaways Financial planning up front helps set appropriate expectations (and feasibility) Traditional and specialty are similar, but require separate considerations Financial modeling forces a review of ramp up, budgeting for capital assets and cash flow Can incorporate model into implementation and use as a foundation of financial reporting 11 Partnering for Better Health
Specialty Pharmacy Overview Brent D. Brumagin, MBA, MHA, PMP 340B Program Manager Vanderbilt University
U.S. Spend (Billions) Specialty Medications: Double Digit Growth $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 U.S. Spending on Specialty Drugs 1 $192 $87 $402 2012 2016 2020 Year Key Messages Specialty pharmacies are the fastest growing segment in pharmacy Specialty three-year CAGR is 66.8% compared to traditional drugs (4.1%) 2 AMCs generate many of the specialty prescriptions VUMC is not alone. AMCs across the nation are providing specialty pharmacy programs 3 Sources & Notes: 1). CVS Caremark 2). Express Scripts 3). Example AMCs with Specialty Programs include Mayo Clinic, Cleveland Clinic, Johns Hopkins, University of Michigan, Duke, Rush, University of Wisconsin, UNC, Wake Forest, University of KY, University of KS, University of MN 13
Specialty Medications: Different Paths With the help of our specialty partner, we were able to launch our specialty services program in less than three months from the time we began in-depth discussions about what we wanted to do with a relatively minimal investment. Rick Couldry, MS, RPh University of Kansas Economics was the other piece in looking at total cost of care, we wanted to have complete say in the dollars being spent on specialty medications. We want to be sure that patients on specialty medications should really be on them and are using them properly; this includes the right dose, which can mean a lower dose to prevent side effects or a higher dose to increase efficacy. Kyle Skiermont, PharmD Fairview Amgen Pharmacy Affairs Newsletter, Spring 2014, Volume 1, Issue 1 14
Specialty Medications: Minimum Required Services Closed door retail pharmacy Medication procurement and dispensing Mail service delivery/cold chain distribution Benefits investigation Prior authorization Co-pay and medication assistance program Call center support 24/7 (contract out) Specific therapeutic management clinical specialists Patient education/counseling teaching REMs program management Staff education training Adherence/compliance programs Case management 15
Be Aware of Stakeholder Barriers Existing provider relationships Limited distribution drugs Narrow networks and payer/plan access Payer lockouts 16
Specialty Pharmacy: Service Model 17 All new prescriptions referred to Specialty Pharmacy Specialty Pharmacy coordinates all steps in ordering/authorization of specialty drugs Pharmacy assumes case management responsibilities for specialty meds Conducts benefit verification If not yet contracted, prescription is forwarded to appropriate specialty pharmacy Obtain prior authorizations utilizing shared EMR Locates/facilitates alternate funding for patients in need of financial assistance Coordinates delivery and home injection teaching (if necessary) Patient management Medication therapy management services for complex therapies using best practices Conduct monthly follow-up and medication adherence education for all patients to ensure the best clinical outcomes possible Pharmacy meets regularly with prescribers and clinic managers to review operations and provide clinical updates
New Rx Clinic Authorization Hospital Specialty Pharmacy Pharmacist Billing Coordinator Patient Care Coordinator Rx Referral Pick Up/Delivery Dispensing Hospital Specialty Pharmacy Pharmacist Pharmacy Technicians 18
Refill Rx Authorization Patient Follow-Up Hospital Specialty Pharmacy Billing Coordinator Patient Care Coordinator Pick Up/Delivery Dispensing Hospital Specialty Pharmacy Pharmacist Pharmacy Technicians 19
20 Thank You