Get excited about the opportunity to drive higher value care in this complicated, confusing, frustrating and expensive ‘system’ we have co-created Goals 2
to Prescription Drugs Hospital 32% Physician & Clinical Services 20% Dental Services 4% Prescription Drugs 10% Nursing Care 5% Home Health Care 3% Remaining Personal Health Care 11% Other Health Spend 15% Source: Altarum monthly national health spending estimates. Health Spending by Category, September 2016
but one, technology makes things better and cheaper. Why is it that innovation increases the cost of health care? Jonathan S. Skinner, James Freedman Presidential Professor in the dept. of economics at Dartmouth College, Dartmouth Institute for Health Policy & Clinical Practice at the Geisel School of Medicine; published MIT Technology Review, Sept 13, 2013 • Vast array of treatments of variable value • Generous payer system creates irrational markets
50 percent of the time, used to describe drugs not approved by the FDA, and 14 percent of the time to describe drugs that had only worked in mice. The leap from helping a mouse to saving a human is uncertain, long, and overwhelmingly unsuccessful. JAMA Oncol. 2016;2(1):139-141. doi:10.1001/jamaoncol.2015.3931
Decisions of new Oncology Drugs in the United States and Other Selected Countries www.jmcp.org Vol. 23, No. 2 February 2017 JMCP Journal of Managed Care & Specialty Pharmacy US Medicare 100% covered UK NHS 47% covered France 42% covered Canada Australia 33% covered 31% covered 45 Approvals 2009 to end 2014
to Power "Moon Shots" Mission MD Anderson News Release OCT 18, 2013 Big Data Insights to Help Accelerate Translation of Cancer-Fighting Knowledge to Cutting Edge Medical Practices $62M And three years later…….. FEB 19, 2017 MD Anderson Benches IBM Watson In Setback For Artificial Intelligence In Medicine
options across benefits • Clinical policies and PA efficiencies • Patient education & training • Patient engagement • Therapy specific care management • Prescriber and care team collaboration • Benefit design • Site of care optimization • Patient copay assistance strategies • Rebates across benefits • Pharmacy network options • Drug waste management • Reduction in overall medical spend • Aligned cost-sharing • Improved health outcomes • Value of Rx treatment realized • Enhanced provider engagement • Patient satisfaction Total Drug Management
cost and improved outcomes* • Assure NCCN Guideline Concordance • Reduce PA processing time • Improve member and provider experience * adherence to evidence based treatment guidelines 24
Epub 10/18/16 Journal of Oncology Practice Background • Previously, medical claims were reviewed post-service for compliance to the Guidelines. • 7% of medical oncology claims were being denied Objectives Identify whether CDS solution can have impact on speed of authorization, number of denials, drug costs, and adherence to NCCN Guidelines®. Methods Compare Oncology CDS solution implemented for Florida commercial and Medicaid market vs. traditional post-service review in 2 other geographic regions: national without FL, Southeast without FL. Newcomer L et al, J Oncol Pract 2016.10.18 epub doi: 10.1200/JOP.2016.015198;
Florida in May 2014, national launch June 2015 • Provides NCCN concordant CDS, though does not yet include treatment cost information 28 Clinician enters patient clinical data System generates list of treatments concordant with NCCN guidelines Clinician selects a treatment Clinician receives authorization decision within three minutes
drug cost trends between June 1, 2014 and June 1, 2015. • The study analyzed costs from the practices in Florida that were using the new prior authorization system against practices in other states that were using a traditional process of reviewing claims. 29
trend decreased 9%, the rest of the nation (same payer and LOB) increased 10% Difference in Drug Cost Trends Denial rate 1% 58% $5.3 M 95% of authorization requests processed through the system obtained immediate approval of authorization requests processed through the system obtained approval in 24 hours annualized estimated drug savings for Florida given cost difference
2015, resulting in 98.5% clinically appropriate treatments 31 20% 80% 60% 40% 70% 28.5% Immediate Approval Approved after P2P or Redirection Pended or Denied <1.5% > 7800 Oncologists Engaged in all 50 states
may have a far greater impact on the health of the population than any other improvement in specific medical treatments. Haynes RB. Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2001, Issue 1.
or prescription is right “intelligent” noncompliance • Fear of dependence on, or loss of control, to the drug • Side Effects: Fear of side effects can dissuade a patient from taking medication • Not convinced the medication is making a difference: Such patients may claim that cost drives their noncompliance. Becomes a question of value or investing time and money in something that provides no perceived return. • Denial or Repression of the Problem • Difficulty incorporating the medical regimen into their routine 35
trade a week of their lives to avoid the pills, and 8% said they would be willing to give up as many as two full years of life to avoid the pills. • More than 20% said they would pay $1,000 or more • About 10% said they would pay between $5,000 and $25,000; and • 3% would pay up to $25,000 Circulation: Cardiovascular Quality and Outcomes , March 2015 Academic Research: One in Three Americans Would Choose Early Death Over Daily Meds 36
is unique, and doctors have always tried to tailor their treatments as best they can to individuals. You can match a blood transfusion to a blood type — that was an important discovery. What if matching a cancer cure to our genetic code was just as easy, just as standard? What if figuring out the right dose of medicine was as simple as taking our temperature? ~President Obama — January 30, 2015
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