[S1] Best Practices: Integrating the Medical and Pharmacy Specialty Benefit ACPE UAN: # L04-P

Transcription

1 [S1] Best Practices: Integrating the Medical and Pharmacy Specialty Benefit ACPE UAN: # L04-P Wednesday, October 8, :00 am - 11:30 am Ballroom B Speakers Elizabeth Engelhardt, RN, BSN Marty Mattei, PharmD F. Michael White, PharmD, CSP

2 SPEAKER BIOGRAPHIES Elizabeth Engelhardt, RN, BSN Accountable for the development, design and execution of clinically sound, cost conscious medical, specialty medical pharmacy and specialty pharmacy pharmaceutical management for Aetna members. Responsible for leading cross functional team of clinician s to achieve organizational goals and corporate objectives. Marty Mattei, PharmD As Vice President of Clinical Product Innovation and Strategy at MedImpact, Marty Mattei, PharmD, is responsible for providing oversight and direction for clinical product strategy, product management and product development for the organization. Previously, he served as AVP, Pharmacy Solutions for The TriZetto Group, a healthcare technology solutions company where he led pharmacy strategy for the enterprise, and was Pharmacy Director at Colorado Access, a regional Medicaid/Medicare HMO in Denver Colorado. Dr. Mattei is also Clinical Assistant Professor in Pharmacy Practice at the University of Colorado, School of Pharmacy. F. Michael White, PharmD, CSP Dr. Michael White is the Director of Clinical Pharmacy Services at BlueCross BlueShield of Tennessee (BCBST). In this capacity he is responsible for all clinical initiatives across the BCBST enterprise and for all aspects of maintaining the clinical integrity of the pharmacy care management programs, utilization management oversight, the pharmacy appeals process and the specialty pharmacy program. Dr. White was one of the founders of the BCBST specialty pharmacy program when it began in Currently he leads the development and implementation of specialty initiatives across pharmacy and medical management and serves as the primary clinical contact for specialty pharmacies, pathways programs and pharmacy-centric diagnostic testing vendors. He is the lead preceptor for the advanced pharmacy practice experience rotations for the four colleges of pharmacy that he has agreements with and is also the Residency Program Director at BCBST. He was appointed to the Blue Cross Blue Shield Association s Medical Policy Panel in the summer of 2012 and became certified as a specialty pharmacist by the National Specialty Pharmacy Certification Board in the fall of Dr. White has nearly a quarter of a century of clinical experience and has been with BCBST for the past fourteen years. Dr. White enjoys membership in several professional organizations including the Tennessee Pharmacists Association, where he has served as Chair of the Managed Care Committee, the Chattanooga Area Pharmacists Society, where he held the office of President for a number of years, the Academy of Managed Care Pharmacy, and the National Association of Specialty Pharmacy.

3 Best Practices: Integrating the Medical and Pharmacy Specialty Benefit Learning Objectives Describe two advantages to integrating the medical and pharmacy benefits when discussing specialty pharmaceuticals. Explain key differences between the coding language for pharmacy benefits and medical benefits. Summarize the differences with reimbursement between the pharmacy and medical benefits. Identify at least two barriers to integrating the medical and pharmacy benefit and provide recommendations on how to overcome these barriers. Specialty Benefit 1

4 Continuing Pharmacy Education Credit Visit Click on Claim my CPE Have available: AMCP member ID NABP e profile ID Complete and submit session evaluation no later than November 10, 2014 (11:59 PM ET) Information in CPE Monitor after December 10, 2014 Financial Relationship Disclosures Elizabeth Engelhardt served on an advisory board for Managed Care Network and participated in a payer survey for Ariad Pharmaceuticals. F. Michael White and Marty Mattei report having no financial relationships with any commercial interests during the past 12 months. Specialty Benefit 2

5 AMCP Antitrust Guidelines AMCP s policy is to comply fully and strictly with all federal and state antitrust laws. This session will be monitored for any antitrust violations and will be stopped by the session monitor if any such violation occurs. Please refer to page 5 of the AMCP Nexus 2014 final program or for more information. How to Participate in Audience Response Have your cell phone ready Text responses to Standard text messages apply Poll Everywhere cannot see your telephone number EXAMPLE Specialty Benefit 3

6 SILENCE Speakers Michael White, PharmD, CSP Director, Clinical Pharmacy BlueCross BlueShield of Tennessee, Inc. Chattanooga, Tennessee Elizabeth Engelhardt, RN, BSN Vice President, Specialty Product Aetna Inc. Northport, New York Marty Mattei, PharmD Vice President, Clinical Innovation and Strategy MedImpact HealthCare Systems Inc. San Diego, California Specialty Benefit 4

7 Best Practices: Integrating the Medical and Pharmacy Specialty Benefit F. Michael White, PharmD, CSP Director, Clinical Pharmacy BlueCross BlueShield of Tennessee Learning Assessment Question #1 True or False. Alignment between utilization management and benefits is one advantage to integrating the medical and pharmacy benefit for specialty drugs. a. True b. False TEXT TO a b Specialty Benefit 5

8 Learning Assessment Question #2 True or False. Automating utilization management is one way to overcome a barrier associated with integrating the medical and specialty benefit. a. True b. False TEXT TO a b Learning Assessment Question #3 True or False. Pharmacy and medical benefits both use NCPDP as their claim format. a. True b. False TEXT TO a b Specialty Benefit 6

9 Learning Assessment Question #4 True or False. Prior authorization, step therapy, and quantity limits are not typically used to contain specialty drug costs. a. True b. False TEXT TO a b Learning Assessment Question #5 True or False. Provider contracts are one of many factors that must be considered when benefit packages are being created that will cover specialty medications. a. True b. False TEXT TO a b Specialty Benefit 7

10 Learning Objectives At the completion of this activity, participants will be able to: Describe two advantages and two barriers to specialty pharmacy integration within the medical and pharmacy benefits. Explain key differences between the reimbursement and the coding language for pharmacy benefits and medical benefits. Describe the utilization management techniques that are typically used to contain specialty pharmacy costs. Explain several key factors that must be considered when benefit packages are being created that will cover specialty pharmacy medications. 15 Medical Rx Claims Payment: The Unmet Needs Obstacles Solutions Overview Difficult data extraction Vague claim content UM can be challenging Utilization Management Typically Manual Higher overhead Constrained UM options Accuracy of Paid Claims Reimbursement is based on variable fee schedules Limited checks & balances 16 Specialty Benefit 8

11 Facts and Considerations Specialty pharmacy utilization & costs are escalating. Significant differences in the pharmacy & medical benefits exists. Utilization management ensures appropriate prescribing & contains costs. Should we stay in our silos, merge the benefits, or find a compromise? 17 Specialty Pharmacy is Thriving Total Pharmacy Spend % % Pipeline 31% Traditional 69% Specialty Per Member Per Year 2012 $ $ Specialty Benefit 9

12 Focused Approach Drug Distribution Channel: Benefit Design Utilization Management Contracting and Rebates Site of Care 19 Benefit Design 20 Specialty Benefit 10

13 Comparison of Medication Claim Payment Variables Pharmacy Medical Providers Types Pharmacies contracted with PBM or health plan Physicians, Facilities, Specialty Pharmacies, etc. Provider Identification NABP, NCPDP, NPI NPI Pricing Reference FDB and/or Medi Span Medicare or contract Coding Terminology NDC HCPCS Claim Formats NCPDP CMS Payment Strategies bendamustine bevacizumab carboplatin docetaxel fulvestrant trastuzumab J9033 J9035 J9045 J9171 J9395 J Specialty Benefit 11

14 Medical Rx Claims Payment: Identified Solutions Obstacles Overview Difficult data extraction Vague claim content UM can be challenging Solutions Reporting based on NDC s Facilitated rebating Cross benefit strategy Utilization Management Typically Manual Higher overhead Constrained UM options Automated Resources freed up PBM type platform Accuracy of Paid Claims Reimbursement is based on variable fee schedules Limited checks & balances NDC based pricing Eliminate pay for wasted drug 23 Utilization Management 24 Specialty Benefit 12

15 Medical Benefit Management P & T Committee 25 Be Proactive & Not Reactive Provide Policy Developments Move to ASP Fee Schedule Implement Coverage Criteria Criteria & Benefit Must Be At Parity 26 Specialty Benefit 13

16 Unintended Consequences Specialty Benefit 14

17 Utilization Management Safety First Clinical Review Initially Periodically Chronically Appropriate Use PBM Benefit Medical Benefit Ensure Cross Benefit Parity Preferred Drug Outpatient Facility Provider Office Ambulatory Infusion Center Home Infusion Optimize S.O.C. 29 Rebates & Site of Care 30 Specialty Benefit 15

18 Silo Business Processes Are Not the Solution PBM Rx PBM SpRx Medical SpRx Medical HIT 31 Integration Within the Health Plan Pharmacy Management P & T Committee PBM Clinical Pharmacists Medical Management Medical Policy UM Nurses & Medical Directors Business Engineering Coding Medical Informatics Provider Education Provider Networks 32 Specialty Benefit 16

19 References harmstudybr3final.pdf S11.pdf 101/challenges reimbursing throughmedical vs pharmacy benefit scripts.com/insights/specialtymedications/medical benefit management forspecialty rx 33 Specialty Drug Management: Looking Forward Integrating the Medical and Pharmacy Specialty Benefit Elizabeth Engelhardt Specialty Product, Aetna Pharmacy Management Specialty Benefit 17

20 Learning Objectives At the completion of this activity, participants will be able to: Describe two advantages and two barriers to specialty pharmacy integration within the medical and pharmacy benefits. Explain key differences between the reimbursement and the coding language for pharmacy benefits and medical benefits. Describe the utilization management techniques that are typically used to contain specialty pharmacy costs. Explain several key factors that must be considered when benefit packages are being created that will cover specialty pharmacy medications. Soon most prescriptions will be written for generic, but most of the costs will be for specialty medications Projected Growth of Specialty Spend 77% of drug spend associated with 6 therapeutic categories 1 40% of drugs filed for FDA approval are specialty 2 25% Expected growth rate for compared to 1 3% year over year expected growth rate in traditional meds 1. Aetna analysis. 2. Medications calculated are nearing final FDA approval. The numbers are estimates due to frequent changes in the drug pipeline. 3. Visante study for Pharmaceutical Care Management Association. Sept $125 billion Projected growth of specialty spend by Aetna Confidential and Proprietary Information 1 Specialty Benefit 18

21 Specialty pharmacy costs are only part of the challenge Unit costs % of Total Costs for Specialty Pharmacy users 90,000 projected shortfall of physicians by ,000 projected shortfall of specialists by % of drug spend falls under the medical benefit Aetna claims data, Aetna Confidential and Proprietary Information 66% Non drug related spend for specialty pharmacy patients 2 2 Aetna Confidential and Proprietary Information There are a wide variety of specialty therapies for different conditions Multiple Sclerosis Hepatitis C Oncology Est. Prevalence 400,000 3,200,000 13,000,000 Disease Variations Drug Treatment Options Treatment Formulations Aetna Confidential and Proprietary Information 3 Specialty Benefit 19

22 SUCCESSFUL SOLUTIONS NEED TO CONSIDER ALL OF THE CHALLENGES Premier specialty pharmacy services require decisions supported by sophisticated analytics Drug choice Comprehensive clinical evidence and polices for therapy Site of Care Analytics Affordable options for delivery of care A knowledgeable support system that covers all patient needs Aetna Confidential and Proprietary Information 5 Specialty Benefit 20

23 Focus on Oncology Multiple drivers of cost Medical costs are projected to reach at least $158 billion dollars by 2020 a 27% increase over Medication costs are one of several cost drivers for oncology. 2 Est. Prevalence 13, 000,000 Disease Variations 100+ Drug Treatment Options 100+ Site of care impacts Community based oncologists have been impacted the most by the changes in chemotherapy reimbursement rates; pushing care into hospital settings. Specialty medication wave Over 55 drugs in Phase III trials, many more in earlier stages of development. 3 Drug Choice Diagnosis validation Dose and frequency edits Precertification Step Therapy Treatment pathways Support Case Management Disease Management Drug Focused Care Management Behavioral Health End of life support Today Aetna Confidential and Proprietary Information Site of Care Oncology Patient Centered Medical Homes Tiered Networks 1. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the Cost of Cancer Care in the U.S.: J Natl Cancer Inst Jan CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC. 3. Aetna Pipeline Review Analysis. Tomorrow Aetna Confidential and Proprietary Information 6 Focus on Multiple Sclerosis Drug Costs Wholesale drug therapy costs for MS are as much as $48,000 annually. 1 More medications in the pipeline 5 drugs in Phase III trials. 2 Est. Prevalence 400,000 Disease Variations 4 Drug Treatment Options 10 More diagnosed every week There are an estimated 200 new diagnoses every week. 3 Drug Choice Precertification Dose and frequency edits Step Therapy Copay Differentials Support Case Management Disease Management Drug Focused Care Management Behavioral Health Today Aetna Confidential and Proprietary Information Site of Care Site of care steerage Redefine how decisions made on where drug is covered 1. NY Times, Andrew Pollack citing Journal Neurology, July 20, Aetna pipeline analysis. 3. Multiple Sclerosis: Hope Through Research National Institute of Neurological Disorders and Stroke Last updated August 14, Tomorrow Aetna Confidential and Proprietary Information 7 Specialty Benefit 21

24 Focus on Hepatitis C Est. Prevalence 3,200,000 Most don t know Up to 3 in 4 people who are infected don't know they have Hepatitis C so they aren't getting the necessary medical care. 1 New Treatments Recent approvals as well as anticipated launches will change the way patients are treated. Lack of specialists No corresponding rise in the number of physicians with specialized training to care for these patients. 2 Drug Choice Precertification Quantity Limits Mandatory Generics Copay Differentials Genetic Testing Support Case Management Disease Management Drug focused disease management Behavioral Health 1. CDC.GOV 2. Gastronenterology & Endoscopy News, Oct. 2011, Revamping a specialty: Advanced/Transplant Hepatology. Disease Variations 6+ Drug Treatment Options 7 Drug Choice Collaborative partnerships to establish treatment pathways Support Development of tools to support non specialists in the care of Hepatitis C patients. Site of Care Preferred provider network that follows established treatment pathways Aetna Confidential and Proprietary Information Aetna Confidential and Proprietary Information 8 Sophisticated analytics TREATMENT PATTERNS Requires deep expertise across multiple datasets TREND ENGAGEMENT Integrated view allows for more comprehensive insights into treatment practice patterns and real world experience CLINICAL OUTCOMES Critical to continue focus on building solutions to meet the evolving Market needs Aetna Confidential and Proprietary Information 9 Specialty Benefit 22

25 Integrating the Benefit STEPS IN THE RIGHT DIRECTION Specialty Cost Management Specialty medications can make a big difference in the lives of those with complex conditions. They can also be expensive. Aetna uses precertification policies, system edits, care management support and provider contracting efforts to better manage the increasing spend associated with specialty drugs while ensuring a high quality member experience These are applied across Medical AND Pharmacy Aetna Confidential and Proprietary Information 46 Specialty Benefit 23

26 Provider Contracting Strategy Aetna s network provider reimbursement strategy mitigates potential up charging practices by providers. We have developed a blended reimbursement strategy for certain injectable and self injectable drugs that are administered as part of a physician office visit or in an outpatient setting and billed as a medical claim. The goal is to address the varying costs of drugs within a class of therapeutics that have similar or equivalent outcomes. Uses a most cost effective price for a therapeutic class to set the maximum dollar amount for reimbursement. Aetna Confidential and Proprietary Information 47 System Edit Solutions Precertification: Helps ensure that the covered services members receive take place in an appropriate setting, meet the medical necessity criteria of the health plan, and are paid appropriately. System Edits: Claim edits can identify inappropriate billing, overutilization, fraud and waste. *Aetna claims editing saves (on average) 3% to 8% a year. Aetna Confidential and Proprietary Information 48 Specialty Benefit 24

27 Aetna Medical Pharmacy System Edits Medical Necessity Checks All medical claims are processed through a diagnosis validation algorithm (Aetna Standard Table {AST} Edits). These edits compare the ICD 9 code submitted with the claim against the ICD 9 codes listed in the Clinical Policy Bulletin (CPB). Claims will deny for diagnosis ICD 9 codes considered Experimental & Investigational. Non Participating Provider Claim Review All J code claims over $600 by non participating providers are reviewed by a claims examiner Miscellaneous J code Pricing All claims that are submitted with a miscellaneous J code (i.e. J3490, J3590, J7599, J7799, J8999, and J9999) are required to have an NDC code submitted with the claim. These claims then go to the pharmacy claim system (APMCAS) for proper pricing based upon current AWP rates. Medically Incredible Dosing Dosing checks for J code claims based upon FDA labeled maximum dosing limits examples include Herceptin, Remicade, and Neulasta. Expanded the list to the top 100+ J codes (based on spend). J code Frequency Edits Aetna's medical claims system validate the dosing frequency and submitted charges of certain specialty or injectable medications administered in the physician s office. This frequency threshold is safety driven and is based upon dosing frequency in the product labeling, Food and Drug Administration dosing guidelines, and peer reviewed, published medical literature for each drug. Duplicate Claims Check Matches claims that come in for J codes from a providers office and compare s this to claims from Aetna Specialty Pharmacy to avoid having Specialty Pharmacy send the drug to the provider and then also have the provider bill Aetna medical for the drug. Aetna Confidential and Proprietary Information 49 What does the future look like? Collaboration can result in better outcomes Medications administered in a clinically appropriate setting at a rational price. Networks to support evidence based medicine treatment pathways. Wide array of benefit tools to ensure clinically appropriate therapy. Patient, Provider and Caregiver support system designed to be efficient and deliver best health outcomes. Meaningful trend reductions. Aetna Confidential and Proprietary Information 10 Specialty Benefit 25

28 Thank you Best Practices: Integrating the Medical and Pharmacy Specialty Benefit Marty Mattei, Pharm.D Vice President, Clinical Innovation and Strategy MedImpact HealthCare Systems, Inc. San Diego, California Specialty Benefit 26

29 Learning Objectives Describe two advantages and two barriers to specialty pharmacy integration within the medical and pharmacy benefits. Explain key differences between the reimbursement and the coding language for pharmacy benefits and medical benefits. Describe the utilization management techniques that are typically used to contain specialty pharmacy costs. Explain several key factors that must be considered when benefit packages are being created that cover specialty pharmacy medications. 53 What We ve Come to Realize This isn t There are no And it s definitely not Specialty Benefit 27

30 Specialty Management Continues to Evolve Comprehensiveness of Approach Negotiating Drug Discounts Managing Appropriate Utilization with Prior Authorization, Step Therapy Developing Formulary, Identifying Preferred Agents Managing Medical Care, Drug Therapy in an Integrated Manner Steering Dispensing Administration to Most Objective Channel, Treatment Site Evolution of Specialty Management The Impact of Growing Medical Pharmacy Spend Medical Pharmacy Annual Drug Spend Equals $120M per 1 Million Covered Lives Drugs Billed Under the Pharmacy Benefit Well established process Strong controls Advanced processing and data management Integrated Management Needs intelligent analytics and processes delivering Accuracy Precision Control Drugs Billed Under the Medical Benefit Manual process Minimal controls Inability to access or manage data Incomplete reporting Specialty Benefit 28

31 Pain Points in Integrated Benefit Management Lack of Data Integration/Technology Many payors are managing medical pharmacy using manual processes Critical information remains in separate disparate systems The result is increased administrative burden placed on payors to effectively manage pharmacy risk (anecdotal estimates at $1.00 $1.20 PMPM) Complicated Benefit Designs Traditional healthcare benefit designs do not adequately accommodate newer therapies Financial risk and management can reside under either medical or pharmacy departments leading to inconsistent management practices Pain Points in Integrated Benefit Management Inconsistent Billing/Coding Lack of uniform coding procedures across benefits can result in over or underpayment on specialty pharmaceuticals Payors committing increased amounts of time and resources to management and analysis of these therapies Clinical/Utilization Management Tools Variable clinical oversight for pharmaceuticals covered under the medical benefit Current solutions are, in many cases, manual and paper based Staff responsible for medical management generally is not sufficiently trained in drug utilization management Specialty Benefit 29

32 Partnering with our Clients to Deliver End to End Solutions Plan Design Provider Network Eligibility Formulary Holistic Analytics Notification ChoiceSpecialty Claims Processing Utilization Management Integrated Analytics MedPatterns provides a dynamic data platform and tools to profile populations for clinical interventions based on a holistic integrated data set Identify high risk members by disease state Support care and disease management activities Provide quality metrics for assessing therapy * Future phase enhancements 60 Specialty Benefit 30

33 Optimal End State for Integrated Management of Specialty Integrated claims analytics PA criteria/step Therapy/Utilization Management Patient centered programs Dispensing Channel & Site of Service Management Appropriate/effective pricing For therapies under Medical and Pharmacy For therapies under Medical and Pharmacy MS, Hemophilia, Oncology Via Specialty Provider Network Via Specialty Provider Network Closing Thoughts Payers, PBMs, and other vendors are all at various points along the continuum of integrated specialty management New, innovative solutions are being developed to transcend the limits of current benefit designs (site of care, analytics, patient centric care programs, etc.) There is no one best way to address the issues of integrated specialty management, but there are key program components that should be included in any integrated management offering Specialty Benefit 31

34 Learning Assessment Question #1 True or False. Alignment between utilization management and benefits is one advantage to integrating the medical and pharmacy benefit for specialty drugs. TEXT TO a b a. True b. False Learning Assessment Question #2 True or False. Automating utilization management is one way to overcome a barrier associated with integrating the medical and specialty benefit. a. True b. False TEXT TO a b Specialty Benefit 32

35 Learning Assessment Question #3 True or False. Pharmacy and medical benefits both use NCPDP as their claim format. a. True b. False TEXT TO a b Learning Assessment Question #4 True or False. Prior authorization, step therapy, and quantity limits are not typically used to contain specialty drug costs. a. True b. False TEXT TO a b Specialty Benefit 33

36 Learning Assessment Question #5 True or False. Provider contracts are one of many factors that must be considered when benefit packages are being created that will cover specialty medications. a. True b. False TEXT TO a b Thank You! Specialty Benefit 34