Specialty Pharmacy -- Still An Issue Presenters: Jerry Buller, DPh. MMHC Vanderbilt University Medical Center
FACULTY DISCLOSURE The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CE activity: - Jerry Buller - None
LEARNING OBJECTIVES: 1. Analyze how the decision to build or partner plays out in inpatient care vs. outpatient/ambulatory. 2. Outline the financial impact these strategies have. 3. Specify what influence major payers have on the decisions health systems make?
Institutional Profile
Institutional Profile VUMC Pharmacy Enterprise
Institutional Profile Key Pharmacy Financials
Institutional Profile Retail Pharmacy TVC Pharmacy 100 Oaks Pharmacy 5 Pharmacies Patients and Employees Located in MOBs MCE Pharmacy MSS* Facility - Mail-Order - Home Delivery - Central-Fill Children s Pharmacy *Melrose Support Services
Beginning the Journey Phase I o Began evaluating the possibility of establishing a Specialty Pharmacy program in the 2009 2010 timeframe. o More payers were shifting infused drugs to pharmacy benefit o Needed to be in position to accommodate changing landscape
Beginning the Journey Phase I o Proforma/Break-Even Analysis o Margin supported additional staff o Require members of VU Health plan use in house specialty Pharmacy
Beginning the Journey Phase II o Formal proposal was submitted to Senior Leadership and approved in 2011. o Establish a service to address the Specialty drug needs of Vanderbilt patients (not just employees). o Proforma developed for ALL specialty disease categories o E-Prescribing Data o Assumed 50% Capture Rate o VUMC Specialty incidence > national average o Regional referral center o
Beginning the Journey Advantages In-House Vanderbilt Employee/Heath Plan Reduced Specialty Drug Spend Better employee experience VUMC Enterprise Provides significant revenue and margin for the clinical enterprise. Better al Care that pays for itself
Beginning the Journey Advantages In-House Vanderbilt Patients Enhanced patient service and continuity of care. Patients would no longer have to go to outside pharmacies to acquire their specialty medications. Patients medication therapy would become part of the VUMC medical record. Positions VUMC to deliver / manage future medication therapies. Patient care, outcomes and costs are under VUMC control.
Modest Beginnings First three years of operations took place in existing space in one of our retail pharmacies. The Good Minimal Capital Expense Start Quickly Leverage Existing Payer Contracts Close Proximity to Referral Base
Modest Beginnings Growth and uptake of the business quickly exerted pressure on existing infrastructure. The Bad Minimal Room for Growth Operations Suffered Bottlenecks Dispensing Errors Cold Chain Lapses
Initial Service Model If you want buyin, this is a patient care issue. You need to put a pharmacist in every clinic al Pharmacist -Titus Daniels, MD Vice Chair for al Affairs, Department of Medicine HUB Call Center Payer Specialty Pharmacy Payer Payer VUMC Specialty Pharmacy provides medication if contracted.
Getting Started - Summary What is the Opportunity? What is the best model? High Touch Traditional SP C-Suite Buy In? Buy or Build? What is my Current Infrastructure? Consultant?
The Next Level
Governance and Oversight VUMC C-Suite created a Steering Committee in an effort to overcome challenges and roadblocks with implementation. Executive Steering Committee Meetings with Leadership C-Suite Eliminate Roadblocks Provide Resources Dashboards Administrators/Managers Medical Directors Partnership & Aligned Goals Dashboards
Revenue in Millions Governance and Oversight Although we experienced growth, the flattening of that curve revealed that clinic buy-in is a MUST to achieve budgeted targets. Revenue & Key Milestones $10 $9 $8 $7 $6 $5 $4 $3 Steering Committee Initial Pilots Initial Staff Expansion Budget Pharmacists in VUMC Engaged consultants to help with throughput $2 $1 -$1 URAC Accreditation FY 14
Revised Service Model al Pharmacist Pharmacy Technician Moved Techs into the clinic to create pharmacy team Specialty Pharmacy Payer Payer Payer VUMC Specialty Pharmacy provides medication if contracted.
Getting to the Next Level Continued growth of the business demanded more infrastructure. Chief Pharmacy Officer Ambulatory Pharmacy Director Program Director Specialty Pharmacy You don t have enough people here to run a gas station -Fletcher Lance Principal, North Highland Consulting
Getting to the Next Level Continued growth of the business demanded more infrastructure. Chief Pharmacy Officer Chief Pharmacy Officer Ambulatory Pharmacy Director Director Specialty Pharmacy Admin Assistant Program Director Specialty Pharmacy Program Director Manager Customer Svc Program Director al Manager URAC SOP/P&P Quality Compliance Education Market Access Manufacturers Payers Other Stakeholders al Pharmacist al Pharmacist al Pharmacist al Pharmacist al Pharmacist al Pharmacist al Pharmacist al Pharmacist al Pharmacist al Pharmacist al Pharmacist
Capable Infrastructure In an effort to support the growth of the Specialty Pharmacy and the unique clinic/patient centered model, investments in facilities and technology were made. Vanderbilt Integrated Pharmacy Mail Order and Central Fill 3,000 Rx/Shift Scalable to 10,000 Rx/Day Melrose Support Services
Capable Infrastructure In an effort to support the growth of the Specialty Pharmacy and the unique clinic/patient centered model, investments in facilities and technology were made. HUB/Call Center Staffed by Pharmacists & Technicians 24 Full-Time Employees Melrose Support Services Financial Counselors
Capable Infrastructure In an effort to support the growth of the Specialty Pharmacy and the unique clinic/patient centered model, investments in facilities and technology were made. VSP Embedded Team VSP al Pharmacist Specialist VSP Pharmacy Technician Part of al Team al Assessment Face to Face Patient Engagement Vanderbilt s
Interoperability and al Outcomes VSP Received approval in 2015 to develop an all in one specialty pharmacy solution. Positioning VSP for outcomesbased future. Atlas Rx Identifies Opportunity Referral Management Captures Time to Fill etc. MPR and PDC al Management Real-Time Data from EMR Labs, Appointments PharmD. encounter/visit sent to EMR
Diverse Portfolio VSP has clinical pharmacists supporting 20 specialty clinics. Oncology & Hematology Pulmonary IPF Cystic Fibrosis PAH Inflammatory Disease Rheumatoid Arthritis IBD Dermatology Cardiology Lipid Disorders Orthostatic Hypotension Hemophilia Hypercholesterolemia Infectious Disease Hepatitis-C HIV Endocrinology Multiple Sclerosis Movement Disorders Huntingtons Parkinsons Orthostatic
Realizing Success After implementing changes and hiring staff to support a $ multi-million business, VSP and the clinical care of our patients has reached new heights
Today Specialty Pharmacy Service Model Opportunity Management Opportunity Management Patient Identification Benefits HEART Investigation of The Success Business Tracking Proactive! Opportunity Management Opportunity Management al Pharmacist nician Opportunity Management Patient Education Prior Value Authorization Proposition Appeals Copay Assistance Melrose Support Services HUB VIP HUB & Call Center Opportunity Management Medication Delivery Assistance (MAP) Opportunity Scheduling Patient & Foundation Management Coordination Assistance Experience Opportunity Management Opportunity Management Opportunity Management Opportunity Management
Today Specialty Pharmacy Service Model Opportunity Management Opportunity Management Opportunity Management Vanderbilt Integrated Pharmacy VIP Dispensing Automated Melrose Support Services Packing (HVS) Cold High Chain Capacity Shipment State of Art HUB VIP Opportunity Management Opportunity Management Opportunity Management Opportunity Management Opportunity Management Opportunity Management Opportunity Management
Optimization- Summary Governance? C-Suite Open to Outside Help. Consultants Investment in Infrastructure? People Capital Space and Equipment Different Mind-Set Inpatient vs. Ambulatory
The Future
For Illustrative Purposes Outcomes VSP is positioning itself to participate in the valuebased market that will exist in the coming years. It is doing this through investment in outcomes projects and technology (Atlas Rx). Margin $ Opportunity Y1 Y2 Y3 Y4 Y5 Y6 Y7 Y8 Y9 Y10 Payers Higher Reimbursement Rates Access to SP Contracts Data/Outcomes Agreements Population Health Manufacturers Access to LDD Drugs Data/Outcomes Agreements Population Health Other Ventures PharmCo. Industry Partners (Acentrus) GPO
HCV- Intensive Management 2% PAP vs 30% Natl. Avg. Key Points 717 Patients Referred 717 (100%) Patients Started Therapy Response Rates Comparable to al Trials VSP Completion Rates Statistically Better PAP Required 2% vs National Average of 30%
Cascades of Care Recent real world reports of over 15,000 patients with HCV found that 37% of patients prescribed HCV treatment in 2016 did not actually initiate treatment 2. Conversely, within the ID clinic, 97% of patients prescribed treatment were initiated on treatment
More than one way to skin a cat.
Structure Comparison Buy or Build Patient Intake Key Element Who performs the service? Pro Con Medication Dispensing and Shipping Patient Management Payer Contracting Dedicated al Pharmacist and Technician Specialists ( and HUB) Accountability. Seamless process from start to finish Dedicated SP team in mail order facility. Focus on specialty prevents errors Have two types of staff, specialty and non al Pharmacist and Technician Specialists ( and HUB) Dedicated pharmacist manager focused on payer, manufacturer relations and data. Our own staff could document and communicate in EMR. Keeps constant pressure on these stakeholders Squeaky Wheel Costs Costs Costs of having high level person. Manufacturer Product Access (same person as above) Same as above. Same as above. Data Collection and Reporting (same person as above with assistance from data analyst) Same person keeps consistent understanding of contracts, requirements and capabilities Costs of having high level person. Accreditation Dedicated pharmacist manager who oversees QI, Compliance, SOP, P&P and accreditation Hosp. compliance infrastructure focused on Inpatient. Had to build from ground up for specialty. Costs of having high level person.
Summary The Vanderbilt Specialty Pharmacy has been a win-winwin for patients, Pharmacy and the clinical enterprise by enhancing patient care in a financially viable model. Transformed Pharmacy ops. & provided opportunity to establish a new practice model. Help clinic nurses to be able to serve at the top of their license. Financially successful allowing VUMC to continue to provide and serve its patients. Metric FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 Prescriptions 3,820 13,919 26,152 36,000 46,000 Revenue $18 million $68 million $161 million $200 million $260 million
Final Thought Example of what can be accomplished when a variety of stakeholders collaborate and work toward a common goal in a supportive and entrepreneurial environment.