Specialty Rx EFFECTIVE STRATEGIES TO MANAGE COSTS - Health Action Council
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Specialty Rx EFFECTIVE STRATEGIES TO MANAGE COSTS
WELCOME
KEVIN GREGORY
VP, Business Solutions
Health Action Council
AGENDA • Welcome • FEATURED PRESENTATION – Specialty Rx and Effective Strategies to Manage Costs • Resources
50%
SPECIALTY DRUGS WILL
ACCOUNT FOR HALF OF ALL
2021 DRUG SPEND
MY SPECIALTY DRUG COSTS ARE RISING! WHAT CAN I DO?
W HAT D O YOU THI NK?
Please share your thoughts in the chat box!
Have you adjusted or installed specific
specialty drug stop loss programs?
W HAT D O YOU THI NK?
Please share your thoughts in the chat box!
Are you using manufacturer copay
cards?
W HAT D O YOU THI NK?
Please share your thoughts in the chat box!
Have you adjusted the employee cost
share or plan design?
W HAT D O YOU THI NK?
Please share your thoughts in the chat box!
What else have you considered?
Specialty Rx and Effective Strategies to Manage Costs Tierra Ford, PharmD Senior Clinical Advisor, Specialty Client Solutions, CVS Health
Evaluating Specialty
Carve Out
Important considerations to help you determine
what’s best for your plan and members
©2019 CVS Health and/or one of its affiliates. Confidential and proprietary.Control costs when and where they
occur
Utilizers of Drive about half of
specialty pharmacy spend
medication 11%
cost of new
start to therapy
2.5% ~ 50%
89%
cost incurred after
first fill
The source for data in this presentation is CVS Health Enterprise Analytics unless otherwise noted.
Please see the disclaimer page at the end of this presentation for more information.Utilization management:
potential savings via higher denial rates using
Understanding the more restrictive criteria
Copay optimization: apply maximum value of
strategies of manufacturer copay cards to payor share of
“carve out” specialty claims
vendors Condition-specific:
manage and obtain funding for high-cost
conditions, such as fertility and hemophilia
Foundational fund support:
offset plan costs using charitable funds
intended for low-income patients
International sourcing:
potential savings by procuring drugs
Carve out approach: contracting with a third
party for any combination of services internationally
Integrated approach: working with one PBM or Full carve out of adjudication and/
specialty vendor for all specialty pharmacy
services, which is recommended for maximum
or dispensing in addition to any combination of
savings, better health outcomes strategies listed here
PBM (Pharmacy benefit manager).
The source for data in this presentation is CVS Health Enterprise Analytics unless otherwise noted.
Please see the disclaimer page at the end of this presentation for more information.
53354BThe risks of carving
out PERCEIVED
BENEFITS
→ Significant savings
→ Tighter control, more oversight of the PA process
may outweigh → Focus on getting the right drug to the right patient
No “incentive” to dispense
the perceived benefits →
→ Avoid “gross overpayment”
→ No “chasing rebates”
REALITIES AND Vendors provide inflated savings estimates
RISKS
Financial
Loss of rebate value and pricing discounts
Increase in administrative fees
Higher trend
Safety Clinical concerns procuring drugs from outside U.S.
Unknown clinical rigor of UM criteria
Delays in care
Member Siloed, fragmented care
experience, health Additional member and prescriber burden
outcomes Loss of care management programs, adherence support
and digital tools
Administrative Coordination with multiple vendors
burden Challenges with integrated accumulations
Loss of transparency and reporting
PA (Prior authorization). UM (Utilization management).
14 proprietary 53354BCVS Health’s integrated approach to specialty
benefit managementStart therapy
with certainty
Tighter control to prevent unnecessary utilization
2.3% YoY increase in overall denial rates* due to criteria and process
enhancements; 11.5% savings in managed classes
EHR connectivity validates treatment
More clinically accurate PA submission leads to
higher final denial rate**
Get the lowest net costs by therapeutic category
+$2.8B in savings in 2019 from formulary strategies***
Enhance savings with copay plan design
Save up to 21% gross savings;Eliminate waste
throughout
Prevent excess drug accumulation
Automated monitoring, timely interventions
~$1,200 savings per targeted specialty patient in first 10 weeks*
Minimize waste by preventing
inappropriate dose escalation
Indication and weight-based dosing applied at PA
Avoid costly, adverse events with embedded nurse
EHR connectivity and digital tools optimize engagement
$2.1K+ estimated savings PEMPY; 11% decrease in hospitalizations
PEMPY (per engaged member per year) *A specialty pharmacy service performed by
CVS Specialty for contracted payors. Targeted patients make upIntervene
when needed
Uncover the need to change or stop therapy
Adherence score calculated every day, for every patient
Clinical intervention* saved ~$2K per patient in 90 days**
Real time symptom tracking connects patients to
right level of care
92% of respondents completed the survey after which they all
received immediate clinical guidance*
Constantly innovating to uncover new
cost savings
Pilots investigating drug holidays and our ability to reduce the
use of biologics
*CVS Specialty dispensed patients **~2K savings per targeted patient. Savings projections are
based on CVS Caremark data. Actual results may vary depending on benefit plan design,
member demographics, programs implemented by the plan and other factors. Client-specific
modeling available upon request.
18 ©2021 CVS Health and/or one of its affiliates. Confidential and proprietary. 53695YBringing it all together EHR connectivity to
validate treatment with
more clinically accurate PA
Copay Card Optimization
with best-in-class member
experience
improving your members’ experience with
support every step of the way
2.4% higher final Up to 21% in gross
denial rates2* savings
Drive most appropriate, on specialty3 Convenient access to
low-cost therapy pick up or delivery
from the start
97%
11.5% savings on value choice
Mary’s diagnosis: average
in how they
in managed
rheumatoid arthritis receive their
classes1
medication4
She needs coordinated support to 65% lower 88%
help her start
readmission rate CVS Specialty medication
than possession
and stay on therapy Coordinated infusion national average8 CareTeam rate for RA5
Enhanced care
coordination
care with highly-trained
Coram nurses with EHR connectivity
84% of new >$2,100 savings
specialty patients per engaged
are optimally member per year6
adherent7
Secure messaging helps
with better condition Personalized care management
management
EHR (Electronic health records) *Compared with providers not enrolled.
52465Sample Client case study
Reducing specialty trend through strategic, innovative solutions
Trend Utilization is the main
driver of specialty trend
20.8% 14.3% 9.4% 5.0% 1.3% -6.7% -10.5% with a 13.7% increase
2019 Programs in place Program opportunities Client implementing Enhanced SGM
Unmanaged 2021
Specialty spend Specialty for 2021 to strengthen clinical criteria
PA savings Managing Program and address utilization increases
inappropriate adoption
quantities PrudentRx copay card strategies will
$6.5M Increased formulary
management help mitigate future specialty spend
$4.9M Enhanced increases & maximize Pharma funds
Core Specialty PA Copay card available in the market
Specialty Guideline Specialty $4.4M criteria program
Management (SGM) quantity
limits Medical Specialty Management
Advanced Control $3.7M opportunity employers are looking to
Medical specialty
$100M Specialty
Formulary
$8.0M strategy strengthen management on cross-
Enhanced
SGM benefit specialty medications
$3.8M
1,176 PrudentRx
members impacted Members Site of Care Drug
pay $0 Benefit
Alignment
4,176
members 590 members
eligible impacted
Source: CVS Health Analytics & Savings Analysis.
Illustrative example, potential overlap between savings components. Price Protection is also considered a rebate.
53524Delivering results now
and into the future
With every member
Start therapy with certainty
Eliminate waste throughout
Intervene when needed
53695UOUR RESOURCES EMPOWER EMPLOYEES 2021 WHITE PAPER Build greater healthcare literacy Find the Uncommon: Revealing inside your organization with this Disparities in Care and Prescribing customizable presentation. for Common Conditions HEALTHACTIONCOUNCIL.ORG/EMPOWER HEALTHACTIONCOUNCIL.ORG/UNCOMMON MANAGE HEALTHCARE COSTS MEDICATION MATTERS Insights to Effectively Managing Improve medication adherence to help Your Healthcare Spend insight for employees achieve better health and employers. lower costs. HEALTHACTIONCOUNCIL.ORG/MANAGE HEALTHACTIONCOUNCIL.ORG/MEDICATIONADHERENCE
E D U C AT I O N
• Monthly e-newsletter and
webinars
• Trend research
• Insight articles
• SHRM and HRCI provider
• CEUsHEALTH IMPROVEMENT • Leapfrog Hospital Safety Grade • Find the Right Care website and campaign • Step It Up Challenge • Healthy Kids campaign
GROUP
PURCHASING
• Save money
• Improve outcomes
• Retain control over benefit
programsENDORSED VENDORS
MEDICAL PHARMACY
For over a decade, we've Nineteen straight years with either negative
successfully teamed up to improve or single digit trend. Annual audit and market
population health. Our trend is check included.
more than 50% better than the
national average.
VISION FLU SHOTS
Simple and flexible because we Full-service onsite flu shot clinics
listen and offer open-sourced and convenient voucher programs
solutions designed with members to help ease the administrative
in mind. burden
HEALTHACTIONCOUNCIL.ORG/GROUPPURCHASINGCONTINUE THE CONVERSATION SIGN UP: MONTHLY E-NEWSLETTER EMAIL US: INFO@HEALTHACTIONCOUNCIL.ORG VISIT: HEALTHACTIONCOUNCIL.ORG
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