how specialty pharmacies can use data to drive revenue

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How Specialty Pharmacies can use Data to Drive Revenue


Prepared by Therigy LLC | CONFIDENTIAL | Copyright © 2015 2


Technology SuiteTherigy has built a proprietary suite of technology products for specialty pharmacies to deliverbest-in-class patient support.

Therigy’s experts provide hands-on consulting services to assist clients in planning and executing operational, clinical and technology initiatives.

Therigy’s data analytics solutions support the complex data capture and unique reporting requirement in the specialty space.


3Prepared by Therigy LLC | CONFIDENTIAL | Copyright © 2015

Agenda

• Growth of Specialty

• Revenue Opportunities

• Business Requirements

• Key Success Factors

• Looking Ahead

•Questions



Growth of Specialty



Growth of Specialty

Prescription Drug Spend



Growth of Specialty

2010 2014

$37,494,000,000

$47,769,000,000

$9,471,000,000

$28,721,000,000

Sales of Top 10 US Drugs: All vs. Specialty

All Drugs Specialty Drugs



Growth of Specialty

2010 2014

$1,795

$5,670

Revenue per Patient of Top 10 Drugs by Year



Growth of Specialty

Greater Revenue

Fewer Patients



Business Requirements




High cost specialty therapies

SPs need to provide high quality care

Need to demonstrate their performance to payers and manufacturers to succeed



Traditional Specialty Pharmacy ServicesSpecialty Pharmacy Services

Referral Intake Educational Materials Inventory of Specialty Products and Ancillary Supplies

Reimbursement Support Clinical Intervention Services Shipping and Ancillary Supplies at no charge

Benefit Monitoring Adherence/side effect management

Inclusion of Ancillary Supplies: Needles, Syringes, Alcohol Swabs, Sharps

Prior Authorization Assistance Safety Monitoring Temperature-controlled Shipping and packing supplies

Access to Information on Alternative Coverage Programs

Managing of Dose Changes Product and Administration Training

Initial Clinical Assessment Refill Reminder Phone Calls/Delivery Coordination

Delivery directly to the Home, Physician Office, or Other location

24-hour Availability with access to Pharmacist or Nurse

Coordination of Home Training or Infusions Time Sensitive delivery




Specialty Pharmacy Network Decision

Ability of specialty pharmacy provider to:

• Engage patients effectively

• Collect clinical and patient feedback to meet quality reporting requirements of new payment and care delivery models

• Help patients and providers understand the implications of specific medication

use throughout the care continuum

Ability of specialty pharmacy provider to:

• Reduce inappropriate utilization

• Ensure appropriate dose of medication

• Coordinate reimbursement and eligibility

• Improve compliance and persistency

Manufacturer Considerations Payer Considerations

Specialty Pharmacies must support the unique contractual requirements of pharmaceutical manufacturers to access Specialty Drugs and those of payers to secure reimbursement. Data is the key factor to both.




*EMD Serono Specialty Digest™, 11th Edition

Specialty Pharmacy Reporting Services



Business RequirementsAdvanced Renal Cell Carcinoma

(RCC)

Chronic Myelogenous

Leukemia (CML)

Chronic lymphocytic

leukemia (CLL)

Non-Small Cell Lung

Cancer (NSCLC)

Prostate Melanoma Multiple Myeloma

Exclusiv

e

Limited

Open

Limited to Exclusive

Open to LimitedOpen to LimitedOpen to LimitedOpen to Limited



Key Success Factors



Key Success Factors

• Specialty Pharmacy Operating Model and SOPs

•Data Collection and Reporting Capabilities



Key Success Factors

1 2Intake

1Rx Entry Benefits

VerificationClinical

Assessment

Create Order

Verify Rxs (PV1)

Adjudicate Claim Pick Order

Verify Order (PV2) Pack Order Ship Order

2 3 4

5 6 7 8

9 10 11

Referral Process

Order Process

Specialty Pharmacy – New Prescription Process Flow



Monitoring and reporting of key operational and clinical metrics

1 2Intake

1Rx Entry Benefits


Assessment

Create Order

Verify Rxs (PV1)



2 3 4

5 6 7 8

9 10 11

Referral Process

Order Process

Time to therapy / Referral status




1 2Intake

1Rx Entry Benefits


Assessment

Create Order

Verify Rxs (PV1)



2 3 4

5 6 7 8

9 10 11

Referral Process

Order Process

Prior authorization status / Benefits verification




1 2Intake

1Rx Entry Benefits


Assessment

Create Order

Verify Rxs (PV1)



2 3 4

5 6 7 8

9 10 11

Referral Process

Order Process

Adherence / Medication Possession Ratio




1 2Intake

1Rx Entry Benefits


Assessment

Create Order

Verify Rxs (PV1)



2 3 4

5 6 7 8

9 10 11

Referral Process

Order Process

Therapy performance standards




1 2Intake

1Rx Entry Benefits


Assessment

Create Order

Verify Rxs (PV1)



2 3 4

5 6 7 8

9 10 11

Referral Process

Order Process

Dispensing accuracy / Daily shipments




1 2Intake

1Rx Entry Benefits


Assessment

Create Order

Verify Rxs (PV1)



2 3 4

5 6 7 8

9 10 11

Referral Process

Order Process

Rxs requiring intervention / Non-dispensing errors



Key Success Factors

•Monitoring and reporting of customer service / call center performance:–Customer service Speed of Answer–Total blocked and abandoned calls –Member prescription order resolution–Member complaint resolution



Monitoring and reporting of customer service / call center performance

Inbound call volume vs.

abandonment rate



Looking Ahead



Future Opportunities

• According to CMS, an ACO (Accountable Care Organization) is:

“an organization of health care providers that agrees to be accountable for the quality , cost and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service

program who are assigned to it.”




• The Centers for Medicare and Medicaid Services (CMS) have implemented the Five Star Quality Rating System to help educate consumers on quality of health care and make quality data more transparent.

• The program rates health plans on multiple measures related to medication management in the following areas:–High-risk medications–Diabetes treatment–Medication adherence for diabetes–Adherence for hypertension–Adherence for cholesterol




• High star ratings qualify health plans for federal bonus payments and allow them to market their plans all year long.

• Higher star ratings translate into higher premiums. Health plans can get quite a bit of money for having higher star ratings; pharmacy benefits are an integral part of that formula.

• To increase their own rating, health plans can adjust their preferred networks to include only better pharmacies that help contribute to their higher rating.


30

Dispense Accuracy / Payer Contract Penalties

Prepared by Therigy LLC | CONFIDENTIAL | Copyright © 2015

Appendix A



Appendix A

• Dispensing Accuracy Rate means (i) the number of all specialty prescriptions dispensed by Pharmacy in each month with an incorrect drug, strength, form, and directions for use, or a shipping-related error causing medication to be delivered incorrectly, divided by (ii) the number of all specialty prescriptions dispensed by Pharmacy in such month.

• Guarantee: 99.98% or greater specialty prescriptions filled with no dispensing errors in each month (Payer book of business only measurement).

• Penalty: $20,000 for each full 0.01% shortfall in accuracy/per month with maximum per year penalty of $150,000.



Appendix A

71%

3%

3%

9%

9%

6%

Medication Errors – 2014Q4

Wrong Quantity (n=25)Wrong Medication (n=1)Wrong Sig (n=1)Wrong Patient (n=3)Wrong Form (n=3)Wrong Strength (n=2)

Total Errors = 35



Appendix A

K1

J0

I9

H8

G7

F6

E5

D4

C3

B2

A1

99.60% 99.65% 99.70% 99.75% 99.80% 99.85% 99.90% 99.95% 100.00%

99.76%

99.93%

100.00%

100.00%

99.94%

100.00%

99.92%

99.88%

100.00%

100.00%

99.93%

99.88%

100.00%

99.98%

99.98%

99.94%

99.94%

99.99%

100.00%

99.96%

99.93%

99.98%

99.97%

99.98%

99.97%

99.96%

99.91%

99.99%

99.95%

100.00%

99.97%

100.00%

99.94%

2014Q42014Q32014Q2

99.98%


34

Pharmaceutical Manufacturer Reports


Appendix B



Appendix BRequired (Y/N) # Data Class Column Name NCPDP Name/# Data Type Length Column Description

Y SDI required field Record Code Identifier Text 4

Record indicator for Patient information.

Must contain the value PAT

Used by SDI Encryption process.

Y SDI required field Patient Last Name

Patient Last Name (311-CB) Alphanumeric 80 Used by SDI Encryption process.

Y SDI required field Patient First Name

Patient First Name (311-CA) Alphanumeric 80 Used by SDI Encryption process.

Y SDI required field Patient Address Patient Street Address (322-CM) Alphanumeric 80

Street Address (No city, state)


Y SDI required field Patient Zip Code

Patient Zip/Postal Code (325-CP) Numeric 5

5 digit ZIP

Used by SDI Encryption process

Y SDI required field Date of Birth

Date of Birth (304-C4) Numeric 8

Patient Date of Birth

Must be in YYYYMMDD format


Y SDI required field Gender

Patient Gender Code (305-C5) Numeric 1

Code identifying gender

1 for Male,

2 for Female,

0 for Unknown or Not Specified.


Y SDI required field Filler Alphanumeric 1

For future use and

Leave Blank


Y 1 Record ID N/A Numeric 10 Unique ID for each record. This record ID should be persistent across all VENDOR data feeds.

Y 2 Record ID Record Action Type Code N/A Text 20

Possible values:

INSERT= this record is a new record

UPDATE= this record is a restatement of a previously sent record with the same Record ID

DELETE= all previously sent records with the same Record ID as this record should be deleted



Appendix BRequired (Y/N) # Data Class Column Name NCPDP Name/# Data Type Length Column Description

Y 82 Patient Patient status N/A Text 20 PENDING – A referral has been received but product has not yet been shipped to the patient.

DENIED – A referral has been received but the SPP will not provide service. The patient did not receive any shipment.

DISCONTINUED – The patient has received at least one shipment from the SPP but will no longer be serviced by the SPP.

SHIPPED – The patient has received shipment from the SPP and is actively receiving product.

Y 83 Patient Patient status reason code N/A Alphanumeric 20 Detailed patient status reason codes

PENDING Reasons:

P01: New referral

P02: Pending benefits investigation

P03: Pending prior authorization

P04: Order cleared, ready to ship

P05: Pending patient decision

P06: Pending physician decision

P07: Unable to contact patient

P08: Other

P09: Pending clinical reason

P10: Pending for inventory

P11: Pending re-authorization

P12: Delay in treatment initiation

DENIED Reasons:

DN01: Patient’s choice, product not covered by insurance planDN02: Patient’s choice, co-pay too high

DN03: Patient’s choice, other


37

URAC Accreditation Measures


Appendix C



Appendix C

how specialty pharmacies can use data to drive revenue

Health & Medicine