Health System Priorities: Strategies for Pharma · 2016-05-02 · Health System Priorities:...

Health System Priorities:

Strategies for PharmaScott Hayworth, MD, President & CEO, CareMount Medical Group

John Strapp, Jr., Co-Founder & Chairman, The Kinetix Group

New York Pharma Forum

April 25th, 2016

Confidential. Do not distribute.

The Changing Healthcare Landscape

Priorities for Health Systems

Strategies for Pharma

Best Practice Case Studies

Appendix

1

234

5

2

Overview






Appendix

1

234

5

3

Key Drivers


Aging Population and High Costs are Key

Drivers for Reform

CATASTROPHIC CONDITIONSExtremely heavy healthcare userswith advanced/critical illness

MULTIPLE CHRONIC CONDITIONSHeavy users of healthcare system, mostly for more than one chronic disease

AT RISK FOR MULTIPLE CHRONIC CONDITIONS Fairly heavy users of healthcare system who are at risk of becoming more ill

STABLEGenerally healthy, with light use of healthcare services

HEALTHYGenerally healthy, often not using healthcare system

48.8%

27.4%

PATIENTS

12.4%

7.9%

3.5%

7.2%

17.7%

COST

19.0%

22.6%

33.5%

5


CATASTROPHIC CONDITIONSExtremely heavy healthcare userswith advanced/critical illness

MULTIPLE CHRONIC CONDITIONSHeavy users of healthcare system, mostly for more than one chronic disease

AT RISK FOR MULTIPLE CHRONIC CONDITIONS Fairly heavy users of healthcare system who are at risk of becoming more ill

STABLEGenerally healthy, with light use of healthcare services

HEALTHYGenerally healthy, often not using healthcare system

PATIENTS COST

6

Small Number of Patients Driving the

Disproportionate Healthcare Costs

As the Baby Boomers reach retirement age, healthcare costs have become unsustainable

48.8%

27.4%

7.2%

17.7%

23.8%PATIENTS

75.1%OF

OVERALL

COST

Current Landscape


Pioneer ACO

Model• Align payment model with value

• Implement: performance

measurement, internally

distributing shared savings

payments, and clinical leadership

• Invest in population health and

care management system, and

integrate with EHR

AAAHCIOM Report

Crossing the

Quality Chasm

Medicare

Modernization Act

Crossing the

Quality Chasm

First PCMH

Accreditation

Program

Patient Protection and

Affordable Care Act

Transition of Healthcare to Triple Aim

Medicare and Medicaid Reform

• Medicaid demonstration models

created around bundled payments,

global capitated payments, and ACOs

• Medicare payments to hospitals for

preventable readmissions reduced

Full CMS

Finalized

Domains and

Measures/Dimens

ions Implemented

• Efficiency

• Outcomes

• Clinical Process

• Patient

Experience

of Care

Health Market Place Exchange

• Coverage begins in state-based

insurance exchanges

• Established Independent Payment

Advisory Board on Medicare Spending

Timeline of Change: Policy Reform Reflects

Shift from Volume to Value and Risk Mitigation

Development of

Physicians to

Group Practices

CMS

Comparative

Effectiveness

Research (CER):

HITECH Act

Private Sector

Historical

Medicare

CCM Billing

Push for

Meaningful Use

Use of Fee for

Service (FFS) for

all reimbursements

Begin Using

Bundled Payment

CMS grant to PCORI

Greater financial

risk, more shared

savings rewards

New reimbursement

for chronic care

management providers

Moody’s Reacts

Recognition of emerging

trend towards value

Pilot bundled-

payment programPatient-Centered Outcomes

Research Institute (PCORI)

Established

CMS Center for

Innovation established

Next Generation

ACO Model

MACRA Legislation

Alternative Payment

Models (APMs) and

streamlined quality

measures to track

performance

2000 – 2008 2009 2010 2011 2012 2013 2014 2015 2016 – BEYOND

8


The New Value Models Include Financial Risk

and Are Expected to Become the Norm

Represents vast majority Medicare,

Medicaid & commercial payments in U.S. Paid to IDNs,

hospitals, IPAs, medical groups

ACOs, clinically integrated networks, contracts between

commercial payers & providers, MSSPs &

Pioneers

FINANCIAL RISK TO ACHIEVE VALUE:Payment models are changing as payers demand that providers, as well as consumers,

have some “skin in the game” – that they accept new reimbursement models

Unsustainable Ultimate goalCurrent focus

Small Risk Moderate Risk Large Risk

Fee-for-serviceP4P & PCMH

Bonuses

Shared Savings

Partial Risk

Capitation

Capitation + Quality

Bonuses Or Penalties

Volume based

Value based

Focus of new systems of care

9

Confidential. Do not distribute.10

30%

85%

50%

90%

Traditional FFS payments tied to quality or value

• ACOs

• Bundles

Medicare payments tied to quality or value

• Hospital value-based purchasing

• Hospital readmissions reduction programs

2016 2018

CMS Accelerates the Tipping Point for AllThe Movement towards Value Continues


ACO Participation is Growing Rapidly Similar increases are seen in public and commercial ACOs

744 ACOs23 Million Lives






Appendix

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12


REDUCE

PER CAPITA

COST OF

HEALTHCAR

E

IMPROVE

INDIVIDUAL

EXPERIENC

E

OF CARE

IMPROVE

HEALTH OF

POPULATION

S

The Triple Aim

Strategic Initiatives

What Keeps Customers Up at NightHow to Achieve The Triple Aim


The Triple Aim: A Value Care Delivery Approach

Better PatientOutcomes

Improve

population

health

Better PatientExperience

Improve patient

experience of care

(including quality

and satisfaction)

LowerCost

Reduce per capita cost of healthcare

14

Stakeholders Are Creating New Models Of Care That focus on achieving the Triple Aim


Healthcare Costs & Quality of Care

Many Care Delivery Challenges to Achieving

the Triple Aim

15

Poor PCP-Specialist

Communication

Practice/Provider Variation

Lack of Data Sharing

Capabilities

Poor Care

Coordination

Poor PatientEngagement

Challenges


The Physician in Today’s World

16

• Low physician satisfaction

• Physician incomes aren’t keeping up with the cost of living

• Work-life imbalance

• High physician burnout

• Physicians are not trained to practice value-based care

• Physician shortages

• Increasing need for data

• Consolidation of health systems and practices

• Mergers of systems and payers

• Transition from volume to value

Low Morale Lack of Training Marketplace Changes


Healthcare’s New Reality Is Driving the

Payment Model Shift From Volume to Value

• There has been a growing shift in healthcare towards service delivery models emphasizing cost containment, integrated care, and quality of care improvement

• Shift to value holds providers financially responsible for the value of the care they provide in both primary and specialty care

Value

Quality

Cost

17

Alternative payments will comprise 30% of 2016 CMS Reimbursement and 50% of 2018 Reimbursement


• Individual patient

• Fee-for-service

• No clear quality incentives

• Siloed care-team members

• Entire patient populations

• Risk-based payment

• Quality-based incentives

• Coordination of care among providers

Volume to Value Transition Focuses on

Improving Patient Population Outcomes

18

Volume Value



Addressing these areas will help health systems shift to value-based care

1 Population Health Management

2 Team-Based Care Coordination

3 Transitions of Care

4 Patient Engagement

5 The Use of Data and Health Information Technology (HIT)


Population Health Management

20

“If we don’t develop a thorough discharge plan, our patients will be right back in the hospital a

couple weeks later. And we don’t want that for the hospital readmissions penalties, but more imp

ortantly we don’t want that for the patients.”

– CMO at a East Coast Academic Medical Center

Important Considerations:

Care coordinators act

as liaisons between PCPs,

specialists, caregivers, and

community resources

Home monitoring and

follow-up is important to

ensure patients comply with treatment regimen

Ensure that patients

understand their treatment plan at

discharge to avoid

readmissionsand improve their health outcomes

Use of technology is increasingly important to

manage patient health

The emergence of bundled payments

encourage a population health

management approach to patient care


Coordination

Collaboration

Sta

nd

ard

iza

tio

n

Co

nti

nu

ity

Hospital Discharge Planning

Community Service

Patient Evalualtion

Diseases, Lifestyle, Diet

Medication Management

Post Discharge Clinic or PCP

Followup

Virtual Care Team

Pharmacy Case Management Social Work Home Health

Team-Based Care Coordination

“Care needs to be coordinated between the right providers of the right levels to make sure that

patients get the most effective care a the right cost.”

– CMO at a West Coast Large Integrated Health System

21

Examples of Team-Based Care:

Accountable Care Organizations

Patient-Centered Medical HomesCMS Practice

Transformation Networks

Hospital Care Team Community Care Team


Long-Term Care Coordination and Co-Management

Transitions of Care

22

Elements of successful care transitions:

• “Medical Neighborhood” of community assets to ensure effective patient management

• “Parallel Care” through engaging with the patient and specialist to promote a seamless handoff

• Active coordination, bi-directional flow of information, timely communication, and data transfer

between providers and care settings

Patient

Identification

Risk

Assessment

Specialist

Referral

Disease

Treatment


Considerations for patient engagement:

Patient Engagement

23

Use Motivational

Interviewing

techniques to foster

patient-centered

relationships

Enhance the

use of technology to

provide access to

patient health

information

Understand

socioeconomic

differences between

patients

Address

health literacy

issues among patients

“Patient engagement is the key to successful disease management. The secret sauce is having

tools and resources available that provide personalization at the individual patient level to help

providers and patients achieve their disease management goals.”

– Medical Director at an East Coast Academic Medical Center


The Use of Data and HIT

24

The importance of health information technology:

Actionable data to provide

information-powered clinical

decision-making

Activate patients in their own

care through access to health

information

Exchange of patient data

between providers

“Understanding the importance of technology means understanding that there will always be a

growing, aging population and a shortage of primary care physicians, and that many of these

mechanisms and deliveries have to be delivered from a technology solution.”

- Chief Clinical Officer at an East Coast Integrated Health System






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25


Change the Conversation Move from a Transactional to Business to Business Relationship

PHARMA

PROGRAMS

PHARMACY

DIRECTORS

Traditional Pharma Programs

QUALITY

IMPROVEMENT

TEAM

PHYSICIANS

UTILIZATION

MANAGEMENT TEAM

MEDICAL POLICY

GROUP

PATIENT

C-SUITE

DECISION MAKERS

26


Change the Conversation

TKG SOLUTIONS:

Population Health Management

Value Based Outcomes

Comparative Effectiveness

Health Economics

Care Delivery Models

Patient Satisfaction

QUALITY

IMPROVEMENT

TEAM

PHYSICIANS

UTILIZATION

MANAGEMENT TEAM

MEDICAL POLICY

GROUP

PATIENT

C-SUITE

DECISION MAKERS

PHARMACY

DIRECTORS

ACCOUNT EXECUTIVE

Become Part of the Conversation via Strategic and Tactical Solutions

27


Health System SurveyThe opportunity for pharma collaboration

28

Do you currently use any Pharma/Life Sciences industry

Resources?

Yes

No

40.74%

59.26%

If a Pharma/Life Sciences company had a completely

non-branded program in an area of need, would you consider

utilizing their resources?

Yes

No

96.30%

3.70%

Key Takeaway

Over 96% of health

systems surveyed

are willing to

collaborate with the

industry to address

care gaps and

improve the process

of care delivery.


What areas of your interests and needs should the Pharma/Life

Sciences industry explore that you would support/participate in?

Care TeamImplementation

Key Takeaway

Health systems

are interested in

unbranded

programs that

address these

identified areas

of need

Partnership Areas of InterestUnbranded programs for pharma to develop

29

PatientExperience

Patient Education

DiseaseManagement

Market Insights

62.96%

44.44%

66.67%

66.67%

40.74%


The Voice of Your Customer

Putting this together is hard, no pharma has figured it out yet-Former Chief Medical Officer at Large Payer

If (pharma) is going to go at risk and offer a support program with the product and

the system achieves a certain result, (pharma) will give some money back based on

the risk-based contract in place -Former Executive Medical Director for Large Health System

If we have a risk-based contract in place regarding outcomes, we will be willing to go

to the payer to ensure that the drug is on formulary and available for our use Director of

Pharmacy and Chronic Disease Management for Hospital-Owned Organization-Director of Pharmacy and Chronic Disease Management for Hospital-Owned Organization

Chronic Disease is a crowded space; there needs to be an understanding

(from Industry) of the process and address the gaps within that process.-CMO, Large IDN, East Coast


Opportunities for Collaboration with PharmaThree areas to address chronic conditions

31

Medication AdherenceDisease State Education Patient Engagement

• SoCs are open only to unbranded education

• SoCs need help with capturing and organizing information regarding medication adherence

• Targeting polypharmacy can also help with adherence

SoCs expressed interest in:

• Support for education/engagement through care teams and non-traditional community channels

• Disease-specific tools and training for motivational interviewing

• Tools and resources integrated with patient portals

… None of us want branded things. And we won’t trust branded things and won’t

hand patients branded things

What role could pharma play in the development of that HIE that would say these

prescriptions are getting filled… a lot of this is getting us organized. And the win-win there

is if we get patients to adhere…

I think there’s an opportunity out there to have good information on chronic diseases

out of portals, out of EMR, that pharma can help us with... You know, [patients] love their

doctor. They only see them twice a year. The rest of the time… what we do with them

can really change their behavior.






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Improving Relationships for Cross Functional

TeamsScalable Multi-System QI Initiative

Challenge

Opportunity

Program Development

• Need to integrate in compliant fashion Commercial and Medical Teams

• Limited opportunities for commercial publications

• Looking to sale to broad Health System audience

• Leverage TKG relationship with national 3rd party member organization

• Integrate existing, non branded resources

• Initiative kicked off with commercial and medical involvement in development of QI measures

• Sponsor included in each meeting, web-ex with participating systems over a 18 month period

• Participant results being published by 3rd party and distributed through medical field teams

#1

on the HIRC Report

18 Participating Systems

Representing 100k Patients

all 18 are using the collaborative as a

model for quality improvement programs

Increased revenue in

75% of targeted systems

25%

of targeted systems retained

revenue growth

Results

33


Improving Market AccessPayer Stakeholder Engagement Platform with Phase ll Risk Share

Agreement with upside at 70% of achievement

Challenge

Opportunity

Program Development

• New therapeutic area for pharma

• 3rd to market in crowded therapeutic area

• Clinical differentiation based on safety in patients with significant, known side effects

• Achieve corporate expectations of market leadership

• Define appropriate utilization / product placement

• Gain unrestricted formulary access

• A comprehensive market access strategy and pre-launch plan was developed to engaged the payer customers, and provide profitable access to the client’s product

of those covered by commercial and

Part D plans have access to portfolio

without a PA

Lowest branded copay

coverage in the US

for Part D

80%

Results

34


Increasing ROI via Key Account ManagementCommercial Effectiveness Platform

Challenge

Opportunity

Program Development

Results

• Competitor gaining market share

• Need for increased field team knowledge on enhancing customer relationships

• Existing strong Key Account Management team

• Unbranded Platform was developed focusing on co-management and transitions of care

• TKG/Client hired 15 KAMs to call on Target Accounts for pilot

• Program was introduced and implemented by KAMs, while pull-through was conducted by field sales

• The traditional field model was kept as an opportunity for baseline comparator, while a Reach and Frequency Model composed of branded messaging was implemented with the new platform

• Increased access at Target Accounts with KAMs

• Elevated access from Pharmacy level to Administrators/Key Decision Makers

• KAM accounts grew 12% compared to national sales

35

Thank you!

Scott Hayworth, MD: [email protected]

John Strapp, Jr.: [email protected]






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Health Systems and Payers are Increasingly

Becoming Interested in Pharma Having

Accountability for Outcomes

LEVEL OF INTEREST

Pharma interest is growing, especially in diagnostic and imaging centers

Risk-based contracting should only be used if needed to achieve differentiation in a competitive market

Health Systems prefer programs that involve shared savings upside potential, rather than penalties for poor performance

Benefit needs to outweigh the burden for both health systems and payer

POTENTIAL OPPORTUNITIES

Develop risk-based contracting platform or model to ensure that pharma has “skin in the game” for clinical outcomes that pharma claims the product achieves

Incorporate a protocol or standard of care to support alignment on product utilization and process to motivate adherence

Track and monitor metrics (ie. readmissions, side effects, medication adherence) to align on outcomes and risk-sharing


Performance Is Tracked Using Nationally

Recognized Quality Measures

Physician Hospital Health Plans

CMS Physician Quality

Reporting System (PQRS) System that encourages reporting of

quality of care to Medicare in order to

assess the quality of care provided to

patients and quantify how often particular

quality metrics are met

Joint Commission:

Accreditation, Health Care,

Certification (JCAHO) Evaluates and accredits health care

organizations, health plans and health

care networks in order to recognize an

organizations commitment to meeting

certain performance standards

NCQA Healthcare Effectiveness

Data and Information Set

(HEDIS) Quality measuring tool used to evaluate

performance across 5 domains of care;

effectiveness of care, access/availability

of care, experience of care, utilization and

relative resource use, and health plan

descriptive information

Hospital Consumer Assessment

of Healthcare Providers and

Systems (HCAHPS)Standardized, publicly reported survey

instrument and data collection

methodology for measuring patients'

perceptions of their hospital experience

CMS Five-Star Quality Rating

System (Medicare Star)Nursing home rating between 1 and 5

stars which measures performance based

on health inspections, staffing and quality

measures

National Committee for

Quality Assurance (NCQA)

Organizations must annually report on their performance to obtain the

NCQA seal which is a reliable indicator of high quality, well-managed

care and service


Our Business Structure

Agency for life sciences companies

with industry-experienced client

management and project support

AGENCY SERVICES

• Strategic development

• Content creation

• Tactical execution

• Creative services

• Account management solutions

• Over 100+ combined years of

experience

• Network of strategic advisors and

industry experts

Engagements with health systems and

payer stakeholders leveraging robust

clinical networks and care delivery

expertise

CARE DELIVERY CONSULTING

• Key market drivers

• Care processes

• Workflow mapping & optimization

• Metric tracking

• Value-based care redesign

Our goal is to know our customer’s customer better than our customer does.


The Alignment of the Two Sides of Our Business

Provides Clients with Relevant Insights for

Impactful Results

Clinical Quality

Improvement EducationWorkflow Design Care Team Tools Care Team Training

Marketplace Dynamics

Training Speaker Programs Partnerships

Disease Education

and Impact

CARE DELIVERY

AGENCY


Our Commercial Excellence Model:

Aligning with Today’s Customer


TKG has done this with multiple programs across various therapeutic areas

Results from Our Model

Payer, SoC, Physician, and Patient

Improve Managed Markets Access

Build and Implement an effective organized customer B2B model

Enhance Customer Relationships

Proven Results

Drive Revenue Growth

Innovation Fueled by Deep Market Knowledge2

1

3

+ +

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Health System Priorities: Strategies for Pharma · 2016-05-02 · Health System Priorities:...

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