Date post: | 31-Dec-2015 |
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Specialty Drugs Are Smart:
• Rituximab (Rituxin) by Roche can improve survivorship in lymphoma by 50%
• Smart drugs create fewer side effects
Specialty Drugs Are Costly:
• Average cost $65,000 per person per year
• Doctors using two or three biologicals at one time
• Problem: managing the rapidly escalating costs of specialty drugs
The Future Looks Expensive:
• 641 class D drugs licensed in Canada
• + 800 specialty drugs in the pipeline
• 35,000 patents in 2009 for specialty drugs
RCM’s Integrated Service:
• RCM manages the total specialty drug benefit from start to resolution
• for TPAs,
• benefits consultants
• insurers
• drug plans or employers
RCM’s “Lean On Me” Service:
• This service provides the client with a:– Mentor– Advisor– Medications Expert– Purchasing agent– Logistics manager – Confidante and– Friend
OUR NEIGHBOURHOOD:
Customer Rx
Clinical Planreview
RCM
Treatmentreview
Treating doctors Clinical researchers
Case conference
Top DOCS
Determine Txoptions
Evidence based report
Alternatives
Genetic marker testing
siRNA
Clinical trials
Prior authorization
Finalize Rx
Purchase
DistributorsSuppliers
Infusion centers
Cold chain
Competitive sourcing
Coordination of benefits
Coordination of care
Monitoring/Aftercare
Employer funding
PAP
Private funding
Public funding
Other sources
Gord’s Case Study:
• Gord is a 60 year old business person• Leukemia + Non-hodgkins lymphoma• Rituxin from Roche was advised• Not eligible for the provincial plan • Coverage with his private drug plan• Infusion issue in hospital• Outcome: 50% improvement
in survival
RCM’s Enhanced Customer Experience:
• Clarity in communications
• Decision support that is impactful
• Guidance that is relevant
• Effective advocacy
• Emotional support
• Engagement of patient + family
RCM Provides Decision Support
• Audit the clinical situation
• Review the treatment plan
• Source second opinions if required
• Invites outside experts to a virtual case conference
• Keeps patient fully informed
Pharmacogenomic Testing:
• RCM arranges tests for genetic variation
• Determine if drug will work and ensure that side effects will be minimized
• HER2 test with Trastuzumab (Herceptin)
• K-RAS test with Cituximab (Erbitux)
• EGFR test with Gefitinib (Iressa)
Option of Clinical Trials:
• RCM tracks clinical trials
• Understands the entry criteria
• Assesses the design • Blinded• Unblinded• Placebo group
• Completes the paper work
• Ready with Plan B, C, D if rejected
RCM’s Job One: Ensure Appropriate Utilization:
• RCM ensures that:• The right person • Gets the right medication• For the right indication• At the right dose • At the right time• Through right route• At the right price • For right length of time
Many Possible Funding Sources:
• RCM can seek public or private funding
• RCM uses patient assistance programs
• Access pharma company sponsorship
• Access employer funding on an exception basis
RCM Monitors Compliance + Adherence:
• RCM monitors if the drug is being used properly to achieve the best possible outcome for the cost incurred
RCM Delivers Lowest Cost Sourcing:
• RCM seeks the lowest cost product using competitive sourcing
• RCM understands “off label” indications
• Different products with same benefit sold at markedly different price points
Realize Cost Savings:
• Treatment of macular degeneration
• Use Lucentis $2000 per treatment
• Or use Avastin at $100 per treatment
• Savings for the drug plan of $1900 per treatment with RCM’s benefit management
Benefits Of Retaining RCM:
• 1. Lower costs for the employer + the plan• Improve the sustainability of the plan• Delivery of performance metrics
• 2. Seamless transitions
• 3. Continuity of care
• 4. Enhanced customer experience
• 5. Hopefully better outcomes
• 6. Enhanced employee loyalty