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Specialty Pharmacy -- Still An Issue Presenters: Jerry Buller, DPh. MMHC Vanderbilt University Medical Center
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
Key Pharmacy Financials
Institutional Profile
MSS* Facility
- Mail-Order
- Home Delivery
- Central-Fill
100 Oaks Pharmacy
MCE Pharmacy
Children’s Pharmacy
*Melrose Support Services
Retail Pharmacy
• 5 Pharmacies
• Patients and Employees
• Located in MOBs
Institutional Profile
TVC Pharmacy
• 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
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 categorieso E-Prescribing Datao Assumed 50% Capture Rateo VUMC Specialty “incidence” > national averageo Regional referral center
o
Beginning the Journey Advantages “In-House”
• Reduced Specialty Drug Spend
• Better employee experience
Vanderbilt Employee/Heath Plan
• Provides significant revenue and margin for the clinical enterprise.
• Better Clinical Care that pays for itself
VUMC Enterprise
Beginning the Journey Advantages “In-House”
• 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.
Vanderbilt Patients
Modest BeginningsFirst three years of operations took place in existing space in one of our retail pharmacies.
• Minimal Capital Expense
• Start Quickly
• Leverage Existing Payer Contracts
• Close Proximity to Referral Base
The Good
Modest BeginningsGrowth and uptake of the business quickly exerted pressure on existing infrastructure.
• Minimal Room for Growth
• Operations Suffered
• Bottlenecks• Dispensing Errors• Cold Chain Lapses
The Bad
Initial Service Model
Clinic
Payer PayerPayer
Specialty Pharmacy
Clinic Clinic Clinic
Clinic
VUMC Specialty
Pharmacy
provides
medication if
contracted.
Clinical Pharmacist
HUBCall Center
“If you want buy-in, this is a patient care issue. You need to put a pharmacist in every clinic”
-Titus Daniels, MD Vice Chair for Clinical Affairs, Department of Medicine
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
Executive Steering Committee
Meetings with Clinic Leadership
C-SuiteEliminate Roadblocks
Provide ResourcesDashboards
Clinic Administrators/ManagersMedical Directors
Partnership & Aligned GoalsDashboards
VUMC C-Suite created a Steering Committee in an effort to overcome challenges and roadblocks with implementation.
Governance and Oversight
Revenue & Key Milestones
Although we experienced growth, the flattening of that curve revealed that clinic buy-in is a MUST to achieve budgeted targets.
FY 14
Governance and Oversight
-$1
$1
$2
$3
$4
$5
$6
$7
$8
$9
$10
Rev
en
ue
in M
illio
ns
Budget
VUMC Engaged consultants to help with throughput
Steering Committee
Pharmacists in Clinic
URAC Accreditation
Initial PilotsInitial Staff Expansion
Clinic
Payer PayerPayer
Specialty Pharmacy
Clinic Clinic ClinicClinic
VUMC Specialty
Pharmacy
provides
medication if
contracted.
Clinical Pharmacist
Pharmacy Technician
Moved Techs into the clinic to create pharmacy team
Revised Service Model
Getting to the “Next Level”
Continued growth of the business demanded more infrastructure.
Program Director Specialty Pharmacy
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Ambulatory Pharmacy Director
Chief Pharmacy Officer
“You don’t have enough people here to run a gas station”
-Fletcher LancePrincipal, North Highland Consulting
Continued growth of the business demanded more infrastructure.
Program Director Specialty Pharmacy
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Pharmacy Tech
Ambulatory Pharmacy Director
Chief Pharmacy Officer
Director Specialty Pharmacy
Clinical ManagerProgram DirectorManager
Customer Svc Program Director
Admin Assistant
Pharmacy TechPharmacy TechPharmacy TechPharmacy TechPharmacy TechPharmacy TechPharmacy TechPharmacy TechPharmacy TechPharmacy TechPharmacy Tech
Clinical PharmacistClinical PharmacistClinical PharmacistClinical PharmacistClinical PharmacistClinical PharmacistClinical PharmacistClinical PharmacistClinical PharmacistClinical PharmacistClinical Pharmacist
URAC SOP/P&PQualityComplianceEducation
Market AccessManufacturersPayersOther Stakeholders
Chief Pharmacy Officer
Getting to the “Next Level”
Capable Infrastructure
Melrose Support Services
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
• 3,000 Rx/Shift
• Scalable to 10,000 Rx/Day
• Mail Order and Central Fill
Melrose Support Services
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
• 24 Full-Time Employees
• Staffed by Pharmacists & Technicians
• Financial Counselors
Capable Infrastructure
Vanderbilt Clinics
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 Clinical Pharmacist Specialist
• VSP Pharmacy Technician
• Clinical Assessment
• Face to Face Patient Engagement
• Part of Clinical Team
Capable Infrastructure
Interoperability and Clinical Outcomes
• Identifies Opportunity• Referral Management• Captures Time to Fill etc.• MPR and PDC• Clinical Management• Real-Time Data from EMR• Labs, Appointments• PharmD. encounter/visit sent
to EMR
Atlas Rx
VSP Received approval in 2015 to develop an all in one specialty pharmacy solution. Positioning VSP for outcomes-based future.
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
Diverse Portfolio
After implementing changes and hiring staff to support a $ multi-million business, VSP and the clinical care of our patients has reached new heights
Realizing Success
Specialty Pharmacy
Service Model
HUB VIP
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Melrose Support Services
Clinical Pharmacist Pharmacy TechnicianPatient EducationValue Proposition
Prior AuthorizationAppealsCopay Assistance
Opportunity Management
Patient IdentificationBenefits InvestigationSuccess Tracking
HEART of The BusinessProactive!
HUB & Call Center
Medication Assistance (MAP)Foundation Assistance
Delivery Scheduling & Coordination
Patient Experience
Today
Clinic
HUB VIP
Clinic
Opportunity Management
Opportunity Management
Clinic
Opportunity Management Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Clinic
Opportunity Management
Melrose Support Services
Vanderbilt Integrated Pharmacy VIPDispensing PackingCold Chain Shipment
Automated (HVS)High CapacityState of Art
Specialty Pharmacy
Service ModelToday
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
Margin $
Y1 Y2 Y3 Y4 Y5 Y6 Y7 Y8 Y9 Y10
Opportunity
VSP is positioning itself to participate in the value-
based market that will exist in the coming years. It is
doing this through investment in outcomes projects
and technology (Atlas Rx).
• Higher Reimbursement Rates• Access to SP Contracts• Data/Outcomes Agreements• Population Health
Payers
• Access to LDD Drugs• Data/Outcomes Agreements• Population Health
Manufacturers• PharmCo.• Industry Partners (Acentrus)• GPO
Other Ventures
For
Illu
stra
tive
Pu
rpo
ses
Outcomes
HCV- Intensive Management
• 717 Patients Referred
• 717 (100%) Patients Started Therapy
• Response Rates Comparable to Clinical Trials
Key Points
2% PAP vs 30% Natl. Avg.
• 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 treatment2. Conversely, within the ID clinic, 97% of patients prescribed treatment were initiated on treatment
More than one way to skin a cat.
Key Element Who performs the service? Pro Con
Patient Intake Dedicated Clinical Pharmacist and Technician Specialists (Clinic and HUB)
Accountability. Seamless process from start to finish
Costs
Medication Dispensing and Shipping
Dedicated SP team in mail order facility. Focus on specialty prevents errors Have two types of staff, specialty and non
Patient Management Clinical Pharmacist and Technician Specialists (Clinic and HUB)
Our own staff could document andcommunicate in EMR.
Costs
Payer Contracting Dedicated pharmacist manager focused on payer, manufacturer relations and data.
Keeps constant pressure on these stakeholders “Squeaky Wheel”
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.
Buy or BuildStructure Comparison
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
• 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.
The Vanderbilt Specialty Pharmacy has been a “win-win-win” for patients, Pharmacy and the clinical enterprise by enhancing patient care in a financially viable model.
Summary
Example of what can be accomplished when a variety of stakeholders collaborate and work toward a common goal in a supportive and entrepreneurial environment.
Final Thought
