How Does CCNC s Model Align with Value Based Payments? Lead Community Pharmacy Coordinator CCNC V.P. Moose Pharmacy Joe Moose, PharmD

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1 Improving care through shared knowledge How Does CCNC s Model Align with Value Based Payments? Lead Community Pharmacy Coordinator CCNC V.P. Moose Pharmacy Joe Moose, PharmD

2 $100 Total Healthcare Spend $10 Pharmacy Spend Non-pharmacy Health Care Spend $90

3 ( our community pharmacy experience) Dilemma: How to Scale Team-Based Medication Optimization Efforts? >32,000 Individuals received CCNC Transitional Care Support in 2015

4 Breaking Out of the Bubble ( our Policy Experience trying to Sell Community Pharmacy ) Care Team-Based extremely important Care Team focus less important

5 The Opportunity: In Health Reform Terms

6 Opportunity Knocks CCNC Enrollees with total Enrollees on Enrollees on Enrollees on Medication CCNC Enrollees medical cost > $10,000 CCNC Priority list TC Priority list Management Priority list Total number of members 1,348, ,529 17, ,241 6,377 Total medical cost $ 4,078 $ 27,527 $ 23,813 $ 18,215 $ 25,345 # of Inpatient visits Inpatient costs $ 369 $ 3,464 $ 5,337 $ 2,924 $ 6,456 # of mental health inpatient vi ED visits ED cost $ 178 $ 745 $ 1,262 $ 816 $ 1,657 Outpatient visits Mental health outpatient visits PCP visits Pharmacy visits Pharmacy costs (Pre Rebate) $ 721 $ 5,177 $ 3,342 $ 4,298 $ 6,183

7 It s Not Just About Star Ratings The reality of what is coming... or what may already be here Single = ACE-I Prescribed and Taken Home Run = BP < 140/90 Grand Slam = Patient Hospitalization Avoided

8 Refocusing on what matters Documenting what you did to get paid. Sharing what you did to help others care for your patient. Sharing Patient Aspirations Sharing what you found to aid in care delivery. Sharing what you plan to do next with the patients so others are aware.

9 What Does CPESN NC look Like?

10 Community Pharmacy Enhanced Services Network Enhanced Pharmacy Services - Services that transcend conventional requirements of an outpatient pharmacy program contract that are focused on improving clinical and global patient outcomes Examples include, but are not limited to: In-home delivery with patient status review medication synchronization with clinical review, Adherence packaging with patient coaching; and Care management services.

11 CPESN Distribution

12 Types of Enhanced Services 24 Hour Emergency Services Adherence Packaging Collection of Vital Signs Compounding Comprehensive Medication Review Home Delivery Home Visits Long-Acting Injections Med Synchronization Program Multi-Lingual Capability Naloxone Dispensing Nutritional counseling Point of Care Testing Smoking Cessation Standardized Assessments (PHQ-9) Disease State Management Programs

13 The Collaboration Card Moose Midland Pharmacy (704) Moose Pharmacy Mount Pleasant (704) (704) Moose Professional Pharmacy (704) Akers Pharmacy (910) TAS Drug (910) Realo Discount Drugs (704) Keever Pharmacy (704) CareFirst Specialty Pharmacy (704) Dilworth Drug (704) Rx Clinic Pharmacy The Pharmacy Locator Application 24 Hour Emergency Service/On Call (Dispensing) X X 24 Hour Emergency Service/On Call (Non-Dispensing) X X X X X X X Adherence Packaging X X X X X X X X X X Clozapine Dispensing and Monitoring X X X X X X X X Collection of Vital Signs X X X X X X X X X Compounding (Non-Sterile) X X X X X X X X X Compounding (Sterile) Comprehensive Medication Review X X X X X X X X X X DME Billing (Medicare and Medicaid) X X X X X X X Home Delivery (Free) X X X X X X X X X X Home Delivery (Fee Applies) X Home Visits X X X X X X X X X In Depth Counseling/Couching X X X X X X X X X Long-Acting Injections X X X X Med Synchronization Program X X X X X X X X X X Multi-Lingual Capability X X X X X X Naloxone Dispensing X X X X X X Nutritional Counseling X X X X X X X

14 We Must Determine Impactable Risk To prove a ROI to the payer Determine which patients are impacting the metrics of the payer Determine pharmacy activities that optimize medical benefits Determine how to enhance referral patterns to those that can do something about the problems

15 ONC National Meeting, January 24, 2014

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17 Targeting Strategy CCNC Goals: 1) $30M in Savings 2) Increased Quality 3) Integration with Medical Home Care Management Structures Attributed Patients with Continuous Eligibility* Attributed Patients with DTP Declaration** Attributed Patients with CMR Received at CPESN Pharmacy*** (n = 27,252) (n = 2,973) (n = 409) Total Health Care Cost $6,717 (SD: $18,529) $20,678 (SD: $31,556) $25,649 (SD: $36,655) Preventable Health Care Cost $5,802 (SD: $15,341) $16,284 (SD: $21,570) $19,908 (SD: $24,383) Impactable Cost $258 (SD: $783) $804 (SD: $1,578) $1,172 (SD: $1,952) Number of ED visits 1.3 (SD: 2.7) 3.1 (SD: 5.4) 4.7 (SD: 6.6) Number of IP visits 0.2 (SD: 0.7) 0.9 (SD: 1.7) 1.0 (SD: 1.8) Global Risk Score 59.4 (SD: 13.8) 73.4 (SD: 10.8) 79.3 (SD: 8.0) * Patients are required to have continuous eligibility to Medicaid from 7/1/2014 to 6/30/2015 ** Patients had at least one DTP declaration in the 12 months period from 7/1/2014 to 6/30/2015 *** Patients had received Comprehensive Medication Review (CMR) in the past 120 days from 3/1/2015 to 6/30/3015

18 Targeting Strategy

19 The Opportunity: In Economic Terms to Medical Benefit

20 The Opportunity: In Economic Terms to Pharmacy Typical Referred Patient 10 Rx/Pt/Month Profit per Rx ~$10 How it Breaks Down ~ pts/day/referred to NC CPESN $1200/pt/yr X 200 pts = $240,000 in annual net profit per day

21 The Big Picture Increase, Develop and Sustain High Performing Networks of Pharmacies that provide enhanced services offerings Create Marketplace Presence of CPESN Networks Create Marketplace Dependency on CPESN Networks Facilitate local value propositions to other care team members to establish margin positive referral patterns Create care team dependency on clinical activities performed by community pharmacies to mitigate against risk narrow networking or reimbursement reductions on product distribution Establish Relationships and Reimbursement models with Medical Benefit side of payer infrastructure

22 The Value Proposition at the End of the Day What are patients, employers, taxpayers paying for? Some expenditures are investments, others are the result of lack of investment

23 What s driving this? It s all about pivoting toward payers & alternative primary care providers Desire to not be dependent on PBM s $1,000,000,000,000 CMS Quadruple AIM

24 ( our community pharmacy experience) Wake Up Call #1 I worry that [these pharmacies] we rely on for specialized services for our challenging patients are going to go out of business as their reimbursement continues to fall -Practicing Physician (and Medical Director)

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26 Contact Information Joe Moose, PharmD VP, Moose Pharmacy Lead Community Pharmacy Coordinator, Community Care of North Carolina Moose_Pharmacy