THE 2015 GENENTECH ONCOLOGY TREND REPORT

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THE 2015 GENENTECH ONCOLOGY TREND REPORT Perspectives From Managed Care, Specialty Pharmacies, Oncologists, Practice Managers, and Employers 2015 Genentech, South San Francisco, CA February 2015

1 THE 2015 GENENTECH ONCOLOGY TREND REPORT Perspectives From Managed Care, Specialty Pharmacies, Oncologists, Practice Managers, and Employers 2015 Genentech, South San Francisco, CA February 2015 MCM/031015/0062 Mission Statement The mission of The 2015 Genentech Oncology Trend Report: Perspectives From Managed Care, Specialty Pharmacies, Oncologists, Practice Managers, and Employers is to provide timely and useful information on the latest cancer care trends and developments. Updated annually, the publication is designed to serve as a unique resource for those seeking an understanding of the issues surrounding cancer management and practice. The content of this report was prepared by Emron with the guidance of an editorial board and is based on primary research of key stakeholders, as well as published literature. Statements and opinions contained in this report do not necessarily reflect those of Genentech or the editorial board. 2 1

2 Background Genentech contracted with Emron, a health care research and communications firm, to do the following Assemble an editorial board of oncology leaders to provide guidance Develop five surveys targeting Managed care organizations (MCOs) Specialty pharmacies (SPs) Oncologists Oncology practice managers (OPMs) Self-insured employers Recruit participants and field Web-based surveys Collect and analyze the data and publish an annual report from the results 3 Sample Size and Demographics Survey Group N Region Other Details MCOs 105 SPs 30 Oncologists 200 OPMs 198 Employers 201 National: 19% Regional/state: 81% National: 90% Regional:10% NE: 26% W: 24.5% MW: 25% S: 24.5% NE: 25.8% W: 21.7% MW: 22.2% S: 30.3% National: 27.4% Regional: 72.6% a Average no. of members Medical benefit: 2.3 million Pharmacy benefit: 1.6 million Ownership 13 PBMs; 8 Independents; 9 Other Community practice: 48.5% Academic/medical center-based: 29.5% Hospital-based: 22.0% Community practice: 50% Hospital: 28.8% Academic/medical center: 21.2% No. of employees Status : 33.3% Full time: 69.5% : 37.3% Part time: 30.5% >5000: 29.4% ªState-level organizations are considered part of the applicable region. 4 2

Presentation Organized by Key Themes Guidelines & Pathways Cancer Drug Management Oncology Practice Drug Spending & Revenue Cancer Drug Coverage & Access Oncology Practice Consolidation, Workload &

3 Presentation Organized by Key Themes Guidelines & Pathways Cancer Drug Management Oncology Practice Drug Spending & Revenue Cancer Drug Coverage & Access Oncology Practice Consolidation, Workload & Staffing Palliative Care & Advance Care Planning Cancer Survivorship Care Pharmacogenomics Population Health Management Health Information Technology & Mobile Health 5 Guidelines & Pathways Balancing Standardization With Personalization a Treatment standardization refers to guidelines and pathways; personalization refers to molecular and biomarker testing. MCOs section, Illustration, page

Guidelines & Pathways Use by MCOs Percentage of MCOs

2013 and 2014 Types of cancers treated using

National Comprehensive Cancer Network; ASCO = American

4 Guidelines & Pathways Use by MCOs Percentage of MCOs following cancer treatment guidelines or pathways, 2013 and 2014 Types of cancers treated using guidelines and pathways Cancer Treatment Adapted from the MCOs section, Figure 6, page Guidelines & Pathways Use by Oncologists NCCN = National Comprehensive Cancer Network; ASCO = American Society of Clinical Oncology. Adapted from the Oncologists section, Figure 10, page

Guidelines & Pathways Commercial Payer Incentives for Oncologists Use Incentives received from payers to encourage guideline and/or pathway useª Faster processing of prior authorizations

5 Guidelines & Pathways Commercial Payer Incentives for Oncologists Use Incentives received from payers to encourage guideline and/or pathway useª Faster processing of prior authorizations (PAs)/precertifications Expedited reimbursement processing Reduced PA/precertification requirements Improved drug reimbursement Individual or group physician bonus payments ªBased on 30 oncologists reporting incentives. Adapted from the Oncologists section, Figure 10, page Cancer Drug Management MCOs Integrated Payer/Provider Initiatives PCMHs = patient-centered medical homes; ACP = advance care planning. Adapted from the MCOs section, Figure 9, page

Adapted from the MCOs section, Figure 9, page 18.

6 Cancer Drug Management MCOs Adopt Patient-Centered Medical Homes Organization of PCMHs adopted by MCOs Percentage of MCOs (n=31) PCMHs = patient-centered medical homes. Adapted from the MCOs section, Figure 9, page Cancer Drug Management MCOs Apply New Provider Payment Models Payment models implemented or piloted with network oncologists Adapted from the MCOs section, Figure 10, page

Brown bagging is defined as obtaining drugs through the patient who receives the drug(s) from an SP and transports them to the office.

7 Oncology Practice Drug Spending & Revenue Drug Buy and Bill Among Practices Drug sources for in-practice administration ªWhite bagging is defined as obtaining patient-specific drugs directly from the specialty pharmacy (SP) for in-practice use. Brown bagging is defined as obtaining drugs through the patient who receives the drug(s) from an SP and transports them to the office. Adapted from the OPMs section, Figure 4, page Oncology Practice Drug Spending & Revenue OPMs Forecast Drug Expenses in 2014 vs 2013 Adapted from the OPMs section, Figure 4, page

15 Cancer Drug Coverage & Access Escalation in Patient Out-of-Pocket Costs Was identified among the top 3 most pressing

8 Oncology Practice Drug Spending & Revenue Oncology Practice Parenteral Drug Margin Change over the last 12 months Initiatives to mitigate decline GPO = group purchasing organization. Adapted from the OPMs section, Figure 11, page Cancer Drug Coverage & Access Escalation in Patient Out-of-Pocket Costs Was identified among the top 3 most pressing challenges facing cancer care today by 73.3% of SPs 64.1% of OPMs 51.5% of oncologists 40.8% of employers Adapted from illustrations on pp. 39, 52, 72, and

Cancer Drug Coverage & Access OPMs See Changes in Patients Health Insurance

service; HIX = state and/or federal health insurance exchange.

17 Cancer Drug Coverage & Access MCOs Forecasts for Drug Cost Sharing in

9 Cancer Drug Coverage & Access OPMs See Changes in Patients Health Insurance Change in select patient populations over the last 12 months FFS = fee for service; HIX = state and/or federal health insurance exchange. Adapted from the OPMs section, Figure 1, page Cancer Drug Coverage & Access MCOs Forecasts for Drug Cost Sharing in 2015 MCOs forecasting increased oncology drug cost sharing for 2015 Adapted from the MCOs section, Figure 14, page

Cancer Drug Coverage & Access Practice Collection of Patient OOPs Reported

common policies regarding OOP collection Patient support through financial

Adapted from the OPMs section, Figure 14, page 72.

Strategies Reported by Oncologists Economic and clinical impact of drug

10 Cancer Drug Coverage & Access Practice Collection of Patient OOPs Reported by OPMs Success in collecting patient OOP drug cost share, 2010 to 2014 Most common policies regarding OOP collection Patient support through financial assistance EOB = Explanation of Benefits. Adapted from the OPMs section, Figure 14, page Cancer Drug Coverage & Access Drug Shortages: Consequences and Coping Strategies Reported by Oncologists Economic and clinical impact of drug shortages over the last 12 months Practice strategies to cope with drug shortages Adapted from the Oncologists section, Figure 12, page

Cancer Drug Coverage & Access Drug Distribution Channels Reported by MCOs

Practice Reorganizational Strategies Current and/or Under Consideration

11 Cancer Drug Coverage & Access Drug Distribution Channels Reported by MCOs Distribution channels for oncology drugs Adapted from the MCOs section, Figure 15, page Oncology Practice Consolidation, Workload & Staffing OPMs Report on Practice Reorganizational Strategies Current and/or Under Consideration Major drivers of reorganization ªRelationship established by a physicians services agreement. OPMs section, Figure 5, page

12 Oncology Practice Consolidation, Workload & Staffing How MCOs Ensure Use of the Most Cost-Effective Site of Service Utilization Management Create site-specific rules for certain conditions and services Institute PA/precertification to ensure selection of the lowest-cost site Develop a drug list appropriate for home care or self-administration Move infusion services to 340Bqualified hospital infusion centers Promote the community hospital setting over the academic setting, where appropriate Oncologist Reimbursement Set reimbursement for physicianadministered drugs at the specialty pharmacy rate Increase reimbursement for in-practice drug administration vs hospital administration Provide recommendations to oncologists for the most cost-effective sites and infusion suites Enter into risk-sharing arrangements with providers PA=prior authorization. Adapted from the MCOs section, Illustration, page Oncology Practice Consolidation, Workload & Staffing How MCOs Ensure Use of the Most Cost-Effective Site of Service (cont.) Member Awareness Encourage members to choose the most cost-effective options through cost-share differences and education Direct case-management referrals to cost-effective settings Encourage members to discuss site-ofcare cost differences with their oncologist Contracting Contract with appropriate sites and implement narrow or preferred networks Direct care away from the outpatient hospital setting Set up outpatient infusion clinics Adapted from the MCOs section, Illustration, page

Oncology Practice Consolidation, Workload & Staffing Communication Demands and EHRs Fuel Oncologists Workload EHRs = electronic health records. Adapted from the Oncologists section, Figure 2, page 42.

of APPs, nurses, pharmacists, medical assistants, and care coordinators Hiring/adding medical scribes Cross-training staff Hiring more staff Adjusting practice hours; scheduling more time for patient

13 Oncology Practice Consolidation, Workload & Staffing Communication Demands and EHRs Fuel Oncologists Workload EHRs = electronic health records. Adapted from the Oncologists section, Figure 2, page Oncology Practice Consolidation, Workload & Staffing How OPMs Are Improving Practice Efficiency Initiatives to Improve Practice Efficiency and the Oncologist-Patient Interaction Expanding the role of APPs, nurses, pharmacists, medical assistants, and care coordinators Hiring/adding medical scribes Cross-training staff Hiring more staff Adjusting practice hours; scheduling more time for patient visits Implementing EHRs, voice recognition software, automated check-in, and patient portals APPs = advanced practice providers; EHRs = electronic health records. OPMs section, Illustration, page

27 Palliative Care & Advance Care Planning Top MCO Initiatives Regarding

14 Palliative Care & Advance Care Planning Oncologists Described the Timing of Palliative Care Discussions Oncologists section, Illustration, page Palliative Care & Advance Care Planning Top MCO Initiatives Regarding Palliative Care and ACP ACP = advance care planning. MCOs section, Table 3, page

29 Cancer Survivorship Care Resources Used to Create Survivorship Care Plans (SCPs) ASCO =

15 Cancer Survivorship Care Survivorship Care Plans (SCPs) Provided by Oncologists Provision of written/printed SCP (N=200) Oncologists section, Figure 6, page Cancer Survivorship Care Resources Used to Create Survivorship Care Plans (SCPs) ASCO = American Society of Clinical Oncologists; NCCN = National Comprehensive Cancer Network. Oncologists section, Figure 6, page

Pharmacogenomics How MCOs Manage Molecular/Biomarker Testing New molecular/biomarker tests sometimes (45.7%) or always (9.

8% of MCOs are considering their review protocols for a new molecular/biomarker test 34.

7% of MCOs require a prior authorization for biomarker testing, 21.9% restrict drug coverage to favorable results, and 21.

16 Pharmacogenomics How MCOs Manage Molecular/Biomarker Testing New molecular/biomarker tests sometimes (45.7%) or always (9.5%) trigger a Pharmacy & Therapeutics committee and/or coverage review of cancer agents by MCOs 23.8% of MCOs are considering their review protocols for a new molecular/biomarker test 34.3% are in the early stages of strategy development to manage testing platforms and laboratories 26.7% of MCOs require a prior authorization for biomarker testing, 21.9% restrict drug coverage to favorable results, and 21.0% restrict testing coverage based on evidence 31 Pharmacogenomics Oncologists Provide Precision Medicine Increase in referrals over the last 12 months Whole-genome Sequencing (WGS) Initiatives to identify appropriate use and preferred vendors Impact of precision medicine on costeffectiveness of treatment decisions Oncologists section, Figure 9, page

Population Health Management Employers Offer Cancer Programs Nearly four in 10 employers offer population health management programs 72.2% (n=57) offered a cancer program in 2014 8.

17 Population Health Management Employers Offer Cancer Programs Nearly four in 10 employers offer population health management programs 72.2% (n=57) offered a cancer program in % (n=7) plan to offer a cancer program in 2015 Only one-fifth of the cancer programs include health care consumerism, quality, and cost transparency tools Interest in encouraging cancer program participation 78.9% are more inclined to offer financial rewards than a year ago 49.1% are more inclined to offer financial penalties than a year ago 33 Population Health Management Health Risk or Well-Being Assessments Health risk or well-being assessments are part of employers health benefits strategy Offer incentives to encourage voluntary assessment completion (n = 116) Employers section, Figure 9, page

Population Health Management Differential Insurance Premiums for Employees Who Smoke Incentives for smoking cessationᵃ Employment decisions made

Adapted from the Employers section, Figure 12, page 88. 35 Health Information Technology & Mobile Health EHR Features and Capabilities 75.

18 Population Health Management Differential Insurance Premiums for Employees Who Smoke Incentives for smoking cessationᵃ Employment decisions made based on smoking statusᵇ a Value of incentive applied to cost of individual health coverage. ᵇIn states where legal to do so. Adapted from the Employers section, Figure 12, page Health Information Technology & Mobile Health EHR Features and Capabilities 75.8% OPMs (n=150) reported EHRs in 2014; 27 OPMs (13.6%) expect to implement them in EHRs = electronic health records. Adapted from the OPMs section, Table 4, page

Health Information Technology & Mobile Health Mobile health (mhealth) mhealth continues to grow among stakeholders About half of the MCOs offer mhealth apps; few (5.

19 Health Information Technology & Mobile Health Mobile health (mhealth) mhealth continues to grow among stakeholders About half of the MCOs offer mhealth apps; few (5.7%) are cancer-specific Include retail pharmacy locators, refill and appointment reminders, physician finders/directory Many SPs offer (46.7%) or plan to offer in 2015 (33.3%) Apps include refill and adherence reminders, proactive messages on order status, simple assessments and education, patient and oncology specialist interaction regarding oncology therapy questions 37.0% of oncologists use mobile devices to access EHRs; 59.0% have secure with staff and patients; 25.0% had secure texting in 2014/planned for in Health Information Technology & Mobile Health Alternative Patient Visits Using Technology Telehealth and e-communication are emerging areas to watch Few MCOs currently pay oncologists for telehealth (9.5%) and e-communication (11.4%). Nearly one-third of MCOs are considering payment strategies for alternative visits in 2015 Three SPs provided video consults in 2014, one SP will offer them in 2015, and nine SPs are developing a telemedicine strategy 38 oncologists across all practice settings provided telehealth in 2014/plan for % of OPMs reported use of telehealth in 2014 and 9.1% plan to provide it in

20 THE 2015 GENENTECH ONCOLOGY TREND REPORT Perspectives From Managed Care, Specialty Pharmacies, Oncologists, Practice Managers, and Employers 2015 Genentech, South San Francisco, CA February

Problems with Current Health Plans

Problems with Current Health Plans Poor Integration, Coordination and Collaboration - Current plans offer limited coordination between the health plan, Providers, and the Members, as well as limited mobile