Value-Based Contracting Capabilities Needed for Success

Transcription

1 GAME CODE LOWCOST Value-Based ing Capabilities Needed for Success March 9, 2017

2 Agenda Key Drivers of Value-Based ing (VBC) Major Hurdles to Overcome VBC Adoption Trend VBC Capability Framework 1

3 Setting Context Key Drivers of Value-Based ing The shift from volume to value is gaining traction Key Pressures Driving Change VOLUME TO VALUE CONSOLIDATION OF BUYERS INCREASED COMPETITION ENGAGED PATIENTS Changes in reimbursement are shifting focus towards outcomes, blurring payer and provider roles, and pushing risk to providers Payers and providers are consolidating; creating fewer, smarter customers with more leverage AND CHANGING REGULATIONS Increased competition due to generics, biosimilars, new technologies and changing regulations Patients are shopping around as never before due to greater out-ofpocket cost, concern for their experience and greater access to information These pressures are causing stakeholders to seek greater costeffectiveness in their purchasing and prescribing of medications To defend market share and slow margin erosion, it is imperative for the life sciences industry to address these challenges and demonstrate their value proposition in new ways e.g., RWE and Value-Based ing 2

4 Major Hurdles to Overcome For the most part, the current healthcare ecosystem lacks the resources, capabilities and trust to enable widespread acceptance of value-based contracts Currently, stakeholders face many challenges in executing value-based agreements Strategic Operational Population Definition Misalignment on definition of patient population for tracking/measurement Outcomes Measurement Misalignment on defining outcomes/metrics to be measured Technology Challenges with collecting, linking and analyzing data Sparse resources and capabilities to analyze data Uncontrollable Factors Patient adherence to therapy HCP skill / error Legal / Compliance Gov t Price Reporting Anti-kickback Statute HIPAA privacy and security standards Potential for off-label promotion or unsubstantiated claims Payment and Valuation Complexity in quantifying outcomesbased benefits and must address three foundational needs to enable the success of value-based care Resources to dedicate to this effort Trust among providers, payers and manufacturers Capabilities to execute 3

5 Value-Based ing Adoption Trend The US market has been slow to adopt VBCs, however we re seeing more experimentation and an increased desire to explore these types of arrangements. Date Announced Life Sciences Co Payer/PBM Drug Name Therapeutic Area/Disease Outcomes Metric 2/22/2017 Amgen Harvard Pilgrim HC Enbrel Rheumatoid Arthritis Aggregate score based on six factors 10/11/2016 Merck Aetna Januvia, Janumet Type II Diabetes Achieve or maintain treatment goals 6/27/2016 Eli Lilly Harvard Pilgrim HC Trulicity Type II Diabetes A1C level reduction 5/10/2016 Amgen Cigna Repatha Cholesterol LDL cholesterol level reduction 5/10/2016 Sanofi Cigna Praluent Cholesterol LDL cholesterol level reduction 5/1/2016 AstraZeneca Express Scripts Iressa NSCLC AZ to reimburse for costs of treatment is patient is nonresponsive to drug and discontinues treatment prior to third prescription refill 5/1/2016 Eli Lilly Humana Effient Heart disease Hospitalization rate reduction 5/1/2016 AstraZeneca UPMC Regional Health Plan Brilinta Heart disease AZ to cover a portion of costs of treating patients who have had additional heart attacks after taking Brilinta, if rate of heart attacks exceeds a threshold 2/9/2016 Novartis Aetna Entresto Chronic Heart Failure Reduction in rate of heart failure hospitalizations 2/9/2016 Novartis Cigna Entresto Chronic Heart Failure Reduction in rate of heart failure hospitalizations 11/23/2015 Amgen CVS Repatha Cholesterol LDL cholesterol level reduction 11/9/2015 Amgen Harvard Pilgrim HC Repatha Cholesterol LDL cholesterol level reduction 7/23/2015 Gilead United Healthcare/OptumRx Harvoni Hepatitis C Unknown 3/16/2011 EMD Serono Cigna Rebif MS Hospitalization and emergency room visits avoided 4

6 Value-Based ing Lifecycle Framework Multiple domains of expertise and capabilities are needed to address the key steps throughout the value-based contracting lifecycle. ing Strategy: Where to play? Operational Execution: How to Implement? Product Selection Cost/Value Analysis Customer Targeting Design/ Authoring Patient Engagement & Support Data Collection, Integration, Storage, & Governance Without a comprehensive strategy and the necessary operational support/infrastructure, successfully executing VBCs will continue to be a challenge. Performance Monitoring & Analysis Administration & Compliance Mgt. Validation & Audit Analytics & Outcomes Measurement 5

7 ing Strategy Capabilities A four step approach should be used to define VBC opportunities and engage customers. Product Cost/Value Customer Patient Design/ Engagement Selection Analysis Targeting Authoring & Support Data Collection, Integration, Storage, & Governance Performance Monitoring & Analysis Analytics & Outcomes Measurement Administration & Adjudication Validation & Audit 1 2 Cost / Value 3 4 Design & Product Selection Customer Targeting Analysis Authoring Which products are most suitable to valuebased contracting? What value can be created within selected therapeutic areas? Who are the ideal stakeholders to target with a value-based deal? How should the contract be structured? Portfolio assessment and product outcome identification Real world data analysis to confirm the product and outcome/measure Segmentation to identify right stakeholders deal structure design 6

8 Product Selection Process A filtering framework should be used to assess a product portfolio and identify the strongest candidates for value-based contracts. Therapeutic Areas Crowded Class / Low Differentiation Perceived Clinical Uncertainties Outcome/Measure Practicality Organizational ROI TA/Drug Candidates for VBC 7 1 Product Selection 2 3 Cost / Value Analysis Primary Questions Customer Targeting 4 Design & Authoring Are the current and forecast levels of competition and innovation in the TAs conducive to VBCs? What level of clinical uncertainties of the drug(s) exist and what budget impact does the TA(s) have for payers? What outcomes/measures are agreed upon by all parties involved that can be collected and evaluated for the TA(s)? Does achieving the outcome represent a win-win situation for the manufacturer and external partners? Key Actions Conduct Opportunity Analysis that details out where there are clinical opportunities compared to best in class markets Determine Measurable Outcomes that will drive potential opportunity to contract with stakeholders Assess each Therapeutic Area to determine if there are opportunities to drive cost and value based on competitive profiles and innovation

9 Cost/Value Analysis Overview 1 Product Selection 2 3 Cost / Value Analysis Customer Targeting 4 Design & Authoring Rigorous actuarial analytics are needed to calculate the economic value for selected products / portfolios for specific customers. Upfront Considerations Define Customer Values Define Value Drivers For which customer are you trying to understand value derived from the selected product(s)/portfolio(s)? For each customer selected, how does each derive value from the selected product(s)/portfolio(s) Key Actions Determine Detailed Disease Breakdown utilizing claim, disease burden, and clinical information to determine actionable areas within the continuum of care to find opportunities for efficiency Provide Clinical Insights on potential actions, changes in behavior, or changes in risk profile that impact value drivers Conduct Cost / Value Analysis by value driver which integrates the clinical event and the potential change under the new treatment or services, which could be changes in utilization by service categories (e.g., inpatient services, outpatient services, professional services, drugs, etc.) or modification of potential risk profiles and frequency of events 8

10 Customer Targeting Considerations Ideal customer profiles should be identified based on a number of attributes from the cost / value analysis 1 Product Selection Attributes from Cost / Value Analysis 2 3 Cost / Value Analysis Customer Targeting 4 Design & Authoring How payer interacts with care givers? Who owns the risk? Who gets the benefit of change delivery? What is the profile of their policyholders? How competitive is their market? How long to generate ROI? Key Actions CUSTOMER TYPE IDNs PBMs ACOs Commercial Payers IDN selected for cost/value analysis in step 2 Economic value modeled for IDN against selected product / portfolio Ideal Customer Profile IDN Market Size and competitive profile Geographic location Volume and strategic value of customer IDN mix of services Capabilities in place to support types 9

11 Value Based ing Types There is no one-size fits all approach. The contract type should reflect the value driver and the objectives of the parties involved in the deal. 1 Product Selection 2 3 Cost / Value Analysis Customer Targeting 4 Design & Authoring Note: Basic discounts excluded 10

12 Analytics Expertise Powered by Deloitte Outcome Audit A Closer Look at Operational Execution The Platform should enable the entire operational execution process. Product Selection Cost/Value Analysis Customer Targeting Design/ Authoring Patient Engagement & Support Data Collection, Integration, Storage, & Governance VBC Strategy to Implementation Performance Monitoring & Analysis Analytics & Outcomes Measurement VBC Solution Administration & Adjudication Validation & Audit 11

13 Patient Engagement Capabilities Most VBCs will require connection between patients and the healthcare system to deliver better treatments and collect the necessary data. Patient Engagement & Support Provide patient supportive services to help ensure adherence and compliance The Platform should: Accelerate patient access to therapy and provide high- touch, consistent patient interactions across shared business processes and therapeutic programs Leverage tools to engage and educate patient; act proactively to ensure product, therapy, and care plan adherence, reducing discontinuation Increase insights into patient treatment and interactions gain RWE to demonstrate value to health plans and improve drug efficacy Provide value to HCPs and providers through shared patient insights and a platform for care team collaboration; facilitate interactions between HCPs and patients 12

14 Data Collection, Storage, Mgt. and Analytics Capabilities Platform should provide Cloud-based Secure Environment to operationalize VBCs Data Collection, Storage, & Mgt. Analytics & Outcomes Assessment Key Features Standard compliant data repository that enables disparate data integration into standard vocabularies Security and redundancy best practices Collect and securely store patient level data Establish adequate infrastructure and resources to measure relevant realworld outcomes Platform should provide: The infrastructure for aggregating, storing and analyzing data to support VBCs A secure way to analyze patient level data and report out A neutral location in-between the payer and LS company that provides transparency and helps alleviate trust issues 24/7 support Data Visualization and Reporting Full range of analytical services on demand 13

15 Outcomes/Measures Validation and Audit Capabilities For situations where a neutral third party validation is needed, the VBC Platform should be able to objectively audit the outcomes/measures. Risk areas for measurement Priority risk areas Patient population selection Patient baselines Comparator products Instill trust and transparency concerns between all parties Validation & Audit Data linkage algorithms Measurement logic and scripts Types of Audits Outcome/Measure Audit Outcome/measure verification Data collection and measurement methods analysis Financial Verification Rebate amount validations 14

16 s Administration and Adjudication Capabilities The platform should provide the ability to administer and adjudicate VBCs s administration for Managed Care outcomes based contracts Rebate calculation based on outcomes/ measures Gross-to-Net calculation to assess contract impact on the bottom line Outcomes based contract impact on government pricing Admin. & Adjudication Translate outcomes measures into contractual implications 15

17 Payer 1 Payer 2 Deal quality estimate $- $0.050 $0.100 $0.150 $0.200 $0.250 $0.300 $0.350 Performance Monitoring & Analysis (CPMA) Capabilities Tracking performance and identifying opportunities for improvement is vital to VBC strategies 1. What is the net sales and market share impact from VBCs and how does that compare against traditional contracts? Rebate payments by sales Script Sales Millions Productivity of Rebate Spend Average Rebate $$s Spent Per Life 2. What is the VBC contract ROI at the plan level? Plan level drill-down Rebate amount paid = size of pie slice Performance Monitoring & Analysis ROI on VBC 3. Which doctors should I call on with patient support services or to improve pull through? Copyright 2016 Deloitte Development LLC. All rights reserved. 16 Proprietary & Confidential DRAFT - For Discussion Purposes Only

18 In Summary The shift to a Value-Based Care Model will Necessitate Value-Based ing Successful experimentation with VBCs will: Improve confidence and trust among the stakeholders Shine more light on how to address and overcome the strategic and operational hurdles As adoption increases and the number of VBCs rise, the need to determine how best to operationalize and scale the required capabilities will be accelerated Copyright 2016 Deloitte Development LLC. All rights reserved. 17 Proprietary & Confidential DRAFT - For Discussion Purposes Only

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