How is WEA Trust Reclaiming Healthcare? Tim Bartholow, MD VP & Chief Medical Officer Alan Lukazewski, Director of Clinical Pharmacy How is WEA Trust Reclaiming Healthcare?

What does “reclaiming” mean? Talented, trusted team that serves our members first Appropriate, affordable care Careful selection of physicians/systems who reach for higher value

Why is the Trust different? We talk to the member We remove physicians who aren’t safe for members We will deny care that is not appropriate or unnecessarily uses too many resources

Why is the Trust different? We work with physicians to make care more consistent and appropriate in areas like : Cardiology Orthopedics Gastroenterology Psychiatry Rheumatology Oncology 70% of claims We do not micromanage physicians, but expect their best thinking

Why is the Trust different? We seek bundles and warrantees We are all Wisconsin employees We are smarter, faster through analytics (R programming, Use of WHIO, Use of statisticians, decisioning science, use of tool developers)

Reclaiming Healthcare: Quality Help keep people well If not well, be sure the patient receives “appropriate” care Provide appropriate care with as little variation as possible Shared decision making that empowers the patient Anticipate future care needs

Reclaiming Healthcare: Affordability We are stewards of resources (with physicians) Unless we buy differently, hospital systems will not/cannot change Waste in health care is paid from employee earnings Brent James, MD, Intermountain (Salt Lake): “Quality Healthcare can be delivered for half” Attention to affordability makes higher quality

Pharmacy Focus: Quality & Affordability

Pharmacy Benefit Goals Deliver value High quality Based on best evidence for positive outcomes AND reducing risk for harm from medications Affordable benefit Talk about better managing the pharmacy drug spend, which was 9.7% of the HC spend in 2011 but has outpaced HC spending and inflation since then to now constitute 14-16% of the total HC spend. So I want to update you on what we are doing that he Trust to bend down the cost curve while delivering high value, which can be defined as delivering an affordable product but also high quality, which is focused on improving outcomes and reducing harm from medications.

Lowest Net Cost High-Cost Generic Program Preferred Drug List PBM program to reduce drug spend Work within Value Choice Drug Plan Preferred Drug List Formulary interchange program Substitute with effective lower cost equivalents High-touch member engagement

Specialty Drug Strategy: Cost and Safety Less than 2% of utilization 35% or more of total drug spend By 2018: more than 50% Average $4,200 per script 20% annual trend Price, Mix and Utilization PBM and Medical spend strategies Adhere to lowest cost therapies Avoid downstream medical costs from ADEs

Cost Focus: Specialty Drugs Case 1: Office-based infusion for asthma Proclaimed failure of inhaled asthma medications Intervention: Reviewed claims data to discover <33% adherence over 6 months Outcome: Denial of expensive, inconvenient infused product AND offered support for adherence to lower cost therapy

Safety Focus: Specialty Drugs Case 2: Infantile spasms High cost therapy >$100,000/short-course New evidence for lower cost therapy Alternative associated with permanent vision loss in 30% Interventions: Advocate and collaborate Outcome: Avoided more toxic therapy Strategy: Revise prior authorization criteria to support safer options