Defense Health Agency Pharmacy Operations Overview Pharmacy Shared Services October 31, 2013

Agenda Agenda Item Speaker Overview of the Defense Health Agency (DHA) Lt Gen Douglas Robb Overview of DHA Pharmacy RADM Thomas McGinnis What is the DHA’s Part? How DHA Pharmacy Will Support You Business Process Reengineering Initiatives Col George Jones Long-Term Pharmacy BPR Initiatives Key Metrics for Success Key Milestones Home Delivery Growth TRICARE for Life Prescription Pilot What is Your Part?

Why the DHA? The MHS has a bill to pay: MHS will meet $17 – 22 billion savings by FY19 DHA shared services will meet $2.3 billion savings by FY19 Pharmacy must deliver $1.3 billion of that savings The way we do business matters Lt Gen Robb: The MHS is required to deliver $17 – $22 billion in savings to the government through FY19. Of this, DHA shared services are responsible for delivering $2.3 billion in savings by FY19, with the pharmacy shared service responsible for over 56% of these dollars. To achieve these savings, we are all responsible for improving the way we do business and deliver care.

Healthcare Operations Pharmacy Operations Division Structure and Vision of the DHA The DHA will enable the medical Services to provide a medically ready force and a ready medical force in both peace time and wartime CJCS Secretary of Defense USD(P&R) Combat Support Agency Responsibilities Defense Health Agency Army SG Sec Army Service MTFs Policy NCR Directorate MTFs Navy SG Air Force SG Army MEDCOM Navy BUMED Air Force MAJCOMS Sec Navy Sec ASD(HA) Pharmacy Shared Service Support to the Services USUHS Execution Healthcare Operations Pharmacy Operations Division Lt Gen Robb: (Discuss your vision of the DHA and its interaction with the rest of the MHS) DHA and Services working together to better integrate how we deliver care. The Pharmacy Operations Division (the POD) will operate as part of the Healthcare Operations Directorate.

Structure of the DHA: Pharmacy Operations Division Pharmacy Operations Division Chief CIV, 1 FTE Service SGs FTEs At IOC 76 By 30 September 2014 79 Service Consultants/ Board of Advisors Deputy Chief MIL, 1 FTE Chief of Staff / Personnel Operations CIV, 1 FTE Informatics & Operations Branch Chief CIV, 1 FTE TPharm Operations Branch Chief CIV, 1 FTE Integrated Utilization Branch Chief CIV,1 FTE Pharmacoeconomic Branch Chief MIL, 1 FTE Informatics & Operations Deputy Chief MIL, 1 FTE TPharm Operations Deputy Chief MIL, 1 FTE Integrated Utilization Deputy Chief MIL, 1 FTE Overview of Roles and Responsibilities: To manage and support execution of ongoing and future enterprise-wide pharmacy activities RADM McGinnis: The POD aims to increase cooperation and enable business partnerships among Army Medicine, Navy Medicine, the Air Force Medical Service and the DHA to facilitate efficient delivery of outpatient pharmacy services. We will facilitate agile, responsive, data-driven decision-making regarding the delivery and accessibility of pharmacy services by establishing uniform standards and business rules. We will implement a collaborative governance process to coordinate and advocate for DoD-wide pharmacy programs and initiatives in order to promote joint interoperability, efficiency, effectiveness and responsiveness in support of Health Readiness. We’re looking to onboard three new positions to support the POD in further integrating pharmacy operations across all components. Your Service Pharmacy Consultants will continue to be your points of contact for communications regarding pharmacy programs. DHA POD Staff MIL, CIV, & CTR, 69 FTEs Army Navy Air Force New position to be filled by a nominated Service billet 5 Two-way communication between DHA and Services

DHA’s Part: DHA Pharmacy Operations Mission: To direct the DoD Pharmacy benefit in support of the MHS’ mission through effective planning, programming, budgeting, and execution of DoD pharmacy operations Goals: Advise DoD Health Affairs (HA) on policy development and priorities related to Pharmacy Create and implement a unified set of business rules to guide and execute DoD policies for Pharmacy, with consideration for: Beneficiary satisfaction Cost-effectiveness Evidence-based best practices Retail recapture to Home Delivery and MTF Data-driven performance measures Align efforts across the enterprise to support pharmacists to provide medication management Transfer maintenance prescriptions to home delivery to allow pharmacists to spend less time filling prescriptions and more time delivering medication therapy management Develop authorized clinical pharmacist positions to participate in direct medical care (i.e., Patient Centered Medical Home (PCMH)) RADM McGinnis: What we are trying to achieve: The POD aims to improve pharmacy operations, resource allocation and deliver significant savings through a series of standardization initiatives, accountability for performance measures, and policy and legislative changes. We will advise DoD Health Affairs (HA) on policy development and priorities related to Pharmacy. We will create and implement a unified set of business rules to guide and execute DoD policies for Pharmacy, with consideration for: Beneficiary satisfaction Cost-effectiveness Evidence-based best practices Retail recapture to Home Delivery and MTF Data-driven performance measures Ultimately, our goal is to be an integral part of patient care delivery.

How DHA Pharmacy Operations Will Support You With the TRICARE for Life (TFL) pilot beginning soon, the DHA Pharmacy Operations Division (POD) will provide uniform guidance and central resource support to efficiently move prescriptions from retail to home delivery and MTFs Initiative Benefit to Pharmacy Community 1 Business Process Reengineering Results will standardize select pharmacy processes across MTFs in order to improve operational efficiency and to enhance the pharmacy experience for beneficiaries 2 Centralized Pharmacy Checkbook The DHA POD will centrally manage funds for outpatient pharmaceutical purchases and support requirements associated with workload growth RADM McGinnis: What’s changing? You’ll receive unified guidance on how to simplify or enhance your operations, developed in concert with your Services and subject matter experts. Guidance will cover a variety of topics, such as handling prescription transfers, optimizing the formulary, and efficient drug purchasing practices. In future years, we will ensure funding is available to support your operational needs. The POD will exercise decision authority, as appropriate, to augment or redeploy funds for the purpose of supporting you in delivering effective pharmacy services to beneficiaries. We will support workload growth by providing required staff resources and coverage for outpatient pharmaceutical purchases. 3 Staff Augmentation Contract to Meet Workload Requirements The DHA POD will guide contract staffing augmentation process to support increased workloads resulting from retail recapture

Current BPR 1: Prescription Transfer Process DHA Pharmacy Ops worked with MTF-level Service SMEs to develop policy and guidance designed to make the transfer process into the MTF easier and more efficient: HA policy with DHA procedural guidance to support prescriptions that are transferred into the MTF should a beneficiary request it MTF pharmacies will transfer prescriptions that are on the DoD Uniform Formulary into their MTF should a beneficiary ask DHA standard tool to help facilitate transfers with less manual effort from MTF pharmacists Interim tool will include a standard transfer authorization with common data fields necessary for transfer Final tool will be an online transfer database to eliminate time spent trying to call other MTFs to validate and complete transfers DHA Pharmacy Ops expects the policy and operational guidance to be published in the near future Col Jones

Current BPR 2: Centralized Pharmacy Checkbook DHA Pharmacy Ops will control the Pharmacy “checkbook” for outpatient pharmaceutical purchases to ensure MTFs are able to make consistent and cost-effective enterprise based purchasing decisions: Consistent implementation of Uniform Formulary product selection Central funding will allow the DHA to provide flexible staffing and resources to support recapture DHA will be able to plus-up drug supply, augment staffing based on workload increases, centrally support automation contracts and services, and support expanded MTF formularies Col Jones

Current BPR 3: Staff Augmentation Contract DHA Pharmacy Ops is committed to supporting MTF pharmacies, should prescription workload increase, by supplying flexible staffing consistent with changing workloads: Provide MTF outpatient pharmacies with the opportunity to acquire pharmacy manpower through one or more DHA-established staff augmentation contracts The DHA Pharmacy Ops manpower standard will be used to assess changes in MTF workload and identify the need for additional staff Manpower model is based on the validated AF staffing model FY13 data is the baseline for prescription workloads Col Jones

Future Pharmacy BPR Initiatives Process 2013 Sep Oct Nov Dec Jan Develop Structure and Process to Manage Central Pharmacy Funding Prioritize & Organize Develop Enterprise-Wide Strategic Communications Approach Identify/Baseline Workload-Based Staffing Model; Identify and Redeploy Staff Manage Refill Transfer Process Monitor Recapture and Adjust Resources Levels (Supplies and Manpower) Identify Opportunities to Deploy Clinical Pharmacists in Appropriate Care Settings Enhance Communication of Business Rules to Providers and Ordering Staff--Develop provider Report Card; Develop Educational Materials; Manage Compliance Metrics and Feedback Enhance Reporting (Automated); Develop and Utilize Dashboard to Monitor Compliance and Implementation Conduct Analysis Reports and Market Scans PRIORITY 1 Ongoing Ongoing Ongoing Ongoing Col Jones Ongoing Ongoing Minor procedural/logistical change Reengineering (significant change) Engineering (new process) Kick-Off Meeting Current State Assessment Design and Pilot Future State Pilot Implementation Initiative Implementation Implementation

Key Metrics for Success: Near Term # Metric Management Question Development Status 1 Maintenance medication refills filled at all points of service drilled down by catchment area and distribution of enrollment status Are our MTF pharmacy workloads increasing as a result of pharmacy benefit change? 2 MTF, retail, and mail order market share by catchment area and distribution of enrollment status Are we reducing retail pharmacy use? 3 Net pharmacy cost to government per member per year by catchment area and distribution of enrollment status Are pharmacy benefit costs decreasing as a result of changes to the benefit? 4 % of prescriptions filled as generic when generic is identified as a preferred agent Are our MTFs purchasing drugs in alignment with enterprise's formulary decisions? 5 % compliance with purchasing from national contracts (Prime Vendor); augment with PDTS data for product match Are our MTFs purchasing drugs in alignment with enterprise's purchasing strategy? Col Jones In development Developed, but no baseline Baseline & targets exist

Pharmacy Key Metrics* - Mid/Long Term # Metric Management Question Development Status 6 Net total healthcare cost to the government per member per year by catchment area and distribution of enrollment status Are we managing total cost of care for a person over time? 7 Staffing variance with the adopted universal MTF outpatient staffing standard How much additional manpower do we need to support retail recapture? 8 % of civilian provider prescriptions e-prescribed and filled at MTFs Are our MTF pharmacy workloads increasing as a result of private sector providers' e-prescribing? 9 Annual projected cost-avoidance estimate for a formulary course of action selected compared to a baseline formulary status for each class review completed How much are we saving by monitoring the market and updating the formulary with equally effective, lower cost drugs? 10 Cumulative annual cost-avoidance estimate of all classes reviewed at each quarterly P&T meeting Col Jones In development Developed, but no baseline Baseline & targets exist *Based on CONOPs, BPR, and Reports to Congress

Pharmacy Key Metrics* - Mid/Long Term # Metric Management Question Development Status 11 Execution of the process for limiting coverage of newly approved FDA innovator drugs not yet reviewed by the P&T Committee N/A 12 % adherence to purchasing maintenance contracts for automation products via centralized contracts Are our MTFs purchasing pharmacy automation in products/services in alignment with enterprise's purchasing strategy? 13 % adherence to purchasing automation products and services via centralized contracts 14 Ratio of pharmacists embedded in PCMH to patients Are our medical home patients achieving better clinical outcomes due to pharmacists’ inclusion in care management teams? 15 Percentage of MTFs that have pharmacists embedded or supporting MTF PCMH Teams Col Jones In development Developed, but no baseline Baseline & targets exist *Based on CONOPs, BPR, and Reports to Congress

Pharmacy Key Metrics* - Mid/Long Term # Metric Management Question Development Status 16 Medication adherence rates in PCMH (for selected medications) Are our medical home patients achieving better clinical outcomes due to pharmacists’ inclusion in care management teams? 17 Clinical pharmacy penetration into geriatric population Do clinical pharmacy services at MTF outpatient pharmacy/clinics improve patient outcomes? 18 Percent of newly identified high risk patients receiving medication therapy management review by a clinical pharmacist Are we taking care of patients with chronic illness or complex medical/social problems? 19 MTF outpatient pharmacy patient wait time for initial contact with the concierge Are our patients satisfied with MTF outpatient pharmacy? 20 MTF outpatient pharmacy patient wait time for service Col Jones In development Developed, but no baseline Baseline & targets exist *Based on CONOPs, BPR, and Reports to Congress

Pharmacy Shared Services: Key Milestones in FY14 Progress Publish the TRICARE For Life pilot interim final rule % Complete: 75% Tasks completed: Sent to OMB Tasks remaining: OMB to publish the interim final rule Improve MTF prescription transfer process Tasks completed: Performed current state analysis, identified process improvement opportunities, drafted future state policy and guidance Tasks remaining: Disseminate the draft prescription transfer policy and guidance and solicit comments, finalize the policy and guidance Develop POD strategic communication plan % Complete: 25% Tasks completed: Developed the project charter, drafted the project plan Tasks remaining: Develop project plan, conduct working session Improve Home Delivery Prescription Transfer Process % Complete: 50% Tasks completed: Developed beneficiary communications plan, identified customer service improvements Tasks remaining: Define current state, identify improvement opportunities, execute contract modifications Define process for the management of centralized pharmacy funding % Complete: ~10% Tasks completed: Developed the project charter Tasks remaining: Develop project plan, conduct current state assessment, identify change requirements, develop the future state, pilot, implement Establish centralized staffing contract % Complete: 10% Tasks remaining: Develop project plan, establish DHA contract(s) Col Jones

Volume Growth From Prior Year Retail Maintenance Volume: Can We Deliver? – Yes! Home Delivery Growth Col Jones Volume Growth From Prior Year 2011 2012 2013 YTD Home Delivery 9.9% 31.2% 10.0% Retail -0.2% -10.0% -6.8% Retail Maintenance Volume: Down 2.5% in 2011; Down 14.6% in 2012; Down 13.1% in 2013 YTD Source: Express Scripts Home Delivery Growth Dashboard

TRICARE For Life Prescription Pilot – Coming Soon TRICARE beneficiaries who are Medicare eligible (using TRICARE for Life) must refill their brand-name maintenance prescriptions using either Home Delivery or MTF Pharmacy Implementation dependent on Office of Management and Budget (OMB) approval and publication of interim final rule (expected mid-November 2013) Communications planning underway Letters to affected beneficiaries Explanation Of Benefit (EOB) messages Express Scripts education and marketing Civilian and MTF provider education Materials will be shared with MTFs Col Jones

MTF’s Part – Your Responsibility to Meet Our Goals During this transition, the Service’s network of pharmacies will play vital roles in the success of each initiative: Execute standardized pharmacy operations – eliminate variance Support patients in transferring prescriptions to and from other pharmacy locations Evidence-based best practices Beneficiary satisfaction Execute optimization of the pharmacy benefit Retail recapture to Home Delivery and MTF Share your expertise, experience and knowledge base with DHA Pharmacy operations Participate in BPR working groups At the end of the day, we must provide a high-quality, affordable and sustainable pharmacy benefit Col Jones

Questions?