1. 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?

2. 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

3. 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

4. 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

5. 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)

6. 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

9. 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

10. Pharmacy Focus: Quality & Affordability

11. 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.

12. 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

13. 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

14. 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

15. 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