What to Expect at AMCP Nexus 2018

AMCP Nexus 2018: Preparing for the Next Generation of Care is the Academy of Managed Care Pharmacy’s annual meeting that will be held at the Orlando World Center Marriott from October 22–25 in Orlando, Florida. The meeting is comprised of professionals from all across the managed care spectrum that come together to share data on the latest developments in health care cost management. Due to the constantly changed health care profession, AMCP Nexus will give attendees current, actionable knowledge to further organizations and careers. 

The conference is geared toward giving attendees insight into how managed care can best serve the needs of the millions of patients in the country who rely on health care decision makers to guide them into affordable and quality care. Additionally, attendees will gain valuable knowledge on the latest innovations and important clinical, government, and business issues facing the industry. Managed care professionals will also be introduced to powerful tools to help find solutions for any issues, ranging from improving outcomes to reducing heath care costs. 

First Report Managed Care has compiled a brief overview of the meeting and educational sessions, including commentary from some of the speakers, to help inform and excite attendees. For the complete agenda, including educational sessions, speakers, locations and other events, please refer to the meeting website (www.amcpmeetings.org). 

EDUCATION TRACKS

The AMCP educational tracks allow professionals, ranging from medical directors to nurses, to customize their meeting experience. The meeting is organized into color-coded sessions that allow attendees to easily navigate the meeting tracks in order to get the most pertinent information out of their conference experience. 

The education sessions are categorized in five targeted program tracks:

• Preparing for the Next Generation of Care
• Drugs, Diseases and the Managed Care Impact
• Legislative and Regulatory Trends: From Rhetoric to Practice
• Managed Care Research in Action
• Specialty Pharmacy Management: Keeping Up With Runaway Innovation

HIGHLIGHTED SESSIONS 

Tuesday, October 23, 2018

8:15 AM – 9:30 AM 

Specialty Pharmaceuticals in Development 

During this session, Aimee Tharaldson, PharmD, senior clinical consultant of emerging therapeutics at Express Scripts, and Jefferey Hawes, PharmD, vice president of sales at Citizens, Rx, LLC, will discuss new and emerging specialty medications and will also explore their likely role in therapy. Additionally, this session will discuss the potential impact of these agents on the managed care market. Following this session, attendees will be able to recognize recently approved specialty medications, identify specialty medications that are likely to be approved in the next 12 months, and report the effect of new specialty medications on the managed care market.

9:50 AM – 11:20 AM
Using Artificial Intelligence to Optimize Health Outcomes

Adam Hanina, chief executive officer at AiCure, and Sam Leo, PharmD, director of specialty clinical programs at Magellan Rx, will provide an overview of the current and emerging artificial intelligence (AI) technology uses in managed care pharmacy. They will also discuss the challenges faced by managed care organizations in validating, adopting, and integrating these new solutions into their existing infrastructure. Mr Hanina and Dr Leo will also discuss an ongoing pilot of a managed care organization that is deploying an AI-based smartphone application that optimizes clinical outcomes in a nationwide patient population with hepatitis C virus.

See interview with Dr Leo below. 

Dr Leo discusses how artificial intelligence (AI) is being used within managed care and addresses issues payers may face in the future.  

What is AI and how can it be used in health care? Are many health systems currently aware of AI?

At its core, AI is using computer systems to perform a myriad of tasks that normally require human intelligence. We are seeing developments and innovations in both machine learning and natural language process technologies that will have health care applications in decision making support, speech and facial recognition, predictive analytics, forecasting and budget impact modeling, care management tools, customer service, drug discovery, and many more. 

Most health system stakeholders are aware of the concept of AI and its potential impacts, however compared to many other business sectors, and due to some inherent challenges around security, privacy, and data structure, the health care industry tends to lag behind other fast adopters. The initial challenge will be building the foundation within our data systems to put us in the position to leverage solutions. Health care data, although plentiful, is still very disjointed and unstructured. 

What AI is currently available for payers?

As of 2016, there were more than 100 startups with a focus on transforming health care with AI, so the available choices are abundant. Payers consequently are challenged to sift through the numerous options to find the right opportunities for them. First and foremost, payers should have realistic expectations and not get caught up in the hype. Once a payer believes they have a strong analytic base and organized data collection processes, my advice would be to start small in a pilot setting and define what success will look like whether it’s to improve patient care outcomes, improve efficiency, improve the patient experience, or other goals. We then need to ensure results are measurable and gather lessons learned to determine if there is a viable path to scaling the technology in a cost-effective manner. 

In the near term, health systems will need to be prepared to evaluate and make formulary and coverage decisions on new health care technologies that leverage AI. Improved modeling can predict impact of new drugs, formulary placement, and specific criteria on utilization and outcomes in a specific population. Furthermore, we will likely see more adoption of diagnostic AI tools. Health plans will need to consider and evaluate how to encourage and reimburse new predictive diagnostic tools, as well as, determine the value in partnering and incentivizing providers who are early adopters. 

Are payers currently utilizing AI? Do you believe more payers will adopt the use of AI in the near future?

While I wouldn’t yet say AI is widespread among payers, there are plenty of examples of organizations exploring pilot concepts and rolling out new AI technologies in certain targeted areas within customer service and care management. Magellan Rx specifically has developed multiple predictive analytic tools that leverage machine learning to proactively identify at-risk patients. We have also recently partnered with AICure to explore the impact of a digital virtual assistant mobile application that uses facial and pill recognition technology to ensure patients are taking medications as prescribed. From a payer perspective, we are interested in the impact on health outcomes and whether patients are willing and able to use it. We’ve been more than happy with the results seen to date and are excited to discuss the pilot and potential next steps at the upcoming AMCP meeting. 

I do think for a variety of reasons we will see more AI adoption in the health care system as a whole in the near future. First, most patients as consumers are welcoming and more willing than ever to accept the use of more digital tools in health care. Second, it will likely become a competitive advantage to the organizations that adapt and grow in the appropriate areas: to improve the patient experience and to help us target and focus on preventative care. 

How does the use of AI impact costs? 

This is obviously very dependent on the type of AI technology we are discussing. In brief, AI can be a tool that helps us use our resources more efficiently to identify high-risk patients and proactively intervene to prevent a negative and costly outcome before it occurs. This of course will have to be balanced with the cost of rolling out such technologies in the first place. 

How will the use of AI impact competition among payers? Will they start to aim to have the lowest reduced costs? 

AI can support efforts to improve patient experience and provide the most effective care to prevent negative outcomes, improve budget and cost impact of formulary and benefit structures, and more effectively identify cases of fraud and abuse. These and others will certainly create market competition among payers.  

Will payers face issues adopting the use of AI? How will they address these issues? 

Organizing and structuring multiple data streams upfront is one of the biggest initial issues. And even after that, there are many other challenges to address, including patient access and inequity (in other words are all patients able to use AI-based care management tools equally), unknown regulatory considerations, impact on health data security, and ensuring any technology is validated and accurate. There is no quick or easy way to address these issues, but instead all need to be carefully considered and evaluated before any vast incorporation of new technology or processes. 

Can  you share what you are most excited about and what you hope the attendees take away from your session?

I am most excited that a topic like this is coming to the forefront in a forum like AMCP. Payers continually are challenged with a changing and adapting market and the introduction of more digital and AI health care tools will be another one of many challenges we face as we aim to ensure cost-effective and appropriate use of medications. I hope payers attending the session will be able to walk away with a better understanding of what questions they should ask and what challenges they should anticipate when evaluating AI-based health technologies. I also hope they can walk away encouraged that some of these tools have the potential to impact patient care and experience in a hugely positive way. 

9:50 AM – 11:20 AM
The Voice of the Patient: Using Patient-Reported Outcomes to Continuously Drive Improvements in Clinical Programs 

During this session, Nick Page, PharmD, chief pharmacy officer at WellDyneRx, and Patty Taddei-Allen, PharmD, MBA, director of outcomes research at WellDyneRx, will address the recent shift to incorporate patient-reported outcomes (PROs), and their associated measurement tools, patient-reported outcomes measures (PROMs), into the overall measurement of health care performance. Additionally, Drs Page and Taddei-Allen will explain how PROs can be included in formulary management and payer decisions. 

See interview with Dr Taddei-Allen below.

Dr Taddei-Allen explains the roles that patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) play in formulary management and payer decisions. She hopes AMCP attendees will now have a better understanding of these measures prior to the conference. 

Can you give a brief description of PROs and PROms? How are these measures being used in pay-for-performance models?

PROs are outcomes that are directly reported by patients regarding their health that is not interpreted by a health care provider. PROMs are the tools that are used to measure PROs.  These measures may be incorporated into pay-for-performance contracts, along with clinician-reported and performance-based outcomes measures.  

How can payers and other health care industry workers use patient-reported measures?

Payers and other healthcare industry workers, such as health systems or physician practices, may use the PROMs in aggregate in order to assess clinicians or organizations on how their patients compare to peers. 

Can PROs assist in improving health care and clinical outcomes? How can these measures help lower costs?

PROs assist in improving health care and clinical outcomes at both a patient-specific level and a population health level.  At a patient specific level, PROs allow for improved patient-provider communication, patient satisfaction with the care they are receiving, and overall improvement in the management of their chronic conditions.  In aggregate, PROs help organizations to improve their overall clinical care programs, which translates into improved downstream health care costs.

Do you believe that more health care systems will adopt the use of PROMs? Is it going to be more common to measure health outcomes from the patient perspective versus traditional clinical measures?

I believe that PROs will continue to gain traction as one of the parameters that is used to assess the overall quality of care delivered, but it will not entirely replace clinician-reported and assessed outcomes measures.

Can you discuss some of the challenges associated with collecting PROs and incorporating them into health care quality assessment?

Challenges exist from the perspectives of both the providers and the payers.  From the provider’s viewpoint, incorporating PROs into the workflow and EHR, as well as making sure that the PROM being used matches with a patient’s health literacy and understanding how to interpret the different PROM data, are concerns that must be addressed.  Also, providers are worried about biased comparisons with benchmark data, particularly since PROs have not typically been incorporated into the general healthcare workflow.  

From a payer’s perspective, the lack of understanding of the role of PROs in overall health care, and the lack of standardization across all disease or drug categories, makes it difficult to assess the value of incorporating PROs into payer decisions.  

In October you will be presenting on this topic at AMCP 2018. Can you tell us what you are most excited about for the meeting and share what you hope the attendees will take away from your session?

I am most excited to share that PROs and PROMs are valuable tools to enhance and promote patient-centered care across the healthcare continuum—from direct patient contact, to better engagement of patients with their health care, to improves clinical programs at the population level, which ultimately will result in improved clinical outcomes.

Wednesday, October 24, 2018

8:00 AM – 9:30 AM
Optimizing Medication Use in Value-Based Models of Care: Insight Into Developing a Successful Collaboration Between a Health System and Managed Care Organization 

Christopher Diehl, PharmD, MBA, BCACP, clinical pharmacist at Excellus BlueCross BlueShield, and Erica Lynn Dobson, PharmD, manager of pharmacy services at Accountable Health Partners, will describe the collaboration between a clinically integrated network (CIN) and managed care pharmacist during this session. Drs Diehl and Dobson will detail the process of developing, implementing, and tracking cost saving and quality initiatives from the health plan and CIN’s perspective. Additionally, this session will provide insight for ongoing and future collaborative opportunities that include cooperating on the management of high cost specialty medications and promoting biosimilars. 

3:00 PM – 4:30 PM
Assessing the Value for a One-Time Therapy for Rare Diseases From an Individual Payer Perspective: Subscriber Retention
Considerations 

E. Anne Jackson, FSA, MAAA, principal and consulting actuary at Milliman, Inc, and Edmund J Pezalla, MD, MPH, CEO and consultant at Enlightenment Bioconsult, LLC, will discuss expectations for subscriber retention that can be used in the assessment of value of a one-dose, high-value therapy. Additionally, the session will cover recent study findings that quantify the longer expected retention of certain subscribers.

4:45 PM – 5:45 PM
Ready or Not: The Impact of Health System and Policy Change on Managed Care Pharmacy

Market change, including large scale corporate mergers, delivery systems integrating, new ways of paying providers, the potential for technology companies to enter the market, and a large discussion on drug pricing, is surrounding the health care system. Dan Mendelson, MPP, founder of Avalere Health, will highlight the biggest commercial and policy issues facing the practice of managed care pharmacy during this must-attend session. Additionally, Mr Mendelson will explain how commercial and policy issues and changes that are most likely to affect the work of health care providers. 

See interview with Mr Mendelson below. 

Mr Mendelson discusses the impact health system and policy change has on managed care pharmacy. He highlights recent health system mergers, formulary drug exclusions, current issues facing managed care pharmacy, including prescribing rates, and more. 

How do you believe health care mergers and acquisitions are impacting Americans and their health plans? The current thought is that health care mergers will lower costs for these health systems. Will the patient also see these lowered costs?  

Value-based payments are changing the way that health plans think about addressing their markets. Now that substantial payments to the plans are based on quality measures, plans are funneling more resources into these clinical areas (including diabetes, cardiovascular disease, and prevention), and figuring ways to move incentives to improve care to providers. The mergers and acquisitions we see today are largely focused on establishing a stronger integrated operating model in a value-based world. Some M&A is focused on integrating downstream providers (eg, home health assets), some is focused on increasing scale in government growth markets, and some is targeting improvement in the sophistication of IT engagement. Consumers are starting to see more sophistication in plan operations, and better engagement around quality.

 I expect that these efforts to improve scale, improve quality, and better integrate care are valuable and will result in lower costs for consumers. With that said, costs of health care increase every year due to the labor intensity of the services and because of technology that drives cost, so improvements that attenuate cost growth may not be visible to consumers.

Express Scripts recently announced that they are dropping nearly 50 drugs from their formulary exclusions for 2019. Why do you think drugs are being dropped and will this trend continue? How does this impact the number of choices for patients? Does this now leave them with more expensive choices? 

Pharmacy benefit managers continue to get more aggressive about formulary design.  Consumers are seeing increased cost sharing—often charged as a percentage of the drug cost, in addition to growth in the use of step therapy and smaller formularies. This represents a transfer of expense to individuals who have chronic illness, and certainly has caused cost hardship for many consumers. But it’s important to understand that these policies are being adopted to address consumer and payer demand for lower overall pharmacy and medical costs, so expect that the trends presently observed will continue to be refined over time.

In May, President Trump announced his plan to lower drug prices. Do you think the current administration is on track to follow-through with the blueprint and do you see a future of lowered drug prices? How would more generic drugs impact costs for insurers and pharmacy?  

The Administration is responding to broad concern by consumers about rising exposure to drug costs.  They have a range of proposals under consideration that are focused on price transparency, reducing the use of rebates, modifications to the anti-kickback statute, and some modest modifications to Medicare and Medicaid that can be changed through regulation.  While I do believe they are on track to make such changes, the elements of the blueprint in process presently will not deliver dramatic price reductions before the mid-term elections, nor will they enable the Administration to make high profile claims of success.  In fairness, anything that significantly reduces prices for consumers would likely require legislation that would not be feasible in this environment. As a result, I expect that drug prices will, once again, be a campaign issue for those challenging the status quo. 

Certainly, generic substitution is a key way to keep costs for consumers under control. The FDA has done a good job of approving generics as rapidly as feasible under the law. However, particularly in the area of biologics, there are market and policy limitations that have prevented a more rapid access to biosimilar alternatives.

Can you discuss some of the issues facing managed care pharmacy? What are issues specifically facing insurers, pharmacists, and patients? Can these issues be easily fixed? Do you believe that collaboration between managed care and pharmacy can improve issues such as costs?

One of the key issues is the role of the pharmacist in clinical care. Pharmacists are trusted by patients, are cost-effective relative to other clinicians, and can be a key participant in the care journey if they have sufficient information on which to act. Health plans can improve the value that pharmacists deliver by using data to integrate the patient interaction into core activities such as gap closure and adherence programs.

How do health care policies impact prescribing rates? Are some hospitals/facilities more likely to prescribe higher cost drugs compared with other facilities?

It’s no secret that health care providers respond to financial incentives. Providers are now operating in an environment where financial incentives around prescribing vary. For example, in the oncology space, programs such as the Oncology Care Model incentivize cost-effective prescribing while core Medicare Part B compensates a provider more for prescribing a more expensive drug. Patients have reason to be concerned with the downsides associated with either of these models—and need to be conscious of the incentives that come along with the model in which they are receiving care.

For your session at AMCP 2018, can you share what you are most excited about and what you hope the attendees take away from your session?

The shift to value-based payment is changing health plan operations and provider markets fundamentally. Change is being driven by both market reactions and government engagement. Leaders in managed care pharmacy need to anticipate these changes to succeed.