Using Decision Support to Promote Value Based Prescribing

Using Decision Support to Promote Value Based Prescribing Session 218, February 14, 2019 Adam Szerencsy, DO Medical Director, Ambulatory Informatics NYU Langone Health 1

Conflict of Interest Adam Szerencsy, DO Has no real or apparent conflicts of interest to report. 2

Agenda Why are we doing this? Prioritizing medication classes to target Interventions Results Limitations Factors impacting success 3

Learning Objectives Formulate a strategy for deploying decision support to influence medication prescribing Evaluate what types of metrics should be used to measure success Identify what factors contribute to provider acceptance of lower cost, therapeutic equivalent medications Define external processes that may limit the effectiveness of clinical decision support interventions Recognize barriers that may impact provider and patient adoption and limit cost savings 4

Background Value based payment programs continue to expand Healthcare organizations are consolidating to achieve efficiencies Healthcare technology is critical to measure and improve care 5

& NYU Langone IPA Over 400,000 attributed lives 2 billion in annual healthcare expenditures 3500 providers Approx. 75% of providers using our enterprise-wide EHR Value based arrangements with all major commercial and government funded insurers 6

& NYU Langone IPA Value Based Medicine Screening and Prevention Chronic Disease Management Appropriate Use Quality Cost Saving Bundled Payment Out of Network Spend Readmissions Reducing prescription drug costs Patient Satisfaction HCAHPS CGCAHPS 7

Can we use clinical decision support to guide clinicians to prescribe lower cost medications? 8

Prioritizing Therapeutic Classes to Target High per member per month (PMPM) med spend Alignment across plan formularies Little risk that a medication change will impact care Significant cost differential between high cost medication and alternative Strong evidence that therapeutic alternatives have similar efficacy Clinical leadership willing to support the initiative 9

*ULCER DRUGS/ANTISPASMODICS $2.02 17 351.3 $69 89.5% *TETRACYCLINES $0.84 28 96 $105 92.5% 10

Classes Individual Drugs Biguanides Tetracyclines PPIs Glumetza Fortamet Metformin MOD Oracea Doryx Morgidox Monodox Acticlate Solodyn Nexium Dexliant Aciphex Vimovo (PPI/Naproxen) 11

Drug Pricing Alphabet Soup Wholesale acquisition costs (WAC) Maximum allowable cost (MAC) Federal Upper limit Usual and customary (U&C) (FUL) Average manufacturer price (AMP) Estimated acquisition cost (EAC)

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only...the pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. 13 Source: Lexicomp

Source: Goodrx.com

Source: Goodrx.com

Therapeutic Class Biguanide High Cost Agent Fortamet (Metformin ER) Average Wholesale Price (AWP)* Preferred Alternative Lowest Retail Price/Month* Price Differential/ Month $1260 Metformin ER $18 $1242 Biguanide Glumetza (Metformin ER) $3300 Metformin ER $18 $3282 Biguanide Metformin ER MOD $3600 Metformin ER $18 $3582 16 *Source: Lexicomp

Therapeutic Class High Cost Agent Average Wholesale Price (AWP)* Preferred Alternative Lowest Retail Price/Month* Price Differential /Month Tetracycline Acticlate/Doryx (Doxycycline Hyclate) $953/$1315 Doxycycline Hyclate $18 $935/$1297 Tetracycline Tetracycline Tetracycline Oracea/Monodox (Doxycycline Monohydrate) Solodyn (Minocycline) Morgidox Kit (Doxycycline Hyclate) $609/$394 Doxycycline Monohydrate $13 $596/$381 $1219 Minocycline $20 $1999 $550 Doxycycline Hyclate $18 $532 *Source: Lexicomp

Therapeutic Class High Cost Agent Average Wholesale Price (AWP)* Preferred Alternative Lowest Retail Price/Month* Price Differential/ Month PPI Dexilant (Dexlansoprazole) $310 Omeprazole Lansoprazole Pantoprazole $11 $18 $13 ~$295 PPI Nexium (Esomeprazole) $288 Omeprazole Lansoprazole Pantoprazole $11 $18 $13 ~$273 PPI Aciphex Rabeprazole $529 Omeprazole Lansoprazole Pantoprazole $11 $18 $13 ~$514 PPI Combination Vimovo Naproxen- Esomeprazole $2473 Omeprazole Lansoprazole Pantoprazole $11 $18 $13 ~$2450 (+ Naproxen) ($8) *Source: Lexicomp

Interventions Preference List Modifications Standard extended release formulation ($) Modified release formulations ($$$$) 2019 Epic Systems Corporation. Used with permission. 19

Interventions Preference List Modifications Removed high cost agents from provider and facility preference lists 2019 Epic Systems Corporation. Used with permission. 20

Interventions Preference List Modifications and substituted them with lower cost alternatives. 21 2019 Epic Systems Corporation. Used with permission.

Interventions Alternative Alerts Interruptive messages recommending lower cost alternatives to providers Design Principles 1. Substitute same medication whenever possible 2. Maintain similar dose and frequency 3. Simple message 4. Provide a reference for additional information 5. Mechanism for feedback 22

Interventions Alternative Alert Mapping High Cost Medication Doryx 100 mg tablets (Doxycycline Hyclate) Solodyn 45 mg daily tabs (Minocycline) Fortamet 500 mg daily (Metformin ER) Fortamet 1000 mg daily (Metformin ER) Dexilant 30 mg daily (Dexlansoprazole) Vimovo 500-20 mg daily (Naproxen-Esomeprazole) Lower Cost Alternative Doxycycline Hyclate 100 mg capsules Minocylcine 50 mg capsules Metformin ER 500 mg daily Metformin ER 1000 500 mg daily Metformin ER 750 mg daily Lansoprazole 15 mg daily Pantoprazole 20 mg daily Lansoprazole 30 mg daily Pantoprazole 40 mg daily (No Naproxen) 23

Interventions Alternative Alerts 25 2019 Epic Systems Corporation. Used with permission.

Interventions Socialization and Education Approval at CIN Clinical Practice Committee Support from clinical chiefs within therapeutic areas Presentations at various committee meetings EHR end-user communication and newsletter announcements 26

Acceptance Rate Results Metformin Metformin Alternative Acceptance Rate (n=1437) 35% 32.9% 30% 25% 20% 15% 16.8% 18.5% 10% 9.4% 5% 0% Overall Primary Care Endocrine Other Specialties Provider Specialty 27

Results Metformin Metformin Acceptance Rate by Dose/Formulation 25.0% 21.3% 20.0% 15.0% 12.8% 10.0% 5.0% 0.0% Metformin 500 mg /750 mg ER -> Glumetza 1000 mg ER Metformin 500 mg ER -> Glumetza 500 mg ER 28

Acceptance Rate Results Tetracyclines Tetracylines Alternative Acceptance Rate (n=783) 50% 45% 43.4% 40% 35% 30% 25% 20% 16.5% 17.1% 15% 11.9% 10% 5% 0% Overall Derm Primary Care Other Specialties Provider Specialty 29

Results Tetracyclines Alternative Acceptance Rate by Dose/Formulation 80.0% 70.0% 68.8% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1.7% Doxycycline 20 mg - > Oracea 40 mg Doxy 100 mg caps - > Adoxa 100 mg tabs 30

Acceptance Rate Results PPIs PPI Alternative Acceptance Rate (n=12,488) 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 10.1% 10.3% 10.4% 9.8% 0% Overall Primary Care GI Other Specialties Provider Specialty 31

Results PPIs Alternative Acceptance Rate by Dose/Formulation 35.0% 30.0% 30.8% 25.0% 20.0% 15.0% 10.0% 10.6% 5.0% 0.0% Omeprazole 20 mg -> Esomeprazole 20 mg Pantoprazole 40 mg -> Dexlanzoprazole 60 mg 0.6% Omeprazole 20 mg -> Vimovo (Naproxen/Esomeprazole) 32

Results REASONS FOR CONTINUING ORIGINAL MEDICATION Prior failure/intolerance of alternative medication 21% Dosing differences Unwilling to change/ Change not necessary Convenience Patient preference 55% Alternative medications not covered 6% Dosing regimen not appropriate 4% Other (Comments) 14% 33

Acceptance Rate Results Summary Over Time 18.0% Acceptance Rate By Month 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 34

Results Payer Data 2017 vs 2018 Baseline Period: 01/01/2017-12/31/2017; Current Period: 01/01/2018-09/30/2018; Claims Paid Through 09/30/2018 PMPM Paid Scripts/1,000 Unit Cost % Generic Baseline Current $ Trend % Trend Baseline Current % Trend Baseline Current % Trend Baseline Current *Biguanides** $2.37 $1.78 -$0.59-24.8% 245.4 244.9-0.2% $116 $87-24.7% 97.9% 98.5% *Tetracyclines* $0.84 $0.59 -$0.25-30.1% 96.0 88.0-8.4% $105 $80-23.7% 92.5% 95.0% *Proton Pump Inhibitors** $1.49 $1.19 -$0.31-20.5% 289.0 267.3-7.5% $62 $53-14.0% 88.6% 90.5% Naproxen-Esomeprazole $0.31 $0.53 $0.22 71.3% 1.8 2.7 52.9% $2,083 $2,334 12.1% 0.0% 0.0% Decrease of $0.93 PMPM

PMPM Net Change Results Payer Data Net Change in PMPM Cost 2017 vs Jan-Jun 2018 (therapeutic classes combined) $1.00 $0.80 $0.60 $0.40 $0.20 $0.14 $0.15 $0.00 -$0.20 -$0.40 -$0.23 1 -$0.60 -$0.80 -$1.00 -$0.77 High Cost Meds Low Cost Meds Unit Cost: High Cost Meds Unit Cost: Low Cost Meds= -$0.71 Overall Net Change PMPM Source: Anthem Commercial Monthly

Limitations Disparate claims data from payers and member roster changes make it challenging to calculate total savings and definitively attribute them to our interventions Inability to intervene for DAW brand medications Not all providers using enterprise-wide EHR Inability to filter alerts for just our attributed patients 37

Looking Ahead 2019 Epic Systems Corporation. Used with permission. 38

External Influencers 39

Prescription Drug Market Once daily dosing Combined meds Prepackaged kits Drug delivery mechanisms Convenience Cost Rx plan design Formularies Tiered Co-payments Prescriber EHR Efficacy Better adherence Patient

Warehouse Store Convenience Cost Sig: 0.65 oz po daily x 28 days Disp: 18.2 oz $12.99/18 oz - $4.00 Rebate $8.99/18 oz Consumer $5.99/12 oz $9.00/18 oz December 21, 2017

Warehouse Store Morgidox Kit 100 mg capsules (#30) + Acuwash cleanser Convenience Cost $549.04 $16.76 Prescriber EHR Patient Source: Goodrx.com December 21, 2017

Warehouse Store Morgidox Kit 100 mg capsules (#30) + Acuwash cleanser Convenience Cost $549.04 $16.36 ~ $30 - $50 Co-payment Prescriber EHR Patient ~ $5 - $15 Co-payment Profits Missed savings December opportunity 21, 2017

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Provider Influencers Favoring High Cost Meds VS Favoring Lower Cost Meds Patient preference Status quo bias Pharmaceutical drug promotion Health system education EHR Provider incentives 45

Conclusions CDS interventions for promoting lower cost alternative medications are effective Alternative medications with same dose/frequency correlate with higher rates of alternative acceptance Patient preference greatly impacts acceptance rates - ease of dosing regimen Many external factors, misaligned incentives and complex relationships within the prescription drug market pose significant challenges to achieving maximum benefit 46

Questions/Comments Special thanks! Lisa Anzisi, PharmD Jin Gwon David Ranson Osman Khalid Chrystal Johnson Contact: adam.szerencsy@nyulangone.org 47