Ian Duncan: Predictive risk in a US pharmacy

Proprietary & Confidential, Property of Walgreen Co.

July 8, 2013

Predictive Risk in a U.S. Pharmacy

Proprietary & Confidential, Property of Walgreen Co. ©2013

2

Introductions

Author of several books and peer-reviewed studies in healthcare management and predictive modeling.

Published 2008 (*new ed. October 2013) May 2011

Ian Duncan FSA FIA FCIA MAAA. Vice President, Clinical Outcomes, Analytics Reporting; Head of Clinical Research, Walgreen Co. Chicago. Adjunct Professor at UC Santa Barbara and Adjunct Research Professor, Georgetown Dept. of Health Administration.

Board member, Massachusetts Health Insurance Connector Authority (Exchange).


3

Begin with a New Strategic Vision . . . .


Purpose Help people get, stay and live well.

Brand

Mantra Well at Walgreens: happy and healthy made easy.

Vision To be the first choice in health and daily living for everyone in America… and

beyond.

Mission

In communities across America, be the trusted advisor and convenient

multichannel provider of innovative pharmacy, health and wellness solutions,

consumer goods and services. A destination where health and happiness come

together to help people get well, stay well and live well.


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. . and transition beyond the corner drugstore to be One Destination for Wellness

Immunizations

s

Workplace Health

Centers & Pharmacies

s

Health

Testing s

Community

Pharmacy

s

Take Care

ClinicsSM s

Adherence Programs; Wellness Initiatives

Specialty Pharmacy & Infusion Services

Health Systems Solutions: Outpatient

Pharmcies and WellTransitions

Home Infusion

Mail & Mobile

Pharmacy s


5

Walgreens Core Strategies

Deliver the Well Experience

Transform the customer experience across all touch points, channels and formats

Transform the Role of Community Pharmacy

Offer unparalleled access to innovative, high quality, affordable health and wellness services within our communities

Create an efficient global platform

Become the first global pharmacy-led health and wellbeing enterprise


6

Global Leadership – Walgreens and Alliance Boots

Largest global pharmacy solutions provider

Largest global purchaser of prescription drugs

Over 1 billion prescriptions filled annually

$53 billion in branded pharmaceutical

purchases

370 pharmaceutical wholesale distribution

centers worldwide

12,000 points of care located in more than 25

countries

More than 8000 of the best corners in

America

More than 300,000 healthcare professionals

8 million in-store customer visits daily

More than 1.5 million online customer visits

daily

•Boots international countries: UK, ROI, Thailand, Netherlands, Middle East, Sweden, Norway

•Alphega: UK, France, Italy, Spain, Czech republic, Germany, Netherlands, Russia

•Wholesale countries: France, UK, Turkey, Spain, Germany, Russia, The Netherlands, Czech Republic, Norway, Egypt, Lithuania,

•Romania, Algeria, Croatia, Bosnia, Serbia, Slovenia, China, Italy, Portugal, Switzerland

•Alliance Boots

Retail

Take Care Clinics

Take Care Worksites

Health Systems Pharmacy

Mail

Home Infusion/RT

Specialty

Unequalled Global Presence

Walgreens

©2013 Walgreen Co. All rights reserved. 7

Proprietary & Confidential, Property of Walgreen Co.

Predictive Modeling Applications in the Pharmacy Space


9


Three Predictive Modeling Examples

1. Targeting non-adherent customers

2. Stratifying End-of-Life Patients in our Accountable Care Organizations

3. Identifying Medicare and Health Insurance Exchange patients for wellness

visits and Risk Assessments

Race Composition

Ave. Household Income

Unemployment Rate

% White Collar Workers

% Houses Vacant

% Houses Owned

Patient

Level

Age

Gender

Enabling Factors

Patient Level

Inferred Disease

Severity

Comorbidities

Monthly Rx Costs

Medication

Adherence

Community

(Block Group Level) Predisposing Factor

Patient Reported

Knowledge of Disease

Knowledge of Drug

Health Beliefs

Block Group Level

Marital Status

Ethnicity

Education

Occupation

Patient Level

Co-pay

Plan Type

Drug Regimen

Block Group Level

Average Income

Unemployment Rate

Need Factors

Patient Reported

Illness Perception

Beliefs in Meds

Lack of symptoms

Patient Level

Medication

Complexity

# medications

# prescribers

Patient Past Behavior

Drug Profile

Side Effects

Dosage

Frequency

Patient Level

Prior Proportion of Days Covered

Late Refills

Generic Drug Utilizations

% Transient Population

% Seasonal Population

% Bachelor Degree & Above

Ave. Vehicles/Household

Accessibility of Pharmacy

Population Growth Indicator

A Conceptual Model of Medication Adherence


Actual PDC and Non-Adherence Rate in 6 & 12

Month Periods from the Index Fill – New to Therapy

63.93%

72.55%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

6 Month % Non-Adherence

12 Month % Non-Adherence

0.58

0.48

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

6 Month PDC 12 Month PDC

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Actual PDC Non-Adherence Rate


100.0% 99.7% 98.5% 95.3% 89.3% 79.6% 65.9% 43.7% 16.1% 1.4%

64.0% 64.1% 64.6% 65.6% 67.6%

70.6% 74.5%

80.5%

86.0%

92.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

>=0% >=10% >=20% >=30% >=40% >=50% >=60% >=70% >=80% >=90%

% o

f To

tal P

ati

en

ts

Predicted Risk

% of Total Patients Positive Predictive Value (PPV)

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Positive Predictive Value and % of Total

Patients by Cumulative Predicted Risk


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Overview – ACO Clinical Programs

(1) Prevent over-medicalized End-Of-Life

(EOL) care.

(2) Prevent unplanned Transitions in care.

(3) Prevent Ambulatory-Care-Sensitive

(ACS) hospitalizations.*

(4) Improve decision-making for Preference-

Sensitive Treatments

* especially for patients with a combination of acute + chronic

+ mental health issues.

Key Point: High Opportunity ≠ High Cost or High Risk Score.

High cost and/or

highly intervenable

patients


Preventing over-medicalized End-Of-Life care

↑

Population

health

↓

Administrative

burden

↓

Per capita cost

↑

Patient

experience

Reduction in

inappropriate

life-sustaining

treatments

within 6

months of

death,

including a

reduction in

ER visits.2

Dedicated

case managers

to support

physicians in

caring for

complex

patients that

are at very high

risk of over-

medicalized

end-of-life care

as defined by

Barnato et al.2

Home-

hospice care

associated

with

significantly

lower average

costs ($12,434

versus $4,761

per year in

2007 dollars).5

Patients

receiving in-

home

palliative care

report

significantly

higher

satisfaction

and quality of

life.6

Clinical Program:

• Education for physicians and

their staff on how to instigate

end-of-life conversations.3

• Program to encourage patients

to complete advance directives,

consisting of materials, a

helpline, and a registry.4

• Patient access to hospice and

palliative care.

• Symptom-focused case

management for very high-risk

patients.3

1 Zhang B, Wright AA, Huskamp HA, et al. Health care costs in the last week of life: associations with end-of-life conversations. Archives of Internal Medicine. 2009;169(5):480 2 Barnato AE, Farrell MH, Chang CC, Lave JR, Roberts MS, Angus DC. Development and validation of hospital "end-of-life" treatment intensity measures. Medical Care.

2009;47(10):1098-1105 3 Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver

bereavement adjustment. JAMA 2008; 300(14):1665-73 4 Nicholas L, Langa KM, Iwashyna TJ, Weir DR. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA 2011;

306(13):1447-53 5Shnoor Y, Szlaifer M, Aoberman AS, Bentur N. The cost of home hospice care for terminal patients in Israel. Am J Hosp Palliat Care. 2007 Aug-Sep;24(4):284-90 6 Brumley R, Enguidanos S, Jamison P, Seitz R, Morgenstern N, Saito S, McIlwane J, Hillary K, Gonzalez J. Increased satisfaction with care and lower costs: results of a

randomized trial of in-home palliative care. J Am Geriatr Soc. 2007 Jul;55(7):993-1000.

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End of Life Predictive Model – Performance of Model on Medicare 5% Database

Out of a 10,000 attributed life group, we would expect 430

overmedicalized deaths (4.3%). Based on our model, approximately

46% of these members will have risk scores >.95.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

0 -

10%

10

-15%

16

- 2

0%

21

- 2

5%

26

-30%

31

- 3

5%

36

- 4

0%

41

- 4

5%

46

- 5

0%

51

- 5

5%

56

- 6

0%

61

- 6

5%

66

- 7

0%

71

- 7

5%

76

- 8

0%

81

- 8

5%

86

- 9

0%

91

- 9

5%

96

- 1

00

%

% of Total OM Deaths

% of Total OMDeaths


What is a Medicare/Exchange Wellness Visit?

Components Welcome to Medicare

Preventive Visit

Medicare Yearly

Wellness Visit

• Medical/Social History √ √

• Depression Screening √ √

• Mood Disorders Screening √ √

• Functional Ability Screening √ √

• Falls Risk Screening √ √

• Home Safety Screening √ √

• Physical Exam (height, weight, blood pressure, BMI,

visual acuity, other factors as appropriate)

√ √

• End-of-Life Planning √

• Education, Counseling and Referral √ √

• Written plan for appropriate screenings and other

covered Part B preventive services

√ √

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Walgreens unparalleled access to clinical (drug) data allows us to identify,

stratify and outreach to patients for this (free) service.


Improving 22 Stars/HEDIS Measures:

Functional Status

Advanced Directive

BMI Measurement

Adult Access to

Preventive/Ambulatory

Health Services

Flu Vaccine

Pneumo Vaccine

TAKE CARE CLINIC MEDICARE WELLNESS VISIT ADDITIONAL BIOMETRICS

Breast Cancer Screening

Colorectal Cancer Screening

CV Care – Cholesterol Screening

Diabetes Care – Cholesterol Screening

Glaucoma Testing

Improving or Maintaining Physical Health

Improving or Maintaining Mental Health

Osteoporosis Testing

Diabetes Care – Cholesterol Controlled

Diabetes Care – Blood Sugar

Controlled (HbA1C)*

Colorectal Cancer Screening – Fecal

Occult Blood Test*

Impact up to 6 Stars measures via

services provided during the visit Impact up to 8 Stars measures via

education provided during the visit

Impact up to 5 Part B services via

education provided during the visit

Diabetes Screening – Fasting Blood

Glucose

Pap Tests and Pelvic Examination

Prostate Cancer Screening

HIV Screening of At-Risk Patients

U/S Screening for Abdominal Aortic

Aneurysm

Impact up to 3 Stars measures

via additional biometric services

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Personalized Wellness Plan

Easy-to-understand

wellness plan

Delivered face-to-face with

a clear explanation of the

findings and clear

explanation of follow-up

recommendations

Educates patients about

potential gaps in care

8 Star measures

5 Part B services

Individualized approach that

facilitates member

adherence with

recommended follow-up

services

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Improving HCC Coding & Quality Measures

Drive improvements in HCC coding and 6-14 Medicare Stars and HEDIS measures:

INCREASED

ACCESS/PARTICIPATION

Expand member access to convenient locations, open 7 days a week

Increase member awareness in high-traffic Walgreens retail locations and through

marketing/communications support

Deliver care guided by evidence-based frameworks and assessment tools

Improve member adherence with an exceptional patient experience and an easy-to-

understand Personalized Wellness Plan

Coordinate care with members’ Primary Care Physician through electronic

transmission of informative visit summary

Connect patients with identified gaps in care to needed services

Receive timely, comprehensive data to improve HCC coding and Stars/HEDIS

measures

Identify at-risk patients for case management and disease management programs

CLINICAL EXCELLENCE

CARE

COORDINATION

TIMELY

DATA SHARING

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Health & Medicine

Ian Duncan: Predictive risk in a US pharmacy