As we look back on 2017, it was a year of many milestones on the United States (U.S.) drug approvals front. With 46 novel drugs receiving Food and Drug Administration (FDA) approval, it reached a 21-year high and more than doubled novel drug approvals in 2016. This count does not even include a number of biologics, vaccines, cell-based therapies, and the first ever, direct gene therapy for a hereditary disease.

Among the historic clinical highlights of 2017 was the landmark approval of two CAR-T therapies, tisagenlecleucel (Kymriah™) and axicabtagene ciloleucel (Yescarta™), for select types of leukemia and lymphomas, respectively. CAR-T or chimeric antigen receptor-T (CAR-T cell), is a multiplex process where a patient’s T cells are harvested, genetically modified, and infused back into the same patient to fight cancer cells. 

The role of specialty pharmacies in the invoicing construct for these costly CAR-T therapies is a fascinating component of these new treatment modalities. As illustrated in the CAR-T Invoicing Flowchart, the product is shipped directly from the manufacturing facilities to the certified hospital or treatment facilities. Once the certified hospitals take ownership of the product, they bill the payers who, in turn, pay the certified hospitals. The specialty pharmacies serve as the billing wholesaler between the manufacturers and the certified hospitals to invoice the hospitals and, ultimately, deliver payment to manufacturers. In this unique model, the specialty pharmacy does not handle the drug; rather, it serves as the invoicing clearinghouse between manufacturers and certified hospitals. Hence, there is no interaction between the specialty pharmacy and payers.

Specialty pharmacies are at the epicenter of care for patients with complex conditions. As a high-touch resource, they operate in a clinical environment that leverages specialty pharmacies’ services to dispense, distribute, provide monitoring, case management, adherence programs, reimbursement, and a number of other services particularly for patients with complex and rare diseases. In the CAR-T invoicing construct, the specialty pharmacy takes on the exclusive role of shepherding the invoice.

As we look ahead, future complex therapies will present a new paradigm for all stakeholders including prescribers, pharmacies, payers, patients, hospitals, and regulators. Specialty pharmacies, as an invoicing liaison, may be yet another facet in the evolution towards the next frontier – Specialty Pharmacy 2.0.

Today, much of the conversation around opioid use focuses on ways to more tightly control access, including limits on usage and the mandatory use of databases that can alert physicians to patients’ opioid histories. But for those suffering from Opioid Use Disorder (OUD), combatting addiction is a difficult feat, particularly due to treatment barriers, lack of qualified providers, and waitlists for evidence-based treatments.

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As healthcare evolves, reimbursement models continue to shift from volume to value. That means more providers are taking risk and moving into value-based reimbursement models. One such model is the Accountable Care Organization (ACOs) in which the provider has accountability for achieving quality improvements and spending reductions.

ACOs are not the only model. In today’s market, providers often form and/or contract with entities such as Managed Services Organizations (MSOs), Clinically Integrated Networks (CINs), or Independent Physician Associations (IPAs). For providers, the benefit of these organizations is clear: they supply the infrastructure and tools to be successful in meeting quality and cost targets required for their value based contracts. The result is better care for patients (especially the chronically ill), reduced waste and inefficiencies and financial incentives that are structured on quality benchmarks. ACOs, MSOs, CINs, and IPAs all incentivize primary care providers (PCPs) to improve the health of their entire patient population.

There are hundreds of these organizations across Medicare, Medicaid, and Commercial lines of business and many are executing value contracts and already realizing shared savings for primary care.  As they come together, the providers develop increased access to enhanced technology and expanded patient reach.  As these organizations mature, they are also beginning to engage specialists in value initiatives.

Magellan’s view of value is Specialty Care

To support value in specialty care, Magellan has developed a provider solution that is centered on behavioral health and physical health integration. It is designed specifically for provider organizations to successfully manage population health and take on risk under value based reimbursement through clinical, operational, and digital capabilities. Program components support the entire continuum of care and include:

• Screen & Engage: More accurate diagnosis through tools that are embedded into the primary care practice workflow
• High Performance Networks: Increased access to providers with improved quality and efficiency scores who embrace the vision of population health and support value based payment
• Case Management: Collaborative approach with warm hand-offs between the primary care office to Magellan to drive better outcomes
• Collaborative Care Model: Team-based integrated behavioral healthcare driven by Magellan expertise and digital screening capabilities to track patient progress and treat to target
• Authorization Support, Concurrent Review  & Transitions of Care: Discharge planning and case shaping to support patients transitioning from an inpatient facility to their home
• Telehealth: Increased access to care through a network of telehealth providers and text therapy providers
• Other Digital Solutions: Digital Cognitive Behavioral Therapy (D-CBT) for patients that is integrated with Magellan’s Smart Screener

In addition to the core solution set, Magellan has a comprehensive suite of behavioral health, specialty, and pharmacy products that can be customized for provider organizations. Magellan also supports providers in developing accountable care organizations for complex specialty care such as cardiac conditions. This approach supports and incentivizes cardiologists to proactively managing patients to improve quality and reduce costs. Magellan recently entered into its first specialty ACO relationship and will continue to develop and launch these types of relationships.

Magellan Health Insights: Hi Gina, thank you for sitting down with us. What can you tell us about the ACCOM Pilot project?

Gina Vehige: ACCOM—Accountable Cardiac Care of Mississippi—is the name of a venture between Cardiology Associates of North Mississippi (CANM) and Magellan Health. In November of 2017, CANM and Magellan came together to explore ways for both organizations to gain experience and succeed in a value-based reimbursement environment.

CANM physicians, nurse practitioners, and staff provide and oversee patient care. Magellan provides the data analysis as well as case management, and systems such as utilization management and clinical decision support, case management, and behavioral health screening tools.

ACCOM’s first value-based reimbursement contract is with Blue Cross and Blue Shield of Mississippi. Blue Cross and Blue Shield of Mississippi provides the claims data for Magellan to analyze and set mutual performance targets for cost and quality with CANM.

MHI: Can you explain what value-based reimbursement means and why it’s important?

GV: Value-based reimbursement is a new way of paying for medical care. With value-based reimbursement, providers are given cost and quality targets and the associated responsibility for achieving those targets in order to be paid their fees and a share of the savings as well as quality incentives.

Under the old fee-for-service model, providers ordered tests, procedures, office visits, and so forth and were then paid per service performed. Essentially, the more services provided, the more fees could be made. As a counter balance, payers managed utilization and quality through top-down utilization management measures and quality improvement incentives. These efforts often resulted in additional work for providers to justify each procedure and obtain authorizations by fax, telephone, or web portal. The effectiveness of the utilization management and quality improvement under fee-for-service was debatable.

MHI: You mentioned analytics – why are analytics so beneficial to these arrangements?

GV: Quite simply, physician practices still exist in a void of actionable information. Historically, practices were limited to the data provided in their billing and scheduling systems. Even electronic medical records (EMR) typically evolved to emphasize the storage of patient demographic and encounter data only. If physicians can ONLY get to their own data, they can’t compare or benchmark their cost and quality performance to their competitors.

Magellan’s expertise in analyzing claims data provides physicians with insight into their practice and provides them with the ability to identify opportunities for improvement. It allows them to ask the critical questions that help them manage a population:

• How many patients who were prescribed a medication actually stayed compliant (consumed and refilled) their medication as often as should be expected?
• How many patients with congestive heart failure are actually on the recommended therapy for that disease?
• How many patients who received an implantable device were tried on optimal medical therapy for a sufficient time before an invasive intervention was implemented?
• What percentage of patients are achieving their blood pressure and cholesterol management goals?
• What percentage of patients are keeping their follow-up appointments?

Those are important questions for physicians to have answers to. By having access to this information, a physician can improve outcomes, reduce costs, and improve patient and provider satisfaction.

MHI: What other expertise does Magellan bring to a group like CANM?

GV: The ability to manage the patient across the continuum of care and time—even while they are home— is key to managing the chronic conditions often associated with heart disease. For patients at risk, regular contact with a case manager to ensure treatment plan and medication compliance, can provide motivation and support to deal with the burden of disease. Beyond our analytical capabilities, Magellan brings population management expertise and systems that help the practice manage the patient through their entire case experience, not just when they are hospitalized or seen in the physicians’ office.

Another key toolset that Magellan provides is clinical decision support and utilization management, through the use of our guidelines and systems. These help the providers ensure that the services provided meet national guidelines wherever appropriate. Whenever guidelines are not met, but the procedure or tests are still felt to be appropriate, physicians will enhance the validity of the medical record by thoroughly documenting why exceptions should be made for an individual case. Magellan provides the staff, training, guidelines, and tools that are the basis for such reviews.  The associated reporting that goes along with this activity can help the practice identify opportunities to be more efficient in the provision of care.

Finally, Magellan brings a great deal of expertise in case management. Our services and tools allow the case managers to engage patients and identify priorities for improving their overall health. Regular outreach with patients help provide crucial support and can identify changes in condition that can be addressed via office visits or medication adjustments before symptoms exacerbate and the patient requires emergency room visits or hospital stays. This additional level of contact with healthcare professionals can also be comforting to patients who are anxious about their disease.

MHI: Why CANM—Why were they a good fit for Magellan?

GV: CANM is a large cardiology practice (13 physicians, five nurse practitioners, one pharmacist) based in Tupelo, Mississippi, and supporting the surrounding 26 counties. They have a history of being at the forefront of technology and high quality cardiac care. In addition, CANM embraced the cardiovascular guidelines presented by Magellan. CANM also took the lead on reviewing the pharmacy claims data compiled by Magellan to develop their own practice formulary, focusing on lower cost generic medications wherever clinically appropriate. CANM also engages in cardiology research, helping to identify the best cost and quality interventions to improve cardiac health.

MHI: What are the challenges facing cardiologists in the current marketplace?

GV: Right now, a typical cardiologist “controls” 90 percent of the cardiac spend, but makes in fees about 10 percent of those dollars. For example, if the physician orders a test to be performed in a hospital setting, he or she may get a fee for examining the patient and interpreting the test, but they do not get money for the use of the facility, equipment or staff to run the test. A similar situation occurs when physicians order a medication.

In the fee-for-service environment, income from procedures is high, but under pressure from the focus on utilization management. Time spent counseling and supporting patients to modify lifestyle risks—while vitally important to overall health and cardiovascular disease risk reduction—is less valued. Furthermore, physician satisfaction is at an all-time low, across all specialties. By rewarding providers for managing high-cost procedures and spending time helping patients during and between office visits do more to manage their life-style risks, physicians achieve greater satisfaction from their work and less burn-out.

MHI: What’s next? Where do you see new challenges in the future and how do we meet them?

GV: I see a continued migration to value-based reimbursement arrangements. Provider groups will come together with other provider groups in an attempt to better manage risk within their populations. These provider groups will be the market of the future, and it will serve us well to prepare to serve that market with the valuable services we have established over years of experience serving health plans. Payers will increasingly leave it up to the providers to find the most efficient and effective ways to deliver the full continuum of care with the right partners. Magellan can utilize and improve our existing tools to serve these new markets to help both health plans and providers succeed.

How good are you at coping with adversity? Somehow, life always finds a way to present you with challenges that you didn’t see coming. Fortunately, you can improve your resilience skills—enabling you to bounce back when confronted with a crisis or an overwhelming change.

1. Differentiate problems from your response to them.

You have the option of reacting with panic, or responding in a calmer, measured way that allows you to proceed logically toward a solution. It’s your choice!

2. View your strengths positively.

Remind yourself that you’ve gotten through tough times before and be confident in your ability to re-apply those successful strategies.

3. Always be ready for change.

Remind yourself that life is always ready to throw you a new curve, and that sometimes the advent of a big, intimidating change can end up being a positive learning experience that helps you grow.

4. Keep your perspective.

No matter how overwhelming your problem might seem, try to view the situation in the longer- term context of your life and the larger world.

5. Lean on close family, friends and peers.

Being able to share concerns— and to brainstorm innovative solutions together—can give you more confidence as you move forward.

6. Stay flexible.

Try not to get locked into a single approach to solving a problem and have a flexible mindset.

7. Don’t forget your own needs.

In times of crisis, staying physically and spiritually fit helps you fight off stressors of all kinds!

8. When in doubt laugh at it.

Try to find those nuggets of humor, shake your head, and laugh at life’s wackiness.

9. Look for light at the end of the tunnel.

No matter how difficult or uncomfortable a situation may be, remember that even the darkest of days won’t last forever.

10. Keep building you resilience skills.

It may take time to learn how to stay balanced when times are tough. Keep learning from others who seem resilient, and build upon your valuable experience and personal strengths.

Holidays are meant to be a joyful time celebrating with family and friends, enjoying time off from work, and indulging in delicious meals. That said, it is also easy to get overwhelmed and anxious as you try to keep up with multiple demands on your personal, family and work life.

Try these sanity savers to help you find the right balance so you can focus on making positive memories this holiday season:

• Keep it simple (and be realistic): Perfection is overrated. Don’t put pressure on yourself by committing to every party or making your own party a gala event. Focus on what makes the holidays special for you.
• Set aside differences: Try to accept family members and friends as they are, even if they don’t live up to all of your expectations. Set aside grievances until a more appropriate time for discussion.
• Stick to a budget: Before you start shopping for gifts, food, and decorations, decide how much money you can afford to spend. Don’t try to buy happiness with excessive gifts or lavish meals.
• Plan ahead: Identify possible challenges that can trigger stress and develop an action plan to feel prepared to deal with them. Set specific days for shopping, cooking, traveling, visiting friends, and other activities.
• Keep healthy habits: Don’t let the holidays become a free- for-all. Overindulgence only adds to your stress and guilt. Get plenty of sleep and make as much time for exercise as you can.
• Take a breather: Pay attention to your own needs and feelings. Spend a little time by yourself if you can. Meditate, do some relaxation breathing, or go for a short walk.
• Control the controllable: As families change and grow, traditions often do as well. Choose a few to hold on to, and be open to creating new ones and finding new ways to celebrate together.

Take steps to prevent stress and find peace and happiness this holiday season.

Magellan’s own Chairman and CEO, Barry M. Smith, was recently featured in Behavioral Healthcare Executive, talking about the importance of prioritizing behavioral health as a part of disaster recovery.

In the article, Barry discusses how delivering innovative access to behavioral health services is critical to enabling not only physical, but emotional renewal.

Read Barry’s complete article here.

Mike* was dancing wildly to hip hop music before running up to me and confidently stating, “I’m a leader.” He told me about how he ran to be a class officer and lost but how he was not going to give up. He talked about his search for a life-long mentor and how he wanted to make the world a better place. Not the type of random conversation you would expect at an outdoor community event, but MY LIFE youth are not average.

Since 2007, Magellan Youth Leaders Inspiring Future Empowerment, or MY LIFE, has proactively sought to change the trajectory of young lives engaged in the foster care and juvenile justice systems, as well as youth with behavioral challenges. Led by Greg Dicharry, Magellan’s national director for youth empowerment, monthly MY LIFE groups and annual MY FEST events have provided thousands of youth an opportunity to connect to their community and hear stories of overcoming hardships and reaching for their full potential. In Florida alone, groups in Tallahassee, Orlando and West Palm Beach enable over 100 youth ages 13 to 23 to meet monthly in a safe environment where fun and inspiration are plentiful.

Getting to spend time with youth involved in MY LIFE underscores the impact. One young man who has been attending a Florida MY LIFE group for three years described how the motivational speaker’s life lessons inspired him to focus on his future instead of focusing on his past. He told me about the hard times he was going through now and how the stories of the speakers going through tragic times provided him with the feeling that “it’s not too late for me.” It was a tough thought to imagine that at only 16 years old, this young man felt like the cards had already been stacked against him. MY LIFE provides a consistent message that he and his peers have the power and support to create a future different from their current reality.

And then there was Mike with his boundless energy. He may never lose that energy, which could either lead him down a path that is damaging to himself and others, or one that honors his strengths and abilities as he contributes to society. MY LIFE has helped him set upon the latter path. His future can now be one where his energy is directed into developing his leadership skills, pursuing higher education and a meaningful career, despite the challenges he might face at home or at school.

MY LIFE is just one way Magellan is supporting young leaders to help make our communities stronger.

*Mike is not this individual’s real name.