The sPCMA Business Forum hosts payer-aligned specialty pharmacies and their business partners – payers, PBMs, drug manufacturers, and others. Speakers are among the specialty pharmacy industry’s top thought leaders and the Business Forum hosts the most specialty drug management decision makers of any industry conference.

Conference Program Book

Business Forum 2017 Agenda

Wednesday, March 8
9:00 am - 10:00 am

PCMA Leadership Session

The New Political Landscape

Mark Merritt, President & Chief Executive Officer, PCMA

The Evolution of PBMs from Offering Transactional Health Care Delivery to Care Management Delivery Focused on Population Health

William Fleming, Segment Vice President, Humana Inc. & President, Humana Pharmacy Solutions

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The Evolution of the Pharmaceutical Care Management Association (PCMA) – Taking a step back, what is PCMA?  Member companies have a strong transactional history of building evidence-based formularies and high performing networks to create affordable access to drug therapies for consumers and employers.  But PBMs do more than that—they are uniquely positioned to drive a transformation from transactional focused health care delivery to Care Management delivery focused on population health. The Care Management role of PBMs in value-based reimbursement models will be discussed in the context of the physician community, the drug supply chain, and the innovations of pharmaceutical manufacturers.

10:00 am - 10:30 am

Current Trends in the U.S. Pharmaceutical Market

Doug Long, Vice President, Industry Relations, QuintilesIMS

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This session will address current and future trends impacting the U.S. pharmaceutical market. Topics addressed will include traditional and specialty pharmaceutical market trends, pricing trends, drug innovation, biosimilars, and channel evolution including the growth of health systems.

10:45 am - 11:15 am

Breakout Sessions  (two concurrent)

Seeking Value: Value Frameworks in the New Policy Environment

Ed Pezalla, Payer Expert & Former Vice President and National Medical Director, Pharmaceutical Policy and Strategy at Aetna

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Over the past few years we have seen multiple value frameworks put forward. Why so many? Why now? During this session, Ed will provide an overview of the various value frameworks used by payers and he will discuss the implications for health technology assessment and especially drug evaluation in a rapidly changing health care environment.

By attending this session, you should be able to:

  • Describe what a few value frameworks do; and
  • Outline how they can be used to communicate important data elements regarding new and existing pharmaceuticals.

Formulary and Prior Authorization in an EHR World

Tony Schueth, Chief Executive Officer & Managing Partner, Point-of-Care Partners

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Today, more than 80% of doctors are prescribing electronically and use EHRs to drive clinical workflow. As a result, opportunities exist to integrate utilization management tools within EHRs and ePrescribing workflow for both specialty and non-specialty medications.  This session will examine key trends driving the automation of formulary and prior authorization within EHRs and how payers, PBMs and specialty pharmacies can use electronic prescribing to improve utilization management and eliminate barriers to medication access.

By attending this session, you should be able to:

  • Describe key formulary and prior authorization trends and their impact on prescribing, patient access to medications and medication costs;
  • Identify opportunities to address gaps in the automation of formulary, real-time benefit verification and prior authorization processes; and
  • Outline how coupons are being delivered within EHR workflow.

11:30 am - 12:00 pm

Breakout Sessions (two concurrent)

Addressing Appropriate Access for Managing Orphan Diseases

Lauren Barnes, Vice President, Managed Markets, Vertex

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The biopharmaceutical industry continues to focus on delivering high-value products, with increasing attention paid to specialty markets and orphan diseases. Based on the continued growth of specialty markets, payers are employing an increasing number of utilization management strategies, which can have a direct impact on patient access. This session will explore successful approaches to combating access challenges as well as ongoing challenges facing the biopharmaceutical industry. This discussion will also explore the specific challenges and opportunities presented by precision-medicines.

By attending this session, you should be able to:

  • Describe the current payer landscape as it relates to access for specialty drugs;
  • Outline at least two ongoing payer challenges associated with specialty products to treat orphan diseases; and
  • Identify some of the evolving issues likely to affect specialty and orphan disease access in the near to mid- term.

Confronting the Crisis We Brought Upon Ourselves:  America’s Opioid Abuse Epidemic

David Calabrese, Vice President & Chief Pharmacy Officer, OptumRx

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The opioid epidemic has been cited as one of the worst health care crises in American history.  Unlike previous epidemics our nation has endured, this one is quite unique in that it is the first in our nation’s history that can be attributed to our own health care system and ourselves as a society.  Through the over-prescribing of these medications by our nation’s physicians; the over-promotion of these agents by our nation’s pharmaceutical manufacturers; and our own lax attitudes as a society regarding acceptance, usage, storage, disposal and sharing of these medications.  In turn, we now have the highest per capita usage of opioids, as well as the highest per capita death rate due to opioid overdose, of any country in the world.  With this as a backdrop, we can no longer afford to stand idly as prevalence of opioid use disorder and death toll mounts.  In this session, we describe how our organization is doing its part to bring together resources and expertise from a wide array of disciplines to build out the type of end-to-end solution suite that we are confident will deliver the type of meaningful impact in this area this nation so desperately needs.

By attending this session, you should be able to:

  • Describe why the opioid epidemic can be attributed to our own health care system; and
  • Outline steps OptumRx is taking to confront the opioid epidemic.

1:30 pm - 2:15 pm

The High Price Drug Debate: Pricing and Access Strategies to Support Sustainable Health Care

Steve Miller, Senior Vice President & Chief Medical Officer, Express Scripts

Len Schleifer, Founder, President & Chief Executive Officer, Regeneron

Moderator: Sam Nussbaum, Strategic Consultant, EBG Advisors & Former Executive Vice President, Clinical Health Policy and Chief Medical Officer at Anthem

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The high cost of drugs is an important subject for the PBM and pharma industries today. Recent breakthrough therapies are delivering tremendous value to our health care system.  At the same time, a few bad actors are engaging in irresponsible pricing practices that offer little incremental value. Layered on top of all this, we have a new President who is calling for lower drug prices. These and many other factors are contributing to a business and political environment that threatens the ability for stakeholders to use free market solutions that our system has benefited from for so long.

The thought leaders on this panel will discuss how they are assessing the market in the current political and business landscape. They will address the issues they think are most pressing to make sure cost and access are appropriate, and they will discuss some new paradigms and whether they see the drug channel changing (or not) and how.

2:15 pm - 2:45 pm

Next Generation PBMs: Collaborating Across Health Care to Deliver Better Health for Patients while Reducing the Total Cost of Care

Mark Thierer, Chief Executive Officer, OptumRx

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PBMs have an incredible opportunity to drive innovative change with a new model that “goes beyond the prescription.”  By building new and productive partnerships across the health care value chain – with payers, providers, innovators and pharmaceutical companies – to treat the whole person and support consumers on their health journey, PBMs are uniquely positioned to drive better health outcomes, impact the total cost of care and help all stakeholders succeed in a value-based system.

3:00 pm - 3:30 pm

Breakout Sessions (two concurrent)

Biosimilars are Finally Here: So What Happens Now?

Larry Blandford, Executive Vice President, Managing Partner, Precision for Value

Todd Edgar, Senior Vice President, Specialty Services, Precision for Value

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This session will describe the launch of biosimilars in the U.S. thus far and what key factors will happen next that will shape the future of biosimilars.  Larry and Todd will review the performance of the first marketed biosimilars compared to expectations from previous research.  They will share recent research on how health systems intend to manage biosimilars within their environments, highlighting implications for both payers and manufacturers.  Lastly, they will discuss potential payer actions in light of the experience to date to maximize the potential cost savings from biosimilars, including the impact of patient and provider comfort and understanding, implications with Medicare Part D benefit, the role of interchangeability and pricing and contracting considerations.

By attending this session, you should be able to:

  • Describe the market reaction and uptake to the first launched biosimilars in the U.S. market;
  • Outline how health systems view biosimilars and what impact their actions may have on payers and manufacturers; and
  • Summarize potential actions by payers that will shape the evolution of the biosimilar market.

Considerations around Payer Preferred Pharmacy Networks and Manufacturer Limited Distribution Networks

David Galardi, Vice President, Apogenics, Inc.

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Preferred and limited networks are increasingly used by both PBMs and manufacturers to control drug cost and/or access. PBMs set preferred pharmacy networks to negotiate discounts and generate savings for payer clients.  At the same time and as more specialty products come to market, manufacturers are evaluating channel strategy and channel partners, and they are increasingly limiting the sale of their products to a select number of specialty pharmacies.

During this session, David will discuss the competing needs and interests of these preferred pharmacy and limited distribution networks.  He will review how a PBM sets a network, what is required for network participation, etc.  He will compare this to how manufacturers authorize purchasing and their class of trade considerations when launching a product. He will compare services offered to patients participating in these networks and how competition influences selection criteria.

By attending this session, you should be able to:

  • Outline how a PBM develops a preferred pharmacy network;
  • Outline how a manufacturer considers its channel strategy; and
  • List some of the competing needs of PBM preferred and manufacturer limited distribution networks and their effect on the plan sponsor.

3:45 pm - 4:15 pm

Breakout Session

Speaking of Value: Continuing the Evolution of Evidence Communication

Jay Jackson, Manager, Avalere Health

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Manufacturers and payers have demonstrated interest in the ability to discuss information related to the labels of medical products in order to make informed decisions about the relative value of treatments. Recent clarity on the safe harbors for evidence communication may encourage the proliferation of these types of discussions, however, some uncertainty remains.

By attending this session, you should be able to:

  • Describe the context for recent regulatory and legislative action;
  • Characterize manufacturer perspectives on evidence communication; and
  • Prepare for future developments in discussions of effectiveness in the shift to value.

Thursday, March 9
9:00 am - 9:45 am

The Shifting Landscape of Specialty Pharmacy Business Models

Chris Bradbury, Senior Vice President, Integrated Clinical Solutions and Specialty Pharmacy, Cigna Pharmacy Management, Cigna

Randy Falkenrath, Vice President, Specialty Strategy, Humana Pharmacy Solutions

Daniel Kus, Vice President, Ambulatory Pharmacy Services, Henry Ford Health System

Moderator: Dave Moules, Vice President, U.S. Payer and Channel Access, Pfizer

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The distribution channel for specialty drugs continues to evolve in a dynamic manner with increasing demand for greater clinical and health outcomes, drug and medical savings, integration with other care providers and new revenue growth.  Defined drug distribution agreements continue to grow in number and complexity.  Expansion of 340B pricing continues to drive channel implications. In addition, large health systems are increasingly investing in specialty pharmacy capabilities to serve ongoing patients’ specialty drug needs under the medical and pharmacy benefits.   These changes have important effects for specialty pharmacies’ business opportunities and for manufacturers’ channel strategy. This panel will allow attendees the opportunity to hear different perspectives from various stakeholders in the evolving landscape of specialty drug distribution.

9:45 am - 10:15 am

Beyond the Headlines: Health Care & Regulatory Policies under a Trump Administration

Tom Barker, Partner, Co-Chair, Healthcare Practice, Foley Hoag LLP

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Halfway into the first 100 days of President Trump’s first term, many questions remain about the regulatory and legislative realities we will face in the coming months and years. What will the Administration do (and can they do it)? What will Congress do (and how will they do it)? How will the market stabilization rule released on February 15 change the dynamic, if at all?  Are there more rules to follow? What does a repeal/replace proposal looks like (and when does it happen)? What does a transition/stabilization package look like (and will it work)? Key elements that will be addressed include Medicaid, Medicare and the Individual Market, Executive Orders, and Congressional replacement proposals.

During this session, Tom will explore what we know, what we think we know, and what we want to know.

10:30 am - 11:00 am

Breakout Sessions (two concurrent)

Medical Formulary Management for High-cost Specialty Drugs

Jim Rebello, Senior Director, Formulary Strategy, Magellan Rx

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With specialty drug costs continuing to rise there is urgency to manage trend and costs. Formulary management strategies to minimize the costs of specialty drugs are common on the pharmacy benefit, but rarely are formulary controls implemented on the medical benefit despite medical drugs making up half of the specialty drug spend.  During this session, Jim will discuss the concept of a medical formulary, from the clinical review process to the actual implementation of formulary controls across several key specialty drug categories.

By attending this session, you should be able to:

  • Identify the key high-cost specialty categories that fall on the medical benefit;
  • Describe the review process for identifying which medical drug categories are appropriate for a medical formulary; and
  • Outline the implementation of a medical formulary including the utilization management tools used to encourage appropriate use of the preferred drugs.

Orphan and Rare Disease Products and Exclusive Pharmacy Networks

Bill Roth, Founding Partner, Blue Fin Group
Phyllis Kidder, Principal Consultant, Blue Fin Group

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Orphan and rare disease products are estimated to comprise almost 20% of the dollar value of the pharmaceutical market by the end of the decade.  With uber-small patient populations, the industry will struggle with how these products are likely to be placed in an exclusive pharmacy network.  This exclusive pharmacy network approach is likely to present a frustration, if not a challenge, for payers, integrated health systems operating as ACOs, and the long list of pharmacies potentially left out of this portion of the pharmaceutical market.  This session will explore the importance of channel design, manufacturer considerations for choosing network partners, and how this is likely to evolve over time.

By attending this session, you should be able to:

  • Outline why orphan and rare disease products are likely to be placed in exclusive pharmacy networks;
  • Discuss the frustrations of payers, integrated health systems, and pharmacies that are not included in these networks; and
  • Describe when and how to approach manufacturers and what attributes “win” exclusive pharmacy network status.

11:15 am - 11:45 am

Breakout Sessions (two concurrent)

Specialty Pharmacy Trends and Pharmaceuticals in Development

Jay McKnight, Director, Pharmacy Clinical Strategies, Humana Pharmacy Solutions

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With specialty drug spend on the rise and the pharmaceutical pipeline dominated by potentially high cost blockbuster drugs, it is important for payers to proactively monitor the specialty pharmaceutical pipeline.

By attending this session, you should be able to:

  • Discuss key specialty market trends and recent specialty drug approvals;
  • Identify high impact specialty medications that are likely to affect drug trends; and
  • Discuss indications, efficacy, safety, and potential impact of new and emerging specialty medications.

Oncology Utilization Management: Opportunities or Threats to Improve the Quality of Patient Care

Debbie Stern, Senior Vice President, Medical Oncology and Specialty Drug Management, eviCore

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Health plans and PBMs recognize that they need to tackle the ever-increasing cost of cancer care, but are inundated with various strategies – both proven and unproven – to decrease cost with the promise of improved quality of care. Complicating the situation is the shift in benefit coverage of individual oncology drugs from primarily the medical benefit to a mix of oral and infused drugs covered under both the pharmacy and medical benefit.  It is not unusual for a patient to be taking multiple therapies that span both benefits which may be managed by different entities. This siloed management results in the need for providers to seek drug authorization from multiple entities using different management methodologies.  The end result is delays in treatment and provider office inefficiencies.

This session will highlight some of the latest oncology clinical, utilization and reimbursement tools and assess their ability to shift the value equation to result in true cost savings while increasing the overall quality of the cancer patient’s care.

By attending this session, you should be able to:

  • Describe the role oncology clinical pathways play in promoting evidence based treatment;
  • Identify management practices that improve provider efficiencies;
  • Evaluate the strengths and weaknesses of readily available tools for assessing the value of cancer treatment options; and
  • Identify strategies payers can deploy to optimally increase the value of cancer care in the future.

12:00 pm - 12:30 pm

Breakout Sessions (two concurrent)

Exclusions, Prior Authorization, and Step Therapy: Payer Responses to Manufacturer Strategies

Sharon Glave Frazee, Vice President, Research and Education, PBMI

Jane Lutz, Executive Director, PBMI

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Pharmaceutical manufacturers, payers, and PBMs share many goals including improving overall health of consumers while at the same time creating profitable businesses. However, payers more than ever are faced with financial challenges due to the escalating costs of specialty drugs that have resulted in management strategies to contain these costs. This session will include a discussion of pharmaceutical manufacturer tactics and strategies and the responses from the payer community. Using data from a national survey of employers and other payers, we will illustrate the strategies most commonly used by payers and what they are considering for the next one to two years.

By attending this session, you should be able to:

  • Describe why payers are increasing their management tools;
  • Outline at least two manufacturer tactics for achieving formulary placement; and
  • List at least two of the utilization management strategies payers are using to control drug costs.

Can Digital Technologies Solve America’s Medication Adherence Problem?

Harry Travis, President & Chief Executive Officer, etectRx

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In the United States, the direct and indirect cost of poor medication adherence is estimated to be between $100 billion and $300 billion per year.  The rapid growth of high cost specialty medications and a greater focus on outcomes-based payment models has created even greater urgency to improve medication adherence. Smartphones, the digital revolution and ubiquitous internet access have given the vast majority of patients access to enormous communication and processing power that can be brought to bear on this problem.

During this session, Harry will give a high-level overview of the various technologies that are coming to market to address the medication adherence problem and present criteria for evaluating the products and services.  The market entrants include smartphone apps, avatars, smart pill bottles, smart bottle caps, packaging solutions, counter-top dispensers, smart inhalers, facial recognition selfies, and digital pills.

By attending this session, you should be able to:

  • Quantify the medication adherence opportunity;
  • Outline some of the forces that are making adherence even more important; and
  • Describe case studies of two or three successful innovations of adherence technologies.

2:00 pm - 2:30 pm

Breakout Sessions (two concurrent)

Taking a Close Look at Specialty Drug Trend and Management Implications

Rochelle Henderson, Senior Director, Research, Express Scripts

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The George Santayana quote “Those who cannot remember the past are condemned to repeat it”, is befitting a discussion on the topic of specialty drug trend management. At Express Scripts, we examine specialty trends and patterns in our development of programs to ensure that patients aren’t caught in the middle while manufacturers, payers, and other stakeholders result in lifesaving medications that may be out of balance with the access and ability to pay for treatments and cures. We were the first pharmacy benefit manager to develop an indication-based pricing solution for oncology drugs. This approach is based on establishing contracts with manufacturers that set different prices for different indications based on the drug’s relative value. And we continue to investigate opportunities to extend this approach to other therapies.

By attending this session, you should be able to:

  • Describe specialty drug trends and why they matter as stakeholders think about the future;
  • Outline the SafeGuardRx™ program that payers are utilizing to control specialty medication spend and why clinical, not economic, factors must be the backbone of every solution; and
  • List some of the bold actions taken to control spend while improving outcomes.

MACRA Opportunity and Challenges for Pharmaceutical Companies and Specialty Pharmacy

Stephen George, Senior Consultant, Milliman

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After the presentation the attendees will possess a basic understanding of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as an alternative payment model (APM) and its impact on pharmaceutical companies and specialty pharmacy providers (SPPs). Under the APM, physician payment is tied to quality, Part B drug cost, and patient hospitalizations. The Part B drug cost and demonstrable outcomes will impact the physician payment performance. It is likely physicians will need to understand the value a drug brings to their patients and not just the drug cost. This has the potential to impact pharmaceutical company scientific messaging. SPPs have an opportunity to assist the physician understand the cost benefits of a drug. SPPs can leverage the physician relationships to improve patient adherence and important quality metrics which impact the physician reimbursement.

By attending this session, you should be able to:

  • Highlight key components of alternative payment model design;
  • List some potential challenges that could impact physician reimbursement under MACRA; and
  • Describe some opportunities that are available to pharmaceutical companies and specialty pharmacy providers within the MACRA framework.