HBN_Medco_Personalized Medicine

PowerPoint Presentation: 

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“Advancing Payer’s Healthcare: Medco’s Personalized Medicine Program Concept, Advantage & Value” : 

“Advancing Payer’s Healthcare: Medco’s Personalized Medicine Program Concept, Advantage & Value” Gabriela Lavezzari PhD,MBA Director of Extramural Development October 29, 2011

Topics to be addressed: 

Topics to be addressed Payer Personalized Medicine Program Medco’s model of business partnership with industry, academia, or government Provide a case study that integrated PM to improving payer’s healthcare

PowerPoint Presentation: 

Medco’s Core Competencies 4 PBM Specialty Pharmacy Mail Order Pharmacy Automated Dispensing Scale Purchasing Patient Management (Therapeutic Resource Centers & gaps in care) Utilization Management & Intervention Claims Adjudication Benefit Management Pharma Contracting Retail Network Management Health & Safety Data Management Patient Management Distribution Compliance Monitoring Nursing Services Data Reporting Medco Research Institute Commercial Programs Drug Utilization Genetics for Generics TM Research Labs

PowerPoint Presentation: 

5 Medco Research Institute - Mission Advance smarter medicine through R&D that illustrates how the integration of new science and technology into advanced pharmacy improves patients’ outcomes and reduces health care cost “ What will we do differently because of the result of this research? ”

Advancing Smarter Medicine: The Domino Effect: 

Advancing Smarter Medicine: The Domino Effect 6 MRI MRI Results TRC’s DNA Direct Clinical Practice Medco Programs Pharmacy Practice Accredo Specialty Pharmacy

MRI - Extramural R&D: 

MRI - Extramural R&D “Market Multiplier” “Medco is steadily becoming the go-to organization for diagnostics” Advancing Smarter Medicine™ through R&D collaborations with corporate partners that illustrates how the implementation of clinical innovations into medical and pharmacy practice improves patients’ outcomes and reduces healthcare cost

2010 PBM Client Drug Spend: 

2010 PBM Client Drug Spend

Medco Longitudinal Claims Database: 

Medco Longitudinal Claims Database As a PBM Medco manages outpatient drug benefits on behalf of payers 1/5 Americans are Medco Members (~65 million covered lives) Medco Clients are self-insured employers, health plans, government and Medicare Medco processed >0.5 Billion prescriptions in 2010 Pharmacy and medical longitudinal claims database Longitudinal Pharmacy claims on all 65 Million covered lives Longitudinal Medical claims on 16 Million covered lives Medco Pharmacy & Medical Database

Pharmacogenomic Survey of U.S. Physicians: 

Pharmacogenomic Survey of U.S. Physicians

Background and Objective of Survey: 

Background and Objective of Survey BACKGROUND Collaboration between Medco and the American Medical Association Twenty six questions Survey content: Demographic and professional profile elements Belief of principles behind and utility of pharmacogenomic tests Past and future intended use of pharmacogenomic tests Educational background Preferred PGx information sources (FDA labeling, etc) OBJECTIVES To determine US physician education, beliefs, current and future adoption practices, and preferred information sources regarding pharmacogenomic (Pgx) testing To assess physician and practice characteristics and PGx-related survey responses that are associated with current and future adoption of PGx testing in clinical practice

PowerPoint Presentation: 

Medical school or post-graduate PGx education Ordered a Pharmacogenomic Test in the Last Six Months Anticipate ordering/recommending a PGx test in the next 6 months? Feel adequately informed about PGx testing Believe patient’s genetic profile influences drug therapy 10% 26% 13% 29% 98% Belief in PGx PGx Education Use of PGx Tests Intended Use of PGx Tests Comfort with Ordering PGx Tests Select Overall Physicians Survey Responses

PowerPoint Presentation: 

Reasons Physicians Provided for Not Ordering PGx Tests Concern over privacy Do not prescribe drugs with genomic tests available or recommended Lack of insurance coverage for testing Not enough knowledge about testing/genomic markers Patients’ resistance to genetic testing Little-to-no or uncertain value in testing

Advancing Smarter Medicine™ through R&D: 

Advancing Smarter Medicine™ through R&D Medco Research Institute*

PowerPoint Presentation: 

16 16 16 MRI Clinical Research Studies Powered by a real world data warehouse of more than 60 million patients Clinical pharmacy expertise that accelerates practice translation State of the art CLIA certified lab Clinical call center Clinical Research Study Leading Researchers

MRI Strategic Grid – External Dx Collaborations: 

MRI Strategic Grid – External Dx Collaborations CNS CV Diabetes Gastro Anti- infective Rheumatology Oncology Clinical Practice warfarin Plavix abacavir Selzentry tamoxifen BCR-ABL Development PREDICT PSYMEDS RECEIPT FROST NIMBLE Validation REST DREAMS AKROBATS PICNICC IMMINENT Discovery MANAGE Product-Mix Length (Driven by Time to Market) Product-Mix Width (Driven by member’s needs) High Spend Low Spend Near Term Long Term Discovery Validation Development Commercial

REST Relative Effectiveness of Schizophrenia Therapies: 

REST R elative E ffectiveness of S chizophrenia T herapies 19 SureGene, Medco Research Institute to evaluate the ability of genetic biomarkers to enhance drug selection for serious mental health illnesses LOUISVILLE, Ky. and FRANKLIN LAKES, N.J. , Aug. 24 /PRNewswire/ -- SureGene, LLC and the Medco Research Institute™, LLC, a wholly-owned subsidiary of Medco Health Solutions, Inc. (NYSE: MHS), today announced that they have entered into a novel investigative research collaboration to evaluate whether variation in genetic biomarkers previously identified by SureGene can help predict drug response for widely prescribed antipsychotic drugs in patients with serious mental illness.  The results of this research could help provide evidence supporting the development of genetic tests that would assist doctors to make more precise prescribing decisions, leading to improvements in outcomes, compliance and safety for these mental health patients. Choosing the correct antipsychotic medication for patients suffering from severe psychiatric illness is a major challenge. When patients are not prescribed an effective antipsychotic drug, they are at an elevated risk of experiencing a serious adverse drug event. Current studies have suggested that less than one in three patients suffering from schizophrenia and related disorders will have an improvement in symptoms on the first antipsychotic drug prescribed. Poor response to treatment and the side effects of antipsychotic drugs can also result in low compliance, with 50 percent of patients discontinuing drug use within six months of starting a prescription. SureGene, Medco Research Institute to evaluate the ability of genetic biomarkers to enhance drug selection for serious mental health illnesses

SULT4A1 Marker of Response: 

SULT4A1 Marker of Response Olanzapine SULT4A1-1+ vs. SULT4A1-1- p=0.018 Olanzapine SULT4A1-1+ vs. all other combinations p=0.003 Source: Brennan et al, Pharmacogenomics April 2011 SULT4A1-1 Test SULT4A1-1 Positive SULT4A1-1 Negative CATIE data set N >=20% Responders N >=20% Responders Olanzapine 13 8 61.5% 42 10 23.8% Risperidone 17 3 17.6% 60 17 28.3% Quetiapine 19 7 36.8% 63 14 22.2% Perphenazine 14 5 35.7% 59 13 22.0% Ziprasidone 10 3 30.0% 35 4 11.4% Combined (P, Q , R, Z) 60 18 30.0% 214 48 22.1% 20

Atypical Antipsychotic Medco Drug Data: 

Atypical Antipsychotic Medco Drug Data 5 Atypical Antipsychotics are in the top 100 for annual drug spend >1.2 Million Medco Members received an atypical antipsychotic drug in 2010 Atypical Antipsychotics are used by patients with schizophrenia (65%), bipolar disorder (45%) and depression (15%) Half the volume of Rx for Aytpical Antipsychotics is for Depression BPD (44%) and SCZ (6%) Objective of the REST study is to replicate and extend the SULT4A1 findings in patient’s with bipolar disease

Optimizing Treatment Selection in Psychiatry: 

Optimizing Treatment Selection in Psychiatry Diagnosis 1 st drug 2 nd drug 3 rd drug SULT4A1 GeneSightRx next area of focus Di Rx Diagnostics REST GeneSightRx PREDICT PSYMEDS current area of focus Optimal therapy selection, increase adherence and decrease medical utilization 3.6 million new start in Medco BOB each year, 20% of which start a second drug within 450 days

NIMBLE and RECEIPT: 

NIMBLE and RECEIPT

NIMBLE and RECEIPT – Autoimmune Strategy: 

NIMBLE and RECEIPT – Autoimmune Strategy RA IBD Diagnosis Steroids MTX Biologics Diagnosis Budes/Mesal Thiopurine Biologics TMPT current area of focus Delay time to biologics Rapid biologic cycling next area of focus RECEIPT Thiopurine Metabolites NIMBLE Avise PG

Background: Medco-Mayo Warfarin Study: 

25 Background: Medco-Mayo Warfarin Study Warfarin exhibits large inter-individual dosing requirements Warfarin is a leading cause of morbidity and mortality Two genes account for ~33% of variance in dosing Cytochrome P450 2C9 (CYP2C9) – pharmacokinetics VKORC1 – pharmacodynamics Meta-analysis of 3 clinical trials of warfarin genotyping showed a 32% decrease in major bleeding (RR 0.68, CI 0.22-2.06)* *Eckman MH, Rosand J, Geenberg SM, Gage BF: Cost-effectiveness of using pharmacogenetic information in warfarin dosing for patients with nonvalvular atrial fibrillation. Ann Int Med 2009;150(2):73-83.

Study Groups* : 

Primary Comparison 23 Benefit Plan Sponsors 56 Benefit Plan Sponsors July 2006 – June 2007 n=2688 Historical control July 2007 – February 2009 n=896 Intervention group Comparison of External Controls July 2006 – June 2007 n=2688 External historical control July 2007 – February 2009 n=2688 External concurrent control Medco-Mayo Warfarin Effectiveness Study Study Groups* *6-month follow-up on all patients initiating warfarin in all groups

Flow of the Genotyping Arm: 

Flow of the Genotyping Arm Mayo completed lab test – supplied report to physician and results to Medco Medco identified ‘new starts’ to warfarin on any given day of the week Medco contacted ‘new starts’ to solicit verbal informed consent Medco contacted physician for clinical information and consent for patient to receive genotype test First half of enrollment – Medco arranged for home blood draw – received written informed consent, sent blood to Mayo

NIH/NHLBI sponsored “Clarification of Optimal Anticoagulation Through Genetics (COAG)”: 

NIH/NHLBI sponsored “Clarification of Optimal Anticoagulation Through Genetics (COAG)” Close monitoring and frequent INR measurements, all academic medical centers This is not the real world

Participants from 49 US states: 

Participants from 49 US states

Results: Unadjusted 6 mo. Hospitalization Rates 1 hospitalization per 100 patients/6months: 

Results: Unadjusted 6 mo. Hospitalization Rates  1 hospitalization per 100 patients/6months All cause Bleed or thromboembolism p-value <0.001 0.039 Intention to treat (ITT) Intervention group (n=896) Historical control (n=2688) 28% ↓ 27% ↓

MRI R&D Collaboration Objectives: 

MRI R&D Collaboration Objectives Physician Awareness Patient Advocacy Patient Detection Cost Effectiveness Clinical Utility Clinical Validity Establish definitive association with disease state or drug response Prove significant positive clinical impact on patient outcomes in a real world setting Show net neutrality in total healthcare cost over one year following implementation of innovation Establish a sensitive and specific claims based model for target patient identification Educate physicians regarding clinical utility and operational characteristics of a novel intervention Empower patients regarding disease management and knowledge based healthcare decisions

MRI Collaborator Benefits: 

MRI Collaborator Benefits Current Clinical Care Insights Regulatory and Reimbursement Data Package On-Time Value Based Reimbursement Effortless Market Access and Uptake

MRI Enhanced Implementation Creating a Teachable Moment: 

33 MRI Enhanced Implementation Creating a Teachable Moment Medco identifies patients who are eligible for a test (prescriptions; diagnosis, medical procedure eligibility) Medco contacts patient to inform about test and how it can help with the therapy the doctor prescribed Medco contacts physician to provide information about the test; ordering information, benefits Medco facilitates the delivery and management of the test, ensures that test is performed and results are delivered A teachable moment has been created to inform a physician and a patient about the use of a clinical test to improve patient care and outcomes Physician Awareness Patient Detection Patient Advocacy

PGx Programs Market uptake: 

34 PGx Programs Market uptake Testing potentially appropriate 32,192 Testing potentially appropriate 8,067 Testing agreed to 15,827 49.2% Testing agreed to 4,337 53.8% WARFARIN Physicians TAMOXIFEN Physicians Testing potentially appropriate 12,225 Testing agreed to 4,723 38.6% Patients Testing potentially appropriate 3,778 Testing agreed to 2,127 56.3% Patients Stanek et al. ASHG meeting, October 2010 Physician Education and Patient Advocacy

Translation into Clinical Practice Medco commercial programs increase market penetration: 

Translation into Clinical Practice Medco commercial programs increase market penetration Patients Tested Through Medco Usual Care Testing Patients Tested Through Medco Usual Care Testing Warfarin Testing ↑ 45x 15% 24% .34% 3.6% Tamoxifen Testing ↑ 7x Source: Medco Research Institute™, presented at the ASHG 60th Annual Meeting Effortless Market Access and Uptake

Medco Research Institute – A partner for health: 

Medco Research Institute – A partner for health 36 Leadership Role in Healthcare Innovation from Discovery to Implementation Establishing clinical utility and cost effectiveness Robust pipeline of collaborations Track record of successful execution Diagnostic commercialization and market penetration Advancing Smarter Medicine ™