AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD

Transcript

Lightly edited for clarity.

[00:27] Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare podcast. I'm Justin Venneri, your host and Director of Communications at Capital Rx, and today I'm excited to have the absolute pleasure of chatting with our Senior Director of Clinical Programs, Bonnie Hui-Callahan. We'll be discussing everything you need to know about clinical programs: what they are, how they work, and who they're designed to serve.  

Bonnie, thanks so much for joining me today.

[00:49] Bonnie Hui-Callahan, PharmD: Thanks for having me. It's a pleasure to be here.

[00:51] Justin Venneri: I know. I'm so glad we finally got you on.

[00:54] Bonnie Hui-Callahan, PharmD: I've been waiting, Justin.

[00:57] Justin Venneri: It was inevitable. So, you've been with Capital Rx since 2021, is that right?

[01:03] Bonnie Hui-Callahan, PharmD: Yes, that's correct.

[01:04] Justin Venneri: Awesome. It'd be great to hear a bit about your path to Capital Rx, your background, and your current role here.

[01:10] Bonnie Hui-Callahan, PharmD: Yes, absolutely. So, my background -- I am a pharmacist by training. I graduated from the University of Southern California School of Pharmacy. Upon graduation, I worked for a year at Ralph's company based out in southern California. And then after that year, I completed a PGY-1 pharmacy residency with Kroger Pharmacy and the University of Cincinnati in Ohio, focusing on delivering pharmacist clinical services in the community setting.  

So, with my work in diabetes care in that space during that time, and a few years after that, I became certified as a certified diabetes care and education specialist, or CDCES. And so, over my last, gosh, 14 years now in practice, I worked at a variety of pharmacy settings, starting out in the community pharmacy space. Like I mentioned, I was a district clinical coordinator and then moved to pharmacy manager at crowded. And then from there, I spent four years at OptumRx, building and maintaining their clinical programs, three years at a new local school of pharmacy, building their clinical rotation program, a lot of clinical programs involved and now have been at Capital Rx for the past, gosh, over three years.  

My current role is Senior Director of Clinical Programs, as you mentioned, and my team essentially owns and operates the suite of clinical programs we offer here at Capital Rx.

[02:22] Justin Venneri: Amazing. And for those who may note, totally understand what we mean when we say clinical programs. Can you give us an explanation or holistic definition of what clinical programs are?

[02:33] Bonnie Hui-Callahan, PharmD: Yes, sure thing. So, when we think of a PBM, we think of the core functions, right? Claims, adjudication, formulary, prior auth. As an analogy, because now my kids are all back at school, our, you know, our kids go to school. They have classes in the standard curriculum that we know of. Math, reading, writing, PE. Well, I don't know about your school, but my school also offers an after-school program, right? They've got things like an art program, they've got a Lego building program. They've got even a marathon training program, right? These are all enhancements to the education that our kids get. And I can, as a parent, opt into that for my kids to enhance their learning, to enhance their development.  

So in a similar way, you know, where clinical programs fits into this whole ecosystem is that we bring in an added layer of service to help plan sponsors decrease their cost of care, increase their quality of care, increase patient safety, and help them address specific conditions that may be prevalent in a population such as diabetes.

[03:33] Justin Venneri: Marathon training. Are any of your kids in marathon training?

[03:37] Bonnie Hui-Callahan, PharmD: No. They immediately said no, so I didn't. But, maybe one day.

[03:41] Justin Venneri: They're very smart and have bright futures. Just kidding. I like to run. I just can't do more than like a 5K. So, the way clinical programs are designed to be a complement to the core functions, can you give us some examples of clinical programs and what those are designed to do?

[04:00] Bonnie Hui-Callahan, PharmD: Yeah, so I think at the highest level, what we do here, at least at Capital Rx, is we categorize the programs that we offer into five main buckets: utilization management, cost containment, patient safety, population health, and finally high-touch personalized care.  

So we have a number of programs that fall within each of those five categories. I won't get into each of them for the sake of time, but some examples include our opioid safety program, our adherence and gaps in care program, our medication therapy management program. We even have a pharmacogenomics program. And last but not least, we have a diabetes management as well as a weight loss program.  

So, as you can see, there's really a breadth and variety of programs that we offer because we know our clients have different needs and wants, and they, we are here to really service the solutions that they're looking for.

[04:47] Justin Venneri: Okay. And are some of the programs more common to all PBMs or health plans, or can they be more unique?

[04:54] Bonnie Hui-Callahan, PharmD: So there's certainly programs that are common to many PBMs and health plans like opioid safety, like I mentioned, adherence and MTM. However, when it comes to condition management solutions, those can certainly vary across the PBM and the health plans. There's a lot of point solutions in place now that target various specific conditions: women's health, musculoskeletal. So, you know, there's a lot that exists out there. And so, it's really up to the PBMs and the health plans on what conditions they want to target and therefore what additional programs they want to offer in that space.

[05:28] Justin Venneri: And we have partnerships with Virta and Vida for chronic care, slightly different programs, but those are partnerships. And then we have, like, homegrown stuff. How much of a difference is there when we structure clinical programs like that?

[05:44] Bonnie Hui-Callahan, PharmD: Yeah. So, there's certainly benefits to both setups. Right? We do have and love our partners, our vendors, who offer a high-touch care to our members. These are kind of one to one, clinician to member type of relationship, especially in the chronic condition or disease management space. That really goes a long way, and we utilize vendors for that.  

At the same time, like you mentioned, we do have in house programs. We utilize JUDI® and all the capabilities that JUDI has to offer anywhere from being able to identify specific members based on their pharmacy claims and eventually based on medical claims, and all the way to be able to build out reporting to see the outcomes and the true value that these programs bring to the table for our clients.  

And so, there's a lot of flexibility when we do have our programs also built in house, a lot of the customizations that clients may be looking for, we can enhance our programs and expand what we can do within each of these programs.  

And so, there's certainly value in having both the in-house and certainly our valued partnerships with our vendor-driven programs.

[06:47] Justin Venneri: And I think generally, sometimes there's a misperception out there, or perhaps it's accurate in some cases that clinical programs benefit the PBM because of how they are administered. But maybe that's not always fair. I would love your thoughts on that.

[07:01] Bonnie Hui-Callahan, PharmD: So, at the end of the day, to be honest, clinical programs are designed to serve the member, and that's what I truly believe. I'll give you a few examples.  

So, our patient safety alerts program, these are our point-of-sale edits for that pop up at the point of sale for pharmacists when they're reviewing drug therapy, as well as our opioid safety programs. These all have point of sale edits designed to stop the claim if there is, you know, an issue that's identified via JUDI. And a lot of times these are overridable. So, the pharmacist can use their clinical judgment to say, does this make sense? Is this appropriate or not for the member?  

But again, the idea being there's safeguards in place through these types of programs that make sure that there's a double check and say hey, is this safe for the member to fill or not? Another example, our adherence program. We send messages to members. These are focused on reminding the member to take their medication as prescribed. Our weight loss program -- this is focused on helping members lose at least 5% of their body weight and get them back to a sustainable lifestyle routine that allows them to stay healthy. And our low-cost alternative program, as the last example, we send messages in real time to the member when the pharmacy is processing their prescription to let them know, hey, you could save money by switching to a drug that works very similarly, right? We call this therapeutic equivalent, but costs them a lot less money.  

Now, at the same time, to your point, you know, to the plan sponsor, they benefit as well by seeing potential drug direct cost savings, by switching the member to that slow cost alternative or stopping a medication altogether because they no longer need it or it's considered duplicate therapy. And in addition to that plant, sponsors can see clinical outcomes on their population depending on what program they elect. Like lower opioid exposure, higher med adherence, weight loss, decreased A1C for members with diabetes. So, it really is a benefit to all parties involved. And that's the beauty of clinical programs.

[08:57] Justin Venneri: And many of these you've mentioned, this is for all populations, right? Because I know some of the programs more specifically impact Medicare or Medicaid plans versus Commercial plans, but it seems like these are universally applicable.

[09:09] Bonnie Hui-Callahan, PharmD: For the most part, yes. CMS certainly has requirements on specific programs that Part D sponsors need to have in place. However, what we offer at Capital Rx is we are starting to allow for non-Medicare, more commercial plans to also elect into such programs if they're interested.

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[09:26] Justin Venneri: Okay. And in your opinion, what are the specific conditions or things you just rattled off? So many great examples that clinical programs are best suited to aid. What can plan sponsors plan fiduciaries now do to look at their populations and think about what programs they should consider?

[09:42] Bonnie Hui-Callahan, PharmD: Yes. So, I could definitely spend a lot of time on this topic. I think if I were to boil it down and to kind of simplify the questions that plan fiduciaries want to be asking or how to look at their population, I would start with three questions, right?  

One is where are some of the highest utilization and spend areas for my population? And when I say spend, that includes pharmacy spend and medical spend. ideally both, to look at total cost of care. Right? So from a pharmacy spend perspective, is it appropriate? Are there certain drug classes that may have higher spend than others? And if so, why? And what strategies can we put in place to help control those costs?  

Similar to the same topic with utilization, where is there maybe unnecessary spend? Are there medications where your members are taking that are considered duplicate therapy or they've been filling it forever because it's been on auto refill at their pharmacy? That's the case of my grandma. That's what's happening, for their they didn't realize that they didn't need to take it anymore and haven't had a pharmacist to review their full drug regiment. We have programs to address both of those issues that I just mentioned.  

The second question is what disease states or chronic conditions are most prevalent in your population and leading to perhaps avoidable spend on both the pharmacy and the medical side? Is it diabetes, hypertension, hyperlipidemia, obesity? Looking at medical claims, are there a higher number of ER visits associated with certain conditions like uncontrolled diabetes?  

And then the third question is, what does the adherence rate look like across your population among some of the larger, more prevalent drug classes? Like, and you're going to hear it again and again, diabetes, hypertension and hyperlipidemia. If your population isn't taking the meds they're prescribed, this can lead to downstream impacts that can result in higher costs in the end. So, think heart attack with uncontrolled hypertension, foot amputation with uncontrolled blood sugar.

[11:34] Justin Venneri: Right.

[11:35] Bonnie Hui-Callahan, PharmD: For asthma attack if you're not taking your controller meds. So, the adherence rate is so important as well. But you know, as you can see with these three questions, they all kind of bleed together. But at the end of the day, where are the high spend areas, where are the high chronic condition prevalences and what's the adherence rate in your population?

[11:53] Justin Venneri: And given your background, I would think being a pharmacist by training and being involved in community pharmacies and involved in the care for these conditions, and I would think you have a, you know, bring a unique perspective to us at Capital Rx, but I think one thing is the identification of the total cost of care opportunities and having the medical data to do that. Just a quick follow up question: with the lag on the medical claim side and the immediacy of the pharmacy claim, is there a way plan sponsors can kind of bridge that and be more in tune with what's happening?

[12:26] Bonnie Hui-Callahan, PharmD: Well, the pharmacy claim certainly is very, very helpful. What we have in place today is what we call identification via drug proxy. So we say, okay, we can assume that member has diabetes because they're taking at least two diabetes drugs, and we can see that in their claims history right now, of course. Is that perfect? It's not perfect, and that's why it's so important to marry it with the medical claims data to validate is there a diagnosis code for diabetes? And so there's certainly a value there in having both together. Now, there's limitations to both sides. With the medical claims, as you mentioned, there is oftentimes a lag. And so we here at Capital Rx are trying to work through that. We are starting to support clients who are sending us their medical claims data and integrating that within our logic.

So, we're figuring out how to best solution for some of those limitations. But certainly, the data is there, and the data is very helpful in our identification for these programs.

[13:22] Justin Venneri: Yeah, it's a super exciting opportunity. This is a little bit of a pivot, but not much. You and several others on your team displayed a poster at the 2024 Pharmacy Quality Alliance annual meeting, and that showed findings from a study you did on GLP-1s, obviously the hottest topic of the year, or one of them. So, we'll link that in the show notes. Can you share a little bit about that study? Is that a result of a new clinical program and what were the findings?

[13:50] Bonnie Hui-Callahan, PharmD: Yes. So thanks for the opportunity to talk about that. It is really exciting, and I'm really proud of our team for having gone through this research and being able to showcase it at PQA.  

So, our team did have the opportunity to present this poster, Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist Use. The research our team conducted was tied to our existing patient safety alert program. Now, that is a program we've had in place for a while, not net-new. However, we constantly enhance it and add additional alerts as clinically needed. And so, this program deploys a number of different alerts. But one category is called the duplicate therapy alert. And what it does is alert at the point of sale to prevent instances of overlapping day supply of two big diabetes drug categories, GLP-1s for diabetes, specifically here, and another drug category called DPP-4 inhibitors.  

So why we have this in place is because current guidelines, through American Diabetes Association, as well as the American Association of Clinical Endocrinology, they recommend against the concomitant use of these two drug categories together, just because there's lack of added benefit and the potential for additional side effects at the same time. So that's why we have this edit in place today in JUDI.

So, we found in our analysis that through these safety edits, we were able to reduce the percent of overlap between these two drug classes by 50% from baseline. And we looked at data between January 1 and November 31 of 2023. So almost a year's worth of data.  

So, this is another reason why our clinical team is so dedicated to continually monitoring and enhancing our patient safety alerts, to ensure that we have safeguards in place like this at the point of sale to ensure drug regimens for our members are safe, effective, and cost conscious.

[15:32] Justin Venneri: Forgive the question here, because I know there's no such thing as a stupid question. But that's a win-win, like cost and safety, right?

[15:41] Bonnie Hui-Callahan, PharmD: Yes, absolutely. And, you know, a lot of times, yes, we do have patient safety programs, of course, but at the end of the day, if the edit is allowing the member to no longer have to take that medication because it's not safe for them, the win, at the same time, is that, you know, you're not paying for it, and the plan sponsors aren't paying for it either. So that's where some of the pharmacy savings comes in. And that's really an exciting piece of the puzzle to tie in as part of the neat outcomes of our programs.

[16:10] Justin Venneri: Excellent. Okay, last question for you, Bonnie. What's the most astonishing thing you've seen that you can share, of course, either during your time at Capital Rx or relating to our discussion today over your career?

[16:21] Bonnie Hui-Callahan, PharmD: So, to be honest, for me, it's the growth that this company has had in the short three years I've been here. I think I was employee around 150, and when I last checked, I believe we're nearing 600, which is incredible. And honestly, I'm just, I'm really proud to be part of this team and organization, and I'm really proud of the work that our organization has and will continue to do to further drive quality, decrease costs, and really improve patient safety for our members.

[16:47] Justin Venneri: Okay, Bonnie, thank you so much for taking the time today to chat with us and explain the basics of clinical programs and then dig a little deeper in some of these. It was great to have you on. I hope to have you back to talk about any new developments and hopefully some more data around these programs.

[17:01] Bonnie Hui-Callahan, PharmD: Awesome. Yes. Thanks for the time, Justin. Really excited to be here, and thanks again for the opportunity.

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