1 PHARMOECONOMICS: ARE YOUR DRUG FILE PRICES ACCURATE? UTILIZING PHARMACY DATABASES TO IDENTIFY COST OPPORTUNITIES Andrew Henriksen PBM/CMOP Pharmacoeconomic Data Manager Workshop Objectives 2 Learn tips to optimize local drug file setup Introduction to methods used to validate data using available reports and tools Learn how to access the Pharmacoeconomic SharePoint site and other available resources including future CDW reports and tools 3 Drug File Optimization How cost data gets entered into VISTA 4 Prime Vendor Invoices uploaded via the Drug Accountability application Data must be verified before being accepted Quantity issues (dispense unit vs. order unit, bottle size) Different dispense unit (gram vs. inhaler) Different NDC ordered Items not purchased through prime vendor (omeprazole via repackaging provider) must be updated manually How costs gets into VISTA (and to PBM) 5 File 50: DRUG File Synonyms: Can have multiple NDC’s each with their own price, quantity, dispense unit per order unit entered Only one price at a time, assigns the most recent invoice price or last price change to all fills going forward (not tied to NDC) Does not use CMOP prices for fills dispensed by CMOP, price assigned is current price in local drug file Example -Tiotropium 30 (Prime Vendor) 6 Mck Description Strength Form NDC Item # 1771930 SPIRIVA HANDIHALER 30 18MCG CAP W/DEV 005970075-41 Purchase Unit Price Price Manufacturer Size $54.14 $1.8047 30 Prime Vendor uses capsule for unit price, the VA National Drug File (NDF) uses purchase price for dispense unit price TIOTROPIUM 18MCG INHL CAP 30 ORDER UNIT: BX// PRICE PER ORDER UNIT: 54.14// DISPENSE UNIT: PKG// DISPENSE UNITS PER ORDER UNIT: 30 PRICE PER DISPENSE UNIT: 1.8047 NDF data base-Tiotropium 7 Strategies to optimize file 50 setup 8 TIOTROPIUM 18MCG INHL CAP 30 MESSAGE: DISPENSE PER BOX (NOT CAPSULES) to ALERT pharmacy staff ORDER UNIT: PK// PRICE PER ORDER UNIT: 54.14// DISPENSE UNIT: EA// DISPENSE UNITS PER ORDER UNIT: 30// 1 PRICE PER DISPENSE UNIT: 1.8047 54.14 ******************************************************************************* This entry is marked for the following PHARMACY packages: D - Drug Accountability Select SYNONYM: // 30597007541 INTENDED USE: DRUG ACCOUNTABILITY// NDC CODE: 00597-0075-41// ORDER UNIT: PK// PRICE PER ORDER UNIT: // <leave blank> DISPENSE UNITS PER ORDER UNIT: // 1 PRICE PER DISPENSE UNIT: // <leave blank> Example - Ziprasidone 9 Mck Item # Description Strength Form NDC Purchase Price Unit Price Manufacturer Size 1413988 GEODON CAP 20MG 60 20 MG CAPSULE 00049-3960-60 $397.54 $6.63 60 1380088 GEODON CAP 40MG 60 40 MG CAPSULE 00049-3970-60 $397.54 $6.63 60 1391838 GEODON CAP 60MG 60 60 MG CAPSULE 00049-3980-60 $482.45 $8.04 60 1394576 GEODON CAP 80MG 60 80 MG CAPSULE 00049-3990-60 $482.45 $8.04 60 Some products are essentially “flat priced” all strengths cost about the same Ziprasidone fills 10 va_product Day Qty/ Dose supply Qty day ordered schedule Cost (as written) Cost (if using higher capsule strength) ZIPRASIDONE HCL 40MG CAP 30 120 4 80 BID $795 $398 ZIPRASIDONE HCL 40MG CAP 30 120 4 80 BID $795 $398 ZIPRASIDONE HCL 20MG CAP 30 180 6 60 QAM & QHS $1193 $482 ZIPRASIDONE HCL 20MG CAP 30 180 6 60 QAM & QHS Total: Savings: $1193 $3976 $482 $1760 $2216 ZIPRASIDONE 20MG CAP Strength from National Drug File match => 20 MG Strength currently in the Drug File => 20 MG Strength => 20 Unit => MG POSSIBLE DOSAGES: DISPENSE UNITS PER DOSE: 1 DISPENSE UNITS PER DOSE: 2 DOSE: 20MG DOSE: 40MG PACKAGE: IO PACKAGE: IO Flat Priced Products 11 Dexlansoprazole: once daily dosing, low volume Ziprasidone: BID dosing, big volume Aripiprazole: once daily dosing, big volume Pregabalin: up to QID dosing, growing volume Duloxetine: up to BID dosing, growing volume Desvenlafaxine: once daily dosing, low volume Others? Summary: drug file setup optimization 12 Use Drug Accountability package to lock in appropriate quantity dispense units per order unit Utilize the drug message screen to guide pharmacy staff on how to complete orders Consider provider Quick Orders to aid prescribing Limit possible doses to 1 dose per strength on flat priced items (utilize tablet splitting where appropriate) 13 Questions? 14 Validating Data: Available Reports and Tools Reports and Tools 15 High Cost RX report [PSO HI COST] CMOP Cost Reports http://vaww.national.cmop.va.gov/CostReports/default.aspx Prime Vendor Purchase reports High Cost RX report [PSO HI COST] 16 Run High Cost RX report [PSO HI COST] in VISTA Beginning Date: (APR 1, 2011) Ending Date: (APR 31, 2011) Dollar Limit : (0-9999): 30// 0 Capture all fills DEVICE: HOME// ;255;999999 Send to file, do not need to print out on paper High Cost RX report via Data Warehouse 17 Use CDWwork --(or, could use RDWwork or local data warehouse) select distinct LEFT(DateText,7) as month, d.visn, b.sta3n, Facility, b.RxNumber , b.LocalDrugNameWithDose, c.VAProductIdentifier as CMOPID , c.DrugNameWithDose, c.DrugNameWithoutDose, A.DaysSupply , UnitPrice, Qty, (UnitPrice*QtyNumeric)as Total_Cost , RxStatus from CDWwork.RxOut.RxOutpatFill a inner join CDWwork.RxOut.RxOutpat b on a.RxOutpatIEN=b.RxOutpatIEN and a.sta3n=b.Sta3n inner join CDWwork.Dim.NationalDrug c on a.NationalDrugIEN=c.NationalDrugIEN inner join CDWwork.Dim.VistaSite d on a.Sta3n = d.Sta3n inner join CDWwork.Dim.Date e on a.ReleaseDateTime=e.Date where a.ReleaseDateTime >= dateadd(MONTH, -2, GETDATE()) AND A.Sta3n>0 AND D.Sta3n<999 and ((UnitPrice*QtyNumeric)>1000) and c.DrugNameWithoutDose not in ('imatinib‘, 'nilotinib', 'sorafenib', 'LENALIDOMIDE', 'SUNITINIB', 'ENTECAVIR', 'ERLOTINIB','PEGFILGRASTIM','DARUNAVIR‘) and (VISN =‘#') and a.Sta3n =‘###’ order by month desc, d.visn, b.sta3n, Facility, b.RxNumber, b.LocalDrugNameWithDose, c.DrugNameWithDose, c.DrugNameWithoutDose, Unitprice, Qty, (UnitPrice*QtyNumeric) 18 NDF data base 19 CMOP Cost Reports 20 CMOP-761 RX Cost Report (2/23/2011 12:00:00 AM Through 3/24/2011 11:59:59 PM) New York (630) CMOPID NDC VAPrintName … … XU838 AVK19641 XU845 AVK19840 XU845 AVK19840 XU846 AVK19758 …. DEPEND BELTED W/BUTTONS XTRA ABSORB DEPEND UNDERWEAR SUPER PLUS MEN SM/MED DEPEND UNDERWEAR SUPER PLUS MEN SM/MED DEPEND UNDERWEAR SUPER PLUS WMN SM/MED XU847 UnitCost NumberRX QTY TotalCost … … … … $32.0200 16 34 $1,088.6800 $50.0600 19 22 $1,101.3200 $53.2800 11 16 $852.4800 $50.0600 3 5 $250.3000 DEPEND UNDERWEAR AVK19779 SUPER PLUS WMN XLG $53.2800 2 3 $159.8400 XU874 ATTENDS REGULAR PRKBRB40 BRIEF X-LARGE $28.7600 6 10 $287.6000 … … … … … … … Total Number Rx Total Drug Cost Avg. Drug Cost per Rx 20,292 $540,400.3546 $26.6312 Quantity: 14 or 56? Or 16 or 64? 21 Mck Item # Description Strength Form Purchase Unit Cust Cust Manufacturer Mfr Price Price Cntrct # Cntrct Type Size Name KIMBERLY CLARK 3238912 DEPEND U/W WMN X/AB XLG 16 CS4 $44.43 $2.78 16 CORP DEPEND U/W WMN X/AB XLG 14 CS4 KIMBERLY CLARK ? ? ? 14 CORP Package Size Multiplier 1.00 1.00 Prime Vendor Reports 22 Purchase reports Penny prices Contract compliance Custom reports Purchase Reports 23 SMO Pharmacy Management / Programs Access Reports & Analysis Create Report Canned Report Purchasing Detail Report Invoice Level Detail (choose the dates to search, customers account numbers and items to include) Selected Date Range: 04/01/2010 to 04/15/2011 Customer Unit Ext. Cust# Name EMost# NDC/UPC Item Description Invc/Cred # Invc/Cr Da Ordr Fill Net UOM Price Price VA MED CTRNORTHPORT DEPEND U/W WMN 727477 MED 3238979 03600-0197-58 S/AB S/M 18 CS4 7467106567 3/2/2011 1 1 1 CS $44.43 $44.43 VA MED CTRNORTHPORT DEPEND UWEAR 727477 MED 3238953 03600-0195-58 WMN S/M 20 CS4 7463190472 2/1/2011 1 1 1 CS $44.43 $44.43 Purchase Reports 24 SMO Pharmacy Management / Programs Access Reports & Analysis Create Report Canned Report Purchasing Detail Report Invoice Level Detail (choose the dates to search, customers account numbers and items to include) Cust# EMost# NDC/UPC Item Description Invc/ Cred # Invc/ Credit Date C Unit Ordr Fill Ret Net UOM Price Ext. Price 679786 1383165 00078-0438-15 GLEEVEC TAB 400MG (SCORED) 30 7465244831 2/16/11 Y 1 1 0 1 EA $2,321 $2,321 679786 1383165 00078-0438-15 GLEEVEC TAB 400MG (SCORED) 30 7467164465 3/2/11 Y 2 2 0 2 EA $2,321 $4,642 679786 1383165 00078-0438-15 GLEEVEC TAB 400MG (SCORED) 30 7471758424 4/5/11 N 2 2 0 2 EA $4,570 $9,139 Cost Change Report (Penny drugs) 25 SMO Ordering / Inventory Reports Contract Change Report Cost Change Report (Penny drugs) 26 Item Number NDC Dose Generic Proper Strength Dose Contract Description Form Price Name Generic Name Sell Description CIPROFLOX O/S 0.3% 1265883 61314-0656-25 FAL 2.5ML@ DROPS CIPROFLOX O/S 0.3% 1266089 61314-0656-05 FAL 5ML@ DROPS FELODIP ER TAB TAB SR 1430412 63304-0436-01 5MG RAN 100@ 24H FELODIP ER TAB TAB SR 1432285 63304-0437-01 10MG RAN 100@ 24H CORTIFOAM 1630235 68220-0140-15 15GM POT CHL ER TB 1723915 00085-1718-01 20MEQ SCHE 1000 RISPERID TB 0.5MG 1752245 50458-0591-60 PATR 60@ RISPERID TB 3MG 1763101 50458-0594-10 UD PATR 100@ DESMOPR VL 4MCG/ML FER 2139327 55566-5040-01 10ML TWINJECT 0.3MG 2142701 59630-0802-01 AUTO INJECTOR GLYBURIDE TAB D 2220515 00093-9433-01 2.5MG TEV 100 Size Supplier Account Name Qty FALCON CIPROFLOXACIN HCL PHARMACEUTICALS @ 1 FALCON CIPROFLOXACIN HCL PHARMACEUTICALS @ 1 RANBAXY FELODIPINE PHARMACEUTICALS @ 100 RANBAXY FELODIPINE PHARMACEUTICALS @ 100 MEDA HYDROCORTISONE PHARMACEUTICALS ACETATE INC 1 POTASSIUM SCHERING CHLORIDE CORPORATION 1000 PATRIOT RISPERIDONE PHARMACEUTICALS @ 60 PATRIOT RISPERIDONE PHARMACEUTICALS @ 100 $0.01 0.30% $0.01 0.30% $0.01 5 MG $0.01 10 MG $0.01 10% $0.01 20 MEQ TABLET $0.01 0.5 MG TABLET $0.01 3 MG VIAL COMBO . PKG $0.01 DESMOPRESSIN 4MCG/ML ACETATE $0.01 0.3MG/0.3 EPINEPHRINE TABLET $0.01 FOAM/ APPL TAB ER PRT 2.5 MG GLYBURIDE FERRING PHARMACEUTICALS SHIONOGI PHARMA INC TEVA PHARMACEUTICALS Unit Code Contract End Date EACH 9/30/2011 EACH 9/30/2011 TAB 1/14/2015 TAB 1/14/2015 EACH 1/14/2013 TAB 8/31/2011 TAB 7/14/2013 UNIT 7/14/2013 1 EACH 1/31/2012 1 EACH 5/31/2011 100 TAB 4/14/2013 Contract Compliance 27 SMO Pharmacy Management / Programs Access Reports & Analysis Create Report Canned Report Savings Identification Contract Compliance/ Lost Savings (choose both Contract and Non-contract, display results as CSV) Contract Compliance 28 Item Item Description CITALOPRAM HYDROBROMIDE Pkg Size: 100 Mfg Size: 100 CELEXA TAB 40MG 100 Alt Item Description BLU PHARMACEUTICALS LLC AUROBINDO PHARMA USA @ TORRENT PHARMA INC @ APOTEX CORPORATION CARACO PHARMACEUTICALS @ GREENSTONE LIMITED @ MYLAN PHARMACEUTICALS @ Purch Inv. Date Qty Supplier Name 12/1/ 2010 1 FOREST PHARM/LABS Alt Supplier Name Max Lost Purch Price Savings Available Qty $201.15 BLU PHARMACEUTICALS LLC AUROBINDO PHARMA USA @ $3.83 $197.32 14 $3.91 $197.24 14 TORRENT PHARMA INC @ $6.18 $194.97 14 APOTEX CORPORATION CARACO PHARMACEUTICALS @ $9.04 $192.11 14 $12.44 $188.71 14 $12.63 $188.52 14 $12.75 $188.40 14 GREENSTONE LIMITED @ MYLAN PHARMACEUTICALS @ **Report does not tell you if alternate item was in stock that day; gives stock level of item you ordered not the alternatives. Also, may list alternatives that are not on FSS McKesson Custom Report: Template Using Reports & Analysis 6.6 29 • McKesson Connect Pharmacy Management/Programs Select Access Reports & Analysis Create report Custom report • Formatting: • In the Field Selection, select the following parameters to invoice level: account name, account #, invoice extended price, invoice/credit #, invoice credit/date, invoiced price (dose) invoiced price (pkg.), invoiced quantity, item description, McKesson item #, NDC and package size • Results Display select all Level 1 group by: Account number Level 2 group by: Item description • Saving Report: • In save to my reports box name report and save Third Party: Update 30 Prior to March 18th,2011 maximum collection was $51/Rx After March 18th-third party will pay the actual cost of the Rx plus an administration fee of $11.40 The actual cost billed to third party comes directly from your drug file Important: pricing in the drug file MUST be accurate or you risk losing $$$$$ 31 Questions? 32 Pharmacoeconomic SharePoint site and CDW Link: http://vaww.national.cmop.va.gov/pre/Pharmac oEconomic/default.aspx You can request access from the page or send an email to me at Andrew.Henriksen@va.gov Pharmacoeconomic SharePoint Site 33 National Savings Opportunities Reports Monthly Cost Review Top 25 (100) drugs by Total Cost Unmatched Items Individual drug analysis reports National Savings Opportunities 34 Selection Review of high cost and high volume areas with significant variability in prescribing patterns Lack of evidence to support prescribing differences New contracts or Blanket Purchase Agreements (BPA) that create incentives Areas of concern where community standard may not be evidenced based Measures (ProClarity) Outpatient pharmacy costs only Denominator is OP Pharmacy users only (Pharmacy Unique) Numerator is based on VistA dispensing data Drug costs based on local drug file * National Cost per Pharmacy Unique $1,000 $900 $800 $700 $600 $500 $400 $300 $200 $100 $0 avg min max range SD FY1999 $599 $456 $656 $200 $54 FY2000 $632 $461 $701 $241 $56 FY2001 $655 $500 $722 $222 $55 FY2002 $664 $507 $731 $223 $52 FY2003 $704 $547 $747 $200 $46 FY2004 $774 $616 $827 $212 $47 FY2005 $794 $639 $864 $225 $48 FY2006 $784 $670 $835 $165 $39 FY2007 $751 $666 $779 $113 $34 FY2008 $693 $628 $716 $88 $28 FY2009 $697 $624 $723 $99 $31 FY2010 $705 $615 $745 $130 $36 Cost Avoidance Results FY ’09 12 National initiatives $192 million cost avoidance (6.1% of outpatient expenditures) Drug cost per patient 0.61% compared to FY 08 FY ’10 26 National initiatives $120 million cost avoidance (3.6% of outpatient expenditures) Drug cost per patient 1.08% compared to FY 09 FY ’11 36 National initiatives Target $128 million cost avoidance (~3-4% of projected outpatient expenditures) Savings through Q1: $14.8 million Formulas Most measures are cost per 30 day fill Cost per 30 day based on total costs for drugs in market basket and number of 30 day fill equivalents Market basket to include all relevant drugs in targeted area Drugs costs used in calculations come from local drug file* Results calculated quarterly by PBM Definitions Target – based on average of top 5 VISNs for majority of initiatives or national average where indicated. If there was an outlier, the top 2-6 networks were used. Goal – network specific goal based on 75% of the difference between network baseline and the target (top 5 networks average) Performance Measure Dollar amount based on the national initiatives Finance Committee satisfactory goal (green) is 50% of dollar amount based on the national initiatives (no longer reported though…) National initiatives are not mandatory Monthly Cost Review 40 VISN Cost/Day30RX last 6 mo, 6mo average VISN Cost/ Pharmacy Unique last 4 Qtrs, FY YTD Site Cost/Day30RX last two months and change for previous month Site Cost/ Day30RX last 6mo, 6mo average Site and Complexity Group templates Top 25 (100) Drugs by Total Cost 41 Unmatched Items 42 Individual Drug Analysis Reports 43 CDW, RDW, & VISN data marts 44 Regional Data Warehousing Visual Architecture Source Systems Facility 1 VistA Corporate Data Warehouse Shadow/Journal Reader Process Regional VistA Shadow Near Real Time Facility 2 VistA Facility 3 VistA • SQL Server • Business key • Time stamp • OpCode (I/U/D) Daily Regional Daily Feeder Data Warehouse • SQL Server • Business key • Time stamp • OpCode (I/U/D) • Indexes: - VistAEditDate - Business Key Regional Data Warehouse • SQL Server • Business key • Time stamp • OpCode (I/U/D) Daily Cartoon depicting Regional Data Warehouse Visual Architecture • Business key • Time stamp 45 • Cache Classes define data of interest • Cache Methods insert or update to ODS • Data includes Fact and Dimension data • SQL Server VISN • Business key Data • Time stamp Warehouse(s) • OpCode (I/U/D) • Incremental loads are based upon VistAEditDate timestamp Drug Cost Report 46 Depending on perspective, one can look at the difference between the average, median, and mode cost prices from the pharmacy site acquisition price Drug Cost Report Definitions 47 Unit Price – The price the pharmacy paid for the med National/Region/VISN/Station/PharmacySite Average/Median/Mode Prescriptions – Prescriptions Quantity – Quantity Difference – Difference Between Prices Cost Impact = Difference * Quantity Average Vs Median Vs Mode 48 Average is sensitive to outliers (high and low) Median – Pick the median price among the stations (not bad) Mode – Pick the most common price among the stations (not bad) Reports show all of them depending on the pharmacoeconomists mood and trust of the internal data within the VISN and/or her fellow neighbors Region II Mode Report Region II Median Report 51 Questions? How do I fix errors in my data? 52 Prescription Cost Update [PSO RXCOST UPDATE] back to the date of the price change for each drug entry you are changing a price Date Range Recompile Data [PSO MGMT RPT RANGE COMPILE] back > 1yr once all the prescription cost updates have been run Monthly Rx Cost Compilation [PSO COSTMONTH] How do I request a fix of data I already transmitted to PBM? 53 Send an email request to Mike Wrobel, Alan Celestino and me including the below information Product name Time period to correct Wrong price (from individual prescriptions) Correct price http://vaww.national.cmop.va.gov/pre/PharmacoEco nomic/Document%20Library5/1/PBM%20Data%2 0Correction%20submission.xlsx 54 Questions?