evaluation of virginia’s preferred drug list: interim report
DESCRIPTION
Evaluation of Virginia’s Preferred Drug List: Interim Report. Policy and Research Division. Department of Medical Assistance Services. March 16, 2004. Presentation Outline. . Components of DMAS’ PDL Evaluation. PDL Process: Movement of Prescriptions. - PowerPoint PPT PresentationTRANSCRIPT
Evaluation of Virginia’s Preferred Drug List: Interim
Report
Policy and Research Division
March 16, 2004Department of Medical Assistance Services
2
Presentation Outline
Components of DMAS’ PDL Evaluation
PDL Process: Movement of Prescriptions
PDL Process: Inside Prior Authorization
Budget Savings: Analysis Plan and Next Steps
Health Impacts: Analysis Plan and Next Steps
Conclusions
3
DMAS’ Review of the PDL Has Several Major Components
The framework for this review is broadly designed to address the following three issues:
1) the vendor’s implementation of the program including a focus on the process for prior authorizing non-preferred drugs
2) the impact of the PDL program on the agency’s budget and whether the mandated savings targets are realized
3) the impact of the PDL program on Medicaid patient health outcomes
4
Three Important Research Questions Provide The Focus For The Study
Within the context of this issue framework, the following specific research questions will be addressed in the agency’s full review of the PDL:
• Has the PDL program been implemented in a way to ensure a high rate of compliance by physicians without adversely affecting patient access?
• Has the PDL program produced the $27 million in general fund savings for FY 04 and 05 as required by the General Assembly?
• Is there evidence to suggest that the PDL program has adversely impacted patient health outcomes for those Medicaid recipients who are switched from non-preferred to preferred drugs?
5
Study Report Schedule
Scheduled Report Dates and Frequency of Reporting
Research Component First Report Date Report Frequency
PDL Process Review March 16th, 2004 Quarterly
PDL Budget Impact June 1st Semi-Annually
PDL Health Impacts December 1st Semi-Annually
6
Presentation Outline
Components of PDL Evaluation
PDL Process: Movement of Prescriptions
PDL Process: Inside Prior Authorization
Budget Savings: Analysis Plan and Next Steps
Health Impacts: Analysis Plan and Next Steps
Conclusions
7
Dataset To Track The Movement of Prescriptions Must Account For
Numerous Outcomes
Bolded Boxes Represent PDL Compliance
Pre-PDLPost-PDL
Prescription Activity OutcomeStatus of
Drug Claim
1 Patient was on non-preferred drug
Doctor changes prescription to preferred drug
Prescription is filled Drug claim paid
2 Patient was on non-preferred drug
Prescription written for non-preferred drug and doctor requests PA
First Health or DMAS appeals officer approves the non-preferred drug
Drug claim paid
3 Patient was on non-preferred drug
Doctor requests prior authorization for approval of non-preferred drug
Request denied and no prescription filled
No paid drug claim
4 Patient was on non-preferred drug
No denial or approval found in system
No prescription filled No paid drug claim
5 Patient was on preferred drug
Prescription written for PDL drug
Prescription is filled Drug claim paid
6 Patient was on preferred drug
No denial or approval found in system
No prescription filled No drug claim found
8
The First Health National Drug Code File With PDL Indicator and DMAS Claims Data
Used To Create PDL Analysis File
DMAS FileDrug Name
Hard Edit Date Drug Class
National Drug Code Preferred Indicator
First Health FileDrug Name
NDC FileNational Drug Code
Hard Edit Date Drug ClassDrug Name
Preferred Indicator
DMAS Claims FileNational Drug Code
Paid/Denied StatusService Dates
Recipient Information
PDL Claims Analysis File
Service DateHard Edit Date
Paid/Denied Status
Drug ClassDrug Name
Preferred IndicatorRecipient InformationNational Drug Code
PRE-PDL Claims File
Paid Claims 90 days prior to Hard
Edit Date
POST-PDL Claims File
Paid or Denied Claims 1 to 6 Weeks After the
Hard Edit Date
9
Drug Claims For This Report Were Selected From Files Containing Over Six Million
Records and 1.4 Million PDL-Eligible Claims
Claims Database (Oct 03 to Feb 04)
6,212,505
PDL Eligible Claims 1,486,105
Pre-PDL Claims 90 Days Prior to Hard Edit Date
(multiple claims per recipient and drug)592,609
Post-PDL Claims 1 to 6 Weeks After Hard Edit Date
(multiple claims per recipient and drug) 220,424
Pre-PDL By PrescriptionSingle Claim Per Recipient Per Drug
289,487
Post-PDL By PrescriptionSingle Claim Per Recipient Per Drug
156,163
10
DMAS Policy and Research Staff Tracked The Movement of Nearly 300,000 Drug
Claims In The PDL System
Total Claims289,487
Non-Preferred Rx102,806
Preferred Rx186,681
Change to Preferred Rx*
51,459
Approved as Non-Preferred
3,417
No New Claim47,930
Remained on Preferred Rx
64,269
Recent Pre-PDL Rx
48,538
No New Claim73,874
Later Refill????
No Refill????
Recent Pre-PDL Rx
19,308
Not Found28,620
Denied2 Walk aways
????
Headed to PA????
Later Refill ????
No Refill????
* This count excludes 792 possibly duplicate claims
Pre-PDL Post-PDL
Walkaway????
Claim Not Yet Submitted
????
11
PDL Compliance Rate Is High But Future Status Of Unpaid Claims Must Be Monitored
Pre-PDL Period(Oct 03 to Dec 03)
Post-PDL Period(Jan 04 to Feb 04)
Post-PDL Period(Jan 04 to Feb 04)
36%
64% 97%
31%
69%
289,487 119,145* 167,075**
* Includes only paid claims. ** Includes adjudicated claims and claims not found for drugs that were categorized as non-preferred in the pre-PDL period.
Not on PDL
PDL Status
PDL Drug
Total Claims
12
It Is Too Soon To Draw Conclusions Regarding Unpaid Claims In The Post-PDL Period For Drugs
That Were Non-Preferred Prior To PDL Implementation
Key Facts About Pre-PDL Non-Preferred Claims With No Matching Post-PDL Claim
Jan 1st Feb 29th Feb 1st Jan 15th Jan 19th
Was Last Pre-PDL Prescription Paid
After Jan 15th?
Did Hard Edits For Drug Class Occur
After Feb 1st?
40%60% 59%41%
20%
23%
19%
Cardiac (Beta Blockers)
Analgesics
Gastrointestinal
Total Claims = 47,930
YesNo
Yes
No
13
Compliance Rates Do Not Vary Significantly By Drug Class
TotalGastrointestinal
MedicationsCardiac
MedicationsAsthma
MedicationsCentral
Nervous SystemMedications
97% 96% 94% 93%
83%
Compliance Rate Needed to Achieve Budget Savings
85%
55,562Total Claims 5,508 35,433 12,517 2,104
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Presentation Outline
Components of PDL Evaluation
PDL Process: Movement of Prescriptions
PDL Process: Inside Prior Authorization
Budget Savings: Analysis Plan and Next Steps
Health Impacts: Analysis Plan and Next Steps
Conclusions
15
Four Out Of Every 10 Requests To The Call Center Result In A Change To A Preferred
Drug. There Have Been No Denials.
Total Since January 5
Jan. 5n=173
Jan 12n=398
Jan 19n=787
60%
40%
62%
38%
75%
25%
59%
41%
Prior AuthorizationApproved
PhysicianAgreed to Change to a Preferred Drug
Jan 26n=1,482
56%
44%
Feb 2n=1,572
Feb 9n=1,351
52%
48%
59%
41%
64%
36%
67%
33%
Feb 16n=1,404
Feb 23n=1,498
Week Start Date
16
Calls To The Center Are Increasing Weekly
Average Jan 5 Jan 12 Jan 19
Total Issues Addressed
Total Calls
Calls on Peak Day
2,640
1,643
349
Jan 26
241
1,137
1,822
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2200
2400
2600
2800
Feb 2 Feb 9 Feb 16 Feb 23
Week Start Date
17
Physicians Raise Most of The Calls To The Center
Average
71%
24%
5%
60%
26%
15%
67%
26%
7%
62%
32%
6%
Physician
Pharmacist
Recipient
73%
23%
75%
21%
74%
21%
73%
24%
72%
22%
Jan. 5n=455
Jan 12n=821
Jan 19n=1,421
Jan 26n=1,944
Feb 2n=2,463
Feb 9n=2,314
Feb 16n=2,516
Feb 23n=2,640
6%
Week Start Date
18
Most Inquirers Concern Requests For Prior Authorization
PA Requests
PDL/PPL
Other
Reject 68%
9%
9%
89%
11%
Physician
Pharmacist
Caller Type
Inquiry Type
6%
DUR Codes 4% Guidelines 4%
19
First Health Call Center Staff Are Answering Calls In Less Than 30 Seconds
0:23
2:54
Average Speed to Answer
Average Length of Call
0:00
0:28
0:57
1:26
1:55
2:24
2:52
3:21
3:50
Average Jan 5 Jan 12 Jan 19 Jan 26 Feb 2 Feb 9 Feb 16 Feb 23
Week Start Date
0:24
2:42
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Presentation Outline
Components of PDL Evaluation
PDL Process: Movement of Prescriptions
PDL Process: Inside Prior Authorization
Budget Savings: Analysis Plan and Next Steps Health Impacts: Analysis Plan and Next Steps
Conclusions
21
Budget Impact Will Be Assessed By Comparing Predicted Costs To Actual Costs
Month4
$ M
illi
ons
Actual Medicaid Spending
Month4
Month3
Month2
Month3
Month1
Month1
Month2
Pre-Implementation Months Post-Implementation Months
PDL Implementation
Projected Savings Due
to PDL
Projected Medicaid Spending
Actual Medicaid Spending
22
Other Components of Budget Impact Study
Market share analysis. Model predictions will need to be validated. Market share analysis will allow DMAS to accomplish this. Specifically:– If large savings are estimated using the prediction models
and the PDL is comprised of drugs that controlled only a small share of the market, a large shift in market share should be observed
Analysis of Savings Among Eligibility Groups. The DMAS study team will also determine which eligibility groups witnessed the largest reduction in drug costs. Calculations will be made on a per-member, per-month basis to dampen the effect of enrollment changes.
23
Presentation Outline
Components of PDL Evaluation
PDL Process: Movement of Prescriptions
PDL Process: Inside Prior Authorization
Budget Savings: Analysis Plan and Next Steps
Health Impacts: Analysis Plan and Next Steps
Conclusions
24
Evaluation of PDL Health Effects Poses Methodological Challenges
Sev
erit
y o
f C
on
dit
ion
Pre-PDL Period Post-PDL Period
Time Time
Atypical High Level
Movement Towards Typical Level
25
Research Design Strategies
Design Type How It Works Advantages Disadvantages
Non-experimental
PDL patients’ health status/expenditures are compared from the periods before and after the PDL was implemented
Easy to implement and understand
Design does not address what would have occurred in the absence of the program – results unreliable
Experimental Patients are randomly chosen to participate in the PDL and outcomes are compared to those who were randomly screened off of the program
Cadillac of research designs in terms of producing reliable, unbiased measures of program impact
Not feasible
Quasi-Experimental
Develop a non-randomly assigned group of PDL participants and compare to a non-randomly assigned group of non-participants
Produces measure of program impact without the burden of random assignment
Subject to selection bias which produces non-equivalency among study groups
26
Sample Size For PDL and Control Group Will Be Driven By Program
Compliance Rate
Total Claims289,487
Non-Preferred Rx102,806
Preferred Rx186,681
Change to Preferred Rx*
51,459
Approved as Non-Preferred
3,417
No New Claim47,930
Remained on Preferred Rx
64,269
Recent Pre-PDL Rx
48,538
No New Claim73,874
Later Refill????
No Refill????
Recent Pre-PDL Rx
19,308
Not Found28,620
Denied2
Walk away????
Headed to PA????
Later Refill ????
No Refill????
* This count excludes 792 possibly duplicate claims
PDL Group
Control Group
27
Quasi-Experimental Option Selected By DMAS Study Team
Construct two study groups from the universe of persons who were on non-preferred drugs prior to participating in the program:
– The first group would consist of persons who were switched to a preferred drug by their physician to comply with the PDL program
– The second group would consist of persons who were approved for the non-preferred drugs by First Health or DMAS
These groups could then be tracked over time and compared across the following measures post-PDL:
– Total Medicaid expenditures
– Rate of hospitalizations
– Total inpatient and outpatient Medicaid costs Statistical modeling will be used to account for non-equivalency
between the two groups.
28
Presentation Outline
Components of PDL Evaluation
PDL Process: Movement of Prescriptions
PDL Process: Inside Prior Authorization
Budget Savings: Analysis Plan and Next Steps
Health Impacts: Analysis Plan and Next Steps
Conclusions
29
Conclusions
Study results of the early implementation of PDL in Virginia are favorable:– PDL compliance rate is high and most changes are being
made voluntarily– Patients are not being denied drugs– The Call Center is working well
More conclusive findings must be held in abeyance until the program matures and DMAS has had the opportunity to examine the health effects of the new program.
Interim results on the health effects of the program will likely be presented in the early part of 2005.