Patient Access Schemes from a procurement and operational perspective

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Patient Access Schemes from a procurement and
operational perspective

• Kirsteen Docherty
• Pharmacy Procurement Services Mgr
• UCLH Trust

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Patient Access Schemes

• The good news!
• Increased opportunity for patients to receive
  expensive new medicines.
• Increased access to medicines and enhanced sales
  for Pharma
• Reduced cost for purchasers e.g. PCTs
  commissioners
• Adherence to principles of NICE Qaly of 30K p.a.
• Schemes do not interfere with NHS/PPRS price of
  product
• Opportunity to obtain useful post marketing
  outcome data
• Development of NHS and Industry partnerships
• Outcome schemes focus towards value for money
  e.g. only pay for what works.
• BUT the problem is the implementation of PAS!

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Types of PAS

• Principle NHS List price does not change
• Financially Based Schemes (FBS) Not Risk
  Sharing
• Discounts given via free stock for initial
  treatment, volume based rebates of free stock,
  credit/ cash or cheque.
• No clinical management/results needed.
• Outcome-Based Schemes (OBS) Risk sharing
• Discount based upon achievement of defined
  clinical result. If performance is good then
  no/limited discounts. Post marketing data
  available.
• Could be time limited if success rate
  established.

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Examples of PAS
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Examples of PAS
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Patient Access Scheme Research

• Aim
• To research the operational management of PAS
  within Hospital Trusts
• Method
• Questionnaire circulated to Hospital Trusts in
  the UK Jan 2010
• Researched
• Pharmacy Systems used
• Responsibility for PAS within Trusts
• Operational management of different PAS schemes
• Information management
• Trust preferences

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Pharmacy systems used
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Responsibility for managing the administration of
PAS
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Types of schemes available in operational terms

• Free stock schemes
• (a) Agreed volume at initial part of treatment
  
• (b) Agreed volume delivered at the same
  time as paid stock
• (c) Agreed volume at end of period or when
  outcome achieved.
• Credit given retrospectively (e.g for
  non-responding patients)
• Cash or cheque given retrospectively
• PriceNot strictly defined as Patient Access
  Schemes (change in price) but some Pharma
  companies have given price discounts as part of
  an Access Scheme.

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How Trusts manage free stock for initial treatment
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Management of free stock for initial treatment

• Advantages
• If system allows set up of FOC (zero value) item
  then audit trail available, costs and free stock
  transparent and only costs incurred for paid
  stock will go through financial systems and on to
  PCT
• Average price need not be affected
• Disadvantages
• If pharmacy system cannot manage free stock then
  audit trail can be difficult
• Problems knowing when to dispense FOC or paid
  stock
• If received with paid for stock then affects
  average price so real cost not transparent
  causing financial flow difficulties
• Admin required to claim initial free stock
• Initial training of staff in pharmacy clinical/
  procurement/ dispensary required

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How Trusts manage free stock delivered at the
same time as paid stock
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Management of free stock delivered at same time
as paid stock

• Advantages
• If all stock booked in at same time then overall
  discount achieved. Means product can be managed
  as if it had a price discount so real costs
  easily captured
• If system allows set up of FOC item then audit
  trail available and only costs incurred for paid
  stock will go through financial systems and on to
  PCT
• Disadvantages
• Prices need set carefully initially
• Need to book in all stock at same time
• Must invoice all stock at same time
• Requires intervention in pharmacy procurement
  (and dispensary if set up FOC item)

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How trusts manage free stock delivered
retrospectively
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Management of free stock delivered retrospectively

• Advantages
• None!
• Disadvantages
• Difficult to manage if patient specific as
  patient has already had treatment
• Stock control systems cannot manage this
  effectively
• Rebate may be patient specific but free stock may
  go to another patient. Hence difficult to manage
  effectively costs and rebates to correct budgets/
  PCTs for individual patients.
• Financial flows and total treatment costs not
  transparent
• When to dispense FOC or paid stock
• Receiving as if paid for stock will affect
  average price so treatment costs not transparent
  and all budgets/ PCTS get reduced cost
• Resource intensive across departments to manage
  (procurement/ dispensary/clinical/finance/contract
  s/PCT)

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How Trusts manage credit given retrospectively
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Management of credit given retrospectively

• Advantages
• Can be coded directly to relevant budget and PCT
• Can track credit through financial systems if not
  pharmacy systems
• Need not affect average price
• Disadvantages
• Audit trail on pharmacy system difficult
• Matching credit to specific patient difficult in
  existing systems hence easiest option may be to
  credit pharmacy budget instead of clinical or PCT
• Manual management probably necessary
• Financial flows and total treatment costs not
  transparent
• If used against a later invoice then affects
  average price
• Resource intensive across departments to manage
  (procurement/ dispensary/clinical/finance/contract
  s/PCT)

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How Trusts manage cash or cheque given
retrospectively
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Management of cash or cheque given retrospectively

• Advantages
• Can be coded directly to the relevant budget and
  PCT
• Can track through financial systems
• Does not affect average prices
• Disadvantages
• No audit trail on pharmacy system
• Matching cheque to specific patient difficult in
  existing systems hence easiest option may be to
  credit pharmacy budget instead of clinical or PCT
• Manual management probably necessary
• Financial flows and total treatment costs not
  transparent
• Resource intensive across departments to manage
  (procurement/ dispensary/clinical/finance/contract
  s/PCT)

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Preferred PAS rebate method
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Can pharmacy stock control systems track free
stock, credit, cash or cheque systems at patient
level data?

• If No how managed?
• 50 track patients manually on spreadsheet and
  finance rebates PCT
• 21 provide no patient level detail and pass on
  no rebate to PCT
• 14 finance manage rebates so unsure
• 15 rebate passed on through average price of
  medicines

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Trusts suggested changes to pharmacy stock
systems to make processing of PAS easier

• Ability to differentiate between paid for and
  free stock and ability to track reimbursements
• Ability to allocate specific invoices to
  patients. To be able to flag returns in a billing
  report. Ability to add credits retrospectively to
  system and again be able to flag that in a
  billing report. Ability to assign a particular
  patient to a particular PCT.
• Ability to highlight PAS drugs so that when
  dispensed it can be recognised and a record
  made.
• Option to remove average pricing to handle free
  stock better.
• Should not have to change anything. Schemes
  should fit within the capabilities of pharmacy
  systems
• To be able to zero or return the cost but not
  the issue data for a patient without affecting
  overall drug cost.
• To be able to retrospectively amend orders/
  receipts and enter a credit note against an
  invoice already passed and consequently reduce
  the value of stock that has been issued to a
  particular patient.

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Would Trusts choose an option for the rebate to
go directly to the PCT?

• Yes
• Trust could inform PCT of patients due a
  rebate. PCT could manage it from there
• If PCTs managed rebates administrative effort
  as a whole lowered
• No
• Management and assurance process impossible to
  manage
• Difficult to ensure goes to correct PCT as
  audit trail not robust
• PCTs would not like this method
• For schemes that require clinical outcome data
  the PCT would not have ready access to it

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What would you change to improve the way PAS are
managed in your Trust?
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Example of how a credit reimbursement scheme
usingUCLH pharmacy system is managed

• Medicine purchased and received into dispensary
  stock. Drug given to patient and issued to the
  relevant pharmacy directorate.
• Medicine is PBR excluded and hence costs should
  be passed on directly to PCT and not bundled as
  part of whole treatment. The F2 report (patient
  level detail) is produced by a nominee in
  pharmacy to pick up these issues to help Finance
  Contracts correctly charge the PCT.
• The directorate pharmacist identifies patient due
  a first cycle refund and fills out the Pharma
  company paperwork to claim the credit. Pharmacy
  procurement need to be contacted to provide the
  order number and delivery date.

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Example of how a credit reimbursement scheme
usingUCLH pharmacy system is managed

• Credit is sent from Wholesaler to Pharmacy
  Procurement. Procurement Manager informs
  directorate pharmacist of arrival.
• Directorate Pharmacist identifies issue on PIMS
  relevant to the patient and carries out a return
  transaction from the directorate to the
  pharmacy. This credits the directorate budget and
  results in an increase in stock in the pharmacy
  (although stock not physically there).
• Pharmacy procurement are informed and carry out a
  return to supplier transaction to make zero the
  additional stock holding in pharmacy which does
  not exist physically.
• The return to supplier creates a negative in
  the stock control account. Pharmacy procurement
  code the credit to the stock control account to
  offset the negative.

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Example of how a credit reimbursement scheme
usingUCLH pharmacy system is managed

• Credit sent to Finance Payments division. Must be
  dealt with manually because the pharmacy system
  cannot deal with a credit that is not related to
  physical stock or invoice.
• The return carried out in point 5 appear as
  negative figures on the F2 report. Contracts pick
  up these negative figures and know to credit the
  PCT responsible for that patient.
• The value of the PCT refund is then charged back
  to the directorate budget to offset the credit in
  point 5, resulting in a net zero effect on the
  directorate budget (the directorate will already
  have been paid by the PCT for the medicine).

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Summary

• PAS are complex operationally to manage!
• PAS can be resource intensive!
• Requiring
• Planning and control efforts
• Management and administration across multiple
  departments
• Set up and training
• Audit control systems
• Communication between multiple internal
  external stakeholders
• Manipulation of systems
• Additional clinical monitoring (if an outcome
  based scheme)

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Recommendations

• Review of PAS
• Limit types of schemes available
• Standardise and simplify schemes
• Ensure resource available for PAS management e.g.
  dedicated co-ordinator
• Consider developing an I.T. solution for Trusts
• Standardise PAS management across Trusts
• Simplify internal processes communication flows
• Develop written and agreed procedures
• Audit financial flow processes