Evaluation of Virginias Preferred Drug List: 4th Quarter Report

1
Evaluation of Virginias Preferred Drug List 4th
Quarter Report

• Policy and Research Division

November 2, 2004
Department of Medical Assistance Services
2
Presentation Outline
?

• Components of Evaluation For This Report

• PDL Process Movement of Prescriptions

• PDL Process Inside Prior Authorization

• Preliminary Budget Savings

• PDL Study Group and Comparison Group

• Next Steps and Conclusions

3
Study Components For This Interim Report

• Three issues provide the framework for this 4th
  quarter interim report
• First Healths implementation of the PDL program
  including a focus on the prior authorization
  process for non-preferred drugs
• The impact of the PDL program on the agencys
  budget and whether there is early evidence of
  continued savings in the pharmacy program
• Selection of PDL Control Group

4
Presentation Outline

• Components of Evaluation For This Report

?

• PDL Process Movement of Prescriptions

• PDL Process Inside Prior Authorization

• Preliminary Budget Savings

• PDL Program Group and Comparison Group

• Next Steps and Conclusion

5
The First Health National Drug Code File (With
PDL Indicator) and DMAS Claims Data Were Used To
Create PDL Analysis File
First Health File
PRE-PDL Claims File Paid claims with date of
service 90 days prior to the Hard Edit Date
National Drug Code
PDL Claims Analysis File
Hard Edit Date Drug Class Drug Name Preferred
Indicator
Service Date Hard Edit Date Paid/Denied Status
Drug Class Drug Name Preferred Indicator Recipient
Information National Drug Code
DMAS Claims File
National Drug Code
POST-PDL Claims File Paid or denied claims with
a service date after the Hard Edit date
Paid/Denied Status Service Dates Recipient
Information
6
Drug Claims For This Report Were Selected From
Files Containing Over 14 Million Records And
Nearly 4.5 Million PDL-Eligible Claims
Claims Database (Oct 03 to Sep 04) 14,203,608
PDL Eligible Claims 4,476,739
Pre-PDL Claims 90 Days Prior to Hard Edit Date
(multiple claims per recipient and drug) 786,806
Post-PDL Claims 1 to 6 Weeks After Hard Edit
Date (multiple claims per recipient and drug)
2,288,568
Pre-PDL By Prescription Single Claim Per
Recipient Per Drug 405,539
Post-PDL By Prescription Single Claim Per
Recipient Per Drug 691,989
7
DMAS Staff Tracked The Movement Of More Than
400,000 Drug Claims Through The PDL System
Pre-PDL
Post-PDL
Change to Preferred Rx 84,308
Claim Not Yet Submitted
Approved as Non-Preferred 19,599
Recent Pre-PDL Rx
Non-Preferred Rx 127,279
Walk away
Later Refill
No New Claim 23,372
No Claim Found 23,372
Total Claims 405,539
No Refill
Remained on Preferred Rx 156,020
Recent Pre-PDL Rx 710
Preferred Rx 278,260
No New Claim 122,240
No Claim Found 121,530
8
How The PDL Compliance Rate Is Calculated
(Includes Persons Originally Using Preferred
Drugs)

• Bolded black boxes represent PDL compliance
  Compliance Rate (Black/(BlueBlack))
• Red boxes not used to calculate compliance

9
PDL Compliance Rate Remains High Almost 10 Months
After Program Start Date
Post-PDL Period (Jan 04 to Sep 04)
Pre-PDL Period (Oct 03 to Aug 04)
PDL Status
8
31
Not on PDL
85
Compliance Rate Needed to Achieve Budget Savings
69
PDL Drug (Compliance)
92
Total Claims
405,539
259,927
Includes only paid claims. .
10
DMAS Is Also Interested In Tracking PDL Results
For Only Those Person Who Were On Non-Preferred
Drugs In The Pre-PDL Period

• Bolded black boxes represent PDL compliance
  Compliance Rate(Black/(BlueBlack))
• Red boxes not used to calculate compliance

11
When Focusing Only On Persons Who Were On
Non-Preferred Drugs In The Pre-PDL Period, The
Compliance Rate Is Just Over 80 Percent
Last Reporting Period (Ending May 2004)
Current Reporting Period (Cumulative Ending
September 2004)
89
81
104,884
Total Claims
116,278
12
Using This Method Some Variation In Compliance
Rates Across Therapeutic Classes Is
Observed(Excluding Persons Originally On
Preferred Drugs)
Cardiac Medications
Central Nervous System
94
Total
Asthma/ Allergy
84
81
Analgesics
Gastrointestinal
77
Anti-Biotics
68
66
54
26,870
24,778
Total Claims
84,308
41,402
4,308
3,259
3,133
Notes The chi-square value of 9720.59 is
significant at a .0001 level of significance.
13
Presentation Outline

• Components of Evaluation For This Report

• PDL Process Movement of Prescriptions

?

• PDL Process Inside Prior Authorization

• Preliminary Budget Savings

• PDL Study Group and Comparison Group

• Next Steps And Conclusions

14
Three Quarters of Requests for Prior
Authorization Have Been Granted
1
2
3
3
Denied
Prior Authorization Approved
76
60
60
71
79
77
79
82
80
80
Physician Agreed To Change to a Preferred Drug
24
40
40
29
21
23
20
16
17
17
Total
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
n
34,606
2,393
5,825
5,194
4,430
3,890
3,614
2,770
3,017
3,890
15
Call Center Activity at First Health Remains
Level
2800
2600
2400
2200
Total Issues Addressed
1,800
Average
2000
1800
1,755
1600
1400
1200
Total Calls
846
1000
800
894
600
400
198
Calls on Peak Day
200
188
0
January
February
March
April
May
June
July
August
September
16
Pharmacists Comprise Growing Portion of Callers
To The Center
Physician
63
67
73
73
72
72
54
50
52
49
Pharmacist
33
27
22
23
22
22
41
46
45
47
Recipient
Total
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
n
68,511
4,641
9,933
8,959
7,847
6,370
8,113
6,580
7,147
8,921
17
Calls Are Handled Expeditously
35024
Average
32136
Average Length of Call
241
25248
218
22400
15512
12624
05736
Average Speed to Answer
016
017
02848
00000
January
February
March
April
May
June
July
August
September
18
Presentation Outline

• Components of Evaluation For This Report

• PDL Process Movement of Prescriptions

• PDL Process Inside Prior Authorization

?

• Preliminary Budget Savings

• PDL Study Group and Comparison Group

• Next Steps And Conclusions

19
Market Shift Data By Month Go Here
Pre-PDL Period
Post-PDL Period
PDL Status
13
13
12
12
11
11
12
16
11
22
Non-Preferred Drugs
88
87
87
84
88
89
89
88
89
78
43
43
43
43
42
41
39
Preferred Drugs
57
57
57
57
61
59
58
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
Jun
July
Aug
Sept
Oct
Nov
Dec
2003
2004
20
The Cost Per Script Continues to be Below the
Projected Amount Since PDL Implementation
Pre-PDL Period
Post-PDL Period
62
61
Forecasted Cost Per Script
60
59
58
57
56
Actual Cost Per Script
55
54
53
52
51
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sept
2003
2004
21
DMAS is On Track to Produce Expected Savings of
24 Million in the Overall Pharmacy Program. PDL
Is One Component Of The Savings
550
24.9 million
500
Official Medicaid Forecast for Pharmacy
Expenditures
450
Millions
Actual Medicaid Expenditures
400
350
300
FY 2001
FY 2002
FY 2003
FY 2004
22
Presentation Outline

• Components of Evaluation For This Report

• PDL Process Movement of Prescriptions

• PDL Process Inside Prior Authorization

• Preliminary Budget Savings

?

• PDL Study Group and Comparison Group

• Conclusions And Next Steps

23
Several Steps Were Implemented To Identify The
PDL Study Group And The Control Group
Switched to Preferred Drugs 84,308
Multiple Records (Prescriptions) Per Recipient
Total Claims 103,907
Did Not Switch 19,599
59,829
Single Record Per Recipient
Control Group
All Drugs Non-Preferred in Post-Period 6,387
PDL Group
All Drugs Preferred in Post-Period 44,570
Some Drugs Preferred, Some Non-Preferred in
Post-Period 8,872
Excluded
24
Number Of Recipients In PDL Group and Control
Group
Change to Preferred Rx 44,570
PDL Recipient Group
Recipient Control Group
Approved as Non-Preferred 6,387
Non-Preferred Rx
No New Claim
Total Claims
Remained on Preferred Rx
Recent Pre-PDL Rx
Preferred Rx
No New Claim
25
Only Minor Differences Exist In The
Characteristics of Recipients In The PDL Study
Group And Comparison
Female
43
Urban
62
White
PDL Group
69
59
Suburban
34
87
31
31
Black
24
Rural
Male
Average Age
Gender
Race
Place of Residence
Control Group
Female
47
Urban
67
White
67
58
13
32
Suburban
33
27
Black
Male
21
Rural
N50,957
Chi-square values statistically significant at
.0001
26
Substantial Differences Exists In The Medications
of Recipients In The PDL Study Group And
Comparison
Rate of Use for Certain Medications
55
51
PDL (Study) Group
Comparison Group
31
27
20
10
6
6
4
4
4
3
Cardiac
Gastro-intestinal
Central Nervous System
Analgesics
Anti-biotics
Allergy/ Asthma
Chi-square values are statistically significant
at .0001
27
Presentation Outline

• Components of Evaluation For This Report

• PDL Process Movement of Prescriptions

• PDL Process Inside Prior Authorization

• Preliminary Budget Savings

• PDL Study Group and Comparison Group

?

• Next Steps And Conclusion

28
2005 Study Report Schedule
29
Conclusions

• After nearly one year of program implementation,
  Virginias PDL program gets high marks
• PDL compliance rate is high and most changes are
  being made voluntarily
• Patients are not being denied drugs
• The Call Center continues to operate smoothly
• Program is saving money for the Commonwealth