1. Pharmacy Data Mark W. Smith, PhD July 13, 2005 Health Economics Teleconference Seminar 1-800-767-1750 access code 45043

2. Topics Overview of Data Sources Access & File Names Highlights of Contents Guidance for Use Non-VA Pharmacy Data

3. Abbreviations AAC: Austin Automation Center BPA: Blanket Purchase Agreement CMOP: Centralized Mail-Order Pharmacy DSS: Decision Support System MCRR: Medical Care Cost Recovery program NDE: National Data Extract PBM: Pharmacy Benefits Management VAMC: Veterans Affairs Medical Center VISTA: Veterans Health Information Systems and Technical Architecture

4. Overview - 1 VISTA –Repository of primary data: clinicians enter data directly –Many files comprise pharmacy data “package” –Separate VISTA system at each VAMC PBM v3.0 Database –Data from local VISTA systems + new elements –National coverage: all VA pharmacies –Only outpatient prescriptions available currently DSS National Pharmacy Extract –Data from local DSS systems + new elements –National coverage: all VA (local) DSS systems –Inpatient and outpatient prescriptions available

5. Overview - 2 DSS National Data Extracts –Contains all types of care (inpatient, outpatient, pharmacy) –Separate from DSS Pharmacy Extract –Data from local DSS systems + new elements –National coverage

6. Additional Pharmacy Data Sources Fee Basis files –Data from non-VA pharmacies paid by VA –National coverage DSS Production Data –Contains finer detail than national DSS extracts –Pertains to local DSS system only

7. A Record Represents VISTA, PBM database, DSS national pharmacy extract, Fee Basis: –a single prescription or supply for an individual DSS NDE for inpatient/outpatient care: –all prescriptions and supplies for a person on a particular day

8. A Record Represents DSS production data: –All prescriptions and supplies for a person handled by a particular production unit on a particular day –examples of production units: on-site pharmacy, CMOP

9. Data Format VISTA: ASCII PBM: You may request SAS, MS Access, or Visual FoxPro DSS NDEs at AAC: SAS KLF Menu (DSS): Spreadsheet

10. Access -- Summary PBM: Extracts made by PBM staff (www.vapbm.org)www.vapbm.org DSS Rx NDEs: detailed files stored at AAC and accessed through timeshare accounts; some summary data available for free via KLFMenu VISTA: Difficult to obtain direct access; easier to request data from local IRMS. N.B.: IRMS staff cannot accept Research funds. They do you a favor by making an extract.

11. Access -- Reference See Table 1 of: MW Smith, G Joseph. Pharmacy Data in the VA Health Care System. Medical Care Research and Review 2003;60(3 Suppl): 92S-123S. www.herc.research.med.va.gov/Pubs_medcare2.htm

12. Cost of Obtaining Data PBM –Managerial & oversight projects: no charge –Unfunded pilot studies: usually no charge –Funded studies: charges for programmer time + optional consulting on study design –Ask PBM/SHG staff ahead of time Other sources –No charge to user; AAC charges billed to VAMC –KLF Menu: free unless you need to put in your ID # and password

13. Contents For PBM and DSS Pharmacy Extract: VIReC research user guide: VHA pharmacy prescription data. Hines, IL: Veterans Affairs Information Resource Center (VIReC). 2005. URL:www.virec.research.med.va.gov For all sources (but somewhat dated): Table 2 in Smith and Joseph Med Care Res Rev article.

14. Sample of Data Fields Medication: drug name, NDC, formulary indicators Dispensing: fill date, quantity dispensed, days supplied Cost: purchase price (PBM, VISTA) or VA cost including overhead (DSS NDEs, DSS Pharmacy Extract)

15. Sample of Data Fields Patient: SCRSSN; date of birth, gender, age Provider: provider ID, provider treating specialty Note: Clinical information on related visits/stays can be linked to Rx data using SCRSSN

16. Co-payments VA charges some copayments –Depends on income, disability percentage –Rules & eligibility levels change year to year –Rules available on VA internet Data sources do not show copayments; they show VA’s expense MCRR files could show reimbursement from private insurance, if collected

17. Unit Costs - 1 There may be a contract price –Federal Supply Schedule (FSS) –FSS Tier Schedule –Federal ceiling price (“Big 4”) schedule –VA Blanket Purchase Agreement (BPA) Price files available on PBM web site (www.vapbm.org)

18. Unit Costs - 2 There will be discrepancies across sites –Correct pricing requires *daily* updating of a VISTA price file at each VAMC, which does not occur –BPAs are specific to individual VAMCs National VA formulary may limit use of selected medications –- see PBM website for current formulary, changes to formulary since 1998, and current rules for particular medications

19. Choosing a Source: VISTA Advantages –Greatest detail on costs, use of care –Access to data not available in extracts Disadvantages –Can access data from only the local VAMC –Most often, extracts must be made by IRMS staff using specialized programs –Requires caution in interpreting differences across sites

20. Choosing a Source: PBM Advantages –National coverage in one extract –Only source that provides purchase price (sometimes inaccurate!) –Optional fee-based consulting on pharmacy data needs & use

21. Choosing a Source: PBM Disadvantages –PBM staff must create the extract –Does not show pharmacy clinic costs beyond purchase price –Limited clinical and demographic information

22. Choosing a Source: DSS National Pharmacy Extract Advantages –National coverage –Detailed cost data Disadvantages –Limited prescription characteristics –Cost data do not show purchase price

23. Choosing a Source: DSS Inpatient/Outpatient NDEs Advantages –National coverage –Convenient summary cost data by treating specialty or overall Disadvantages –Limited prescription characteristics –Only summary data: no data on individual prescriptions or supplies

24. Choosing a Source: DSS Data via KLFMenu Advantages –National coverage –Convenient summary cost data –Ease of access and use Disadvantages –Only summary data: no data on individual prescriptions or supplies –Cannot select cases by SCRSSN

25. Validation Studies: PBM vs. DSS Do PBM and DSS data sources contain the same prescription records? Study #1: 1,600 patients with hernias in CSP 456. Result: PBM and DSS Pharmacy Extract have >95% concordance in drug names, # scripts, # units dispensed.

26. Validation Studies: PBM vs. DSS Study #2: >300 patients with heart disease in CSP 424. Result: PBM and DSS NDE daily summary have very poor concordance in monthly or annual pharmacy costs.

27. Grouping Prescriptions DSS sometimes groups two prescriptions into one record if they are for the same NDC and the same person on the same day –PBM does not group prescriptions in this way

28. Other Notes on Pharmacy Data KLF Menu provides summary DSS data on pharmacy spending –Pharmacy spending is one element of many DSS reports –Level: station, VISN, or nation –No data on individuals –Cannot be used to select data on a cohort of individuals

29. Other Notes on Pharmacy Data VA utilization and spending patterns for individual medications is often confidential –E.g.: nationwide prescribing patterns for branded antipsychotics for patients newly diagnosed with schizophrenia –Drug manufacturers seek these data to aid in negotiations with VA –Consult PBM before allowing private firms to see VA pharmacy data

30. Cautions Validation is essential –Fields may have missing or inconsistent values. –Different sites may complete fields differently. –Not clear yet whether all prescriptions are recorded, and how this varies by data source.

31. Cautions Data elements change each year –Written guides become outdated quickly –Crosscheck data elements against printed information: do you know what each field means? E.g.: fill date vs. release date

32. Validity Checks Check data for erroneous values Missing values –If possible, fill in values based on consistency checks (e.g., for gender, age) –Imputing values adds statistical uncertainty: should account for it (or at least mention if used rarely) Inconsistent units –One 50ml bottle could be “50 units” in one record but “1 unit” in another record

33. Non-VA Pharmacy Data In CSP trials, we typically do not ask patients about non-VA pharmacy –Many VA users get all prescriptions through VA –VA is likely to be used for most expensive meds –Over-the-counter and occasional non- VA prescription use is unlikely to affect total Rx spending much

34. Non-VA Pharmacy Sources 1.Drug Topics “Red Book” Published annually Offers “Average Wholesale Price” (AWP), the starting point for Medicaid drug payments 2.Private-sector claims data Proprietary: must pay for access

35. Questions on Pharmacy Data?