Leverage Actionable and Raw Data to Improve Program Design and Market Access

Transcription

1 Leverage Actionable and Raw Data to Improve Program Design and Market Access Brian Burke Vice President, Trade Relations Armada Healthcare

2 SPP Data Flow SPP Pharma Manufcturer 3 rd Party aggregator HUB

3 1 st Things 1 st Distribution Strategy Availability and granularity of data Closed Limited/ Select OPEN

4 Data Field requirements Required Optional Optional if available Required if available?

5 Data Field requirements FMV

6 Data Fields If you ask they will want it ASK WHY

7 Data Fields Category Field Type Description Values Example Facility FACILITY NAME Text Medical facility that the patient or prescriber is affiliated with - could be a referral source Transplant Center, Medical Practice Building, Infertility Center, Nursing Home Infertility Center Facility FACILITY CITY Text City of Facility Open Text Seattle Facility FACILITY HIN Text HIN as provided by HIBCC Open Text AB456XK00 Facility FACILITY ID Number Facility Identifier - known only to member Facility Identifier - known only to member Facility FACILITY STATE Text State of Facility 2-letter string WA Facility FACILITY TYPE Text Type of Factility Nursing Home, Assisted Living, Correctional, LTAC, etc. Nursing Home Facility FACILITY ZIP Number Zip Code of Facility No dashes, only numbers Invoice INVOICE NUMBER Number Invoice Number of Purchase related to dispense Open Text Patient CD4 COUNT Number CD4 count Number of CD4 cells in a sample of blood 500 Patient DONOR TYPE Text Living/Deceased Donor L=Living, D=Deceased L Patient HIV STATUS Text If Patient has HIV or not Positive - Confirmed, Positive - Inferred, Negative or Unknown Positive Patient PATIENT ADDR1 Text Address of Patient Open Text 100 Campus Drive Patient PATIENT ADDR2 Text Secondary Address of Patient Open Text 100 Campus Drive Patient PATIENT ASSISTANCE PROGRAM AMOUNT Number Total amount of financial assistance the patient has received from program for this Rx $XXX.XX $ Patient PATIENT ASSISTANCE PROGRAM NAME Text Name of financial assistance program patient is participaing in Open Text New York PAF Patient PATIENT ASSISTANCE PROGRAM? Text Is Patient participating in any financial assistance program? Y, N Y Patient PATIENT BODY SURFACE AREA Number Either paitent height/weight or Body Surface 2 implied decimal postitions if needed 3.45 Patient PATIENT CITY Text City of Patient Open Text Seattle Patient PATIENT COUNTRY Text Country of Patient Open Text Australia Patient PATIENT DOB Date Patient Date of Birth Written as XX/XX/XXXX 12/21/2012 Patient PATIENT EDUCATION Text Did Patient Receive Training (Marketing Materials)? Y = Yes; N = No Y Patient PATIENT Text Address of Patient Open Text XXX@gmail.com Patient PATIENT EMPLOYER Text Employer of Patient Open Text Medco Patient PATIENT FIRST Text First Name of Patient Open Text Bob Patient PATIENT GENDER Text Sex of the Patient M - Male, F - Female M Patient PATIENT GENOTYPE Text Patient Genotype 1, 2, 3, 4 1A Patient PATIENT HCV 12 WEEK RESPONSE Number Patient Hepatitis 12 Week Viral Load Written as VL / ML 632,060 Patient PATIENT HCV 24 WEEK RESPONSE Number Patient Hepatitis 24 Week Viral Load Written as VL / ML 632,060 Patient PATIENT HCV 8 WEEK RESPONSE (EVR) Number Patient Hepatitis 8 Week Viral Load Written as VL / ML 632,060 Patient PATIENT HCV END OF TREATMENT RESPONSE Text (HCV RNA negative by a sensitive test at the end of treatment treatment length contingent upon genotype & RGT) Patient PATIENT HCV INITIAL VIRAL LOAD Number Patient Hepatitis Initial Viral Load Written as VL / ML 632,060 Patient PATIENT HCV VIRAL LOAD Number Patient Hepatitis Viral Load Written as VL / ML 632,060 Patient PATIENT HEIGHT Number Patient Height (Inches) No dashes, only numbers 78 Patient PATIENT HIV VIRAL LOAD Number Patient HIV Viral Load Written as VL / ML 632,060 Patient PATIENT ID Number Patient Identifier - Id from pharmacy dispensing system Patient Identifier - Id from pharmacy dispensing system Patient PATIENT INTEREST IN MY SPRYCEL Text Was patient interested in "My Sprycel Support" and was warm transfer completed? Y = Yes; N = No Y Patient PATIENT LAST Text Last Name of Patient Open Text Jones Patient PATIENT LOCKING CAP Text Did Patient Receive a Locking Cap? Y = Yes; N = No Y Patient PATIENT MI Text Middle Initial of Patient 1-letter H Patient PATIENT MOBILE PHONE Number Phone # of Patient (Mobile) 10-digits, no dashes Patient PATIENT PHONE Number Phone # of Patient 10-digits, no dashes Patient PATIENT PROGRAM ID Number Unique Patient ID assigned by Hub Unique Patient ID assigned by Hub Y,N Y

8 Data Fields Patient PATIENT REGIMEN Text Patient's Rx Regimen (Episodic / Prophylatic) Open Text Episodic Patient PATIENT RELATION Text Relation to Insured Open Text Father Patient PATIENT SPEAKER Text Person authorized to speakon behalf of patient Open Text Rob Jones Patient PATIENT SSN Number Patient Social Security Number 9-digits, no dashes Patient PATIENT START DATE Date Helps determine if patient is new to pharmacy. Date patient was added or date of first RX Written as XX/XX/XXXX 12/21/2012 Patient PATIENT STATE Text State of Patient 2-letter string WA Patient PATIENT TRANSFER? Text Identifies patient who have been transferred from competing pharmacy Y = Yes; N = No N Patient PATIENT TX DATE Date Date of transplant Written as XX/XX/XXXX 12/21/2012 Patient PATIENT TYPE Text Patient Therapy Association - Primary Fill only Naïve to Therapy, Retreatment, or Partial Relapse Partial Relapse Patient PATIENT WEIGHT Number Patient Weight (applicable to UOM) No dashes, only numbers 180 Patient PATIENT WEIGHT UNITS Text Depict pounds (lbs) or Kilograms (kg) for PATIENT_WEIGHT LBS, KGS LBS Patient PATIENT WORK EXT Number Patient Work Phone Extention No dashes, only numbers 123 Patient PATIENT WORK PHONE Number Phone # of Patient (Work) 10-digits, no dashes Patient PATIENT ZIP CODE Number Zip Code of Patient No dashes, only numbers Patient TRANSPLANT TYPE Text Organ Transplanted HR=Heart,HL=Heart/Lung,IN=Intestine,KI=Kidney,LI=Liver,LU=Lung,PA=Pancreas,PI=Pancreas Islet HR Pharmacy PHARMACY CONTACT Text Contact Name at Pharmacy Open Text Bob Jones Pharmacy PHARMACY CONTACT PHONE Number Phone # of Pharmacy Contact 10-digits, no dashes Pharmacy PHARMACY CORP NAME Text Corporate Name of Pharmacy Open Text Bob's Pharmacy Pharmacy PHARMACY DEA Text DEA of the pharmacy Required if data for more than one pharmacy is supplied AB Pharmacy PHARMACY DEA NAME Text DEA Name of Pharmacy Open Text Bob's Pharmacy Pharmacy PHARMACY NABP Number Same as NCPDP NABP (National Association of Boards of Pharmacy) number as issued by NCPDP Pharmacy PHARMACY NPI Number National Provider ID for pharmacy 10-digits, no dashes Pharmacy PHARMACY ZIP Number Zip Code of Pharmacy No dashes, only numbers Physician PHYSICIAN CITY Text City of Physician Open Text Seattle Physician PHYSICIAN DEA Text DEA # of Physician Open Text AB Physician PHYSICIAN FAX Number Fax # of Physician 10-digits, no dashes Physician PHYSICIAN FIRST NAME Text First Name of Physician Open Text Bob Physician PHYSICIAN ID Number Physician Identifier - known only to member Physician Identifier - known only to member Physician PHYSICIAN LAST NAME Text Last Name of Physician Open Text Jones Physician PHYSICIAN ME Number Medical Education number of the Physician 11-digits, no dashes Physician PHYSICIAN MIDDLE INITIAL Text Middle Initial of Physician 1-letter H Physician PHYSICIAN NPI Number NPI # of Physician 10-digits, no dashes Physician PHYSICIAN PHONE Number Phone # of Physician 10-digits, no dashes Physician PHYSICIAN SPECIALTY Text Specialty of Physician Open Text Cardiology Physician PHYSICIAN STATE Text State of Physician 2-letter string WA Physician PHYSICIAN STATE LIC Number State License # for Physician No dashes, only numbers Physician PHYSICIAN STREET ADDRESS Text Street address of physician's office Open Text 100 Campus Drive Physician PHYSICIAN STREET ADDRESS 2 Text Secondary Street Address Open Text Suite 105 Physician PHYSICIAN TITLE Text Professional designation of prescriber MD, DO, NP, PA MD Physician PHYSICIAN ZIP Number Zip Code of Physician No dashes, only numbers Referral BENEFIT INVESTIGATION COMPLETE DATE Date Date Benefit Investigation completed Written as XX/XX/XXXX 12/1/2013 Referral BENEFIT INVESTIGATION START DATE Date Date Benefit Investigation started Written as XX/XX/XXXX 12/1/2013 Referral DATE OF REFERRAL DENIAL Date Date referral denied (if denied) Written as XX/XX/XXXX 12/1/2013 Referral DATE REFERRAL APPEAL SUBMITTED Date Date appeal submitted (if denied) Written as XX/XX/XXXX 12/1/2013 Referral DATE REFERRAL COMPLETED Date Date referral completed Written as XX/XX/XXXX 12/1/2013 Referral DATE REFERRAL STARTED Date Date referral received Written as XX/XX/XXXX 12/1/2013 Referral DEADLINE FOR REFERRAL PAYOR Date Date appeal submitted (if denied) Written as XX/XX/XXXX 12/1/2013

9 Data Fields Referral HUB PATIENT ID Number HUB Patient ID from Referral Open Text Referral NUMBER OF REFERRAL APPEALS ALLOWED Number Date appeal submitted (if denied) Open Text 2 Referral REASON FOR REFERRAL DENIAL Text Reason referral denied (if denied) Open Text "Not Medically Necessary" Referral REFERRAL APPEAL NUMBER Number Number of Appeal (if denied) Open Text Referral REFERRAL NUMBER Number Number attributed to referral Open Text Referral REFERRAL STATUS Text Current status from referral (ACTIVE, PENDING, DENIED, DISCONTINUED) ACTIVE Referral REFERRAL STATUS REASON CODE Text Current status reason code from referral See attached sheet A01 Referral STATUS DATE / TIMESTAMP Date/Time Date of change to current status of referral Written as XX/XX/XXXX XX:XX 12/1/13 12:32 Rx BENEFIT TYPE Text Medical or Pharmacy Benefit? Open Text Pharmacy Rx BIN NUMBER Number Bank Identification Number - Primary Payor id used by claims switch Rx COINSURANCE Number Patient Coinsurance XX% 0.15 Rx COPAY Number Patient out of pocket costs $XXX.XX $10.00 Rx COPAY CARD TYPE Text Description of the Copay card utilized M = Manufacturer; F = Foundation; O = Other; N = None M Rx COUPON CODE Text Coupon for Copay Reduction Open Text XYZCOUP Rx DATE BILLED Date Date the current claim was processed Written as XX/XX/XXXX 12/21/2012 Rx DATE FILLED Date Date RX was Dispensed Written as XX/XX/XXXX 12/21/2012 Rx DATE ORDERED Date Date of Original Prescription Written as XX/XX/XXXX 12/21/2012 Rx DATE REFERRED Date Date that referral was received at pharmacy Written as XX/XX/XXXX 12/21/2012 Rx DATE SHIPPED Date Date product was shipped Written as XX/XX/XXXX 12/21/2012 Rx DATE WRITTEN Date Date when the Rx was written Written as XX/XX/XXXX 12/21/2012 Rx DAYS SUPPLY Number Days Supply for Quantity Dispensed Days Supply for Quantity Dispensed 30 Rx DAYS SUPPLY WRITTEN Number Days Supply Written on original RX Days Supply Written on original RX 30 Rx DEDUCTIBLE Number Patient Deductible $XXX.XX $ Rx DIAGNOSIS DESCRIPTION Text Primary Diagnosis Verbal Description Open Text Hemophelia Rx DISCHARGE DATE Date Discharge Date Written as XX/XX/XXXX 12/21/2013 Rx DISCHARGE REASON Text Discharge Reason Open Text Patient Healing Rx DISPENSE AS WRITTEN Text DAW Code Yes = DAW; No = Not DAW Yes Rx DISPENSING FEE Number Fee applicable to dispense $XXX.XX $7.50 Rx DOSAGE Number Milligrams per pill or per injections mgs 375 Rx DOSE ADMIN Text Mode of Administration IV = Intravenous, SC = Subcutaneous) SC Rx DOSE VOLUME Number Prescriber Dosage Volume Units per dose (grams for Ig, mg for Alpha1, IU for other) 30 Rx INSURANCE ID PRIMARY Text Primary Insurance ID Open Text Rx INSURANCE ID SECONDARY Text Secondary Insurance ID Open Text Rx INSURANCE ID TERTIARY Text Tertiary Insurance ID Open Text Rx INSURANCE PHONE PRIMARY Number Phone # of Insurance company (Primary) 10-digits, no dashes Rx INSURANCE PHONE SECONDARY Number Phone # of Insurance company (Secondary) 10-digits, no dashes Rx INSURANCE PHONE TERTIARY Number Phone # of Insurance company (Primary) 10-digits, no dashes Rx LIFETIME MAXIMUM Number Health Plan Lifetime Coverage Limit $XXX.XX $10, Rx LOT NUMBER Number Value identifying the production lot or batch Value identifying the production lot or batch Rx MAILORDER COPAY Number Amount of Mail Order Copay if any $XXX.XX $45.00 Rx MAJOR PLAN EXPIRATION Date Date of Insurance Expiration Written as XX/XX/XXXX 12/21/2012 Rx MARKETING CODE Text Marketing Material Shipped with the Product Yes, No No Rx MED GUIDE PROVIDED? Text Was Medication Guide Provided to Patient? Y/N Y Rx MY SPRYCEL INFORMATION Text Was "My Sprycel" information shared with patient? Y = Yes; N = No N Rx NDC Number NDC of the drug dispensed 11-digits, no dashes Rx NOTES Text Details on Status and Sub Status Open Text Patient admitted to hospital Rx OUT OF POCKET Number Out-of-pocket Limit $XXX.XX $ Rx PAID Number Total amount paid on this RX - based on adjudicated claim. Assume cash will be collected. $XXX.XX $300.00

10 Data Fields Rx PAYOR NAME Text Name of Payor Express Scripts, Medco, Caremark, etc. Medco Rx PAYOR TYPE Text Type of Payor MCAID - Medicaid, MCARE - Medicare, CASH, TPP - other Third Party Plan, MED - Medical Claim, MCAREB = Medicare B, MCARED = Medicare D TPP Rx PBM NAME Text Name of PBM Open Text OptumRX Rx PCN Text Payor Processor Control Number Open Text LOUIPR Rx PLAN MAXIMUM Number Health Plan Coverage Limit $XXX.XX $1, Rx PLAN REIMBURSEMENT Number Total paid by all health plans $XXX.XX $ Rx PLAN REIMBURSEMENT QUALIFIER Number Dispensing Fee? 1 - includes dispensing fee, 2 - excludes dispensing fee 2 Rx PRIMARY PAID Number Total amount paid by Primary Payor $XXX.XX $ Rx PRIMARY PLAN CITY Text City of Primary plan Open Text Atlanta Rx PRIMARY PLAN GROUP NUMBER Text Group # for primary plan. Identifies the employer. Open Text Rx PRIMARY PLAN NAME Text Patient Health Insurance Plan Name Open Text Medco Rx PRIMARY PLAN NUMBER Text Plan # (primary) Open Text Rx PRIMARY PLAN PBM Text Primary PBM Name Open Text VA Rx PRIMARY PLAN STATE Text State of Primary plan 2-letter string GA Rx PRIMARY PLAN ZIP Number Zip Code of Primary Plan No dashes, only numbers Rx PRODUCT DESCRIPTION Text Product Name/Strength/Form Used when NDC cannot be identified INCIVEK 375mg TAB Rx QTY Number Quantity Dispensed Quantity Dispensed 90 Rx QTY WRITTEN Number Quantity Written on RX Quantity Written on RX 90 Rx REFILL NUMBER Number New/Refill Code 00 = Original RX, 01 = First Refill, 02=Second Refill, etc. 01 Rx REFILLS AUTHORIZED Number Number of Refills specified by prescriber on prescription Number of Refills specified by prescriber on prescription 5 Rx REGIMINE Text Prescriber Treatment Regimen Episodic vs. Prophylactic, ITT Episodic Rx RX DC DATE Date Date RX was discontinued Written as XX/XX/XXXX 12/21/2012 Rx RX DC REASON Text Reason for RX dicontinuation Open Text Admitted to hospital Rx RX ICD10 (WHEN IMPLEMENTED) Number ICD-10 code for RX Open Text G Rx RX ICD9 Number ICD-9 code for RX Open Text Rx RX ICD9 2 Number Secondary ICD-9 code for RX Open Text Rx RX NUMBER Number Number attributed to RX No dashes, only numbers Rx RX PA DATE Date Date for Prior Authorization Code Written as XX/XX/XXXX 12/21/2012 Rx RX PA EXPIRATION DATE Date Expiration Date for Prior Authorization Code Written as XX/XX/XXXX 12/21/2012 Rx RX PA REQUIRED Text Prior Authorization Required? (Y=Yes, N=No) Y, N N Rx RX RECEIVED Text Was the RX Transferred from another Facility? Y/N Y Rx RX SIG Text Prescription Directions (SIG) Open Text 1 TAB BID Rx RX TRANSFERRED Text Was the RX Transferred to another Facility? Y/N Y Rx RX TYPE Number Prescription Type 1 = New/Refill, 0 = Adjustment, -1 = Reversal -1 Rx SECONDARY BENEFIT TYPE Text Medical or Pharmacy Benefit? Open Text Pharmacy Rx SECONDARY BIN NUMBER Text Secondary Payor BIN id used by claims switch Rx SECONDARY COPAY Number Patient (secondary) out of pocket costs $XXX.XX $10.25 Rx SECONDARY PAID Number Total amount paid on this RX - based on adjudicated claim. Assume cash will be collected. (secondary) $XXX.XX $45.00 Rx SECONDARY PAYOR NAME Text Secondary Payor Name Express Scripts, Medco, Caremark, etc. Medco Rx SECONDARY PAYOR TYPE Text Type of Secondary Payor MCAID - Medicaid, MCARE - Medicare, CASH, TPP - other Third Party Plan TPP Rx SECONDARY PCN Text Secondary Payor Processor Control Number Open Text LOUIPR Rx SECONDARY PLAN CITY Text City of Secondary plan Open Text Atlanta Rx SECONDARY PLAN GROUP NUMBER Text Group # for secondary plan. Identifies the employer. Open Text Rx SECONDARY PLAN NAME Text Patient Health Insurance Plan Name (Secondary) Open Text Medco Rx SECONDARY PLAN NUMBER Text Plan # (secondary) Open Text Rx SECONDARY PLAN STATE Text State of Secondary plan Open Text GA Rx SEVERITY Text Severity of Hemophilia Mild, Moderate, or Severe Severe Rx SEVERITY TYPE Text Severity Type Type1, Type2, or Type3 Type2 Rx SHIPPED TO CITY Text City of Physician or Facility where medication was shipped Open Text Seattle Rx SHIPPED TO NAME Text Name of Physician or Facility where medication was shipped Open Text Bob Rx SHIPPED TO NPI Number NPI # of Physician or Facility where medication was shipped 10-digits, no dashes Rx SHIPPED TO STATE Text State of Physician or Facility where medication was shipped 2-letter string WA Rx SHIPPED TO STREET ADDRESS Text Street address of Physician or Facility where medication was shipped Open Text 100 Campus Drive Rx SHIPPED TO ZIP Number Zip Code of Physician or Facility where medication was shipped No dashes, only numbers Rx SHIPPER Text Shipping Carrier Open Text Fedex Rx SPRYCEL START OF THERAPY DATE Date Date of therapy start for patient / first fill for patient Written as XX/XX/XXXX 12/21/2013 Rx TERTIARY BIN NUMBER Number Tertiary Payor BIN id used by claims switch Rx TERTIARY COPAY Number Patient (tertiary) out of pocket costs $XXX.XX $10.25 Rx TERTIARY PAID Number Total amount paid on this RX - based on adjudicated claim. Assume cash will be collected. (Tertiary) $XXX.XX $45.00 Rx TERTIARY PAYOR NAME Text Tertiary Payor Name Express Scripts, Medco, Caremark, etc. Medco Rx TERTIARY PAYOR TYPE Text Type of Tertiary Payor MCAID - Medicaid, MCARE - Medicare, CASH, TPP - other Third Party Plan TPP Rx TERTIARY PCN Text Tertiary Payor Processor Control Number used to identify plans within a payor 0 Rx TERTIARY PLAN GROUP NUMBER Text Group # for Tertiary plan. Identifies the employer. Open Text Rx TERTIARY PLAN NAME Text Patient Health Insurance Plan Name (Tertiary) Open Text Medco Rx TRACKING NUMBER Text Tracking Number Open Text 123XCV123 Rx UOM DISPENSED Text Unit of measure for Dispensed Quantity EA, UNIT, ML, GM, PACK (Use NCPDP units when possible) EA

11 Can all Specialty Pharmacies provide the data you need?...in the format you need?...at the right time?

12 Do you need Data across COT? Specialty Pharmacies Retail Chains Wholesale Home Infusion/ Home Health Clinics/ Outpatient Pharmacies Indy Retail Hospital/ACO/IDN Mail Order

13 Market Access

14 Pharma paying attention to Access Source:

15 Access and The Patient Provider Journey Patient Journey Pharmacy Pre- Diagnosis Payer Alternatives Diagnosis Work/Life Lifestyle changes Education Care Givers Compliance Persistence Drug Therapy Family Fulfillment Staff Provider Journey

16 Access The death sentence I really like the clinical benefit of your drug but it s hard to get

17 Barriers to Access Payer perception/acceptance Tier Status Prior Authorization Step Edits Copay REMS Special Handling Site(s) of care

18 HUB Services designed to improve access Standard Coding and Reimbursement Claims Assistance Enhanced Re-Certification Electronic Insurance Verifications (eivs) Advanced Medicare Part D Counseling Patient and Provider Outcomes Patient Assistance Programs Product Replacement Program Persistency and Adherence Prior Authorization Benefit Investigation Foundation Access Referrals Medicare Part D Plan Comparisons Online Services Real-Time Dashboards Do you have the data to decide: What is the right suite of services?

19 Specialty Pharmacies and HUB Can they work together synergistically?

20 Specialty Pharmacies and HUB Can they work together synergistically? HUB and SPP network considerations Criteria for network inclusion A: Payer contracts (medical versus pharmacy) B: Data reporting capability C: Dedicated headcount (therapeutic class minimally) D: Customer service levels (beyond policy and procedures) E: Blocking and tackling (TTF, Conversion rate, MPR) F: Cooperation with HUB and service offerings (PAP, copay) G: Solicitation of organic business (relationships with providers)

21 Dashboards/Portals

22 Considerations Who is going to use it Will they really use it What will it be used for Is it integrated Does it match other reporting Security Compatibility

23 Features Real-Time Pre-Post Dispensed (Specialty) Granularity Measurement Reportable Analyses Actionable

24 Real Time Actionable Data- Manufacturer

25 Pharmacy Portal

26 Pharmacy Scorecard