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RPNavigator Services

Data Analysis Tool: RPNavigator Health Plans
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Consulting Solutions and Services
Health Plans

Pharmacy Analysis

Insights from Integrating Medical and Pharmacy Data

Improving Risk Stratification:
RPNavigator combines medical and pharmacy utilization at the member and physician level. It incorporates National Drug Codes and J Codes to enhance the effectiveness of the CRG grouping software to enable it to more accurately risk stratify the population. Pharmacy data is critical to help determine what stage within the disease spectrum an individual resides.

Pharmacy information complements data received from medical claims sources and may identify conditions which would otherwise not be detected by a purely claims based system. For example, a person with a prior organ transplant may be receiving routine care, but the physician may code only “hypertension” and not indicate there was a transplant several years ago. RPNavigator would identify the use of specific drugs for transplants, and the person would be coded as being in “Transplant Status. This enhanced accuracy better defines what conditions are driving total medical costs.

Quality of Care and P4P (Pay for Performance):
Pharmacy data also can help determine if chronic diseases are being managed according to evidence based national guidelines. For example, asthmatics who have required emergency room or hospital treatment should be on anti-inflammatory medications. RPNavigator can identify members not meeting this guideline so that targeted outreach can be undertaken. This same information, when grouped by physician or IPA, can be the basis for P4P incentives and targeted educational programs to improve HEDIS performance./p>

Provider profiling is enhanced with the addition of pharmacy utilization. Using actual to expected comparisons, the client can quickly identify providers who are over prescribing.Providers may claim their patterns of pharmacy utilization reflect their sicker patient load. RPNavigator corrects for the burden of illness of their panel and then calculates their expected utilization of pharmacy services. RPNavigator case mix and severity adjusts pharmacy cost and utilization data, so that practice style differences can be differentiated from utilization that is driven by the underlying burden of illness.

Improved Care Management:
When drilling down to the individual member level, the user can view pharmacy utilization for the past few years, in addition to seeing a list of all diagnoses and procedures performed during that timeframe. This allows care managers to better understand the patient and his or her needs. Case management plan development is more effective when case managers have pharmacy data so readily available. Individuals who have no chronic condition but are consuming large quantities of medication are frequently candidates for case management intervention. For example, RPNavigator can determine which individuals, without cancer or other serious chronic conditions, are consuming thousands of dollars of medication. This often reflects a pattern of substance abuse, and a behavior intervention can be instituted.

Drug Utilization Review (DUR) Reporting:
In addition to the tightly integrated pharmacy/medical data provided in RPNavigator, outlined above, CAI can provide a Pharmacy Utilization Package. The package consists of traditional pharmacy utilization reports and consulting services. The depth of reporting is governed by the completeness of provided pharmacy claim data. Additional ad hoc reports can be developed to address findings in the reports listed below. The pricing of this module and the services to be included would require further discussion and clarification of the client’s intent.

Typical reports that may be included in the package are listed below.

Report Type	Description

Executive Summary	Monitors overall utilization and costs

Utilization Summary	Analyzes overall utilization for all members
Mail Order vs. Retail Utilization	Compare retail versus mail order utilization: this is especially important for stakeholders who institute mandatory mail-order fill for maintenance prescriptions

Total Transactions	Monitor total number of claims processed

Utilization by Age and Gender	Compare utilization rates by age groups and gender

Prior Authorization Detail	Monitor number of PA requests and percentage approved or rejected

Therapeutic Class Profile Summary	Analyze usage by therapeutic categories and select most expensive ones for further specific drug analysis

Brand versus Generic Utilization	Compare rate of brand and generic utilization and identify any patterns and or trends

Brand Dispensing Rate	Analyze dispensing brand dispensing rate when generics are not available
Generic Efficiency Rate	Analyze rate of generic utilization when generics are available

Top X Drugs	Monitor top X drugs prescribed over this period; Number of top drugs is generally 50 or 100; can be either top 50 or 100 brand or generic.

Top X Physician Prescribing Patterns	Analyze physician prescribing patters to assess prescriber outreach effectiveness, as well as, for adherence to utilization compliance

Top X Non-Preferred Drugs by Therapeutic Drug Class	Monitor non-formulary drugs and the associated utilization, to determine whether these drugs should be added to the formulary

Formulary Utilization	Dispensing rate of drugs on the formulary versus off formulary, including medical exceptions to the formulary, and other metrics. Stakeholder P&T Committees may review this data to help implement appropriate physician and beneficiary education programs.

Number of Prescriptions Per Member Per Month	Monitor members who have high utilization rates and potentially require them to enroll in disease management programs (e.g. diabetes, CHF, asthma) if possible

Peer to Peer Comparisons	Compare across multiple business lines / health insurance products, if possible

Financial Performance Summary	Analyze overall cost and savings of the pharmacy benefit for stakeholder at a summary level

Drug Cost and Net Paid by Levels	Analyze drug cost by levels (e.g. level 3 may be those that have generic equivalents) and stakeholders may implement initiatives (e.g. mandatory generic substitution) to drive utilization

Top X Drug Cost Ranking	Monitors top drugs that account for most of the cost to see what’s causing the high utilization changes (e.g. off-label usage and implement appropriate controls to drive utilization and impact cost)

Top X Generic Drug Cost Ranking	Monitors generic drugs that are high cost

Gross Cost to Stakeholder	Analyze total cost over time; this cost takes into account of network discounts and dispensing fees

Net Cost to Stakeholder	Monitor cost to stakeholder after taking into account of member responses

Net Cost per Script	Analyze this measure to determine whether member-sharing levels are adequate

Net Paid per Member per Month	Monitor member-copay levels

Peer Net Paid per Member per Month	Compare member-cost share and implement new utilization controls (e.g. higher co-pays)

Average Ingredient Cost	Analyze ingredient cost over time and identify those with high costs

Total Brand Cost	Monitor gross cost over time for brands

High Cost Members	Monitor high cost members for any unusual activities, as well as determination for enrollment in mandatory utilization and outcomes management initiatives

Total Generic Cost (MAC vs. Non-MAC)	Monitor gross cost over time for generics

Average Member Cost per Prescription	Analyze this measurement over time

Dispense Fee per Script	Monitor the dispensing fee based on agreed upon dollar amount charge

Average Savings Percent off Average Wholesale Price	Analyze to validate pharmacy benefit value and network discounts

Medication Adherence	Member-, group- or physician-specific rates of medication adherence

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