Use Case 26: Analyze drug cost trends from filled Medicare Part D prescriptions

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Use Case

Use case summary

Description

  • Needs access to Part D Drug Event File (PDE) for cost transparency to pharmacies and patients
  • The PDE data contain prescription drug costs and payment data that enable CMS to make payments to the plans and otherwise administer the Part D benefit. When a beneficiary fills a prescription under Medicare Part D, a prescription drug plan sponsor must submit a record to CMS. The PDE data are not the same as individual drug claim transactions but are extracts using CMS-defined standard fields.

Value

  • Value to customer: Central to operations for drug cost comparisons for use by pharmacists and consumers
  • Value to industry/public: Multiple companies are looking how to better manage costs

Customer

  • rxData (Github @rxdata): Comprehensive, on-demand access to pharmaceutical pricing
  • iMedicare (Github @imedicare): Helps pharmacists acquire and retain customers, while saving them money
  • ProPublica: "...benefit of the ongoing important national discussion--to have more real-time information on payments for drugs (in the aggregate)"

Current data and limitation

  • Data source: Data resides in ResDAC, specifically CCW
  • Challenge:
    • ResDAC is limited to non-profit research
    • ResDAC says to expect 3-4 month delay for request fulfillment, too late for these purposes. Customer reports that data they obtained
    • ResDAC data is refreshed monthly, not frequently enough for these purposes
    • Potentially incomplete datasets:
      "It is released monthly but often with data far longer than a month ago. It misses certain drugs and plans, or formularies can be incorrect. I can come up with some specific examples from the past."

Specifications

Fields:

  • encrypted event #
  • encrypted beneficiary ID
  • 9 cost/payment fields
  • "drug costs and payment data and DIR fees charged to the pharmacy"

Update frequency:

  • At least bi-weekly, ideally weekly

Lag time:

  • No older than one refresh period. But ideally, no older than the date of refresh.

Solution


Via ResDAC


Access method

  • Part D Event data can be accessed through ResDAC's CCW (Chronic Condition Warehouse)


Limitations

  • Lag time in data: Data is refreshed annually and there's a year lag time. (For example, 2014 data will not be available until end of 2015.) -- Based on conversation with ResDAC office
  • Lag time in requests: "Plan for a minimum of 3-4 months between request submission and receipt of data." (Source: Getting Started with Research Identifiable Data)


Cost

  • There are costs associated with fulfilling ResDAC requests. You are required to obtain the cost estimates and submit them with your study request.


Conditions

  • ResDAC users must be non-profit researchers, as per research policy
    "7. CMS will not support research that will lead to the creation of a product or tool that the researcher intends to market. Any tool developed using CMS data is to be made available to the entire public, without charge. CMS will review the source of funding to determine if the requestor is independent of the funding organization. For example, CMS has historically denied data requests from requestors wanting to evaluate the impact of prescription drugs if a pharmaceutical company finances the study."
  • Update: There's an exception to this policy, as of 9/2015. CMS released the PDE as part of the data release for "innovator research", intended for entrepreneurs and other non-academic uses. Instructions on how to apply for access and pricing can be found at http://www.resdac.org/cms-data/request/innovator-research.


Data fields




Monthly/Quarterly Pricing files (Not event based)

There are non-PDE prescription drug files are made available monthly and quarterly by CMS for purchase. These are not RIF (Research Identifiable Files), intended for statistical purposes. However, these files are not atomic claims-level event data.

Potentially relevant files

  • Formulary File - Formulary details for each plan including NDCs, Tier Level, and indicators for Step Therapy, Quantity Limits, and Prior Authorization.
  • Beneficiary Cost File - Plan level cost sharing details for preferred, non-preferred and mail order network pharmacies.
  • Pharmacy Network File - NABP numbers for each network pharmacy including preferred, retail, and mail order indicators.
  • Pricing File - Included in the quarterly file, plan level average monthly costs for formulary Part D drugs.


Limitations

  • Not readily available. Must fill out request form. Has to get reviewed by privacy board.
  • Inconvenient format: CD ROM, instead of online. Also adds lag time.
  • Not free.


Cost

  • "Monthly - Prescription Drug Plan Formulary and Pharmacy Network Files": $250.00 per month
  • "Quarterly - Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information": $750.00 per quarter




Public use files

  • For 2008: Basic Stand Alone (BSA) Prescription Drug Events (PDE) Public Use File (PUF) http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/BSAPUFS/BSA_PDE_PUF.html > This is a Public Use File for Prescription Drug Events drawn from the 2008 Beneficiary Summary File of Medicare beneficiaries enrolled during the calendar year 2008, and their associated Medicare claims. The most important aspects of this file are as follows, 1. 5 percent simple random sample drawn without replacement from 100 percent 2008 Beneficiary Summary File. 2. This sample is disjoint from the existing 5 percent CMS Research Sample and the other 2008 PUFs. 3. Sample contained 2,392,893 unique beneficiaries of which 1,265,691 had at least one PDE. There were 51,905,367 PDE in the initial sample file.
  • Already indexed on HealthData.gov
  • CMS 2008-2010 Data Entrepreneurs Synthetic Public Use File > The DE SynPUF is built from a 5 percent random sample of Medicare beneficiaries in 2008 and their claims from 2008 through 2010. The DE SynPUF contains five types of data, Beneficiary Summary, Inpatient Claims, Outpatient Claims, Carrier Claims, and Prescription Drug Events. Each file contains the same variables across years.
  • Already indexed
  • Can be used to:
    1. allow data entrepreneurs to develop and create software and applications that may eventually be applied to actual CMS claims data;
    2. train researchers on the use and complexity of conducting analyses with CMS claims data prior to initiating the process to obtain access to actual CMS data; and,
    3. support safe data mining innovations that may reveal unanticipated knowledge gains while preserving beneficiary privacy.




ResDAC workaround

This option deals with a potential ResDAC workaround for for-profits

  • In limited and controlled situations, it may still possible for for-profit companies to fund research via ResDAC.
  • In such a case, the principal investigator will sign the Executive Summary ([(http://www.resdac.org/cms-data/request/materials/profit-funding) "for-profit funder letter"]) to attest that the funder will not be involved with the research and will only receive final results. CMS has developed specific language for this letter and the language in this letter cannot be modified.
  • ResDAC assists with the following Medicare and Medicaid-related data tasks:
    1. Understanding and interpreting Medicare and Medicaid program policies and coverage
    2. Learning about the strengths, weaknesses, and applications of Medicare and Medicaid data
    3. Understanding the creation of CMS's administrative data files and claims processing
    4. Reviewing the methods of cohort identification and file specifications
    5. Generating cost estimates and invoices for CMS data
    6. Preparing a request for CMS data




Other Cost Inputs

PBMs negotiate drug cost rebates with manufacturers. In order to calculate the true cost of a claim to CMS or a health plan, it's not enough to look at the claims price. The negotiated rebates need to be subtracted from the cost . However, CMS is prohibited from participating in these negotiations. The DDOD team is in the process of determining whether the drug rebate data are accessible to CMS once the plans are in place.

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