An Overview o

f

VA Pharmac

y Dat

Mark W. Smith

Februar

y, 2010
T i op cs

O i fD S Overview of Data SourcesAccess & File Names Access & File NamesHighlights of ContentsGuidance for UseNon-VA Pharmacy Data
Abb i i Abbreviations

AITC: Austin Information Technology CenteAITC: Austin Information Technology CenteBPA: Blanket Purchase AgreementCMOP: Centralized Mail CMOP: Centralized Mail-Order Pharmacy Order PharmacyDSS: Decision Support SystemMCRR: Medical Care Cost Recovery program MCRR: Medical Care Cost Recovery programNDE: National Data ExtractPBM: Pharmacy Benefits Management PBM: Pharmacy Benefits ManagementVAMC: Veterans Affairs Medical CenterVISTA: Veterans Health Information System

Technical Architecture
O i verv ew - VISTA

Primary repository of clinical data

– Clinicians enter data directly into CPRS– Ph d t id i ti Pharmacy order system guides prescription proce

Many files comprise pharmacy data Many files comprise pharmacy data “package package”Separate VISTA system at each VAMC Separate VISTA system at each VAMC
O i verv ew - PBM

Name: PBM V3.0 DatabaseContents: selected VISTA data fields + new elementsScope: nationalYears: Outpatient data available for 10+ years inpatient Years: Outpatient data available for 10+ years, inpatient 

last few years only
O i verv ew – DSS Ph E DSS Pharmacy Extr

Name: DSS National Pharmacy Extract 

(or “Pharmacy NDE”)

Contents: selected VISTA data fields + new elementsScope: nationalYears: both inpatient and outpatient available since FY2
O i verv ew – DSS Encounter-L l 

Level 

N DSS NDE f I ti t d O t ti t C Name: DSS NDEs for Inpatient and Outpatient CareCo te ts: se ected V S data e ds ew e e e ts ntents: selected VISTA data fields + new elements

** all pharmacy in the stay (inpatient) or day (outpat

rolled up – no prescription-level data **

Scope: nationalYears: both inpatient and outpatient available since FY
O i verv ew – DSS P d ti D 

DSS Production D

Name: DSS production dataContents: Components of each encounter, including ind

prescriptions

Scope: local VISTA system onlyYears: available since FY1999
Fee Basis Files

Data from non-VA pharmacies paid by VAC l hl h d Contents: total monthly payments to pharmacy vendo

individual pharmacy records only for medications during( ) a clinic visit (HCPCS “J codes”)

Scope: national Years: Available since FY1999 or earlier
Wh D R d R 

What 

Does a 

Recor

d

Represen

 In VISTA PBM and DSS Pharmacy Extract a r

In VISTA, PBM, and DSS Pharmacy Extract, 

a r

represents a single prescription or supply 

 - for one 

person

 - on one day 

Note that inpatient medications are typically 

dispensed every day. Thus 7 days of a medicis often 1 outpatient prescription or 7 inpatienis often

1 outpatient prescription or

7 inpatien

prescriptions. 
Wh D R d R 

What 

Does a 

Recor

d

Represen

 DSS NDEs for Inpatient and Outpatient Care: DSS NDEs for Inpatient and Outpatient Care:

– all prescriptions and supplies

– for one person for one person

– on one day 

 Exception: medications injected in clinic (HCPC

codes”): these are outpatient procedures and only sometimes appear in prescription files sometimes appear in prescription files. 
Wh D R d R 

What 

Does a 

Recor

d

Represen

 DSS Production Data: DSS Production Data:

– a single prescription or supply– for one person

– on one day– in one production unit

 Examples of production units: on-site pharmacy, C
D F ataormat

 VIS A ASC STA: ASCII PBM: SAS, MS Access, or Visual FoxPr DSS NDEs at AITC: SAS  DSS data via VSSC website (KLFMenu)

Spreadsheet
Access -- Summary

 VISTA

– Difficult to obtain direct access 

– Easier to request data from local IRMS

Easier to request data from local IRMS

 N.B.: IRMS staff cannot accept research 

funds. Making extracts is extra work. 
Access -- Summary

 PBM data PBM data

– Extracts made by PBM staff– Must submit documentation of research appro

Must submit documentation of research appro

 DSS Pharmacy Extract and NDEs DSS Pharmacy Extract and NDEs

– User accesses AITC files via timeshare accou– Summary 

 data available for free via KLFMen

the VISN Support Services Center (VSSC) wsite
C f Ob i i D Cost o

f Obta

i

n

ing 

Data

 PBM

– Managerial & oversight projects: no charge–

U u ded p o s ud es: usu y o c ge nfu

nded

pil

ot 

s

tud

ies: usuall

y n

o

charge

– Funded studies: charges for programmer time 

optional consulting on study design 

– Ask PBM staff ahead of time

 Other Sources Other Sources

– No charge to user; AITC charges billed to VA
U f KLFM Uses of KLFMenu

 VA intranet web page (klfmenu med va gov) VA intranet web page (klfmenu.med.va.gov) No documentation exists Some examples of available data: Some examples of available data:

– Use: # prescriptions, # 30-day-equivalent prescrip– Cost: total sp g g p gp p 

ending, average spending per prescri

– Categories: VA drug class and certain sub-catego– Other: fiscal year, location (station, VISN, nation)

 R l b d l dd E l d

Results can be downloaded to an Excel spread
Data Fields - 1

 Medication

drug name, NDC, formulary indicators

 Dispensing

fill date, quantity dispensed, days supplied

 Cost

p p( , ) 

urchase price (PBM, VISTA) or VA cost includ

overhead (DSS NDEs, DSS Pharmacy Extract)
Data Fields – 2

 Patient

SCRSSN, date of birth, gender, age

 Provider

provider ID, provider treating specialty 

 Note: Clinical information on related visits/stays c

linked to Rx data using SCRSSN.
Copayments

 VA charges some copayments VA charges some copayments.

– Depends on income, disability percentage

– Rules & elig y gy y ibility levels change year to year– Rules available on VA internet

 Data sources do not show copayments; they show 

VA’s expense.

 MCCR files could show reimbursement from pr

insurance, if collected
Di i C spensing Cost

 Contains direct labor indirect costs of the pharmacy Contains direct labor, indirect costs of the pharmacy

department, and supplies

 Only estimated in DSS NDEs
UiC n tosts

 There may be a contract purchase price: There may be a contract purchase price:

– Federal Supply Schedule (FSS) – FSS Tier Schedule – Federal ceiling price (“Big 4”) schedule – VA Blanket Purchase Agreement (BPA)

 To find prices and formulary, visit 

www pbm va gov www.pbm.va.gov. 

– Drug prices: click on Drug Prices, Contracts & Agree– Formulary: click on National Formulary
UiC n tosts - 2

 K i id eep in mind:

– The purchase price does not include overhe

direct dispensing costs direct dispensing costs.

– Sites are able to purchase off-contract.
UiC n tosts - 3

 The e w be d sc epa c es ac oss s es. re will be discrepancies across sites.

– Correct pricing requires daily updating of a 

VISTA price file at each VAMC, which does occur

– Blanket Purchase Agreements are specific to 

individual VAMCs.
Ch i S VISTA Choos

ing a 

Source: VISTA

 Advanta

ges

– Greatest detail on costs, use of care– Access to data not available in extracts

 Disadvantages

– Ca access data o o y t e oca V C n access data fr

om 

onl

y

t

h

e local 

VAM

C

– Most often, extracts must be made by IRMS 

using specialized programs

– R i ti i i t ti diff Requ

ires caution 

in 

i

n

terpreting differences a

sites
Ch i S PBM Choos

ing a 

Source: PBM

 Advantages

– National coverage in one extract– Only source that provides purchase price Only source that provides purchase price– Optional fee-based consulting on pharmacy d

needs & use
Ch i S PBM Choos

ing a 

Source: PBM

 Disadvantages

– PBM staff must create the extract– Does not show pharmacy clinic costs beyond Does not show pharmacy clinic costs beyond

purchase price

– Limited clinical and demographic informatio
Choosing a Source: DSS Nation

Pharmac

y Extract

 Advantages

– National coverage – Detailed cost data

 Disadvantages

– Limited prescription characteristics– Cost data do not show 

p p urchase 

price
Choosing a Source: DSS 

In

p p atient/Out

patient NDEs

 Advantages

– National coverage – Convenient summary cost data by treating spec

or overall

 Disadvantages

– Limited prescription characteristics– Only summary data: no data on individual 

prescriptions or supplies
Choosing a Source: DSS Data 

KLFMenu

 Advantages

– National coverage – C i t td t Conven

ien

t summary cos

t

d

a

ta 

– Ease of access and use

 Disadvantages

– Only summary data: no data on individual 

prescriptions or supplies prescriptions or supplies

– Cannot select cases by SCRSSN
Validation Studies: PBM vs. DSS N

Study #1

1, p 600 

patients with hernias in CSP 456 

 PBM and DSS Pharmacy Extract have >95

concordance in dr g names # scripts # niconcordance in dr

u

g names, 

# scripts, 

# uni

dispensed.

 Source: VIREC Technical Report #1 

(http://www.virec.research.va.gov/References/TecRe

p p p) orts/VIReCTechnicalRe

port1.

pdf)
Validation Studies: PBM vs. DS

N s DE

s

Study #2 >300 patients with heart disease in CSP 42 Result: PBM and DSS NDE daily summary 

very poor concordance in monthly or annu

pharmacy costs.
Di i scuss on

 You want to study patterns in prescribing of n

You want to study patterns in prescribing of n

replacement therapy over a five-year period in Which data sets would be g p ood o tions? 

 VISTA DSS NDE for inpatient/outpatient care DSS pharmacy NDE PBM database
Comparison: PBM vs. DSS ND

Study #3 (HERC Technical Report #22) All medications for 894 people enrolled in CSP #4Results:  95% of DSS Pharmacy extract records can be mat

95% of DSS Pharmacy extract records can be mat

PBM records within +/- 10 days.

 PBM cost and DSS variable VS_Cost differ by les

$0.80 on average.
G i P ii Group

ing 

Prescr

ipt

ions

 DSS sometimes groups two prescriptions into on

record if they are for the same NDC and the samperson on the same day person on the same day

Æ PBM does not group prescriptions in this 

way.
Oth N t Ph D t Other 

N

o

tes on Pharmacy 

D

a

t

- Pharmacy use patterns affect contract negotiation

Pharmacy use patterns affect contract negotiation

- Drug manufacturers seek these data to aid in 

negotiations with VA.

 Consult PBM staff before allowing private fir

t t VA h d t to see recen

t VA p

harmacy 

d

a

ta.
Oth N t Ph D t Other 

N

o

tes on Pharmacy 

D

a

t

 Example of a problematic request from a drug 

company: 

“Among VA patients newly diagnosed with 

schi h i i th l t 12 th h d 

hizop

hren

ia 

in the 

las

t 12 months, 

how 

doe

use of antipsychotic Vacoquel relate to total healthcare spending in the following year?”
T E l f R P bli ti Two 

Examp

les o

f

Rx 

P

ublicatio

Summary of medication use patternsSernyak MJ, Rosenheck RA. Antipsychotic use in 

treatment of outpatients with schizophrenia in thtreatment of outpatients with schizophrenia in th

from fiscal years 1999 to 2006. Psychiatric Serv2008;59(5):567-569.

Comparative effectiveness of medicationsSwartz MS Stroup TS McEvoy JP et al What CASwartz MS, Stroup TS, McEvoy JP, et al. What CA

found: results from the schizophrenia trial. Psychiatric Services 2008;59(5):500-506.
C i aut ons

 OTC medications disp 

ensed from ward stock du

often do not appear in pharmacy databases.

 Outpatient medications dispensed outside a phar

may appear any of these ways:

– as procedures only (HCPCS as procedures only (HCPCS “J code” or othe

or othe

– as prescription only– as both p pp rocedure and prescription
C ti au ons

 D t l t h C h kd t l t Data elements change. Crosscheck data elements 

against printed information: do you know what efield means?

 E.g.: fill date vs. release date
V lidi Ch k Validity Checks

 Check data for erroneous values Check data for erroneous values Missing values

– If p, y ossible, fill in values based on consistency 

(e.g., for gender, age) 

– Imputing values adds statistical uncertainty: s

account f it ( t l t ti if d 

t for it (or at least mention if used rare

 Inconsistent units

– One 50ml bottle could be One 50ml bottle could be “50 units 50 units” in one re

in one re

but “1 unit” in another record
Non-VA Ph U VA Pharmacy Use

 We typically do not ask patients about non We typically do not ask patients about non-VA

pharmacy

– S VA t ll i ti th h 

Some VA users get all prescriptions through 

but Medicare Part D enrollees most likely use Medicare and VA

– VA is likely to be used for most expensive m– Over-the-counter use is unlikely to affect tota

spending much
D l U f VA d N Dua

l

Use o

f VA an

d

Non-VA Phar

Johnson ML Petersen LA Sundaravaradan R et al The associatioJohnson ML, Petersen LA, Sundaravaradan

R, et al. The associatio

Medicare drug coverage with use of evidence-based medicationVeterans Health Administration. Ann Pharmacother. 2009 Oct;4

1565

-75.

Morgan RO, Petersen LA, Hasche JC, et al. VHA pharmacy use in 

wi h M di d A J M C 2009 M 16 

i

t

h

M

edicare 

drug coverage. 

Am 

J

Manag 

Care. 2009

Mar 16

French DD, p , ,p q Cam

pbell RR, Rubenstein LZ, S

pehar AM. Ac

quisitio

use of Medicare Part D-excluded drugs in Veterans Health Admlong-stay nursing home residents: a national, descriptive, seconanalysis. Drugs Aging. 2008;25(10):855-60.
Non-VA Ph S VA Pharmacy Sources

 D T i “R d B k” Drug Topics “Red Book”

– Published annually– Off “A Wh l l P i ” (AWP) 

Offers “Average Wholesale Price” (AWP)

starting point for Medicaid drug payments

 Private-sector claims data

– Pi f roprietary: must pay for access
Non-VA Ph C VA Pharmacy Cost

Thought exercise: What would outpatient VA pharmacThought exercise: What would outpatient VA pharmac

were provided in the private sector?

See: ML Render, J Nowak, et al. Methods for estimating and 

comparing VA outpatient drug benefits with the privMedical Care 2003;41(6 Suppl): II-61 – II-69.
VIR C R VIReC Resources

1 Research User Guide: VHA Pharmacy Prescription D1. Research User Guide: VHA Pharmacy Prescription D

- documents PBM and DSS prescription-level data

2. VIReC Technical Report #1

- contrasts coverage in PBM and DSS datasets for people in on

3. Research User Guide: Medical SAS Outpatient Data

- documents OPC which has HCPCS/CPT procedure codes for 

documents OPC which has HCPCS/CPT procedure codes for 
HERC Resources

1 Guidebooks for DSS inpatient and outpatient encoun1. Guidebooks for DSS inpatient and outpatient encoun

National Data Extracts

- contain pharmacy totals within encounters or bedsection segmnot prescription-level data

2 Guidebook on Fee Basis data 2. Guidebook on Fee Basis data

- contains pharmacy totals per month and, for injectibles, proce

3. Technical Report #22 (Smith and King, 2007)

- “Comparing Outpatient Cost Data in the DSS National Pharmand the Pharmacy g Benefits Management V3.0 Database”
Questions?