Internal Information © 2014 Express Scripts Holding Company. All Rights Reserved. 11 Internal...

Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.

11Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.

Big Data in the Pharmacy Benefit

Douglas Mager, MA. Director of Research

HIMSS Midwest Gateway Chapter Speaking Event

March 11th, 2015


2

Express Scripts Overview

National Leader in Pharmacy Benefits• 1.4 billion prescriptions per year

• 85 million members

• 3,500 clients

• 30,000 employees

Respected and Recognized • Business model aligned with

our clients’

• Scientific research to develop meaningful prescription-drug solutions


3

Pharmacy PBM

The Role of a Pharmacy Benefit Manager

Member

Take prescription and ID card to

pharmacy

Receive prescription drug

Submit online claim to PBM

Fill prescriptionCollect copayment

Verify eligibilityDetermine benefit

Drug utilization review

Send online response

Store information


4

What is ‘Big Data’ in the Pharmacy Benefit?

65,000 pharmacies

1 million prescribers

85 million members

1.4 billion Rx per year

Per second:100 claims

Per day:500,000 calls

3.6 million pharmacy events

1.7 million member contacts

Claims

Web Data

Fax/Rx Images

Call center records

We manage 20+ PETABYTES of data across our data ecosystem

We actively manage a large volume of administrative data, resulting from the daily operations with its clients and patients that it serves.

VOLUMEMore than 150

data stores

VELOCITYStreams from

applications and devices

VARIETYVarious data sets

(structured, unstructured)


5

74%of U.S. physicians actively ePrescribe

Wiring Healthcare: ePrescribing

ePrescribing has become the standard channel for physicians to route prescriptions to pharmacies

• Over 66% of home delivery new prescriptions are ePrescribed

• Over 50% of retail prescriptions are ePrescribed

• Over 2M eligibility requests daily — eligibility provides formulary data and identifies home delivery pharmacy

• Over 1M medication history requests daily


6

The Two Most Important Things to Know About Administrative Data

The primary purpose of a claim is payment

From the provider’s and payor’s perspective,

if a claim is good enough to make an accurate payment, IT IS GOOD ENOUGH.


7

Advantages of Administrative Data

Vast Amounts of Information

Observations/records

Data fields (over 300 fields captured on

each pharmacy claim alone)

RelativelyInexpensive

Data is captured as part of the

adjudication process

LongitudinalLook

Typically spans multiple years

S


8

Limitations of Administrative Data

ContinuityDifficult to track

members or clients longitudinally if they do

not remain with ESI

Population Biases“Sample of

convenience” data from commercially insured members

Not Always Generalizable

Coverage may vary by region or

demographically depending of client mix

Cannot Measure All External

FactorsOther, unmeasured factors influencing

utilization and program acceptance


9

What Can We Do With Administrative Data?

• Outcomes research

• Research on trends and patterns of medication cost and utilization• Drug Trend Report

• Forecast cost and utilization based on market shifts and patent expirations

• Predictive modeling• Focus resources based on predicted

future behavior

• Combine with outside data (often via collaboration with other institutions)


10

Example: Predictive Modeling (PM) and Medication Adherence

What is predictive modeling1

Why is medication adherence important 2

Benefits of PM in medication adherence3


11

Predictive Model Life Cycle

Set Campaign Goals

Execute Campaign

Analyze Campaign Success

Monitor Model

Performance

Re-estimate

Model

Develop Model

Set Modeling

Goals

Gather and

Explore Data

Pass

Fail

Marginal

1

2

3 4

5

6

78


Predictive Modeling in Action

Identification:

• Members most likely to be non-adherent on medication• Multiple therapy classes

• New starts and continuing utilizers

Investigation:

• Factors most predictive of future non-adherence


13

Benefits of Predictive Modeling in Medication Adherence

• Enables intervention before problems become well established.

New Starts

• Mitigates the impact of self-correction and regression to the mean

Continuing Utilizers

• Stop driving by the rearview mirror alone

• What really matters is what’s ahead

All Users

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bottom Third Middle Third Top Third

Popu

latio

n D

istr

ibuti

on

Predicted Compliance

Compliance Self-Correction By Predicted Terciles

>80%

50-80%

<50%

Post Period

Compliance

Pre-Period Compliance < 80% For All Members Analyzed


14

75%Exhibit some form of medication non-adherence4.

Why Is Medication Adherence Important?

$308B Annual Direct Costs1

23M ER Visits2

125K Deaths3

1. Express Scripts 2010 Drug Trend Report2. New England Healthcare Institute: Thinking Outside the Pillbox, August 20093. R McCarthy “The Price You Pay For The Drug Not Taken”, Bus Health 19984. National Community Pharmacists Association: “Take As Directed: A Prescription Not Followed” December 15, 2006

Each Year


15


PrescriptionFill

Alex

Milagro

Andrea

Chris

Marcus

Simone

Victor

Yvette

Brendan

Patricia

Who will miss their medication?


16


Who will miss their medication?We have to wait to find out.

ScheduledFill

Alex

Milagro

Andrea

Chris

Marcus

Simone

Victor

Yvette

Brendan

Patricia


17


Who will miss their medication? We have to wait until a refill to find out.

ScheduledFill

Alex

Milagro

Andrea

Chris

Marcus

Simone

Victor

Yvette

Brendan

Patricia


18


Who will miss their medication? Interventions are reactive.

Alex

Milagro

Andrea

Chris

Marcus

Victor

Yvette

Brendan

Patricia

ScheduledFill

Intervention

MissedScheduled

Refill

Simone


19


Who will miss their medication? We need to intervene earlier. But how?

Alex

Milagro

Andrea

Chris

Marcus

Simone

Victor

Yvette

Brendan

Patricia

?Scheduled

Refill


20


How do we predict individual behavior? Crunching the data gives us insight into each member.

+ + + + +

• Over 400 total factors

=43

Express Scripts

Adherence

IndexSM

Simone


21


How do we apply it? Every script gets an index that identifies at risk members.

PrescriptionFill

Chris

Brendan

Andrea

Simone

Marcus

Victor

Patricia

Alex

Yvette

Milagro

ScheduledRefill

(Predicted Result)

32

43

38

39

67

73

76

82

84

87

Express Scripts Adherence

IndexSM

Interventions


22


How do we apply it? Early intervention improves results..

PrescriptionFill

Marcus

Victor

Patricia

Alex

Yvette

Milagro

32

43

38

39

67

73

76

82

84

87

Express Scripts Adherence

IndexSM

Chris

Brendan

Andrea

Simone

ScheduledRefill

Interventions


23

Summary – Big Data at Express-Scripts

• Vast amounts of data available

• Gain insights into opportunities to drive out waste

• Understand the drivers of trend and utilization

• Help clients maintain the pharmacy benefit for their employees/members

• Drive down prescription cost for clients and patients



Questions?



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