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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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)
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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.
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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)
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
10
Example: Predictive Modeling (PM) and Medication Adherence
What is predictive modeling1
Why is medication adherence important 2
Benefits of PM in medication adherence3
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
12Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
15
Predictive Modeling in Action
PrescriptionFill
Alex
Milagro
Andrea
Chris
Marcus
Simone
Victor
Yvette
Brendan
Patricia
Who will miss their medication?
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
16
Predictive Modeling in Action
Who will miss their medication?We have to wait to find out.
ScheduledFill
Alex
Milagro
Andrea
Chris
Marcus
Simone
Victor
Yvette
Brendan
Patricia
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
17
Predictive Modeling in Action
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
18
Predictive Modeling in Action
Who will miss their medication? Interventions are reactive.
Alex
Milagro
Andrea
Chris
Marcus
Victor
Yvette
Brendan
Patricia
ScheduledFill
Intervention
MissedScheduled
Refill
Simone
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
19
Predictive Modeling in Action
Who will miss their medication? We need to intervene earlier. But how?
Alex
Milagro
Andrea
Chris
Marcus
Simone
Victor
Yvette
Brendan
Patricia
?Scheduled
Refill
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
20
Predictive Modeling in Action
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
21
Predictive Modeling in Action
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
22
Predictive Modeling in Action
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
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
Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
2424Internal Information© 2014 Express Scripts Holding Company. All Rights Reserved.
Questions?