The Ohio Department of Medicaid (ODM) administers a $28.2 billion program that represents 23 percent of the State’s general fund budget. As is the case in most states, Ohio’s Medicaid Prescription Drug Programs represent both an opportunity and risk when it comes to lowering costs, enhancing patient outcomes and improving the health of the population. Recent challenges—including the rate at which opioid-based drugs are prescribed to Ohioans, a lack of transparency into the excessive profits of Pharmacy Benefit Managers, and the need to preserve beneficiary access to community pharmacies—serve as markers that are prompting state leadership to introduce strategic reform measures.
Analytics plays a key role in Ohio’s Medicaid Reform initiatives. The State’s Health and Human Services–Enterprise Data Warehouse (EDW) serves as a strategic asset for a host of standard reports and advanced analytics that will be leveraged to improve the health of Medicaid recipients, while insulating taxpayers from excessive costs. Before the State can leverage its EDW in support of reforms, it needed to assess and develop a set of comprehensive requirements.
Pharmacy Benefit Manager Reforms
Among ODM’s most pressing concerns are the historical practices of the State’s contracted Pharmacy Benefit Managers (PBM). Following intense scrutiny, it was reported that the PBMs had been skimming hundreds of millions of dollars off the Medicaid Prescription Drug Program through previously-hidden “spread pricing” tactics. In addition to the wasteful costs imposed on taxpayers, these practices frequently diverted available Medicaid funding from community pharmacies which were beginning to close at an alarming rate.
In response, Ohio introduced sweeping changes to the way the Medicaid Managed Care Program administers pharmacy benefits. Among these changes were the introduction of new pricing models that eliminated the black box that PBMs operated in. These models facilitated a level of transparency that will enable ODM, citizens, and other stakeholders to see exactly what is paid out for all pharmacy transactions in the future.
This initiative is among many opportunities that necessitate integrated, enhanced, and centrally-managed data in support of essential analytic measures that make it possible for the State to plan, implement, manage, and sustain successful reforms.
Business Case
Ohio’s Department of Medicaid elected to enhance and exploit the State’s HHS–EDW investment to drive improved outcomes for Medicaid beneficiaries, and the state’s taxpayers.
Ohio recognized that the value of insights generated by its analytics platform in support of strategic initiatives is heavily dependent upon the ability to extract, transform, and load new and complementary datasets into the EDW, and enrich the data for use in analyses, beginning with those required for the Pharmacy Benefit Management Program.
The Solution
CMA is proud to have been selected for this important role. During Phase 1 we were charged with developing the State’s adopted set of requirements, as well as the Implementation Plan for the subsequent design, development, testing, and implementation of an enhanced set of strategic capabilities that will enable ODM to optimize outcomes associated with its Medicaid Prescription Drug Program.
This engagement required CMA to conduct a comprehensive analysis of the source PBM data environment; develop a comprehensive plan to ensure the safe and secure transport and staging of highly sensitive prescription data from the PBM platform to the EDW; establish linkages between the merged data sets to enable more comprehensive and longitudinal analyses; integrate Pharmacy, Drug Rebate, Prior Authorization, and Prospective Drug Utilization (Pro-DUR) data unique to the PBM into the EDW; design, develop, and implement predefined reports and analytical structures to support the ad hoc reporting requirements of analysts using a variety of tools (Cognos, SAS, and Tableau); and establish service levels and operational processes that promote the availability and performance of these strategic enhancements.
CMA leveraged its proven and repeatable methods to promote the success of the project. As the State’s partner, we collaborated with key stakeholders including ODM, the Department of Administrative Services – Business Intelligence Team, and Change Healthcare to assess how best to integrate new data sources without disrupting PBM or EDW operations. CMA facilitated this collaboration through numerous JAD sessions to produce a ratified set of requirements and an adopted plan for the design, development, testing, and implementation of the project.
Based upon the outcomes of this project, the State of Ohio subsequently awarded Phase 2 of the initiative (extract, transformation, and loading of source data into the EDW) to CMA.