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340B Insight provides members and supporters of 340B Health with timely updates and discussions about the 340B drug pricing program. The podcast helps listeners stay current with and learn more about 340B to help them serve their patients and communities and remain compliant. We publish new episodes twice a month, with news reports and in-depth interviews with leading health care practitioners, policy and legal experts, public policymakers, and our expert staff.
Narration (00:03)
Welcome to 340B Insight from 340B Health.
David Glendinning (00:12)
Hello from Washington DC and welcome back to 340B Insight, the premier podcast about the 340B drug pricing program. I'm your host David Glendinning with 340B Health. Our guest for this episode is Christina Carrizales Cortez, a member of the 340B team at UI Health in Chicago. Cristina was one of many compliance experts who brought their expertise to the most recent 340B Coalition Conference
where she discussed inventory management best practices with attendees. We wanted to share just a few of those best practices with our listeners as well. But first, let's do a quick recap of some of the latest news about 340B.
A federal district court has ruled in favor of hospitals in a major dispute with the federal government over when newly opened hospital outpatient facilities known as child sites can begin accessing 340B drug pricing. The decision sets aside a long-standing Health Resources and Services Administration policy that delayed access to 340B discounts until new child sites were included on a hospital's filed Medicare cost report and registered with the agency.
a process that could take up to 23 months. The government has 60 days from the date of the decision to decide whether it will appeal, and HRSA may request that the judge's order be delayed pending the outcome of an appeal. Please visit the show notes to learn more.
And now for our future interview with Christina Carrizales Cortez with UI Health. Inventory management is one of the most important responsibilities for a hospital pharmacy department, and that job becomes all the more complicated once you add 340B into the mix. We met up with Cristina to find out more about how she and her team keep track of all the prescription drugs coming in and going out their doors. Here's that conversation.
I am sitting here with Christina Carrizales Cortez, Associate Director of 340B Compliance at UI Health. Cristina, thank you very much for being here. Welcome to 340B Insight.
Christina Carrizales Cortez (02:31)
Thanks David, it's a pleasure to be here just enjoying the positive energy with the 340B community and just sharing amongst my peers and learning from everyone in this just ever evolving landscape of what's going on.
David Glendinning (02:44)
Well, we're catching you not just right after you gave your presentation, but it is actually during the 340B Insight Ice Cream Social. So maybe a little bit cruel to have you just have that in the background, people enjoying their gelato. we'll get you through this interview and then we can go get some ice cream afterwards. If you can start, please tell us a little bit about UI Health and the patients you serve there.
Christina Carrizales Cortez (03:08)
So UI Health, have three covered entities and then I primarily oversee the DISH side, the DISH-Proportionate Share Hospital. It's a 450 plus bed state academic hospital with 30 plus outpatient clinics. And then we have seven outpatient pharmacies that are system owned and we collaborate with our health sciences colleges, which are seven of them. And it's a great organization to just meet the mission.
of our patient population.
David Glendinning (03:38)
And we are here to speak about your presentation topic, was inventory management. Now we have spoken about this subject before, but we're always looking to hear new perspectives from different hospitals and health systems, maybe things that are going on in that area that ⁓ are relatively new or know worthy. Before we get into that, maybe you could describe a little bit about why inventory management, at least in the 340B context, ⁓ is such a
challenging area for hospitals today.
Christina Carrizales Cortez (04:08)
Perfect way to start, David. It's challenging in the sense that you have to focus on or you have to leverage data from multiple systems. So it's not necessarily inventory management when you think of it from the broad context of it. Seems very simple. Purchase what you need to dispense to have the sufficient inventory cycles. But when you add the complexity of 340B, you're adding additional data feeds, additional training to your buyers.
additional time stamps when the data flows in and out and it becomes a little bit more complex and what access you have to what contracts you have access. Are there interfaces at your disposal and are there any deviations to your traditional standard workflow operations that you have to do?
David Glendinning (04:56)
Okay, and what happens when everything doesn't go according to plan with that? You had mentioned, and I saw a little bit of your presentation talking about inventory discrepancies. So how does an inventory discrepancy happen? How does that typically show up?
Christina Carrizales Cortez (05:10)
So
typically you could find it in your routine auditing as covered entities have as part of their standard auditing procedures. And then sometimes you just stumble upon it through something doesn't look right and then you go down that rabbit hole of like investigating and you become this inventory investigator to identify where was the gap. And it can be a multitude of things that can lead to that discrepancy and it just has to do with
Lots of ins and outs are impacting that inventory target and how you purchase.
David Glendinning (05:46)
Could you give an example or two of what an inventory discrepancy might be?
Christina Carrizales Cortez (05:52)
Absolutely. So when you're looking at your data feeds, you need to evaluate what inventory location are you looking at? Do you have a mapping and do you understand where is this impact coming from? Is it coming from your system not communicating with your TPA? Is it your TPA not receiving it from one of the vendors? So it could be a multi-source and then others can be, is it a manual process that you just forgot to do?
So a perfect example of that is sometimes you have vendors, ⁓ wholesalers that you acquire these medications from, and unfortunately there is no electronic data interface. When that electronic data interface is absent from the equation, you don't have this automatic feed going into your accumulator to decrement. So making sure you have the steps and workflow processes to identify, it's that time, we haven't uploaded something.
having that routine cadence of checking the health of your accumulations for lack of a better term and just making sure that you are decrementing and are receiving that claim information and to making sure that those accumulations are accurate. And then making sure that those uploads are accurate and appropriate. And if you can remove some manual processes and investigating to see how AI can help, that's...
an area where AI can be embedded where it's not PHI, but it's a way to use the tools that you have at your access, at your disposal, and see how you can make that better and populate the data into that manual file to then upload to your TPA.
David Glendinning (07:30)
So it's my basic understanding that hospitals use different types of inventory models. How might the choice of inventory model for a particular hospital affect its potential risk for these types of discrepancies happening?
Christina Carrizales Cortez (07:44)
So a virtual replenishment model is neutral inventory on your shelf. You need to purchase the item first on your non-340B account and then receive the accumulations or the dispensed data in order to fill up your 340B bucket. Physical inventory is different. You are having two separate stock areas of the same drug or different NDCs of the same drug.
and you need to know that one is only solely sourced for 340B eligible patients and the other one is not. So depending on what model and depending on what access you have available at that point in time, perhaps one contract is not executed or fully uploaded at one point when you need to service a patient. So then what are the documentation parameters that you're taking to make sure you have those auditable records and making sure that you are ⁓ sourcing or
dispensing the medication to a true eligible 340B dispensation.
David Glendinning (08:40)
You had referenced before the issue of a wholesaler perhaps without electronic data interfaces, manual edits, that sort of thing. are some of the other pitfalls for hospitals when they are trying to source all of these 340B drugs from multiple wholesalers or suppliers?
Christina Carrizales Cortez (08:58)
would say going back to the basics and kind of just setting up your mapping. So whether creating a file where anybody on your team or you could communicate with somebody outside of the 340B team and say this account lines up to this particular inventory location, this shipping address, and this is who we service and this is how this account is used. Identifying is there an EDI feed, yes or no. Simply making a column just for that feature so then it
provides a transparency to everyone within your stakeholder group to understand the complexity of navigating the inventory, but then also it kind of helps you build where you're going to go to next and kind of pivot and discover where could the gap happen. If there is no EDI interface, then you can eliminate that as a source of potential error. So then that brings you into a different drawing board.
David Glendinning (09:53)
When you and I spoke in advance about your presentation and about this podcast interview, you had given me an example of a test claim. Could you go through that example in a little bit more detail of how a test claim could lead to one of these inventory discrepancies?
Christina Carrizales Cortez (10:13)
Yeah, absolutely. So a test claim, it's common practice for providers to call the pharmacy. Hey, is this covered for my patient? What's the copay? Because they don't want to prescribe something that the patient's not going to take, right? That's not effective. Why prescribe something that the patient's not going to take or is not covered? You want the patient to have in-time medication, reduce that gap, and provide that access. So pharmacies will do a test claim and tell the provider immediately, like, this is covered.
But it's basically a send off to the patient's pharmacy benefit manager or their insurance to basically do a checkpoint. Is this drug covered at this quantity? It doesn't go into details of directions or anything. All you want to know is this covered or not, yes or no. The problem arises or the gap arises is if there's a disconnect between that automatic pullback of that paid claim. So while it may not look like a paid...
claim in the pharmacy system because it's only a test claim and it'll be removed from the patient's profile, it still lingers in this cyber world because it's still tested. So then creating a discrete prescription number, perhaps within your own system saying, hey, all these test claims that are testing now that we're using this test function feature, let's have them all start with one particular prescription number. That way, when you're using a disparate system,
you're able to identify by the prescription number. So then it becomes easier for the analyst to identify, okay, all these prescriptions that start with a nine, a seven, or whatever arbitrary number that you select that's not part of your standard prescription numbering sequence, then that's easy to identify. Any prescription number that starts with this, then you need to investigate because it doesn't have that matching reversal. And then taking it a step further, it becomes an issue if it tests as 340B. And if it doesn't,
then it becomes something that we need to work with our RevCycle team and tell them to make sure that they did not receive payment for this particular claim as it was never dispensed.
David Glendinning (12:18)
So I'm starting to get the concept that there are all sorts of very good reasons why you might have an inventory discrepancy. Why is it so important to take some of these steps to recognize that? Why do you need to recognize discrepancies when they occur?
Christina Carrizales Cortez (12:34)
It's important for two avenues. ⁓ One is your potential for missing 340B savings that you may have access to. So you're going to incur perhaps more wax spend if you're missing those feeds. And then from the different aspect as well is the compliance. We want to be good stewards of the program and making sure that the appropriate decrementations are occurring to ensure that that is reflective of what we're actually dispensing and what we're actually purchasing.
David Glendinning (13:02)
Yes, I can see how having the accuracy on both of those ends is very important for a hospital. In your presentation, you had emphasized the concept of looking really closely at your auditing workflows. In your experience, where do you think hospitals most often fall short when it comes to those workflows?
Christina Carrizales Cortez (13:23)
Sometimes it's time, it could be staff, and it can be understanding the system that you're working with and understanding the time stamps. From my personal experience, I can speak to this, is when I refer to an encounter, I'm referencing an eligible patient encounter within the EMR, within the electronic medical record. But that terminology does not translate to my IS team.
an encounter to them as any touch point perhaps within the medical ⁓ record. So it's important to make sure you have the appropriate stakeholders at the meeting, but then be able to translate your 340B complex issue and be able to pull back and explain it in a way that anyone could understand. And it's hard to do because 340B is very complex and there's a lot of intricacies that go with the program.
But being able to peel back the layers to be able to explain it to someone, it takes you farther to go ahead and solve those problems.
David Glendinning (14:26)
On a day-to-day basis, it's clear you're dealing with a lot of data, a lot of numbers, of different systems. So how do these data feeds, the system interfaces that you use, factor into preventing one of these issues from happening or identifying when one has happened?
Christina Carrizales Cortez (14:42)
So
we monitor them routinely. We do a thorough comprehensive look on a monthly basis to assess that there are data feeds flowing into our TPA. There are instances where maybe there's a mismatch of a file that went out. So then that impacts 340B accumulations where we're missing them. And that has to do with an interface, whether it be from our electronic medical record that was not taken, perhaps during downtime, perhaps during an update.
So those are just some examples, ⁓ making sure that you have different checkpoints along your way, not just daily, but look at them. Look at the trends. What do you see monthly? Look at the dates. The dates tell you a lot, the timestamps, whether you have missing data. Sometimes there's something that's going on within a particular timeframe. The more descriptive you are with identifying the date and time that it took place, it'll help your vendors and the communication within the different stakeholders can help you just
expedite to solve the case.
David Glendinning (15:42)
Well, I'm sure everybody attending your presentation really appreciated the best practices you were bringing into that conversation. Looking at best practices, if hospitals could take just a few practical steps to reduce their inventory risk, what would you recommend they do?
Christina Carrizales Cortez (15:59)
mapping it out, what accounts you have, all your vendors, not just your default, and what service lines you service. And then routinely auditing your split billing software, your TPA, just to see is there an update that needs to happen? And then monitoring the trends of accumulations. Are you seeing an upward tick? Is the split or not functioning correctly? And then how do you resolve that? And then just, it's ongoing. I feel like we discover something new.
every day where we're like, ⁓ this happened at this day. But then we just learn from it and move on and just get better at different things that we solve and find, and then just share it with our peers and we just grow as a community.
David Glendinning (16:42)
Well, Christina, every time I have one of these conversations, I'm always kind of in awe of everything that's going on under the hood when it comes to the 3-4-to-B operations side. And we're just very glad to have experts like you to do all that important work. So thank you for that work. And thank you for bringing us the expertise from your presentation, walking past the Ice Cream Social to do it.
Christina Carrizales Cortez (17:04)
yeah, thank you. Now I get a treat afterwards.
David Glendinning (17:07)
Excellent. Thanks again.
Our thanks again to Christina Carrizales Cortez for giving us a glimpse into all the expertise she provided conference goers who attended her panel. This was just one of many operations and compliance panels that feature at these events. So if you want to learn more, please mark July 13th to 15th on your calendar for this year's 340B Coalition Summer Conference taking place here in the DC area. We will be back in a few weeks with our next episode. In the meantime, as always,
Thanks for listening and be well.
Narration (17:43)
Thanks for listening to 340B Insight. Subscribe and rate us on Apple Podcasts, Google Play, Spotify, or wherever you listen to podcasts. For more information, visit our website at 340bpodcast.org. You can also follow us on Twitter @340BHealth and submit a question or idea to the show by emailing us at podcast@340bhealth.org.