Rx15 tpp tues_200_1_walls_2hunt_3paduda

Third-Party Payer Track

PDMPs and Third-Party Payers: Workers’ Compensation

Presenters:

• Phil Walls, RPh, Chief Clinical Officer, myMatrixx

• Dan L. Hunt, DO, Corporate Medical Director, Accident Fund Holdings, Inc.

• Joseph Paduda, MS, Principal, Health Strategy Associates

Moderator: John L. Eadie, Director, Prescription Monitoring Program Center of Excellence, and Member, Rx Summit National Advisory Board

Disclosures

• Phil Walls, RPh; Dan L. Hunt, DO; and John Eadie have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

• Joseph Paduda, MS – Owner: CompPharma; Consulting fees: Healthcare solutions, Helios

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– Kelly Clark – Employment: Publicis Touchpoint Solutions;

Consultant: Grunenthal US– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center– Carla Saunders – Speaker’s bureau: Abbott Nutrition

Learning Objectives

1. Advocate that third-party payers have access to PDMP data as a way to interdict the opioid epidemic.

2. Identify best practices for PDMPs when allowing access to data.

3. Describe the implementation and impact of a private third-party payer accessing Michigan PDMP data.


Phil Walls, RPh

Chief Clinical Officer

myMatrixx

Disclosures

• Phil Walls, RPh, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Traditional Prescription Data Sources

In the absence of PDMPs, data came from disparate sources:

• Medicaid and Medicare programs

• Group Healthcare Pharmacy Benefit Managers (PBMs)

• Workers’ Compensation PBMs

This data was contained in “silo” data warehouses and did not capture significant sources such as cash payments

Limitations of PDMPs

• Inconsistencies between states

• Not “real time”

• Most states rely on a passive approach

• Access is limited to law enforcement, treating physicians and dispensing pharmacists

Developing a PDMP Access Program in Michigan

Dan L. Hunt D.O.

Corporate Medical Director

Accident Fund Holdings, Inc.

Disclosure Statement

• Dan L. Hunt D.O. FACOS, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services

Learning Objectives

• Know that a commercial workers compensation carrier having access to a state PDMP is unusual

• Be familiar with the dual strategies Accident Fund has developed.

• Appreciate the balance of improving the safety of injured worker medical care with protecting the injured workers privacy.

Accident Fund Holdings

• Over a 100 years old- Established in 1912 in Michigan

• 20 Years since privatization

• Insure over 46,000 employers nationwide

• Approximately 1 billion in annual written premium

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Michigan Automated Prescription System

• State of Michigan Public Health Code Act 368 of 1978, Section 333.7333a(b) was amended in 2012 to allow private insurance carriers and law enforcement the ability to access the Michigan Automated Prescription System (MAPS) to help improve claimant safety and as a means of combating fraud.

• Michigan becomes the only state to allow a workers compensation insurance carriers access to the state PDMP.

• Accident Fund Holdings was granted access in December of 2014

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Plans for Utilization

Pharmacy Nurse Case Managers

Individual claim focus

Provide opioid education to the injured worker

Information sharing with the treating provider

Investigative Services Unit

Provider/pharmacy focused

Detect and prevent criminal activity and fraud

Information sharing with law enforcement

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Challenges of Privacy and Confidentiality

• Being the first insurance carrier to utilize a state PBMP carries a high level of responsibility to protect claimant information.

• How to store report information.

• Can the information be shared and with whom.

• Can we discuss medication information that occurred prior to the date in injury and filing of a claim.

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PDMPs and Third Party Payers: Workers’ Compensation

Joseph Paduda

President, CompPharma, LLC

Learning Objectives

• Advocate that third party payers have access to PBMP data as a way to interdict the opioid epidemic

• Identify best practices for PDMPs when allowing access to data

• Describe the implementation and impact of a private third party payer accessing Michigan PDMP data

Disclosures

• Joseph Paduda has financial relationships with proprietary entities that produce health care products and services. These financial relationships are: consulting for IROKO Pharmaceuticals, Millennium Health, Inc., and MedRisk, Inc.

What we’ll cover• The Workers’ Compensation Primer

• Why WC is different from group health, Medicare, and Medicaid

• Workers’ comp pharmacy and drug management

M A R K E T O V E R V I E W

Definitions• Not ‘Members’ - think Claimant - a worker injured or ill due to a cause arising

from or during the course of employment

• Claim - the entire injury or illness – NOT a bill for medical services

A workers comp claim is the legal term for everything associated with the occupational injury

• Covered expense - treatment for the disabling condition and ONLY for that condition

• Lost Time - a claim resulting in the claimant’s absence from work for a defined period of time (usually >7 days)

• Medical Only - a claim that does not result in ‘Lost Time’

• Managed care - Group health techniques and methods from the mid-nineties e.g. broad provider networks, bill auditing, utilization review

• Payer - an insurer, state fund, or third party administrator (TPA) that pays claims

• TPA - a firm that administers workers comp claims for an insurance company or self-insured employer - aka claims processor

How workers’ comp is different from group health

• Work Comp– Regulated by states– Only covers injuries/illnesses occurring

during or arising out of the course of employment

– Return to Work is critical– The insurer owns the claim forever…or

until the claimant is back to work or has reached maximum medical improvement

– Mix of injuries and illnesses is different• Musculoskeletal/orthopedic• Trauma and some cardiovascular

– Coverage is “first dollar, every dollar”• No copays• No tiers• No deductibles

– “Formularies” set by state (3) or PBM

• Group Health

– Regulated by states (fully insured) and/or Federal government (ERISA)

– Covers all types of injuries and illnesses

– Unconcerned about Return to Work

– Covers treatment delivered during the policy year only

– Cost sharing via deductibles, copays, coinsurance

– Formularies dictated by payer and PBM, can be highly restrictive

– Rebates are large and common

How workers’ comp is different from group health

• Work Comp

– WC PBMs don’t handle group or other lines (except Express Scripts Inc(ESI))

– Injured workers can obtain a “covered” script without a card

– Some states have strong managed care laws, others don’t

• Networks

• Employer v. employee choice of provider

• Presumption laws

• Utilization review/evidence-based guidelines

– Provider reimbursement determined by state regulation and/or PPO network contract

• Approximately half of the states have a state-set fee schedule for medical procedures, including prescription drug

• Most Rx fee schedules are based on AWP (CA is not)

• Group Health

– WC PBMs don’t handle work comp (except ESI)

– Member must have a card to get a script

– Managed care dictated by employer, not state

– Provider reimbursement is set by payer

How workers comp is different from group health

• Work Comp

– Provider types - Occupational Medicine, Physiatry/PM&R, Orthopedics, Neurology, Neurosurgery, General practice

– Relatively few physicians handle most WC cases

• 65% of claims in CA handled by 2.2% of physicians (<900 physicians) (source CWCI)

– Comp docs only treat the occupational injury, NOT the ‘whole person’

– Comp docs often have not seen claimant before the injury

– Constant communication with employers about return to work (RTW)

• Group Health

– Wide range of provider types

– Physicians treat the ‘whole person’for all conditions and co-morbidities

– Physicians typically have an ongoing relationship with the person

– Unconcerned with functionality and return to work

– No contact with the employer

5%

15%

29%

22%

5%

20%

4%

DME/Home Health

Drugs

Hospital/facility

Physician

Imaging

Physical Med

Diagnostics

Components of Workers Comp Medical costs

Rx Cost Drivers

• Per drug costs are higher in work comp than in group health

• Dispensing pharmacies earn more per script• Only one state allows “direction” to network providers,

several mandate generic substitution• Significant obstacles to altering prescribing behavior

– No economic incentives available

• Claims adjusters are ill-equipped to deal with Rx issues and questions

• Fear of litigation drives adjusters to pay for non-compensable drugs– “You buy it once, you own it forever”

Drug types used in workers comp

35%

11%

9%

9%

8%

28%

narco analgesics

anticonvulsants

nsaids

sleletal muscle relaxant

antidepressant

other

Does Physician Dispensing Increase Opioid Use?

Credit – WCRI,3/5/2015

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Underlying data include six months of Rx utilization for FL injuries between Jan.–Jun. 2010 (pre-reform) and Jul.–Dec. 2011 (post-reform); Source: The Impact Of Physician Dispensing On Opioid Use

(2014)

© Copyright 2015 WCRI. All Rights Reserved.

3.9%

0.5%0%

2%

4%

6%

8%

10%

12%

14%

16%

Pre-Reform Post-Reform

% O

f W

ork

ers

Wit

h S

tro

ng

Op

ioid

s

Physician Dispensed

* Statistically Significant at the 0.01 level

*

Does Physician Dispensing Increase Opioid Use?Credit – WCRI,3/5/2015

7


(2014)


3.9%

0.5%

12.2%

14.2%

0%

2%

4%

6%

8%

10%

12%

14%

16%


% O

f W

ork

ers

Wit

h S

tro

ng

Op

ioid

s

Physician Dispensed

Pharmacy Dispensed

*


Does Physician Dispensing Increase Opioid Use? Likely


7

3.9%

0.5%

12.2%

14.2%

12.2%12.5%

0%

2%

4%

6%

8%

10%

12%

14%

16%


% O

f W

ork

ers

Wit

h S

tro

ng

Op

ioid

s

Physician Dispensed

Pharmacy Dispensed


(2014)



*

Most Received Physician-Dispensed NSAIDs And Weaker Opioids


9.1%10.1%

24.1%25.8%

3.9%

0.5%0%

5%

10%

15%

20%

25%

30%


% O

f W

ork

ers

Wit

h P

hys

icia

n-

Dis

pe

nse

d R

x

8© Copyright 2015 WCRI. All Rights Reserved.


(2014)

NSAIDs

Weaker Opioids

StrongOpioids

*

*

*


• Drop in physician-dispensed strong opioids with no material increase in pharmacy-dispensed strong opioids

• Increase in workers with physician-dispensed NSAIDs and weaker opioids

• Workers with physician-dispensed NSAIDs and weaker opioids did not subsequently receive stronger opioids

• 12% reduction in workers receiving stronger opioids in the first 12 months after injury

• Physician dispensing may lead to unnecessary opioids

Underlying data includes FL injuries between Jan.–Jun. 2010 in pre-reform group and Jul.–Dec. 2011 in post-reform group; Source: The Impact Of Physician Dispensing On Opioid Use (2014)

RecapCredit – WCRI,3/5/2015

10© Copyright 2015 WCRI. All Rights Reserved.

Third-Party Payer Track


Presenters:

• Phil Walls, RPh, Chief Clinical Officer, myMatrixx

• Dan L. Hunt, DO, Corporate Medical Director, Accident Fund Holdings, Inc.

• Joseph Paduda, MS, Principal, Health Strategy Associates

Moderator: John L. Eadie, Director, Prescription Monitoring Program Center of Excellence, and Member, Rx Summit National Advisory Board

Rx15 tpp tues_200_1_walls_2hunt_3paduda

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