Rx15 vision tues_200_pew_1_reilly_2wendt_3kachur_4nader

One Patient, One Pharmacy, One Prescriber

How Patient Review and Restriction Programs

Can Help Address Prescription Drug Abuse

Cynthia Reilly, B.S. Pharm.Director, Prescription Drug Abuse Project

The Pew Charitable Trusts

Goals for Vision Session

1. Provide an overview of the role of patient review and restriction programs (PRRs) in addressing the prescription drug abuse epidemic

2. Describe models for effective PRRs in state Medicaid fee-for-service, Medicaid managed care, and private-payer plans

3. Provide a forum for stakeholders to ask questions and discuss potential best practices

Pain Management and Prescription Drug Abuse

CDC. MMWR. 2015;64(1):32.

Defining Risk for Opioid Overdose

Yang Z, et al. Journal of Pain (2015), doi: 10.1016/j.jpain.2015.01.475

What is a Patient Review and Restriction Program (PRR)?

• Programs that state Medicaid and private insurance plans use to identify and manage patients at-risk for prescription drug abuse

• Plan identifies a patient receiving large quantities or duplicative opioids from multiple prescribers or pharmacies

• Patient is required to use a designated pharmacy and/or prescriber to obtain controlled substance prescriptions

• PRRs can improve continuity of care

• Patient protections ensure access to pain medicine while lowering the risk of overdose

“PRR programs have the potential to reduce opioid usage to lower, safer levels, and thus save lives and lower health care costs.”

--CDC Expert Panel Meeting Report

2012

Federal Landscape

• Bipartisan legislation in Congress authorizing PRRs in Medicare

• President’s FY 2016 budget request proposes authorization to establish PRRs in Medicare

• Office of Inspector General includes PRRs on its list of 25 recommendations that would positively impact HHS programs in terms of cost savings and/or quality improvements and should be prioritized for implementation

Expert Panel

Melwyn Wendt, Pharmacy Director, Louisiana Medicaid

Sarah Kachur, Clinical Pharmacy Manager, Johns Hopkins Healthcare

Jo-Ellen Abou Nader, Senior Director, Drug Waste Solutions, Express Scripts

Thank You

Cynthia Reilly

Director, Prescription Drug Abuse

The Pew Charitable Trusts

[email protected]

202-540-6916

mailto:[email protected]

Overview of the Louisiana Medicaid Lock-in Program

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Background

The Bureau of Health Services Financing (Medicaid) developed the Lock-In

Program to educate recipients who may be unintentionally misusing program

benefits and to ensure funds are used to provide optimum health services.

The Louisiana Lock-In Program began in the 1970s.

Recipients who misuse pharmacy and physician benefits may be restricted to

one physician/one pharmacy (Physician-Pharmacy Lock-In) or one pharmacy

(Pharmacy-Only Lock-In).

Prior to move to managed care in 2012, approximately 75% of the Lock-In

recipients were in Physician-Pharmacy Lock-In and 25% in Pharmacy-Only

Lock-In.

Overview of the Louisiana Medicaid Lock-In Program * National Rx Drug Abuse Summit * April 6-9, 2015 * Atlanta, GA

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Identification of Potential Lock-In Recipients

Include 9 months of data, 72 or more prescriptions, 5 or more prescribers, 3 or more pharmacies, and Utilization of narcotics, antianxiety agents, sedative

hypnotics, or muscle relaxants

Exclude Long-term care

Also consider prescription-related offenses, referralsGenerate claims-based profiles


Step 1—Claims Review

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Identification of Potential Lock-In Recipients

Four regional Drug Utilization Review (DUR) Committees managed by Fiscal Intermediary (Molina).

Meet monthly.

Composed of physicians and pharmacists.

Review individual recipient profiles containing pharmacy and medical care utilization data.

May eliminate recipients with cancer, terminal prognosis, serious illness such as ESRD, etc.

Make recommendations but final decision made by the Department.


Step 2—Clinical Review

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Notification Process

Recipients are notified by mail. Letter states recipient is being placed in special program to

use Medicaid in healthier way. Recipient chooses PCP, up to 3 specialists, pharmacy, and

specialty pharmacy, if warranted, all subject to Medicaid approval.

Recipient has 30 days to call with provider choices. Call used to reinforce positive benefits of coordinated care. Non-responsive recipients have benefit temporarily

suspended. Provider history drives acceptable provider choices. School of Pharmacy supports the Lock-In Program from

notification, provider choice and ongoing management.Overview of the Louisiana Medicaid Lock-In Program * National Rx Drug Abuse Summit * April 6-9, 2015 * Atlanta, GA

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Appeals

Initial letter also contains appeal rights and form to register an appeal.

If recipient chooses to appeal, Lock-In process stops.Administrative law judge handles appeals.

This also applies to MCOs.

Recipient provider choices are subject to Medicaid approval.


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Lock-In Process for MCOs

In the Shared Plans, process is very similar, except:

There is no Physician-Pharmacy Lock-In because the PCP has the role of the Lock-In Physician.

Plans are sent the PCP’s prescribing history (same profile used by Regional DUR Committees).

Case management is required.

Prepaid Plans (full-risk MCO):

Plans have their own selection criteria.

Plans opted to have no Physician-Pharmacy Lock-In.

In Pharmacy-Only Lock-In, recipient is sent 3 acceptable pharmacies from which to choose.

Overview of the Louisiana Medicaid Lock-in Program * National Rx Drug Abuse Summit * April 6-9, 2015 * Atlanta, GA

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Lessons Learned

Do

Create educational/benefit focus.

Discuss the benefits of a single provider.

Share prescription and medical care utilization patterns with providers.

Encourage case management.

Have emergency procedures in place.

Don’t

Perceive Lock-In as punitive.

Be too restrictive. Need recipient cooperation so offer encouragement and assistance.


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Demographics

Lock-In type # of Members

Physician-Pharmacy 914 (79%)

Pharmacy-Only 250(21%)

Total 1,164

(Prior to Managed Care)

Gender # of Members

Female 857(74%)

Male 307(26%)

Total 1,164


Age # of Members

19-39 324(28%)

40-59 734(63%)

60+ 106(9%)

Total 1,164

903 (78%) are Disabled (Aid Category).

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Results of Analyses

For both Lock-In groups, reductions were noted in:

Pharmacy expenditures. For the Physician Pharmacy Lock-In study group, average monthly

costs declined from $111,207 to $70,347. For the Pharmacy Only Lock-In study group, average monthly costs

declined from $108,798 to $95,953.

Outpatient office visits. For the Physician Pharmacy Lock-In study group, average monthly

number of visits declined from 136 to 91. For the Pharmacy Only Lock-In study group, average monthly

number of visits declined from 135 to 117.


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Results of Analyses-cont’d

Emergency Room admissions For the Physician Pharmacy Lock-In study group, average monthly

ER visits declined from 112 to 71 per month. For the Pharmacy-Only Lock-In study group, pre-lock-in the average

number of ER visits per month declined from 123 to 88.

Inpatient admissions Before lock-in, the Physician-Pharmacy Lock-In study group had an

average of 23 inpatient admissions per month, while, after lock-in, this group had an average of 21 inpatient admissions per month.

For the Pharmacy-Only Lock-In study group, pre-lock-in, the average number inpatient admissions per month was 19, and after lock-in, the average inpatient admissions per month declined to 14.

Overview of the Louisiana Medicaid Lock-in Program * National Rx Drug Abuse Summit * April 7, 2015 * Atlanta, GA

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The number of prescriptions per month for anxiolytics, carisoprodol, and analgesic narcotics decreased post-lock-in.


Physician/Pharmacy Pharmacy Only

Drug ClassPre-

Lock-In

Post-

Lock-In

Anxiolytics 198 81

Carisoprodol 156 53

Narcotic

Analgesics416 151

Maintenance

Medications227 186

Drug ClassPre-

Lock-In

Post-

Lock-In

Anxiolytics 166 123

Carisoprodol 141 92

Narcotic

Analgesics429 262

Maintenance

Medications234 238

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Usual Provider Consistency (UPC)

Physician/Pharmacy Pharmacy Only

UPC TypePre-

Lock-In

Post-

Lock-In

Prescriber 0.48 0.80

Pharmacy 0.60 0.91

Physician 0.65 0.77

UPC TypePre-

Lock-In

Post-

Lock-In

Prescriber 0.45 0.58

Pharmacy 0.57 0.92

Physician 0.63 0.68

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Contact Information

Melwyn Wendt, PharmD

Louisiana Medicaid Pharmacy Director

Pharmacy Benefits Management Section

[email protected]


JHHC Research & Development Unit 24

JHHC Research & Development Unit

Improving the health of populations by developing innovative healthcare solutions based on rigorous research and evaluation

Impact of Provider/Pharmacy

Restrictions for Opiates in a Medicaid

Managed Care Population

April 7, 2015


Program Description

• Maryland Medicaid Managed Care plan with approx. 200,000 enrollees

• Opiate overuse led to quality and costconcerns at plan level

• Program initiated in 2005, continuous operation

• Plan members locked into one prescriber and one pharmacy to fill prescription opioids


CMC – Volume of Cases(# of cases)

0

5

10

15

20

25

30

35

40

45

50

Sum of Reviewed

Sum of Locked In


Program Staffing

• 2 FTE dedicated staff– 1 RN case manager

– 1 MSW social worker

• Program support– Pharmacy technician

– Clinical pharmacist

– Pharmacy director

– Compliance

– Chief Medical Officer (committee chair)


Evaluation Overview

Study Design:Pre-post design with retrospective difference-in-difference analysis


Study Population

• Intervention Group =

– 111 plan members

– 18 years or older

– Initial enrollment in the lock-in program March 2008 –February 2011

• Comparison Group =

– 2248 members from the same health plan

– Identified on a semi-annual screening report for opiate overuse BUT were not evaluated for program.


Primary Outcomes

1 Means reported as unadjusted model predicted means2 Differences reported from both unadjusted model and risk adjusted model (in bold)* p<0.05


Key Secondary Outcomes

1 Means reported as unadjusted model predicted means2 Differences reported from both unadjusted model and risk adjusted model (in bold)* p<0.05


Percent in Substance Abuse Treatment

0%

5%

10%

15%

20%

25%

-5 -4 -3 -2 -1 0 1 2 3 4 5 6

Buprenorphine Tx

IOP

Methadone


Summary• Lock-in program decreases opiate prescriptions and

opiate cost

• Program enrollment had a non-significant impact on emergency department visits, specialist office visits, and total costs.

• The lock-in program did not increase enrollment in substance abuse treatment programs.

• Essential to coordinate with state DHMH and other MCOs within Maryland– Members changing plans

– Criteria harmonized between MCO programs

Curbing Opioid AbusePRR Options and Outcomes: A PBM

Perspective

Jo-Ellen Abou Nader, CFE, CIA, CRMA

Senior Director, Express Scripts - Drug Waste Solutions

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1. Restrict patient to one pharmacy and/or physician for all controlled

substances and muscle relaxers

2. Efficiently manages and reduces risk within population

3. Completed through communications to patient

Automatic Pharmacy Lock Client Choice

Pharmacy Lock | Physician Lock | Pharmacy & Physician Lock

• Express Scripts initiates process once abuse allegation is confirmed

• Letter notifies patient of restriction

• Decision made by client on a case by case basis

• Client chooses to restrict patient to one pharmacy and/or physician

• Letter notifies patient of pharmacy restriction

• Client must choose physician to be restricted

• Patient and physician notified of restriction

PRR Program

Uniquely Positioned to Address Rx Drug Abuse

83%REDUCTION IN DRUG SEEKING

CLAIMS

500+ PATIENTS IN PHARMACY

RESTRICT ION

300+ COMMERCIAL CLIENTS IN FWA

132AUTOMATIC LOCK CLIENTS

Express Scripts Internal Team to field pharmacy change requests

and appeals

• Total narcotic prescriptions received within10 months

• Number of unique prescribers utilized to obtain narcotics

• Number of pharmaciesused to fill the narcotic prescriptions

90% OF NARCOTICS PRESCRIBED

FOR ≤10 DAYS’ SUPPLY

141762

Lock-in implemented to restrict patient to one pharmacy and one physician for controlled substances

Case Study: Restriction Program Benefits

PROBLEM > SOLUTION

Controlled Substance Claims Reduction

83%Compared with before lock-in

Controlled Substance Spend Decrease

81%Compared with period prior to lock-in

Total Drug Spend Decrease

72%Compared with period prior to lock-in

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Lock-in implemented

Lock-in In Action

PRR Proves Savings

Clients

• Ability to take

action on abuse

cases

• Improve patient

health outcomes

• Reduce future

costs

Physicians

• Physician chosen

for lock can manage

care of patient closer

• Full visibility into

patient’s drug profile

Patients

• Patient Safety

• Intervention to

reduce future risk

Value of a PRR Program

Questions

Rx15 vision tues_200_pew_1_reilly_2wendt_3kachur_4nader

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