Tpp 2 eadie wood_baumgartner

PDMP COORDINATION WITH THIRD PARTY PAYERS

John L. Eadie Director, Prescription Drug Monitoring Program Center of Excellence, Brandeis University

Bruce C. Wood Associate General Counsel & Director, Workers’ Compensation

American Insurance Association

Chris Baumgartner PMP Director, Washington State Department of Health

Atlanta Marriott Marquis Atlanta, Georgia

April 22, 2014

Disclosure Statements

•  John Eadie has no financial rela0onships with proprietary en00es that produce health care goods and services.

•  Bruce Wood has no financial rela0onships with proprietary en00es that produce health care goods and services.

•  Chris Baumgartner has no financial rela0onships with proprietary en00es that produce health care goods and services.

Learning Objectives

1.  State the basis for broad access to PDMP database, including third-‐party administrators.

2.  Iden0fy specific strategies for third-‐party administrators to u0lize their state PDMP data.

3.  Outline approaches to data sharing among states.

Prescrip)on Drug Monitoring Programs and

Third Party Payers Mee)ng Report

Working Together to Assure Safe Prescribing and

Interdict the Prescrip9on Drug Abuse Epidemic

Tuesday, April 22nd from 1:45 pm – 3:00 pm Atlanta, GA

PDMP Provision of data to 3rd Party Payers

As of 2012

# of States Data shared with 28 Medicaid and/or Medicare 8 Workers Compensa0on 1 Private 3rd Party Payer Program

Data are from the PDMP Training and Technical Assistance Center 2012 survey of state PDMPs.

There is room for expansion of PDMPs sharing data with Third Party Payers.

How to find contact informa)on for a state’s PDMP?

•  Go to www.pdmpassist.org -‐ website of PDMP Training & Technical Assistance Center at Brandeis University

•  Go to the leY column of Homepage; under “State Contact Informa0on and click on the link for “State Contacts”

•  That will bring up the name of the primary PDMP contact(s) in each state.

•  Click on a name and the individual’s contact informa0on will appear.

www.pdmpassist.org

How to find other informa)on about a state’s PDMP

•  On the homepage of www.pdmpassist.org, click the top tab marked “Resources” •  On drop down menu, click “State Profiles” •  On the next webpage, click the state’s name. •  For each state, there is:

–  The state agency administering the PDMP

–  Informa0on about the state

–  Drug schedules monitored

–  Who may request pa0ent informa0on

–  Legisla0on and regula0ons

EPIDEMIC: RESPONDING TO AMERICA’S

PRESCRIPTION DRUG ABUSE CRISIS

2011

II. Tracking and Monitoring

Evaluate exis0ng programs that require doctor shoppers and people abusing prescrip0on drugs to use only one doctor and one pharmacy. The PMP Center of Excellence at Brandeis University will convene a mee0ng in 2011 with private insurance payers to begin discussions on these topics. (ONDCP/DOJ/HHS/SAMHSA)

Page 6 hhp://www.whitehouse.gov/sites/default/files/ondcp/issues-‐content/prescrip0on-‐drugs/rx_abuse_plan_0.pdf

PDMPs & Third Party Payers First Mee9ng

PDMPs PBMs Privately Funded 3rd Party Payers Publicly Funded 3rd Party Payers Workers Compensa0on Federal Agencies – ONDCP, BJA, CDC, CMS, DEA, FDA, NIDA, SAMHSA Na0onal Organiza0ons Researchers

Workgroups at Mee)ng -‐ 1

Overview: Sharing Prescrip0on Histories with Third Party Payers

Protec0ng PDMP Data and Ensuring Appropriate Use

Iden0fying and Overcoming Barriers to Data Sharing

Evalua0ng Data Sharing Collabora0ons

Workgroups at Mee)ng -‐ 2

Sharing Data with Health Care Systems

Iden0fying Ques0onable Ac0vity by Providers

Third Party Payer Support for PDMPs

Enhancing Drug Abuse Referral and Treatment

PDMPs should be authorized to share prescrip)on data with third party payers.

Insurers have a central role to play in assuring quality health care and addressing the prescrip0on drug abuse epidemic; their use of PDMP data is key to an effec0ve response.

Without it, insurers do not have a complete picture of the prescribing and dispensing carried out by network prac00oners and provided to their enrollees.

Safeguards are essen)al

Providing PDMP data to third party payers is feasible and worthwhile so long as appropriate safeguards are put in place to assure use is appropriate, data are kept secure, and pa0ent confiden0ality is maintained.

Insurers must address concerns about denying coverage based on viewing PDMP data.

Barriers to data sharing can be overcome.

Facilita0ng insurers’ access to PDMP data requires collabora0ve efforts on the part of all stakeholders to modify legisla0ve and regulatory language to permit such access.

It will also require developing policies and procedures on data security, standardiza0on, and interoperability.

Data sharing policies & procedures need evalua)on to maximize effec)veness.

Research is needed to iden0fy process and outcome measures relevant to assessing the impact of third party payer use of PDMP data.

Research could also focus on the wider public health impact of PDMP u0liza0on by insurers, helping to make the case for data sharing ini0a0ves.

PDMPs should be authorized to provide data to health care systems.

Sharing PDMP data with health care systems (e.g., the VA, Indian Health Service, Tricare, Kaiser Permanente) can help improve medical care and iden0fy appropriate paherns of prescribing and use of controlled substances.

Such sharing can also permit quality assurance programs to earlier iden0fy and intervene in problema0c prescribing.

Insurers should use PDMP data to iden)fy ques)onable prescribing & dispensing.

PDMP data on medical providers can be used to help iden0fy fraud, monitor provider performance, and detect pharmacy non-‐compliance with insurance regula0ons.

Third party payers and the wider public would benefit from use of PDMP data to monitor prescriber and dispenser behavior.

Third party payers should support PDMPs.

Since PDMP data can play an important role in insurers’ efforts to improve medical care and reduce costs, they should consider assis0ng PDMPs by means such as:

– educa0ng policy makers,

– direct contribu0ons, or

– collabora0ve efforts to secure stable sources of funding.

Providers should be encouraged to refer pa)ents to treatment.

A primary goal of use of PDMP data, including by third party payers, should be the iden0fica0on of individuals in need of substance abuse treatment or beher pain management.

Providers need educa0on and training in the use of the PDMP and tools such as SBIRT (screening, brief interven0on, referral to treatment).

Insurers can help assure that these objec0ves are met.

PDMPs & Third Party Payers Next Steps: Formally release report Present at Na3onal Summit on Rx Drug Abuse Distribute report to interested par3es Provide informa3on and assistance to states interested in adop3ng recommenda3ons Possible next steps, for example:

–  Plan tests of data sharing in some states –  Plan steps to make tests feasible –  Plan evalua3on of tests

Contact Informa)on

John Eadie, MPA Director

PMP Center of Excellence

Brandeis University

518-‐429-‐6397

[email protected]

Website: www.pmpexcellence.org


Bruce C. Wood Associate General Counsel &

Director, Workers’ Compensation American Insurance Association

Atlanta Marriott Marquis Atlanta, Georgia

April 22, 2014


Disclosure Statement

Bruce Wood has no financial rela0onships with proprietary en00es that produce health care

goods and services


2014 LEARNING OBJECTIVES

1. State the basis for broad access to PDMP database, including third-‐party administrators. 2. Iden)fy specific strategies for third-‐party administrators to u)lize their state PDMP data. 3. Outline approaches to data sharing among states.


LET’S REVIEW . . .

WORKERS’ COMPENSATION: THE BASICS

I Discussion/history of workers’ compensa)on •  Evolu)on of this social insurance program over the

past century = first w.c. program enacted in 1911 (Wisconsin)

•  Subs)tute for tort = quid pro quo •  Trauma)c/occupa)onal diseases •  Na)onal Commission on State Workmen’s Compensa)on Laws (1972) = watershed event/ states’ response

•  Post-‐Na)onal Commission history = benefit expansion; financial crisis (later ‘80s-‐mid-‐’90s)

II Key Program Elements •  All medical treatment “reasonable and necessary” (w/o co-‐pays, deduc)bles, exclusions, dura)on limits) = 1st dollar coverage.

•  Indemnity benefits = commonly 2/3 of gross “average weekly wages” = Paid for:  Temporary total disability (TTD), temporary par)al disability (TPD), permanent par)al disability (PPD), permanent total disability (PTD)

•  Voca)onal rehabilita)on benefits = evalua)on and re-‐training •  Survivor/dependents’ benefits = payable for life or un)l remarriage; dependents un)l 18 or 22 if enrolled in college

III Common Areas of Dispute

• Compensability = Did the injury/disease “arise out of and in the course of employment”?

•  Exclusive remedy = Was the injury encompassed within the compensa)on scheme? Did the employer intend to injure the worker?

Common Areas of Dispute – cont’d •  PPD = Is there residual permanency; when is permanency ascertained and by what means; how is disability determined? Impairment as a proxy for disability? Lost wage-‐earning capacity? = PPD as driver of dispute, li)ga)on, and medical treatment costs = most costly element of w.c. system

• Medical treatment/RTW = Is the treatment “reasonable & necessary”? Employer/insurer is not financier of all medical treatment. Has maximum medical improvement (MMI) been reached? Is worker able to return to work? Restric)ons? Accommoda)ons?

IV The Role of Workers’ Compensa)on Medical Treatment

 Workers’ compensa)on is not a medical program. It is a disability program with a medical component = key difference with group health and informs how medical treatment is delivered and the role of a payer and its agents in administering a claim.

 Key objec)ve in workers’ compensa)on is managing disability = providing all medical treatment reasonable and necessary, of the nature and intensity required, to expedite recovery and return to work. WC medical treatment may cost more but higher cost can expedite RTW and limit indemnity exposure = coordina)ng medical treatment and indemnity.

The Role of Workers’ Compensa)on Medical Treatment – cont’d

Because workers’ compensa)on medical treatment remains first-‐dollar coverage – with no demand-‐side controls on cost and u)liza)on – it reinforces need of payers to use administra)ve tools to control cost, as well as to encourage return to work. These include:

 Ability to direct medical treatment – control of physician/networks

 Treatment guidelines – na)onal = ACOEM/ODG  Unit price controls (fee schedules) = Medicare RBRVS/DRGs

  Impairment guidelines = AMA Guides to the Evalua)on of Permanent Impairment

The Role of Workers’ Compensa)on Medical Treatment – cont’d Delivering medical treatment, )mely, and of the nature and intensity

needed, requires an unimpeded exchange of medical informa)on with providers and evaluators.

•  No authoriza)ons/releases required in workers’ compensa)on.

•  System is intended to be less formal than civil li)ga)on, to promote quick exchange of informa)on in the employee’s interest in receiving necessary and )mely medical treatment, in evalua)ng return-‐to-‐work restric)ons and accommoda)ons necessary, and in an employer’s understanding of poten)al health and safety risks posed by the injury.


In workers’ compensa)on, the employee is not the policyholder but a 3rd party with a legal claim for benefits against the policyholder/employer who the insurer is obligated under law and its insurance contract to defend and indemnify, paying all benefits due. The employer/insurer is obligated under statute to pay benefits w/in a specified )me. For this reason, the employee, who puts his condi)on at issue, does not have the same confiden)ality expecta)ons as do claimants in a group health selng. The claimant is in control of informa)on that legally obligates another party to pay benefits.


The special informa)onal needs of workers’ compensa)on payers is recognized under HIPAA:

“A covered en)ty may disclose protected health informa)on as authorized by and to the extent necessary to comply with laws rela)ng to workers’ compensa)on or other similar programs, as established by law, that provide benefits for work-‐related injuries or illnesses without regard to fault.” [sec. 164.512 – Uses and disclosures for which an authoriza)on, or opportunity to agree or object is not required; 45 CFR 164.512(l)].


 Where state law, itself, mandates disclosure without authoriza)on, disclosure is permired under HIPAA rules and exempt from the “minimum necessary” informa)on disclosure standard. “A covered en)ty may use or disclose protected health informa)on to the extent such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law.” [164.512(a)(1)].

 A covered en)ty under HIPAA rules also may disclose informa)on to any en)ty as necessary for payment, although the covered en)ty may disclose the amount and types of informa)on necessary for payment.


In brief, HIPAA does not erect barriers to a workers’ compensa)on payer obtaining protected health informa)on, whether without an authoriza)on, or pursuant to state law requiring release. HIPAA does not preempt state privacy laws.

 State privacy laws generally do not erect barriers to obtaining medical informa)on from medical providers. Some states = explicit mandates to release informa)on to employer/insurer.

 Other states impose ex parte rules on physician communica)ons with carrier that slow evalua)on/decisions.


To the Point: It is essen9al for workers’ compensa)on payors to obtain access to prescrip)on monitoring program data, to properly assess an injured worker’s use of prescrip)on medica)ons and, broadly, to provide all reasonable and necessary medical treatment and effec)vely manage disability. Without access, it is not possible for a workers’ compensa)on payer to know the full extent of prescrip)on drug use, because a worker may be obtaining prescrip)ons under other benefit systems (e.g., Medicaid, group health, Veterans) or has prescrip)ons through other providers not otherwise reported.

AIA POLICY POSITION

AIA endorses robust PDMPs as one key element for comba)ng opioid abuse.

  Mandatory prescribing and dispensing checking of database, with data entry

  Ac)ve PDMPs pushing informa)on to prescribers and dispensers

 Broad access to PDMP database, including 3rd party payers and law enforcement

 Interstate operability

Use of opioids, especially long-‐ac)ng medica)on, for treatment of chronic pain in workers’ compensa)on can increase chances of a “catastrophic claim ($100,000+) by almost four )mes. Use of short-‐ac)ng opioids raises chances by almost twice. Average claim not involving opioids = $13,000.

-‐-‐ “The Effects of Opioid Use on Workers’ Compensa)on Claim Cost in the State of Michigan; Bernacki, et. al; Journal of Occupa)onal and Environmental Medicine, August 2012.

OPIOID ABUSE: THE MOST URGENT ISSUE FACING WORKERS’

COMPENSATION

 Average claim costs of workers receiving 7+ opioid prescrip)ons for back problems without spinal cord involvement =

–  3X greater than for workers receiving 0 or 1 opioid prescrip)on  Workers receiving mul)ple opioid prescrip)ons =

–  2.7X more likely to be off work

–  4.7X as many days off work

(Swedlow et al., CWCI Special Report 2008)


COMPENSATION

Prevalence of Fentanyl in California’s Workers’ Compensa)on System  More than 1 out of 5 injured workers who were prescribed Schedule II opioids received fentanyl, and among those with non-‐surgical medical back problems (strains and sprains) who received Schedule II opioids, more than 1 out of 4 were given fentanyl.  The top 10% of medical providers who prescribe Schedule II opioids for injured workers in California write nearly 80% of all workers’ compensa)on prescrip)ons for these drugs, which represents 87% of the morphine equivalents provided to injured workers accoun)ng for 88% of all Schedule II pharmacy payments in the CA WC system. Nearly half of Schedule II prescrip)ons = minor back injuries.

[CWCI Research Bulle)n 11-‐05; April 28, 2011]


COMPENSATION

AIA endorses robust PDMPs as one key element for comba)ng opioid abuse.

  Mandatory prescribing and dispensing checking of database, with data entry

  Ac)ve PDMPs pushing informa)on to prescribers and dispensers

 Broad access to PDMP database, including 3rd party payers and law enforcement

 Interstate operability


COMPENSATION

Brandeis 3rd party payer conference agreed unanimously in merit of access to PDMP data

“Insurers have a central role to play in assuring quality health care and addressing the prescrip)on drug abuse epidemic; their use of PDMP data is key to an effec)ve response. Without it, insurers do not have a complete picture of the prescribing and dispensing carried out by network prac))oners and provided to their enrollees.”

THIRD PARTY PAYER ACCESS

WHY IS THIS SO IMPORTANT FOR WC?

 WC Medical Costs are about 2-‐3% of na)onal spend  Overwhelming share of medical costs not captured  WC payers have no ability to know otherwise what is being paid under systems

 WC Prescrip)on Drug Costs are about 20% of WC Medical Costs; Opioids comprise about 13% -‐-‐ 65% of Overall Drug Costs.

 Numbers mask far greater impact = delayed RTW


Brandeis report states: “Safeguards are essen)al. Providing PDMP data to third

party payers is feasible and worthwhile so long as appropriate safeguards are put in place to assure use is appropriate, data are kept secure, and pa)ent confiden)ality is maintained. Insurers must address concerns about denying coverage based on viewing PDMP data.”


WHAT ARE THE IMPLICATIONS FOR WC?  WC = strong safeguards for claimant informa)on. Claim files are comprised of adjustor/arorney work product = policyholder (employer) against whom a legal claim has been filed and to whom insurer owes defense under the policy. These are privileged files. No release of informa)on except pursuant to process, for purposes of either defending claim or in complying with claimant/arorney request/subpoena.


 Can WC Insurers Deny Coverage Based on PDMP Data?

 No Workers are not policyholders; employers are.  Insurers do not know iden)ty of who is employed

 WC is underwriren based on employer’s nature of business, size, number of employees, and experience.

 WC ra)ng plans do not inquire into individual claims.

 Role of ra)ng plans: Unit Sta)s)cal Plan, Uniform Classifica)on System, Uniform Experience Ra)ng Plan


Brandeis Report States: “Barriers to data sharing can be overcome. Facilita)ng

insurers’ access to PDMP data requires collabora)ve efforts on the part of all stakeholders to modify legisla)ve and regulatory language to permit such access. It will also require developing policies and procedures on data security, standardiza)on, and interoperability. “


IMPLICATIONS FOR WC

 Policy ra)onale for permilng access is same regardless of nature of 3rd party payer

 No jus)fiable dis)nc)on between public and private payers

 Sole criterion is whether purpose of access and use of data meets policy objec)ves


Brandeis Report States:

“Data sharing policies and procedures need evalua)on to maximize effec)veness. Research is needed to iden)fy process and outcome measures relevant to assessing the impact of third party payer use of PDMP data. Research could also focus on the wider public health impact of PDMP u)liza)on by insurers, helping to make the case for data sharing ini)a)ves.”


IMPLICATIONS FOR WC

 Agree.  Extensive WC research capabili)es already exist to measure impact -‐-‐ WCRI, CWCI, NCCI

 CWCI report (2013) measured impact of California WC insurers’ access to CURES data = significant impact. 15:1 ROI even with WC insurers’ full funding of CURES.



“PDMPs should be authorized to provide data to health care systems. Sharing PDMP data with health care systems (e.g., the VA, Indian Health Service, Tricare, Kaiser Permanente) can help improve medical care and iden)fy appropriate parerns of prescribing and use of controlled substances. Such sharing can also permit quality assurance programs to earlier iden)fy and intervene in problema)c prescribing.”


IMPLICATIONS FOR WC

 Agree. CWCI Study iden)fied considerable misuse of opoids in CA WC system =

  High rate of inappropriate opioid use;   Limits in statutes/rules/regs make it difficult to regulate within tradi)onal workers’ comp controls   Graduated use associated with adverse injured worker outcomes   Small number of physicians associated with high prescribing parerns   Rapid increase in drug tes)ng associated to high opioid use with no

na)onal guidelines for tes)ng   CURES has significant poten)al to increase QOC and lower cost



“Insurers should use PDMP data to iden)fy ques)onable prescribing and dispensing. PDMP data on medical providers can be used to help iden)fy fraud, monitor provider performance, and detect pharmacy non-‐compliance with insurance regula)ons. Third party payers and the wider public would benefit from use of PDMP data to monitor prescriber and dispenser behavior.”


IMPLICATIONS FOR WC

 Agree. See CWCI Study: “CWCI has es)mated that almost half of all claims with

Schedule II opioids fall outside the pain management medica)on recommenda)ons included in the evidence-‐based medical literature. Many workers’ compensa)on payers, as well as other stakeholders, believe that access to the CURES system, coupled with enhanced medical cost containment strategies including medical provider networks (MPN) monitoring and u)liza)on review (UR) –could significantly reduce the average number of prescrip)ons and the average dose levels of workers’ compensa)on claims that u)lize opioids.” Es9mated Savings from Enhanced Opioid Management Controls through 3rd Party Payer Access to the Controlled Substance U9liza9on Review and Evalua9on System (CURES); Swedow; Ireland, January 2013.


Brandeis Report States: “Third party payers should support PDMPs. Since

PDMP data can play an important role in insurers’ efforts to improve medical care and reduce costs, they should consider assis)ng PDMPs by means such as educa)ng policy makers, direct contribu)ons, or collabora)ve efforts to secure stable sources of funding.”


IMPLICATIONS FOR WC  AIA = No official policy – yet.

 No predisposi)on to object  CWCI study of CURES suggests significant cost-‐effec)veness to access to PDMP data


•  1939 Bureau of Narcotic Enforcement (BNE) creates PMP mandated through the Health and Safety (H&S) Code

•  September 2009, CURES program was enhanced with a web-based Prescription Drug Monitoring Program (PDMP) processing 913,874 patient activity reports.

•  CURES receives over 5 million records each month from more than 6,700 licensed pharmacies.

•  CURES is working with departmental IT to allow for the exchange of PDMP data between state PMPs.

•  Funding cut in 2010; SB 809 restores funding for operations; limits on use and access

CURES Background

Pain Management in the California Workers’ Comp System

Controlled Substance U0liza0on Review & Evalua0on System (CURES)

CWCI 2012. All Rights Reserved

Claims w/ Opioid Scripts

CA Claim Count (2010)

Pcnt of Claims

1 Scripts 34,981 41% 2-‐3 Scripts 21,206 25% 3-‐7 Scripts 14,111 16% >7 Scripts 15,690 18%

Total: 85,988 100%

Building a Business Case: Estimating CURES ROI:

• Estimate number of claims by opioid use • Determine potential savings via CURES access • Adjust for CURES operating budget


Controlled Substance U0liza0on Review & Evalua0on System (CURES)


Controlled Substance U0liza0on Review and Evalua0on System

CURES: ROI for California Workers’ Compensa0on (2012)

Claims w/ Opioid Scripts

Avg Cost/ Claim (2010) Total Payments Est %

Savings Total Es0mated Savings

1 Scripts $11,200 $391,790,539 0% $ -‐

2-‐3 Scripts $14,925 $316,508,020 3% $9,495,241

3-‐7 Scripts $18,284 $257,412,625 5% $12,870,631

>7 Scripts $31,718 $497,653,698 7% $34,835,759

Total: $17,018 $1,463,364,882 5% $57,201,631

Actual savings will depend upon several factors including: •  Medical & Rx trends, Injury mix; •  Appropriate statutes, rules and regs.

CURES Opera0ng Budget (Est.): $3,700,000 ROI for CA WC: $15.5 : $1



Brandeis Report States: “Providers should be encouraged to refer pa)ents

to treatment. A primary goal of use of PDMP data, including by third party payers, should be the iden)fica)on of individuals in need of substance abuse treatment or berer pain management. Providers need educa)on and training in the use of the PDMP and tools such as SBIRT (screening, brief interven)on, referral to treatment). Insurers can help assure that these objec)ves are met.”


IMPLICATIONS FOR WC

 Agree. Objec)ve is inherent to the disability management focus of workers’ compensa)on = providing evidence-‐based medical treatment of proper nature and intensity to expedite recovery and return to work.


CONCLUSION

 3rd party payer access is jus)fied by the seriousness of opioid abuse and its impact on society and the workforce

 3rd party payer access can be accomplished with necessary privacy protec)ons while providing payers with the informa)on necessary to curb unnecessary and inappropriate treatment and to deter fraud and criminal ac)vity.


QUESTIONS?


April 22 – 24, 2014 Atlanta Marrioh Marquis

PDMP Workshops: PDMP Coordina)on with Third-‐Party Administrators

Chris Baumgartner PMP Director

Washington State Department of Health

Disclosure Statement

Chris Baumgartner has no financial rela0onships with proprietary en00es that produce health

care goods and services.

Learning Objec)ves

1.  State the basis for broad access to PDMP database, including third-‐party administrators.

2.  Iden0fy specific strategies for third-‐party administrators to u0lize their state PDMP data.

3.  Outline approaches to data-‐sharing among states.

Public Insurer Access

•  PDMP Statute: Allows PDMP data to be provided to Medicaid and Workers’ Compensa0on

•  Primary Goal: To provide for beher pa0ent care and promote pa0ent safety.

•  Secondary Goal: To assist our public insurers in preven0ng fraud and saving state funding.

Two Types of Access

1.  Healthcare Prac00oners within the Health Care Authority (HCA -‐ Medicaid) and Department of Labor and Industries (LNI – Workers’ Compensa0on) can login with individual account access and request a pa0ent history report.

2.  Once a month each agency provides a file through secure file transfer of all their clients/pa0ents (names, DOB). Our vendor then provides matching data for each client/pa0ent in a file that is returned through secure file transfer.

LNI Early Opioid Interven0on Pilot

•  Iden0fy claims that are 15 -‐ 45 days old AND received ≥ 1 opioid prescrip0ons within 60 days before the injury

•  Clinical review and interven0on by a nurse or pharmacist as necessary

•  Beher coordina0on of medical care and management of claims, promote use of PDMP and reduce cost and disability

LNI -‐ Early Opioid Interven0on Pilot

•  350 – 500 new claims meet this criteria each month (3-‐4% of all claims allowed)

•  Priori0za0on Criteria –  Chronic opioid use (≥ 3 prescrip0ons in previous 3 months)

–  High dose opioid (> 120mg/d MED) –  Other controlled substances (e.g. benzodiazepines, seda0ve-‐hypno0cs –  Timeloss (wage replacement)

•  Clinical review is priori0zed by the number of criteria met

LNI Opioid Guidelines (July 2013)

•  Opioids in the Acute Phase (0-‐6 weeks aYer injury or surgery)

–  Should check PDMP before prescribing opioids

•  Opioids in the Sub Acute Phase (between 6 and 12 weeks)

–  Access PDMP to ensure CS history is consistent

•  Ongoing Chronic Opioid Therapy (every 12 weeks) –  No aberrant behavior iden0fied by PDMP or UDT

LNI Opioid Guidelines (July 2013) •  Opioids for Catastrophic Injuries

–  Injuries in which significant recovery of physical func0on is not expected (e.g. severe burns, crush or spinal cord injury)

–  No aberrant behavior iden0fied by PDMP or UDT

•  Before Surgery -‐ Surgeon and Ahending Provider should: –  Access the PDMP and review worker’s controlled substance history to get accurate informa0on on opioid dose

•  For more informa0on: –  hhp://www.opioids.lni.wa.gov/

HCA – Pa0ent Review & Coordina0on (PRC)

•  Aimed at over-‐u0lizing clients

•  Decrease and control over-‐u0liza0on and inappropriate use of health care services

•  Minimize medically unnecessary services and addic0ve drug use

•  Client and provider educa0on and coordina0on of care •  Assist providers in managing PRC clients by providing available

resource informa0on to facilitate coordina0on of care

•  Reduce overall expenditures

PDMP Assistance to PRC to Date

•  As of May 2012 the PDMP has assisted in iden0fying 20 clients for the PRC program to date (through 5 months of using just the individual query site)

•  The minimum 0me that a client is in PRC is 2 years and they can be 3 years or 5 years.

•  These 20 clients represent 67 PRC client lock-‐in years at $6,000 per year. This amounts to over $400,000 in savings.

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PDMP Bulk Data use by PRC •  PRC Program compliance analysis

– Of 3,800 PRC clients 1,900 are currently Fee For Service •  Of these 1,900, 1,170 clients have at least 1 PDMP prescrip0on.

•  Of the 1,170 clients filling prescrip0ons –  489 Clients paid cash for 2,470 prescrip0ons. And 243 addi0onal clients are listed as paid by 04 private insurance with an addi0onal 2,059 prescrip0ons. This would be a total of 732 clients filling 4,529 total prescrip0ons

– By contrast 898 clients filled 12,240 prescrip0ons paid for by Medicaid during this same period.

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Future HCA Plans •  HCA will look to use bulk data to augment the lock-‐in PRC

program

•  HCA will explore providing data to managed care plans they contract with

•  HCA will look to use the data to monitor Subxone use among clients

•  HCA is considering sending threshold reports to: –  Prescribers with clients prescrip0on informa0on

–  Pharmacies who accept cash from Medicaid clients in viola0on of their core provider agreement

–  Inform their managed care plans of provider outliers

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•  Chris Baumgartner, PMP Director – Washington State Department of Health

–  Phone: 360.236.4806 –  Email: [email protected] – Website: hhp://www.doh.wa.gov/PMP

Program Contact

Tpp 2 eadie wood_baumgartner

Health & Medicine

Transcript of Tpp 2 eadie wood_baumgartner