A Tale of 2 Companies Jim Andrews Senior Vice President, Pharmacy Services, Healthcare Solu=ons Dave Smith Divisional Vice President, Risk Management, Family Dollar Stores Michael Gavin Chief Strategy Oﬃcer, PRIUM Ron Mazariegos Claim Execu=ve, Arrowpoint Capital 1
Learning Objec>ves 1. Highlight opioid management methods available to employers 2. Learn how and when to leverage clinical tools and medical and legal strategies to curtail abuse of prescrip=on drugs 3. Describe the importance of collabora=on between workers’ compensa=on payers and pharmacy beneﬁt managers 2
Disclosure Statement • Jim Andrews has no ﬁnancial rela=onships with proprietary en==es that produce health care goods and services. • Dave Smith has no ﬁnancial rela=onships with proprietary en==es that produce health care goods and services. • Michael Gavin has no ﬁnancial rela=onships with proprietary en==es that produce health care goods and services. • Ron Mazariegos has no ﬁnancial rela=onships with proprietary en==es that produce health care goods and services. 3
Third Party Payer Track: A Tale of Two Companies April 2 – 4, 2013 Omni Orlando Resort at ChampionsGate Dave Smith Jim Andrews, R.Ph. Family Dollar Stores, Inc. Healthcare Solu=ons Divisional VP of Risk Management EVP of Pharmacy Services
Disclosure Statement Jim Andrews, EVP of Pharmacy Services with Healthcare Solu<ons, and Dave Smith, Divisional VP of Risk Management with Family Dollar, have no ﬁnancial rela<onships with proprietary en<<es that produce health care goods and services. 5
Topics of Discussion • Introduc=ons and corporate overviews • The na=onal challenge: opioid abuse epidemic • Three steps to ﬁght drug abuse • How Family Dollar is mee=ng the challenge – Three phases of program development – Program results – CPRx™ -‐ Medicare Set-‐Aside (MSA) case studies • The future of pharmacy beneﬁt management 6 6
Family Dollar Stores, Inc. Corporate Overview CharloMe, NC based stores oﬀering quality merchandise at everyday low prices, in easy-‐to-‐shop neighborhood loca>ons • 54 year anniversary • Fortune 300 company • 7,700+ stores – “Small Box” – One new store every 17 hours – 1 to 3 team members staﬀ the stores – 1 billion customers per year • 11 distribu=on centers • 45 states • 55,000 team members • Annual sales in excess of $10 billion 7
Healthcare Solu>ons Corporate Overview Healthcare Solu>ons, the parent company of Healthcare Solu>ons, ScripNet & Procura Management, is a health services company delivering technology-‐based solu>ons to the workers’ compensa>on & auto casualty markets. Pharmacy Beneﬁt Management (PBM) Program Stringent cost and u/liza/on management controls produce maximum program savings, eﬃcient claims handling & op/mal clinical outcomes. Prospec>ve Concurrent Retrospec>ve • Network Management • Customized • Rx360™ Formularies – Paper Bill Management • Outreach/Enrollment – Physician Dispensing – 850+ employees Services • POS Administra>on – Compound & Re-‐ – First Fills & Dynamic Packaged Drugs – 750+ valued customers – Generic Enforcement Enrollment – ProDUR Rx™ / Clinical – Non-‐Retail Network – URAC accredited – Card Administra=on Edi=ng Billing with Persistent – SSAE 16 compliant – Prior Authoriza=on Outreach Management • Clinical Rx™ – 30% revenue growth year over year – Conversion to Home – Academic Detailing Delivery – Therapeu=c – End-‐to-‐end WC solu=ons Subs=tu=ons • Regulatory & – Narco=cs Management Compliance Oversight – Drug Urinalysis Tes=ng – Physician Reviews 8 8
Iden/fy: Substance Abuse is an Epidemic • 8.7% of the American popula=on used an illicit drug or prescrip=on drug non-‐medically in the past Non-‐medical use = month1 use without a prescrip/on of the individuals own or • 2.4% of the American popula=on used prescrip=on simply for the experience or drugs non-‐medically in the past month1 feeling the drugs caused – Pain relievers: 4.5 million – Tranquilizers: 1.8 million – S=mulants: 970,000 – Seda=ves: 231,000 • In 2010, there were more deaths related to drug overdoses than motor vehicle crashed for the ﬁrst =me2 • Among the prescrip=on drug deaths, opioids are involved in close to 75%3 Sources: 1 Source: Substance Abuse and Mental Health Services Administra=on, Results from the 2011 Na<onal Survey on Drug Use and Health: Summary of Na<onal Findings, NSDUH Series H-‐44, HHS Publica=on No. (SMA) 12-‐4713. Rockville, MD: Substance Abuse and Mental Health Services Administra=on, 2012. 2NCHS Data Brief, December, 2011. Updated with 2009 and 2010 mortality data. 3CDC, Na=onal Center for Health Sta=s=cs, Na=onal Vital Sta=s=cs System. 10 10
Iden/fy: Substance Abuse among the Employed • 75% of all adult illicit drug users • 38% to 50% of all workers’ compensa=on are employed claims are related to substance abuse in the workplace • When compared to non-‐substance abusers, substance-‐abusing employees are more likely to be involved in a workplace accident • Substance abusers ﬁle three to ﬁve =mes as many workers’ compensa=on claims • Opioid abusers generate, on average, annual direct health care costs 8.7 =mes higher than nonabusers2 Preven/ve Measures: Pre-‐employment and employment drug tes=ng Sources: Why You Should Care About Having A Drug-‐Free Workplace Fact Sheet. Drug-‐Free Workplace Kit. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administra=on. Working Partners, Na=onal Conference Proceedings Report: sponsored by U.S. Dept. of Labor, the SBA, and the Oﬃce of Na=onal Drug Control Policy. Substance Abuse and Mental Health Services Administra=on, Center for Behavioral Health Sta<s<cs and Quality, Na<onal Survey on Drug Use and Health, 2007 – 2010 2White AG, Birnbaum, HG, Mareva MN, et al. Direct costs of opioid abuse in an insured popula=on in the United States. J ManagCare Pharm 2005;11(6):469-‐479. 11
Iden/fy: Aberrant Behavior linked to Abuse/Diversion Source of Prescrip>on Pain Relievers Source When Obtained by Used Non-‐medically Friend or Rela>ve From Friend or Rela=ve for 3.1% .2% .2% Free .3% .3% .2% 1.3% 1.9% 1.9% From One Doctor .2% 2% 5.5% 4.2% 5.7% 3.9% Bought from Friend or Rela=ve 4.8% Took from Friend or Rela=ve without Asking Bought from Drug Dealer or Other Stranger 16.6% Some Other Way 54.2% From More Than One Doctor 18.1% 81.6% Bought on the Internet Wrote Fake Prescrip=on Diversion from only one doctor Stole From Doctors Oﬃce, Clinic, Hospital, or Pharmacy Source: Substance Abuse and Mental Health Services Administra=on, Results from the 2011 Na<onal Survey on Drug Use and Health: Summary of Na<onal Findings, NSDUH Series H-‐44, HHS Publica=on No. (SMA) 12-‐4713. Rockville, MD: Substance Abuse and Mental Health Services Administra=on, 2012. 12
Iden/fy: Heavily Abused Medica>ons In 2011 there were 483,000 new non-‐ medical users of OxyCon>n4 Top Abused 2009 WC Rank 2010 WC Rank by Controlled Substance Medica>ons1 by Cost2 U>liza>on3 Oxycodone 1 5 CII Alprazolam Not in top 50 33 CIV Hydrocodone 3 1 CIII Methadone Not in top 50 53 CII Clonazepam Not in top 50 38 CIV Lorazepam Not in top 50 58 CIV Carisoprodol 18 15 CIV Morphine 38 29 CII Zolpidem 21 17 CIV Diazepam Not in top 50 22 CIV Fentanyl 13 28 CII 1: 2008: Na=onal Es=mates of Drug-‐Related Emergency Department visits, Oﬃce of Applied Studies, Substance Abuse and Mental Health Services Administra=on, 2011 2: Lipton B, Laws C, and Li L. Workers Compensa=on Prescrip=on Drug Study: 2011 Update. NCCI. August 2011 3: Healthcare Solu=ons Data 4: Substance Abuse and Mental Health Services Administra=on, Results from the 2011 Na<onal Survey on Drug Use and Health: Summary of Na<onal Findings, 13 NSDUH Series H-‐44, HHS Publica=on No. (SMA) 12-‐4713. Rockville, MD: Substance Abuse and Mental Health Services Administra=on, 2012 13
Iden/fy: Drug Mix Diﬀerences in Claim Age Developing Claims Mature Claims 14 2012 Healthcare Solu=ons Drug Trends Report 14
Iden/fy: High Opioid U>liza>on 96 mg/person in 1997 698 mg/person in 2007 Enough for every American to take 5mg Vicodin every 4 hrs for 3 weeks The share of claims receiving narcotics within one year after injury has increasedNational Vital Statistics System, multiple cause of death data set and Drug Enforcement Administration ARCOS SystemReport of the International Narcotics Control Board for 2005. United Nations, NY. 2006Laws C,. Narcotics in Workers Compensation Drug Study: 2012 Update. NCCI. May 2012 15
Communicate: Predic>ve Markers in Opioid Therapy ↑ Disability dura/on Opioid use in ﬁrst 15 ↑ Medical costs days ↑ Risk of surgery (3 fold) ↑ Late opioid use (6 fold) ↑ Costs ↑ Lost /me from work When 2 or more ↑ Dura/on of paid temporary disability prescrip>ons for ↑ Indemnity opioids present ↑ AQorney involvement ↑ Open claim Opioids with over 100 ↑ Accidental overdose morphine equivalents ↑ Morbidity and mortality (8.9 fold) per day Source: Swedlow A, Gardner LB, Ireland J, Genovese, E. Pain Management and the Use of Opioids in the Treatment of Back Condi=ons in the California Workers’ Compensa=on System. CWCI June 2008 Webster BS, Verma SK, Gatchel RJ. Rela=onship Between Early Opioid Prescribing for Acute Occupa=onal Low Back Pain and Disability Dura=on, Medical costs, Subsequent Surgery and Late Opioid Use. Spine. 2007. 32 (19) 2127-‐2132. Bohnert AS, Valenstein M, Blair M, et al. Associa=on Between Opioid Prescribing Paterns and Opioid Overdose-‐Related Deaths. JAMA. 2011 305:1315-‐1321 16 16
Communicate: Early and High Dose Opioid Use Changes in Narco>c Potency in Daily Morphine Equivalents as a Claim Ages Source: Laws C. Narco=cs in Workers Compensa=on. NCCI. May 2012 2012 Healthcare Solu=ons Trends Report 17
Coordinate: Best Prac>ces in Opioid Therapy Pa>ent Selec>on Ini>al Pa>ent Alterna>ves to Assessment Opioid Therapy Trial of Opioid Therapy Conversion to Long-‐Ac>ng Opioid Pa>ent Reassessment Exit Strategy Opioid Rota>on Con>nued Opioid Therapy 18 18
Coordinate: Physician Interven>on • CPRx™ program uses licensed, prac=cing physicians to review injured workers’ medical and prescrip=on histories Drug Decisions • Physicians examine: Wean – Appropriateness of regimen to diagnosis 12% – Long-‐term pharmacological eﬀects 16% 37% Approved – Poten=al drug interac=ons Conﬁrmed DC – Denial or approval of current regimen 11% Discon=nue – Pa=ent compliance 24% Unrelated – Relatedness of regimen to claim • Automated reports provide recommenda=ons for CPRx based on weighted red ﬂag triggers • Follow-‐up by telephonic nurse support helps to ensure compliance with the agreed upon changes to the injured worker’s medica=on therapy plan 19
Mee<ng the Challenge: Family Dollar’s Pharmacy Beneﬁt Management Program 20 20
Casualty Claims Proﬁle Annually • 8,400 workers’ compensa=on (WC) incidents – 1,400 pending • 10,800 general liability incidents – 1,250 pending Most expensive claim in the past 10 years • 2003 WC claim: $3.2 million – $2 million in pharmacy Annual loss pick • ~$80 million 21
Mee>ng the Challenge: Three phase program to ﬁght WC drug abuse Phase III Phase II CPI Phase I Proac>ve/Opportuni>es Reﬁnement/MSAs Best Prac>ces Program Design 2008 -‐ 2011 Assessment 2007 22 22
Phase One: WC Medical Assessment Family Dollar 2007 Expert Partners • Total WC medical spend was 51% of total claim • Prescrip=on cost was 21% of total WC medical spend Benchmarking Measurement • Industry benchmark • PBM reports • Ourselves Goals 23 23
Phase Two: Pharmacy management program design Phase I Phase III • Healthcare Solu=ons 2008 • GL MSAs • Sedgwick 2009 • California custom MPN • Low hanging fruit • Health and wellness • Health insurance Phase II • Legacy claims Phase III • Pharmacy nurse Proac>ve Phase II • Formulary management Reﬁnement/MSAs management/ opportuni>es (tradi=onal and non-‐ Phase I CPI subscriber) Best prac>ces • Ac=ve prescrip=on review • MSAs/forensics Program Design 2008 -‐ 2011 Assessment 2007 24 24
Family Dollar CPRx™ Results Physician interven>on program CPRx Program Summary Number of CPRs Completed 18 Total Number of Drugs Reviewed 112 Drugs Not Recommended by Reviewer 82% of drugs Discussion Rate 69% of drugs Trea=ng Physician and Reviewer in Agreement 60% of drugs CPRs with Agreement to make a change 50% of CPRs Actual ROI To-‐Date $4.31 : $1 25 25
CPRx Case Study # 1 Injured team member • 46 year old female with November 29, 2008 DOI • Low back injury with previously failed fusion surgery and failed injec=on trials • Prescrip=on drug cost to date: $16,159 • Prescrip=on drug therapy: – Cyclobenzaprine -‐ muscle relaxant – Endocet -‐ opioid / pain medica=on – Fentanyl (generic Duragesic Patch) – opioid / pain medica=on – Meloxicam – NSAID – Tramadol – opioid / pain medica=on Resolu>on: All medica>ons discon>nued. Tramadol is the only drug ﬁlled in the previous 6 months and was last ﬁlled in November 2012 26 26
CPRx Case Study # 2 Injured team member • 41 year old male with May 11, 2010 DOI • Pa=ent was lixing several cases when he strained the lex side of his lower back • Prescrip=on drug cost to date: $23,115 • Prescrip=on drug therapy: – Gabapen=n – an=convulsant / neuropathic pain – Kadian – opioid / pain medica=on – Norco – opioid / pain medica=on – Relistor – cons=pa=on medica=on – Cymbalta – An=depressant / neuropathic pain – Neuropathic cream – topical analgesic Resolu>on: Gabapen>n, Relistor and Cymbalta have been discon>nued. Kadian has been switched to the generic, morphine sulfate and reduced in quan>ty since December, 2012 27 27
Family Dollar’s Success • Total WC medical spend was 51% of total • Total WC medical spend is 37.8% of total claim claim expense (25% reduc=on from • Prescrip=on cost was 21% of total WC 2007) medical spend • Prescrip=on costs are 11.7% of total WC • Family Dollar’s goal: reduce pharmacy claim expense (48% reduc=on from 2007) spend to 14% • Family Dollar’s current goal is to reduce pharmacy spend to 9% • Medicare Set-‐Aside savings of $2,808,616 • Pharmacy costs are 19.5% • Average medical expense is 60% of the total WC claim cost 28 28
Mee/ng the Challenge: Where Is Family Dollar in the Three Stage Process? Phase III Phase II CPI Phase I Proac>ve/Opportuni>es Reﬁnement/MSAs Best Prac>ces 2013 Program Design 2008 -‐ 2011 Assessment 2007 29
Phase Three: Con>nual Process Improvement (CPI) Explora>on of opportuni>es Review• Maintain sen=nel eﬀect on u=liza=on and cost trending • Monitor jurisdic=onal regula=on • Iden=fy opportuni=es – Legacy claims Modify Monitor – Jurisdic=onal MPN expansion – Corporate culture – Health insurance – Educa=on and training 30 30
Family Dollar’s Con>nuing Opportuni>es Open WC claims 1,397 2013 trended WC Medical Total incurred pharmacy Proﬁle losses expense: 2-‐28-‐2013 $125 Million $4.3 Million 2013 trended medical expense: $48 Million 31 31
The Future of Pharmacy Management Transac>onal Services Analy>cal Services Strategic Services • Card administra=on • Program benchmarking • Customized strategy development • POS processing • Quality measurement • Regulatory/compliance oversight • Home delivery • Ad hoc repor=ng • Program/product development Impact on Program Eﬀec>veness • Paper bill processing • Formulary management • Outcomes measurement • Call center support • Clinical management • Payment and billing • Transac=onal audi=ng • Network administra=on • State repor=ng • Provider communica=ons Impact on Expenditures Transac>onal Services Analy>c Services Strategic Services 32 32
Thank You Dave Smith Family Dollar Divisional VP of Risk Management DSmith2@FAMILYDOLLAR.com Jim Andrews, R.Ph. Healthcare Solu=ons EVP of Pharmacy Services Jim.andrews@healthcaresolu=ons.com 33
Arrowpoint Capital • 150-‐year-‐old organiza=on • Acquired US opera=on of Royal & SunAlliance USA in 2007 • Experience in run-‐oﬀ insurance business • “Redeﬁning success” by developing and execu=ng comprehensive solu=ons to manage claims and sa=sfy policyholder obliga=ons.
Claim Resolu>on Assessment Ac>ons Results • Inventory of 121,000 claims, • Iden>ﬁed, capitalized on rapid • Reduced inventory by 92% to including: resolu>on opportuni>es <12,000 maMers • >35,000 workers comp cases • Streamlined and centralized physical handled by 403 adjusters • Centralized claim management oﬃce loca>ons to 1 • >10,000 cases in li=ga=on • Enhanced data tracking and repor>ng • Developed a standardized claim handled by 10 oﬃces through the Data Hut transfer and integra>on process • Staﬀ located in 29 oﬃces • Ensured ‘best prac>ce’ claims from underperforming TPAs and handling with full-‐service capabili>es, disposals • Bi-‐furcated, mul>-‐layered management structure with liMle cross-‐func>onal interac>on • Transi=oned 4,000 claims to governance and control • Implemented li>ga>on management direct handling • Several high-‐cost specialized strategy • Converted >15,000 legal ﬁles from internal units • Cost controls through >me-‐and-‐expense to ﬂat fee reduc=on in law ﬁrms • Improved data sharing, analysis, • Lack of comprehensive data-‐ • Re-‐engineered legal bill review, proﬁling and segmenta>on sharing capabili>es, tools process – ﬂat fees • Leveraged a mul>-‐disciplinary • >3000 external lawyers handling • Specialized technology approach to handling complex claims with hourly billing • Introduced new TPA management maMers • >80 TPAs with services cos>ng func>on • Retained key staﬀ and cri>cal $10m annually • Outsourced specialized func>ons knowledge • Limited interac>on with Actuarial, • Medical case management Reinsurance, other func>ons • Inves=ga=on services • Subroga=on and recovery
Medical Management = Data Management Iden=ﬁca=on and segmenta=on of high value, high exposure claims: • Age of claimant • Occupa=on • Type of injury • Current medical treatment • Current Rx regimen • Future recommended medical treatment (i.e., spinal injec=ons, physical therapy, surgery) • Unrelated co-‐morbidi=es and condi=ons • Medical provider discipline • Setlement Opportunity – Indemnity – Medical – Both – MSA or not
Medical Management -‐ Tools PRIUM • U=liza=on Reviews • Comprehensive Clinical Assessments • Medical Director Reviews PMSI – Pharmacy Beneﬁt Management Vendor • Peer-‐to-‐Peer Reviews • Durable Medical Equipment • Drug Monitoring Program G4S – Inves>ga>ons MHayes – Cer>ﬁed Case Management Crowe Paradis – Medicare Vendor • Medicare Set-‐Asides • Condi=onal Liens Atlas – Structured SeMlement Vendor
Medical Management -‐ Adjuster Ensure ongoing communica>on with the aMending physician regarding the medical treatment being rendered to the injured worker (where permiMed): • Clearly deﬁned and updated treatment plan? • Drug Monitoring – Urinary analysis, pill counts, patch counts • Narco=c Agreement in place? • Conference calls with the trea=ng provider, face-‐to-‐face scheduled mee=ngs with the provider and/or the IME physician. • Understand the applicable state guidelines and evidence-‐based medicine (i.e., ODG, ACOEM). • Outreach leters to the provider – referencing guidelines • Con=nuous medical educa=on – Lunch & Learns, Summits, etc.
Medical Management – State Speciﬁc CA -‐ Establishment of Speciﬁcally Designed Medical Provider Network (MPN) and Pharmacy Beneﬁt Network (PBN) • EK Health – Medical Provider Network • PMSI – Pharmacy Beneﬁt Manager TX -‐ ODG N-‐Drug Project • PRIUM ₋ No=ﬁca=on to the injured worker and prescribing physician of the Closed Formulary changes to take place on September 1, 2013. ₋ Conference calls with the prescribing physician with Claims on conference call. ₋ Follow up writen agreements to wean and change treatment plans. DE -‐ Ensuring Prescrip>ons are Filled In-‐Network • Boone vs. SYAB Services, 2012 Del. Super. LEXIS 407 – The Delaware Superior Court held that the Delaware Industrial Accident Board had the authority to require a claimant to use an employer’s preferred prescrip>on plan rather than receive medica>ons via physician dispensing. • Leters to providers, claimants and counsel advising them will not pay for out-‐of-‐network Rx. PA – UR of Highly Addic>ve Narco>cs on Chronic Opioid Claimants • Bedford Somerset MHMR v. Workers Comp. Appeal Bd. (Turner), 51 A.3d 267; 2012 Pa. Commw. LEXIS 261 (2012): The Appellate Court reversed the full Board’s decision and reinstated the the WCJ decision which determined the highly addic=ve nature of the Fentanyl lozenges as evidenced by Claimants increased use of the medica=on and rendered it unreasonable and unnecessary where an alterna>ve treatment plan could be implemented.
Claim Inves>ga>on • SONAR (Specialized Online Networking Advanced Research)/Social Media • Claim Index Bureau every 6 months • Surveillance (when appropriate) • Criminal Background • DMV • Dunn & Bradstreet • State Records • Area Canvas • Alive and Well (leter vs. in person) • Con=nuance of Disability (in person)
Claim Inves>ga>on in Ac>on • Claimant residing in Florida travels to Long Island, NY once a year to see his doctor and get prescrip=ons ﬁlled. • Doctor writes three-‐month reﬁlls of Oxycon=n and Vicodin and ﬁlls via phone call from claimant to front desk. • No visit, no examina=on. No evidence of drug monitoring (urinary analysis, pill counts, narco=c agreement) being performed. • When asked why drug monitoring tools not being used, doctor becomes extremely defensive. • SONAR inves=ga=on ini=ated (medical record review and Peer-‐to-‐ Peer). • CCA – medical records indicate claimant unable to func=on. • BUT . . .
SeMlement Ini>a>ves • Over 300 New York claims reviewed and targeted for resolu=on. • Setlement counsel retained to perform claim data analysis, provide claim ﬁle review and assessment, and handle all logis=cal/back-‐oﬃce aspects. • Conferences scheduled at various Workers’ Compensa=on Boards throughout New York – Manhatan, Long Island, Peekskill, and Syracuse. It Takes a Village. . . On-‐site team • Defense counsel ( jurisdic=onal knowledge) • Setlement counsel • MSA service provider • Structured setlement vendor • Claims Management Feed them and they will come!
SeMlement Ini>a>ves • Adver=se – Diﬀeren=ate • Adver=sed on the NY Injured Workers’ Bar website as well as the various Boards. • 134 invitations Don’t just *61 RSVP’s 2 no-show send leter! • 6 settled before Call, Fax, initiative began Email • 3 were not settled
Medical/Legal Summit • Three summits held to date. • Approximately 120 insurance, legal, and medical professionals and consultants from around the country gathered for Arrowpoint Capital’s 2012 Medical/ Legal Summit in mid-‐June 2012. • More than 30 defense counsel from 23 law ﬁrms atended from states as far away as California, Wisconsin, and New Hampshire. • Presenters included Arrowpoint’s WC claims management team, along with delegates from some of its WC claims service provider partners, and na=onally recognized expert Dr. Andrew Kolodny.
Medical/Legal Summit Topics • Medical treatment and alterna=ve therapies for trea=ng chronic pain, coordina=on of care, ﬁgh=ng fraud inside the pill mill, monitoring long-‐term opioid use, Medicare and secondary payer rules and regula=ons, and Key States • Medical treatment updates • “Ask a Doctor”/ “Ask a Pharmacist”/ “Ask a DME Specialist” / “Ask a Registered Nurse” sessions • Actual case studies presented by each team on the Summit’s last day
Selec>on of Counsel • Defense Counsel vs. Setlement Counsel • Develop Resolu=on Strategies • Stay informed! Review recent case law and statute updates. • In NY, use the law to your favor, e.g., Labor Market Atachment, Medical Treatment Guidelines, RFA, C8.1. • Conduct discovery! Deposing the atending physicians, claimants and other witnesses can yield useful informa=on. • Appor=onment/subroga=on/third-‐party ac=ons • Consult ODG and ACOEM Guidelines • Conduct IME’s, UR’s
PRIUM • Established in 1987 primarily as a u>liza>on review organiza>on – Perform UR na=onwide and this remains a core competency – Experience in u=liza=on review allows for a unique perspec=ve on both medical and legal avenues – Work primarily within the Workers Compensa=on space, but also do liability • Recogni>on and shiy towards pharmaceu>cal therapy – Recognized overprescribing in the early 2000’s – Developed a product line of reviews to help combat the issue – Focus on physician led interven=on with peer-‐to-‐peer reach out
Culture of over-‐treatment Reimbursement methodology favors treatment over preven=on Interven=onal procedures (vs. cogni=ve medicine) drive economics Inﬂuence of big pharma Total sales of Oxycon=n in 1996: $45 million Total sales of Oxycon=n in 2009: $3 billion Lack of predictability in claims management Who can handle 90 days of hydrocodone without issues? Who will end up dependent on the medica=on? Co-‐morbidi>es Growing in number and complexity Each one gets its own drug!
Statutes: Laws passed by legislators and signed by governors Regula>ons: Rules developed by regulatory agencies Case Law: Judicial decisions resul=ng from challenges to either statutes or rules/regula=ons or from the dispute resolu=on process
Ex Parte Communica>on Medical Treatment Guidelines U>liza>on Review / IME Directed Care Physician Dispensing Prescrip>on Drug Monitoring Programs (PDMPs)
“Prohibited”: Mississippi, Illinois, New Mexico, Colorado, Connec>cut, South Dakota Restricted: Nevada, New Hampshire, Alaska, Minnesota, North Carolina, South Carolina All other jurisdic>ons: No restric>ons on interac>ng with trea>ng physicians
Evidence-‐Based, Na>onally Recognized (e.g., ODG, ACOEM) Texas Nevada Oklahoma California New Mexico Utah Hawaii North Dakota Vermont Kansas Ohio Wyoming Missouri Consensus-‐Based, Locally Developed: Arkansas Maryland New York Colorado Maine Oregon Connec=cut Massachusets Rhode Island Delaware Minnesota Washington Louisiana Arizona, Tennessee: Under Virginia Montana West considera<on
Statutorily Required and/or Recognized: 22 states with 17 of those statutes lending some real authority for the payer Medica>on-‐speciﬁc: Texas, Tennessee, Washington, West Virginia, Ohio
Case Study: Texas Statute: HB 7 passed in 2005 Rules: Texas Administra>ve Code Title 28, Part 2, Chapter 134, Subchapter F, Rule 134.500 Ini<al results: 60%+ drop in Open Formulary for DOI N drug scripts prior to 9/1/11 Two year remedia<on 9/1/11 period for legacy 9/1/13 Open Formulary claims Closed Formulary for for all DOI all DOI Closed Formulary for DOI a^er to 9/1/11
Considera>ons: Claim life cycle Networks Panel-‐driven Regulatory order of opera=ons Fundamental Goal Don’t overlook an opportunity to remove an injured worker from the care of a physician that is failing to provide evidence-‐based care
Prohibited: Allowed: Silent: Massachusets Arizona Connec=cut New York California Indiana Texas Georgia Illinois Illinois Maryland Restricted: Michigan Arkansas Recommenda<on: North Carolina Florida Focus on pricing, not Pennsylvania prac<ce Louisiana South Carolina Maryland Tennessee Minnesota Virginia New Jersey Wisconsin Source: WCRI Study, July 2012
Status: 43 states have programs up and running 6 addi=onal states have programs authorized, but not yet func=onal No Program: Missouri Mandatory Use of PDMP by Physician/Prescriber: Kentucky Massachusets (ﬁrst script for schedule II or III drug only)
Statute/Rule Op>mal for Limi>ng Rx Drug Your State? Overu>liza>on Ex Parte Allowed, no restric=ons ? Communica=on Medical Treatment Na=onally recognized guidelines ? Guidelines mandated U=liza=on Review Mandatory UR ? Direc=on of Care Allowed ? Physician Dispensing Restricted pricing ? PDMP Program in place; ? Mandatory search prior to Rx
Physician Engagement: Do not assume the trea=ng physician is the enemy... un=l the trea=ng physician is the enemy. Follow up, follow up, follow up: Engagement is not a “one =me” event... treatment changes are diﬃcult and must be monitored. Leverage technology: PBMs can help to closely monitor and customize medica=on regimens... use the technology available! Have a Plan B: Collegial engagement doesn’t always work... know what your op=ons are if voluntary engagement fails.