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A tale of_2_companies_final

A tale of_2_companies_final



Third-Party Track: A Tale of Two Companies, National Rx Drug Abuse Summit, April 2-4, 2013, Presentation by Jim Andrews, Dave Smith, Michael Gavin and Ron Mazariegos

Third-Party Track: A Tale of Two Companies, National Rx Drug Abuse Summit, April 2-4, 2013, Presentation by Jim Andrews, Dave Smith, Michael Gavin and Ron Mazariegos



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    A tale of_2_companies_final A tale of_2_companies_final Presentation Transcript

    • 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  
    • 9   9  
    • 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  
    • Claim  Resolu>on  Strategy   Key  Drivers  •  Medical  Management    •  Claim  Inves=ga=on  •  Legal  Strategy  •  Setlement  Ini=a=ves  •  Li=ga=on  Management  •  Data  Management  
    • 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  .  .  .    
    • Claim  Inves>ga>on  •  SONAR  Inves=ga=on  yields  claimant’s  Facebook  photos  
    • 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.