Cost saving strategies_updated

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Third-Party Payer Track, National Rx Drug Abuse Summit, April 2-4, 2013. Presentation by Dr. Steven Moskowitz and Dr. Jeremy Corbett.

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Cost saving strategies_updated

  1. 1. Cost  Savings  Strategies   Steven  Moskowitz  MD,  Senior  Medical  Director,  Paradigm  Outcomes  Jeremy  Corbe>,  Chief  Medical  Officer,  Kentucky  Spirit  Health  Plan/Centene  CorporaFon   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  2. 2. Learning  Objec3ves  •  Learn  the  latest  data  about  the  cost  of   prescripFon  drug  abuse  to  insurance   companies  •  Outline  alternaFves  to  treaFng  paFents  in   workers’  compensaFon  claims  •  Prepare  strategies  that  you  can  implement  in   your  state  
  3. 3. Disclosure  Statement  •  Steven  Moskowitz  has  no  financial   relaFonships  with  proprietary  enFFes  that   produce  health  care  goods  and  services.  •  Jeremy  Corbe>  has  no  financial  relaFonships   with  proprietary  enFFes  that  produce  health   care  goods  and  services.  
  4. 4. Introduc3on  •  Opioid  use  for  non  cancer  pain  commonplace,   without  evidence  of  effecFveness    •  Cost  of  opioids  and  medicaFons  to  treat   complicaFons  have  sky-­‐rocketed  •  Overdose  and  death  rates  conFnue  to  rise  •  The  range  of  soluFons  includes  state-­‐wide   intervenFon  and  direct  case  management  
  5. 5. The  Cost  of  Chronic  Pain     $100  billion  esFmated  annual  cost  in  the  US  of  health   care,  lost  income  and  lost  producFvity  due  to  chronic   pain  according  to  the  NIH1     76  million  Americans  suffer  from  chronic  pain  according   to  the  NIH1     40%  of  physician  office  visits  due  to  pain2    1.    NIH  Guide:    New  direcFons  in  Pain  Research  (NaFonal  InsFtutes  of  Health,   September  4,  1998);    2.  Koch,  H.  “ The  management  of  chronic  pain  in  office-­‐based   ambulatory  care:    NaFonal  Ambulatory  Medical  Care  Survey  (Advance  Data  from   Vital  and  Health  StaFsFcs,  No.  123,  DHHS  PublicaFon  No.  PHS  86-­‐1250)   5  
  6. 6. The  Cost  of  Opioids   ■  Hydrocodone:  “ The  most  popular  medicine  in  the  U.S.  …even  as   a  panel  of  experts  called  together  by  the  Food  and  Drug   AdministraFon  recommended  that  regulators  ban  it.”1       ■  Total  US  societal  costs  of  prescripFon  opioid  abuse  were   esFmated  at  $55.7  billion  in  2007  (USD  in  2009)2    1.  FORBES.com  Americas  Most  Popular  Drugs,  Ma>hew  Herper,  5/11/10  2.  Economic  costs  of  nonmedical  use  of  prescripFon  opioids,  Clin  J  Pain.  2011  Mar-­‐Apr;27(3):194-­‐202  
  7. 7. The  Cost  of  Chronic  Opioids   ■  Admission  rates  for  abuse  of  opiates  other  than  heroin—including   prescripFon  painkillers—rose  by  450%  from  1998-­‐20081   ■  120,000  Americans  a  year  go  to  the  ER  aoer  overdosing  on  opioid   painkillers2   ■  CDC  14,800  prescripFon  opioid  deaths  in  US  in  20082   –  475,000  ER  visits  for  abuse  of  prescripFon  pain  killer   –  12  million  of  non-­‐medical  users  of  prescripFon  pain  killers  1.  Substance  Abuse  and  Mental  Health  Services  AdministraFon,  Office  of  Applied  Studies.  Treatment  Episode  Data  Set  (TEDS):  1998-­‐2008.  NaFonal  Admissions  to  Substance  Abuse  Treatment  Services,  DASIS  Series:  SÐ50,  DHHS  PublicaFon  No.  (SMA)  409-­‐4471,  Rockville,  MD,  April  2010.  2.  Policy  Impact:  PrescripFon  Painkiller  Overdoses,  Centers  for  Disease  Control  and  PrevenFon,  NaFonal  Center  for  Injury  PrevenFon  and  Control,  Division  of  UnintenFonal  Injury  PrevenFon  
  8. 8. Case  Management  Strategies  in   Workers’  Compensa3on   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  9. 9. Worker’s  CompensaFon  Idiosyncrasies    •  LifeFme  medical  cost  coverage  •  Coverage  limited  to  work-­‐related  condiFons  •  Indemnity  issues  •  HIPPA  exempFon  •  State  regulaFons  differ  •  Different  uFlizaFon  review  controls  •  LiFgious    
  10. 10. Opioids  in  Worker’s  CompensaFon  •  Costly  cases  are  a  small  percent  of  all  claims   –  6%  of  cases  account  for  50%  of  costs1  •  According  to  NCCI,  20%  of  WC  medical  costs  of   fully  developed  claims  are  spent  on  prescripFon   drugs;  narcoFcs  account  for  34%  of  this  spend  •  Have  contributed  to  medical  cost  inversion   –  Medical  costs  now  58%  (indemnity  42%)  2  •  Fee  schedules  affect  uFlizaFon  •  LiFgious  issues  make  UR  more  complex   1.  Lipton,  et.al.    “Medical  Services  by  Size  of  Claim”,  NCCI,    2009   2.  Workers’  CompensaFon  Insurance  RaFng  Bureau  of  California,  2008  California  Workers’   CompensaFon  Losses  and  Expenses    
  11. 11. Framing  the  Problem  •  Pharmacy  cost  is  a  major  claims  issue  •  Prescribing  is  the  management  issue  •  Physician-­‐paFent  behavior  drive  prescripFon    •  Why  do  physicians  prescribe  opioids?   –  Observable  behaviors  of  the  paFent  were  the  only   significant  and  meaningful  predictor  of  physicians   opioid  prescribing  pracFces1   1.  What  Factors  Affect  Physicians’  Decisions  to  Prescribe  Opioids  for  Chronic  Noncancer   Pain  PaFents?  Clinical  Journal  of  Pain,  December  1997,  Vol  13,  4  p  330-­‐336  
  12. 12. MaladapFve  Cycle   Illness convictionMaladaptive Catastrophizing Fear avoidance Coping Quick fix seeking Lack of objective measures Quick fixes Trial and error Maladaptive approach Treatment Poly-pharmacy Escalating interventions
  13. 13. Breaking  the  Cycle  •  Physician-­‐specific  intervenFons   –  Monitor  outcome   –  Avoid  adverse  effects   –  Prescribe  less   –  Use  alternaFve  tools  •  Injured  worker-­‐specific  intervenFons   –  Become  less  passive   –  Make  more  effecFve  medical  decisions   –  Less  medicaFon  seeking  
  14. 14. Case  Management  Tools   •  FDA  Risk  EvaluaFon  and  MiFgaFon  Strategy  Federal   •  State  law  and  legal  acFon   •  State  work  comp  regulaFons/formulary   •  State  pharmacy  PMP-­‐40+  states   •  State  medical  boards:  CME/license  renewal   State   •  State  work  comp  UR  guidelines/EBM/Peer   review   –  Risk  assessment,  UDS,  reassessment,   outcomes   –  Opioids  not  effecFve   •  Local  providers  of  excellence   Local   •  Independent  medical  evaluaFons   •  Onsite  case  management   •  PBM  reports,  alerts,  formulary  Carrier   •  Meds  not  approved  for  certain  use   •  Alerts  and  follow  up  
  15. 15. Be  Strategic  •  Pain  is  a  biopsychosocial  problem  •  Manage  opioid  use  in  context  of  larger  pain   management  plan  •  Why  is  the  opioid  a  problem  in  this  IW?   –  Expensive   –  IneffecFve   –  Adverse  effects   –  Use  disorder:  dependence,  withdrawal,            addicFon,  misuse    
  16. 16. Be  Strategic  •  Validate  treaFng  diagnosis  –frequent   inaccurate/incomplete  diagnosis  (CRPS)  •  Coordinate  care  that  is  evidence  based  •  Track  the  outcome  or  lack  of  outcome  •  Define,  acknowledge  and  manage  behavior  
  17. 17. Injured  Worker  IntervenFons  •  Engage  and  moFvate:  stages  of  change  •  MedicaFon  list  review  •  Review  side  effects  of  medicaFons  •  IdenFfy  realisFc  real  life  outcome  measures  •  Offer  alternaFves  
  18. 18. Case  Example  •  36  year  old  obese  male,  two  failed  back  surgeries,   failed  SCS  trial,  repeat  injecFons,  iniFal  MEDD  of   180,    total  “couch  potato”  •  Moved  from  NJ  to  NC  for  his  wife’s  job.  Refilled   medicaFons  in  NJ  as  well  as  in  NC  •  Referred  him  to  new  conservaFve  MD  in  NC  •  Case  manager  worked  with  IW  as  did  MD,  stages   of  change,  slow  wean,  worker  agreeable  •  1  year  later  20  MG  MEDD,  stay  at  home  dad  
  19. 19. MD:    Specific  IntervenFons  •  Engage  MD:  what  is  biggest  reason  MD  prescribes   opioids?  •  Define  behavioral  obstacles  to  recovery  •  Med  list  review  for  effecFveness,  weeding  •  Define  effecFveness  measures  and  outcomes  •  IdenFfy  adverse  effects,  safety  issues  and  misuse  •  Implement  contract  and  UDS  screen  •  Follow-­‐up  of  UDS  results  and  consequences  •  Offer  alternaFves  
  20. 20. Case  Example  •  45-­‐year-­‐old  male  with  low  back  from  1992  injury  •  Status  post  mulFple  failed  back  surgeries,  spinal  cord  sFmulator   and  intrathecal  drug  pumps  and  mulFple  infecFons  and  revision.     Oral  opioids  and  pump  opioids  with  total  MEDD  of  19,000.  Current   infecFon  of  old  sFmulator  site  with  resecFon  of  clavicle    •  IntervenFon:  Engaged  IW:  onsite  case  management,  family   engagement;  Engaged  MD  to  “stand  down”;  inpaFent  rehab  and   detoxificaFon  facility  •  Outcome:  Pump  out,  SCS  off,  off  all  opioids,  fully  funcFonal,  new   MD,  no  more  procedures    
  21. 21. Pain  Outcomes  Pain  Management  Costs   Early  Interven3on  Pain   Chronic  Pain   (referral  less  than  one  year   (referral  average  six  years   from  date  of  injury)   from  date  of  injury)   Decrease  in   Decrease  in   41%   Morphine   61%   Morphine   LOWER   Equivalents   Equivalents   77%   Release  to   32%   Release  to   Return  to  Work   Return  to  Work   78%  
  22. 22. Can  a  Popula3on  be  Managed?  Managed  Care  OrganizaFons  and  PrescripFon  Drug   Abuse   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  23. 23. Centene  Managed  Care  101  
  24. 24. Start  Smart  for  Your  Baby  Health  Steps  IniFaFve  
  25. 25. TOTALS   OVERLAP  Members  idenFfied  as  pregnant   3,149   Members  in  B3  and  B4   22  Pregnant  members  who  filled  teratogens  in  the  last  30  days.   51   1.6%   B3  and  B7   39  Pregnant  members  who  filled  any  amount  of  narcoFcs  in  the  last  90  days.   292   9.3%   B3  and  B8   3  Pregnant  members  who  filled  more  than  90  tablets  of  narcoFcs  and/or  filled  narcoFcs  more  than  three  Fmes  in  the  last  90  days  (heavy  users).   82   2.6%   B4  and  B7   206  Pregnant  members  who  filled  narcoFcs  in  the  last  90  days  but  did  not  qualify  as  heavy  users  (see  above).   210   6.7%   B4  and  B8   4  Pregnant  members  who  have  not  filled  any  prenatales  in  the  last  90  days.   2,441   77.5%   B7  and  B8   10  Pregnant  members  who  filled  more  than  4  disFnct  drugs  in  the  last  14  days  (Poly  pharmacy)   17   0.5%   B3,  B4  and  B7   14  Pregnant  members  who  filled  Methadone  or  Suboxone  in  the  last  90  days.   61   1.9%   B3,  B4  and  B8   1  Pregnant  members  who  have  ever  filled  HIV  medicaFons.   0   0.0%   B3,  B7  and  B8   2   B4,  B7  and  B8   2   B3,  B4,  B7  and  B8   1   Members  in  at  least  one  of  B3,  B4,  B7,  B8  or  B10.   2,535  
  26. 26. Kentucky  Spirit  Health  Plan  Controlled  Substance  Pilot  
  27. 27. “The  best  way  to  do  something  ‘lean’  is  to  gather  a  Gght  group  of  people,  give  them  very  liIle  money,  and  very  liIle  Gme.”  -­‐  Bob  Klein  

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