Michael Gavin

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The Financial Impact to Employers
National Rx Drug Abuse Summit 4-10-12

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Michael Gavin

  1. 1. The Financial Impact to Employers April 10-12, 2012 Walt Disney World Swan Resort
  2. 2. Accepted Learning Objectives:1. Identify the primary causes for increasedhealth care costs as it relates to opioid abuse.2. Outline simple steps that employers canimplement within their work place to reducetheir risks, lower their costs and improveproductivity.3. Explain why employers should beconcerned about prescription drug abuseeven if they are not currently dealing with anabuse-related issue in their workplace.
  3. 3. Disclosure Statement•  All presenters for this session, Michael Gavin and Dennis Jay, have disclosed no relevant, real or apparent personal or professional financial relationships.
  4. 4. The Cost of PainA 2011 report from the Institute ofMedicine estimated the total cost ofdealing with chronic pain is between$560 and $635 billion per year.That same year, drug manufacturersgenerated $11 billion in revenue fromopioids.
  5. 5. How did we get here? Culture of TreatmentHarder Answers: Easier Answers:•  Lose weight •  Surgical intervention•  Change diet •  Prescription drug therapy•  Exercise•  Sleep hygiene•  Socioeconomic / psychosocial factors •  74% of all physician office visits result in a prescription1 •  15-20% of all physician office visits result in a prescription for an opioid2 1 Source: Centers for Disease Control and Prevention 2 Source: IMS Health
  6. 6. How did we get here? Culture of Treatment (cont.)•  $11 billion in annual sales•  Case study: Oxycontin ‒  A substantial and sustained marketing effort begun in the late 1990s led to significant growth in the use of the drug ‒  Sales of Oxycontin in 1996: $45 million ‒  Sales of Oxycontin in 2009: $3 billion ‒  Purdue Pharma ad from 1998 titled I got my life back1 Source: Substance Abuse and Mental Health Services Administration (SAMHSA)2 Source: CDC Vitalsigns publication, November 2011
  7. 7. How did we get here? Culture of Treatment (cont.)•  More than 50M Americans suffer from chronic pain1•  Pain reliever abuse more than tripled, from 6.8% in 1998 to 26.5% in 2008 (Treatment Episode Data Set)1•  15,000+ Americans died in 2008 from prescription drug overdose2•  12,000,000+ Americans (12 years or older) in 2010 reported non- medical use of prescription drugs within the past year2•  500,000+ ER visits in 2009 from abuse or misuse of prescription drugs2•  $72,500,000,000+ in annual costs to health insurers for non-medical use of prescription drugs2•  Enough prescription drugs were prescribed in 2010 to medicate every American adult around-the-clock for one month21 Source: Substance Abuse and Mental Health Services Administration (SAMHSA)2 Source: CDC Vitalsigns publication, November 2011
  8. 8. How did we get here?Lack of Predictability John, Joe, and Jim •  All 42 year old males •  All office-based knowledge workers •  Chronic low back pain •  Failed back surgery •  Failed conservative therapy •  NSAID trial ineffective •  Trial of low dose opioid
  9. 9. How did we get here? Lack of Predictability (cont.) John Joe Jim •  Pain relief •  Tolerance •  Tolerance •  High functioning •  Dose escalation •  Dose escalation •  No dose escalation •  Switch to Oxycontin •  Switch to Oxycontin •  Eventually moves to •  Dependence •  Dependence as needed for the •  Out of work •  Out of work opioid prescription •  Addiction •  Addiction •  Detox/rehab •  Detox/rehab •  Motivated to get •  Unmotivated to healthy and back to return to work At the outset, it s work •  Would rather gamedifficult to distinguish •  Supportive family the system John, Joe, and Jim •  Engaged in treatment
  10. 10. How did we get here? Treatment of Co-morbidities Acute Sub-Acute/Transitional Chronic Pain Syndrome(1-3 months) (3-6 months) (>6 months) PAIN PAIN PAIN •  Insomnia •  Insomnia •  Sexual •  Atrophy •  Atrophy dysfunction •  Fear of •  Depression •  Addiction movement •  Weight gain Source: Dr. Gary Mills, Pacifica Pain Management Services
  11. 11. How did we get here? Treatment of Co-morbidities (cont.)Chronic Pain Syndrome (>6 months) PAIN Oxycontin (… then Fentanyl?) •  Insomnia Ambien •  Atrophy Soma All of this makes the •  Depression Cymbalta pain harder to •  Weight gain identify and treat Surgery? •  Sexual dysfunction Viagra •  Constipation Doc-Q-Lace •  Addiction Source: Dr. Gary Mills, Pacifica Pain Management Services
  12. 12. What to do? Match Case and Context Current medical treatment is sub-optimal, Biomedical what s needed is better medical treatment Employee is receiving inappropriate treatment; Medical / Legal what can be done (by jurisdictional rule)? Identify what s driving the employee behaviorBio-psycho-social and address root cause Legal Employee is engaging in fraud/abuse; involve law enforcement for remediation
  13. 13. What to do? Have a Plan Biomedical These options aren t mutually exclusive – good utilization Medical / Legal management and employee assistance programs can mitigate riskBio-psycho-social
  14. 14. What to do? Guiding PrinciplesDISCUSSION EDUCATION ENFORCEMENT OVERSIGHT STATUTORY ACTION
  15. 15. What to do? Guiding Principles EDUCATION•  Employee by employee, doctor by doctor, case by case•  Multiple areas of education: ‒  Clinical (pharmacology, interactions, alternative therapies) ‒  Claims (best practices, centers of excellence, statutory rules) ‒  Issues (welcome to the first annual National Rx Abuse Summit!)•  Multiple stakeholders: ‒  Doctors, nurses, claims executives, patients, and attorneys
  16. 16. What to do? Guiding Principles DISCUSSION•  Engage the treating physicians / prescribers•  Conversation should be: ‒  Peer to peer ‒  Collegial ‒  Evidence-based•  Not a typical peer review … how can we help?•  Incorporate the psycho-social element
  17. 17. What to do? Guiding PrinciplesDISCUSSION (cont.) 1.  Has the patient signed an opioid treatment agreement or narcotic contract? 2.  Does the provider have the patient undergo regular urine drug monitoring? 3.  Does the provider have the patient fill out a pain scale questionnaire on every visit? 4.  Did the provider consult a prescription drug monitoring database (PDMP) prior to writing the prescription(s)? 5.  Has an opioid risk assessment been completed on this patient to evaluate the possibility of the patient s developing medication use/abuse problems?
  18. 18. What to do? Guiding PrinciplesDISCUSSION (cont.) 5.  Does the provider consult the prescription drug monitoring system database (CURES) prior to prescribing any medications for this patient? 6.  What are the specific treatment goals for this patient given the patient s current objective findings and level of function? 7.  Are there any generic equivalents or more cost-effective alternative equivalents that can be used for the medications that are recommended for continuation? 8.  For any recommendations to continue a medication, please state a recommended timeframe for re-evaluation of the medical necessity of those medications. 9.  If agreement is reached to continue a medication (generic, name brand, therapeutic equivalent), is a reduction in dosage or the number per month/day possible without reducing efficacy?
  19. 19. What to do? Guiding PrinciplesENFORCEMENT•  Integration with the Pharmacy Benefit Manager is critical•  Don t settle for reporting alone; demand solutions•  Recognize the short-term lack of incentive to remove drugs from a patient s regimen•  Demand solutions (and outcomes)
  20. 20. What to do? Guiding Principles OVERSIGHT•  Even when DISCUSSION goes well, consistent oversight is needed to ensure implementation of treatment changes•  Should be nurse-led•  Focus on reinforcing the evidence-based recommendations and agreements with treating physicians•  Engage with the claimant to make a psychosocial assessment of the likelihood of success: ‒  Motivation? ‒  History of substance abuse? ‒  Environment?
  21. 21. What to do? Guiding PrinciplesSTATUTORY ACTION •  When the hand shake doesn t work, deploy the hammer •  In work comp, the tools vary by jurisdiction: ‒  Utilization review (UR) ‒  Independent Medical Exam (IME) ‒  Directed care ‒  Dispute resolution (work comp boards, ALJ, etc.) •  In group health, the tools vary by contract
  22. 22. What to do? Guiding PrinciplesDISCUSSION EDUCATION ENFORCEMENT OVERSIGHT STATUTORY ACTION
  23. 23. Questions?Michael GavinChief Marketing Officer, PRIUMEmail: mgavin@prium.netWebsite: www.prium.netBlog: http://prium-evidencebased.blogspot.com/

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