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Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
Pdmp coordination with_third-party_payers_final
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Pdmp coordination with_third-party_payers_final

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PDMP Workshop 3 …

PDMP Workshop 3
PDMP Coordination with Third-Party Payers
National Rx Drug Abuse Summit
April 2-4, 2013
Chris Baumgartner, Bruce Wood and Alex Swedlow

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  • 1. PDMP  Workshops:    PDMP  Coordina2on  with  Third-­‐Party  Payers   Chris  Baumgartner   PMP  Director,  Washington  State  Prescrip4on  Drug   Monitoring  Program   Bruce  Wood     Associate  General  Counsel  and  Director,  Workers’   Compensa4on,  American  Insurance  Associa4on   Alex  Swedlow   Execu4ve  Vice  President,  Research,  California  Workers’   Compensa4on  Ins4tute   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  • 2. Learning  Objec2ves  1.  State  the  basis  for  broad  access  to  PDMP   database,  including  third-­‐party  payers.  2.  Iden4fy  specific  strategies  to  avoid  risky   prescribing  to  help  physicians  avoid  trouble   with  their  Boards  or  the  DEA.  3.  Outline  approaches  to  data-­‐sharing  among   states.  
  • 3. Disclosure  Statement  Chris  Baumgartner  has  no  financial  rela4onships   with  proprietary  en44es  that  produce  health   care  goods  and  services.  
  • 4. Public  Insurer  Access  •  PDMP  Statute:  Allows  PDMP  data  to  be   provided  to  Medicaid  and  Workers’   Compensa4on  •  Primary  Goal:  To  provide  for  beUer  pa4ent   care  and  promote  pa4ent  safety.  •  Secondary  Goal:  To  assist  our  public  insurers   in  preven4ng  fraud  and  saving  state  funding.    
  • 5. Two  Types  of  Access  1.  Healthcare  Prac44oners  within  the  Health  Care  Authority   (HCA  -­‐  Medicaid)  and  Department  of  Labor  and  Industries   (LNI  –  Workers’  Compensa4on)  can  login  with  individual   account  access  and  request  a  pa4ent  history  report.  2.  Once  a  month  each  agency  provides  a  file  through  secure   file  transfer  of  all  their  clients/pa4ents  (names,  DOB).    Our   vendor  then  provides  matching  data  for  each  client/pa4ent   in  a  file  that  is  returned  through  secure  file  transfer.  
  • 6. LNI  -­‐  PDMP  Bulk  Transfer  •  PDMP  bulk  transfer  uses:   –  Iden4fying  pre-­‐exis4ng  opioid  use   –  Iden4fying  duplica4ve  prescrip4ons  (in  process)   –  Iden4fying  prescribing  outliers  (future)  •  Bulk  transfer  available  in  May  2012  
  • 7. LNI  Early  Opioid  Interven4on  Pilot  •  Iden4fy  claims  that  are  15  -­‐  45  days  old  AND   received  ≥ 1  opioid  prescrip4ons  within  60   days  before  the  injury  •  Clinical  review  and  interven4on  by  a  nurse  or   pharmacist  as  necessary  •  BeUer  coordina4on  of  medical  care  and   management  of  claims,  promote  use  of  PMP   and  reduce  cost  and  disability  
  • 8. LNI  -­‐  Early  Opioid  Interven4on  Pilot  •  350  –  500  new  claims  meet  this  criteria  each   month  (3-­‐4%  of  all  claims  allowed)  •  Priori4za4on  Criteria     –  Chronic  opioid  use  (≥  3  prescrip4ons  in  previous  3  months)   –  High  dose  opioid  (>  120mg/d  MED)   –  Other  controlled  substances  (e.g.  benzodiazepines,  seda4ve-­‐hypno4cs   –  Timeloss  (wage  replacement)  •  Clinical  review  is  priori4zed  by  the  number  of   criteria  met  
  • 9. Future  LNI  Ini4a4ves  •  Complete  the  Early  Opioid  Interven4on  Pilot  •  Require  L&I’s  providers  to  access  PDMP  before   prescribing  opioids  for  a  work-­‐related  injury  (new   guideline)  •  Iden4fy  duplica4ve  prescrip4ons  and  create  a   process  to  intervene  •  Iden4fy  prescribing  outliers  to  improve  L&I’s  new   provider  network  
  • 10. HCA  –  Pa4ent  Review  &  Coordina4on  (PRC)  •  Aimed  at  over-­‐u4lizing  clients  •  Decrease  and  control  over-­‐u4liza4on  and  inappropriate  use  of   health  care  services  •  Minimize  medically  unnecessary  services  and  addic4ve  drug  use  •  Client  and  provider  educa4on  and  coordina4on  of  care  •  Assist  providers  in  managing  PRC  clients  by  providing  available   resource  informa4on  to  facilitate  coordina4on  of  care  •  Reduce  overall  expenditures  
  • 11. PDMP  Assistance  to  PRC  to  Date  •  As  of  May  2012  the  PDMP  has  assisted  in  iden4fying   20  clients  for  the  PRC  program  to  date  (through  5   months  of  using  just  the  individual  query  site)  •  The  minimum  4me  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.  11  
  • 12. 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  PMP   prescrip4on.   •  Of  the  1,170  clients  filling  prescrip4ons     –  489  Clients  paid  cash  for  2,470  prescrip4ons.  And  243  addi4onal   clients  are  listed  as  paid  by  04  private  insurance  with  an   addi4onal  2,059  prescrip4ons.  This  would  be  a  total  of  732  clients   filling  4,529  total  prescrip4ons   –  By  contrast  898  clients  filled  12,240  prescrip4ons  paid  for  by   Medicaid  during  this  same  period.   12  
  • 13. PDMP  Bulk  Data  use  by  PRC  •  Client  Iden4fica4on  analysis  •  Allows  improved  algorithms  with  clients.   –  Iden4fied  >2000  Clients  in  2012  with  Cash  and  Medicaid   paid  schedule  prescrip4ons  on  the  same  day.   –  Iden4fied  478  clients  where  cash  and  Medicaid  fills  were  <   10  days  apart,  the  scripts  were  overlapping,  for  the  same   drug  and  from  different  prescribers.   –  Currently  reviewing  the  top  u4lizers  of  the  478  for  PRC   placement.  13  
  • 14. HCA  -­‐  Narco4c  Review  Program  •  The  Narco4c  Review  Program  (NRP)  evaluates  Medicaid   clients  who  are  receiving  high  doses  of  opioid  narco4cs  to   verify  the  medical  need  for  these  excep4onal  doses.    It  only   applies  to  client  with  chronic  non-­‐cancer  pain.    •  Each  narco4c  prescrip4on  for  these  clients  requires   authoriza4on  as  long  as  the  client  is  in  the  narco4c  review   program.  A  client’s  narco4c  use  will  be  adjusted  to  minimize   pain  and  maximize  func4on.    The  lowest  effec4ve  dose,  or   zero  use  is  determined  by  medical  necessity  and  clinical   considera4ons.  •  PDMP  Data  found  that  83%  of  clients  in  the  NRP  had  scripts   that  were  not  paid  for  by  Medicaid.    14  
  • 15. Future  HCA  Ini4a4ves  •  HCA  will  be  using  bulk  data  to  augment  our  lock-­‐in  PRC   program.  •  HCA  has  already  been  working  on  threshold  reports  to  go   to  managed  care  plans  concerning  clients  using  cash.  •  HCA  will  be  sending  threshold  reports  to:   –  Prescribers  with  clients  prescrip4on  Informa4on   –  Pharmacies  who  accept  cash  from  Medicaid  clients  in   viola4on  of  their  core  provider  agreement  15  
  • 16. Refining  the  Bulk  Transfer  •  Key  Areas  that  were  fine  tuned:   –  Data  Fields:  NPI,  Payment  Type,  etc…   –  Handling  reversals,  voids,  duplicates   –  Provide  back  in  return  file  LNI  pa4ent  name  for  matching  •  Key  Areas  for  improvement:   –  Payment  Type  –  entered  more  accurately   –  NPI  #  -­‐  require  is  to  be  reported   –  Pa4ent  ID  –  more  reliable  matching  
  • 17. Program  Contact  •  Chris  Baumgartner,  PMP  Director   –  Washington  State  Dept.  of  Health   –  Phone:  360.236.4806   –  Email:  prescrip4onmonitoring@doh.wa.gov   –  Website:  hUp://www.doh.wa.gov/hsqa/PMP/default.htm  
  • 18. PDMP  Coordina2on  with  Third-­‐ Party  Payers   Bruce  C.  Wood   Associate  General  Counsel  &     Director,  Workers’  Compensa4on   American  Insurance  Associa4on   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  • 19. Learning  Objec2ves  •  State  the  basis  for  broad  access  to  PDMP   database,  including  third-­‐party  payers.  •  Iden4fy  specific  strategies  to  avoid  risky   prescribing  to  help  physicians  avoid  trouble   with  their  Boards  or  the  DEA.  •  Outline  approaches  to  data-­‐sharing  among   states.  
  • 20. Disclosure  Statement  •  Bruce  Wood  has  no  financial  rela4onships   with  proprietary  en44es  that  produce  health   care  goods  and  services.  
  • 21. WORKERS’  COMPENSATION  ON   THE  FOREFRONT  OF  THE   EPIDEMIC  
  • 22. WORKERS’  COMPENSATION:     AN  INTRODUCTION  
  • 23. I    Discussion/history  of  workers’   compensa2on  •  Evolu2on  of  this  social  insurance  program  over  the   past  century  =  first  w.c.  program  enacted  in  1911   (Wisconsin)  •  Subs2tute  for  tort  =  quid  pro  quo  •  Trauma2c/occupa2onal  diseases  •  Na2onal  Commission  on  State  Workmen’s   Compensa2on  Laws  (1972)  =  watershed  event/   states’  response    •  Post-­‐Na2onal  Commission  history  =  benefit   expansion;  financial  crisis  (later  ‘80s-­‐mid-­‐’90s)  
  • 24. II    Key  Program  Elements  •  All  medical  treatment  “reasonable  and  necessary”  (w/o  co-­‐ pays,  deduc2bles,  exclusions,  dura2on  limits)  =  1st  dollar   coverage.  •  Indemnity  benefits  =  commonly  2/3  of  gross  “average  weekly   wages”  =  Paid  for:    Temporary  total  disability  (TTD),  temporary  par2al   disability  (TPD),  permanent  par2al  disability  (PPD),   permanent  total  disability  (PTD)  •  Voca2onal  rehabilita2on  benefits  =  evalua2on  and  re-­‐training  •  Survivor/dependents’  benefits  =  payable  for  life  or  un2l   remarriage;  dependents  un2l  18  or  22  if  enrolled  in  college  
  • 25. 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  compensa2on   scheme?  Did  the  employer  intend  to   injure  the  worker?      
  • 26. 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,  li2ga2on,  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?    Restric2ons?   Accommoda2ons?      
  • 27. IV    The  Role  of  Workers’  Compensa2on  Medical  Treatment    Workers’  compensa2on  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  objec2ve  in  workers’  compensa2on  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  =  coordina2ng  medical   treatment  and  indemnity.      
  • 28. The  Role  of  Workers’  Compensa2on   Medical  Treatment  –  cont’d    Because  workers’  compensa2on  medical  treatment  remains  first-­‐dollar  coverage  –  with  no  demand-­‐side  controls  on  cost  and  u2liza2on  –  it  reinforces  need  of  payers  to  use  administra2ve  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  –  na2onal  =  ACOEM/ODG    Unit  price  controls  (fee  schedules)  =  Medicare  RBRVS/DRGs    Impairment  guidelines  =  AMA  Guides  to  the  Evalua2on  of   Permanent  Impairment  
  • 29. The  Role  of  Workers’  Compensa2on   Medical  Treatment  –  cont’d    Delivering  medical  treatment,  2mely,  and  of  the  nature  and  intensity  needed,  requires  an  unimpeded  exchange  of  medical  informa2on  with  providers  and  evaluators.       •  No  authoriza2ons/releases  required  in  workers’   compensa2on.     •  System  is  intended  to  be  less  formal  than  civil  li2ga2on,  to   promote  quick  exchange  of  informa2on  in  the  employee’s   interest  in  receiving  necessary  and  2mely  medical   treatment,  in  evalua2ng  return-­‐to-­‐work  restric2ons  and   accommoda2ons  necessary,  and  in  an  employer’s   understanding  of  poten2al  health  and  safety  risks  posed  by   the  injury.      
  • 30. The  Role  of  Workers’  Compensa2on   Medical  Treatment  –  cont’d    In  workers’  compensa2on,  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.  For  this  reason,  the  employee,  who  puts  his  condi2on  at  issue,  does  not  have  the  same  confiden2ality  expecta2ons  as  do  claimants  in  a  group  health  sekng.  
  • 31. The  Role  of  Workers’  Compensa2on   Medical  Treatment  –  cont’d    The  special  informa2onal  needs  of  workers’  compensa2on  payers  is  recognized  under  HIPAA:        “A  covered  en2ty  may  disclose  protected  health   informa2on  as  authorized  by  and  to  the  extent  necessary   to  comply  with  laws  rela2ng  to  workers’  compensa2on  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  authoriza2on,  or  opportunity  to   agree  or  object  is  not  required;  45  CFR  164.512(l)].      
  • 32. The  Role  of  Workers’  Compensa2on   Medical  Treatment  –  cont’d    Where  state  law,  itself,  mandates  disclosure  without   authoriza2on,  disclosure  is  permiqed  under  HIPAA  rules  and   exempt  from  the  “minimum  necessary”  informa2on   disclosure  standard.    “A  covered  en2ty  may  use  or  disclose   protected  health  informa2on  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  en2ty  under  HIPAA  rules  also  may  disclose   informa2on  to  any  en2ty  as  necessary  for  payment,   although  the  covered  en2ty  may  disclose  the  amount  and   types  of  informa2on  necessary  for  payment.    
  • 33. The  Role  of  Workers’  Compensa2on   Medical  Treatment  –  cont’d    In  brief,  HIPAA  does  not  erect  barriers  to  a  workers’  compensa2on  payer  obtaining  protected  health  informa2on,  whether  without  an  authoriza2on,  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  informa2on  from  medical   providers.    Some  states  =  explicit  mandates  to  release   informa2on  to  employer/insurer.    Other  states  impose  ex  parte  rules  on  physician   communica2ons  with  carrier  that  slow  evalua2on/ decisions.        
  • 34. The  Role  of  Workers’  Compensa2on   Medical  Treatment  –  cont’d    It  is  essen?al  for  workers’  compensa2on  payors  to  obtain  access  to  prescrip2on  monitoring  program  data,  to  properly  assess  an  injured  worker’s  use  of  prescrip2on  medica2ons  and,  broadly,  to  provide  all  reasonable  and  necessary  medical  treatment  and  effec2vely  manage  disability.  Without  access,  it  is  not  possible  for  a  workers’  compensa2on  payer  to  know  the  full  extent  of  prescrip2on  drug  use,  because  a  worker  may  be  obtaining  prescrip2ons  under  other  benefit  systems  (e.g.,  Medicaid,  group  health,  Veterans)  or  has  prescrip2ons  through  other  providers  not  otherwise  reported.    
  • 35. The  Role  of  Workers’  Compensa2on   Medical  Treatment  –  cont’d    Washington  State’s  Department  of  Labor  &  Industry  has   access  to  PMP  data.    The  Department’s  role  in  providing   workers’  compensa2on  benefits  is  no  different  from  that  of   other  private  market  insurers  and  self-­‐insured  employers.        Arizona  enacted  legisla2on  last  year  providing  access  for   IMEs  to  that  state’s  PDMP  database  and  the  right  to  disclose   that  informa2on  to  “the  employee,  employer,  insurance   carrier  and  the  [Industrial]  commission.”    [H  2155;  Chp.  156,   Laws  of  2012;  eff.  1-­‐1-­‐13].    
  • 36. OPIOID  ABUSE:    THE  MOST  URGENT  ISSUE  FACING   WORKERS’  COMPENSATION  
  • 37. OPIOID  ABUSE:    THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION      Use  of  opioids,  especially  long-­‐ac2ng  medica2on,   for  treatment  of  chronic  pain  in  workers’   compensa2on  can  increase  chances  of  a   “catastrophic  claim  ($100,000+)  by  almost  four   2mes.    Use  of  short-­‐ac2ng  opioids  raises  chances  by   almost  twice.    Average  claim  not  involving  opioids  =   $13,000.      -­‐-­‐  “ The  Effects  of  Opioid  Use  on  Workers’  Compensa2on  Claim  Cost  in  the   State  of  Michigan;  Bernacki,  et.  al;  Journal  of  Occupa2onal  and   Environmental  Medicine,  August  2012.  
  • 38. OPIOID  ABUSE:     THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION        Average  claim  costs  of  workers  receiving  7+  opioid   prescrip2ons  for  back  problems  without  spinal  cord   involvement  =     –  3X  greater  than  for  workers  receiving  0  or  1  opioid   prescrip2on    Workers  receiving  mul2ple  opioid  prescrip2ons  =     –  2.7X  more  likely  to  be  off  work     –  4.7X  as  many  days  off  work     (Swedlow  et  al.,  CWCI  Special  Report  2008)  
  • 39. OPIOID  ABUSE:     THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION    Prevalence  of  Fentanyl  in  California’s  Workers’  Compensa2on  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’  compensa2on  prescrip2ons  for  these  drugs,  which   represents  87%  of  the  morphine  equivalents  provided  to  injured   workers  accoun2ng  for  88%  of  all  Schedule  II  pharmacy  payments   in  the  CA  WC  system.  Nearly  half  of  Schedule  II  prescrip2ons  =   minor  back  injuries.      [CWCI  Research  Bulle2n  11-­‐05;  April  28,  2011]  
  • 40. OPIOID  ABUSE:    THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION      AIA  endorses  robust  PDMPs  as  one  key  element  for  comba2ng  opioid  abuse.        Mandatory  prescribing  and  dispensing   checking  of  database,  with  data  entry      Ac2ve  PDMPs  pushing  informa2on  to   prescribers  and  dispensers    Broad  access  to  PDMP  database,  including  3rd   party  payers  and  law  enforcement    Interstate  operability      
  • 41. OPIOID  ABUSE:    THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION      FINALLY:    Comprehensive,  well-­‐designed  prescrip2on  drug  monitoring  programs  can  serve  a  cri2cal  role  in  thwar2ng  opioid  abuse,  as  well  as  illegal  drug  diversion.  It  is  essen2al  for  there  to  be  broad  access  to  PDMP  data  –  by  those  with  a  legi2mate  purpose  in  such  data  –  and  as  essen2al  for  PDMP  programs  to  ac2vely  monitor  their  databases  for  suspicious  ac2vity,  thereby  providing  a  cri2cal  check  on  prescribers  and  dispensers  and  facilita2ng  data-­‐sharing.          
  • 42. Prescrip2on  Drug  Monitoring  Program  Workshop:   PDMP  Coordina2on  with  Third-­‐Party  Payers   Managing  Pain  Management  in  the  California  Workers’  Compensa2on  System   Alex  Swedlow   California  Workers’  Compensa4on  Ins4tute   www.cwci.org    
  • 43. Disclosure  Statement  •  Alex  Swedlow  has  no  financial  rela4onships   with  proprietary  en44es  that  produce  health   care  goods  and  services.    
  • 44. Pain  Management  in  the  California  Workers’  Comp  System   Agenda   •  Pain Management in the California Workers’ Compensation System •  Controlled Substance Utilization Review and Evaluation System (CURES)
  • 45. Pain  Management  in  the  California  Workers’  Comp  System   Areas  of  CWCI  Rx  Research   1.  Changing  Role  of  Rx  in  Workers’  Compensa4on   2.  Repackaged  Drugs   3.  Sole  Source  (Brand)  v.  Mul4-­‐source  (Generic)   4.  Opioids  &  Schedule-­‐II  Rx   5.  Compound  Drugs   6.  Drug  Tes4ng  
  • 46. Pain  Management  in  the  California  Workers’  Comp  System  Changing  Role  of  Rx  in  CA  Workers’  Compensa4on     1.  Growing  use  of  pharmaceu4cals   2002:    5%  of  medical  benefits   2010:    10%  of  medical  benefits   2.  Reforms  in  pricing  and  fee  schedules   3.  Growing  influence  of  pain  management  prac4ces   4.  Legisla4ve,  administra4ve  and  payer  responses  
  • 47. Pain  Management  in  the  California  Workers’  Comp  System  Managing  Pain  Management        Rules  and  Regula4ons  and  Medical  Management   •  Pain  Mgt  Guidelines  Implemented  July  2009   -­‐      Compe4ng  MTUS  defini4ons  and  triggers   -­‐  Hierarchy  of  medical  evidence   -­‐  Different  levels  of  specificity   •  Limits  to  Workers  Comp  Medical  Management   -­‐  Few  supply-­‐  and  demand-­‐side  controls   -­‐  Liens  (2012)   -­‐  No  3rd  party  payer  access  to  PDMP  
  • 48. Pain  Management  in  the  California  Workers’  Comp  System   Opioid  Prescrip4on  &  Payments  in  CA  Workers’  Comp  (2012)  
  • 49. Pain  Management  in  the  California  Workers’  Comp  System   Pharmaceu4cal  U4liza4on  &  Cost   Schedule-­‐II  Opioid  Drugs1   321%   345%   1  CWCI  2012.  Calcula4ons  are  on  a  calendar  year  basis  
  • 50. Pain  Management  in  the  California  Workers’  Comp  System   Rx  &  Pain  Management   Report  to  the  Industry   What  is  the  associa4on  between  the  use  of   opioids  on  low  back  pain  on:   •   Average  Benefit  Costs   -­‐  Medical   -­‐  Indemnity   •   Loss  of  Produc4vity/Return  To  Work   CWCI  2008   Exhibit  50  
  • 51. Pain  Management  in  the  California  Workers’  Comp  System  Pain  Mgt  and  the  Use  of  Opioids  Data  &  Methods   •  166,336  California  injured  workers     •  Medical  back  condi4ons  without  spinal  cord  involvement   •  A  total  of  854,244  opioid  prescrip4ons  were  dispensed   •  Controls  (morphine  equivalents)  for  different  types  of   opioids     •  Case-­‐mix  adjusted  outcomes     CWCI  2008  
  • 52. Pain  Management  in  the  California  Workers’  Comp  System   Background  on  Pain  Management   Opioid  Prescrip4ons  on  Medical  Back   Injuries  Not  Involving  the  Spine   Medical  back  injuries  w/  opioids  typically  receive     5.9  prescrip4ons  per  injury   CWCI  2008   Exhibit  52  
  • 53. Pain  Management  in  the  California  Workers’  Comp  System   Evidence-­‐based  Medicine  &     Compara4ve  Effec4veness  Research  on  Opioids   ACOEM  Insights  on  Opioids   •  Opioid  use  is  the  most  important  factor  impeding  recovery  of  func4on  in   pa4ents  referred  to  pain  clinics   •  Opioids  do  not  consistently  and  reliably  relieve  pain  and  can    decrease   quality  of  life  and  func4onal  status   •  The  use  of  opioids  during  the  sub-­‐acute  and  chronic  phases  of  an  injury,   especially  in  the  absence  of  an  objec4vely  iden4fiable  pain  generator,   cannot  be  recommended.                       Genovese,  Harris,  Korevaar    2007  
  • 54. Pain  Management  in  the  California  Workers’  Comp  System  Morphine  Equivalents  Categories   Average Range of MEs in MEs in Category Category Category No MEs 0 0 Level 1 124 3-240 Level 2 406 241-650 Level 3 1,207 651-2100 Level 4 14,870 2,101 and up ME  conversions  based  on  American  Pain  Society  Conversion  Tables   CWCI  2008   Exhibit  54  
  • 55. Pain  Management  in  the  California  Workers’  Comp  System   Adverse  Outcomes:          Increased  Costs   +203%   +196%   +209%   CWCI  2008   Exhibit  55  
  • 56. Pain  Management  in  the  California  Workers’  Comp  System   Adverse  Outcomes:      Reduced  Produc2vity  Paid  Time  Off  Work     +365%   CWCI  2008   Exhibit  56  
  • 57. Pain  Management  in  the  California  Workers’  Comp  System   Adverse  Outcomes:        Higher  Likelihood  of  Lost  Time  and  Li2ga2on   +131%   +60%   CWCI  2008   Exhibit  57  
  • 58. Pain  Management  in  the  California  Workers’  Comp  System   Pain  Mgt  and  the  Use  of  Opioids   Analysis  of  Prescribing  PaUerns  Schedule  II  Opioids     Analysis  of:     1.  Injury  Characteris4cs   2.  Physician  Prescribing  PaUerns   3.  Injured  Worker  Characteris4cs     PBM  and  ICIS  Data:       •  16,890  Claims   •  9,174  Prescribing  physician  DEA  code   •  233,276  Prescrip4ons   •  Script,  dosage  and  days     CWCI  March  2011   •  Pharmaceu4cal  characteris4cs     •  DOS,  billed  and  paid  amount   •  ER  and  EE  characteris4cs   Exhibit  58  
  • 59. Pain  Management  in  the  California  Workers’  Comp  System   Analysis  of  Prescribing  PaUerns  Schedule  II  Opioids      Top  Injury  Categories  w/  Schedule  II  Opioids     Pcnt of S-II Pcnt of S-II Pcnt of S- Opioid Opioid II Opioid Diagnostic Category Claims Scrips Pymnts Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2% Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1% Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5% Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4% Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8% Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7% Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8% Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6% Mental Disturbances 1.2% 1.7% 1.5% Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1% CWCI  March  2011   Exhibit  59  
  • 60. Pain  Management  in  the  California  Workers’  Comp  System   Analysis  of  Prescribing  PaUerns  Schedule  II  Opioids      Top  Injury  Categories  w/  Schedule  II  Opioids     Pcnt of S-II Pcnt of S-II Pcnt of S- Opioid Opioid II Opioid Diagnostic Category Claims Scrips Pymnts Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2% Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1% Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5% Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4% Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8% Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7% Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8% Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6% Mental Disturbances 1.2% 1.7% 1.5% Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%CWCI  March  2011   Exhibit  60  
  • 61. Pain  Management  in  the  California  Workers’  Comp  System   Analysis  of  Prescribing  PaUerns  Schedule  II  Opioids      Top  Injury  Categories  w/  Schedule  II  Opioids   Pcnt of Pcnt of S-II Pcnt of S- S-II Opioid II Opioid Opioid Diagnostic Category Claims Scrips Pymnts Outside  EBM  Guidelines:   Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2% Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1% •   51%  of  Claims   Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5% Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4% Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8% Ruptured Bursitis Tendon, Tendonitis, Myositis & 6.0% 3.6% 2.7% •   60%  of  Prescrip4ons   Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8% Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6% •   62%  of  Payments   Other Mental Disturb 1.2% 1.7% 1.5% Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1% CWCI  March  2011   Exhibit  61  
  • 62. Pain  Management  in  the  California  Workers’  Comp  System   Analysis  of  Prescribing  PaUerns  Schedule  II  Opioids     Cumula2ve  Percentage  of  Schedule  II  Prescrip2ons   (Top  10%  of  S-­‐II  Prescribing  Physicians)   CWCI  March  2011   Exhibit  62  
  • 63. Pain  Management  in  the  California  Workers’  Comp  System   Analysis  of  Prescribing  PaUerns  Schedule  II  Opioids     Cumulative Percentage of Schedule II Payments (Top 10% of S-II Prescribing Physicians) CWCI  March  2011   Exhibit 63
  • 64. Pain  Management  in  the  California  Workers’  Comp  System  Analysis  of  Prescribing  PaUerns  Schedule  II  Opioids     Average  S-­‐II  Opioid  Prescribing  Physicians     per  Claim  (Injured  Worker)   Median:  1.5   CWCI  March  2011   Exhibit  64  
  • 65. Pain  Management  in  the  California  Workers’  Comp  System   Pain  Management   Drug  Tes4ng:   •  High  levels  of  tes4ng  associated  with  increasing  opioid  and  S-­‐ II  u4liza4on   •  Ra4onale  for  drug  tes4ng:   -­‐    Protocols?   -­‐     Type  of  test?   -­‐     Timing  and  frequency?   -­‐    Medical  necessity?   •   Consequences:   -­‐  Injured  worker   -­‐  Physician     -­‐  Employer   -­‐  Claims  administrator  
  • 66. Pain  Management  in  the  California  Workers’  Comp  System   Drug Testing: Calendar Year Payments ($M) CWCI  2012   Exhibit 66
  • 67. Pain  Management  in  the  California  Workers’  Comp  System  Controlled  Substance  U4liza4on  Review  and  Evalua4on  System    (CURES)   CURES Background •  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. •  Now dormant and absent a funding source, the CURES program shuts down on July 1, 2013.
  • 68. Pain  Management  in  the  California  Workers’  Comp  System  Controlled  Substance  U4liza4on  Review  and  Evalua4on  System    (CURES)   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 Claims  w/   CA  Claim  Count   Pcnt  of   Opioid  Scripts (2010) 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%
  • 69. Pain  Management  in  the  California  Workers’  Comp  System   Controlled  Substance  U4liza4on  Review  and  Evalua4on  System            CURES:  ROI  for  California  Workers’  Compensa4on   Claims  w/   Avg  Cost/  Claim   Total  Payments Est  %   Total  Es4mated   (2010) Savings Opioid  Scripts 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     CURES  Opera4ng  Budget  (Est.):  $3,700,000   ROI  for  CA  WC:  $15.5  :  $1 Actual  savings  will  depend  upon  several  factors  including:   •  Medical  &  Rx  trends,  Injury  mix;   •  Appropriate  statutes,  rules  and  regs.  
  • 70. Pain  Management  in  the  California  Workers’  Comp  System   Summary •  High rate of inappropriate opioid use; •  Limits in statutes/rules/regs make it difficult to regulate within traditional workers’ comp controls •  Graduated use associated with adverse injured worker outcomes •  Small number of physicians associated with high prescribing patterns •  Rapid increase in drug testing associated to high opioid use with no national guidelines for testing •  CURES has significant potential to increase QOC and lower cost

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