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Right drug right_test_right_time_final_rev

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Third-Party Payer Track, National Rx Drug Abuse Summit, April 2-4, 2013. Right Drug, Right Test, Right Time …

Third-Party Payer Track, National Rx Drug Abuse Summit, April 2-4, 2013. Right Drug, Right Test, Right Time
presentation by Dongchung Wang, Dr. Lennox Abbott and Tron Emptage

Published in: Health & Medicine

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  • 1. Right  Drug,  Right  Test,  Right  Time   Ms.  Dongchun  Wang   Economist,  Workers’  Compensa3on  Research  Ins3tute   Dr.  Lenox  Abbo:   Director,  Laboratory  Opera3ons  and  Na3onal  Standards,  Quest   Diagnos3cs     Tron  Emptage   Chief  Clinical  Officer,  Progressive  Medical     April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  • 2. Learning  Objec?ves  •  Outline  how  clinical  programs  can  iden3fy   excessive  use  or  misuse  of  opioids  •  Describe  the  impact  of  behavioral   interven3ons  in  chronic  opioid  cases  •  Explain  the  value  of  urine  and  drug  screening  
  • 3. Disclosure  Statement  •  Ms.  Dongchun  Wang  has  no  rela3onships  with   proprietary  en33es  that  produce  health  care   goods  and  services.    •  Dr.  Lenox  AbboS  has  no  rela3onships  with   proprietary  en33es  that  produce  health  care   goods  and  services.    •  Tron  Emptage  has  no  rela3onships  with   proprietary  en33es  that  produce  health  care   goods  and  services.    
  • 4. Opioids  In  Workers’   Compensa3on  WCRI  Annual  Conference   February  2013  
  • 5. Today’s  Discussion  •  Prescribing  paSerns  of  opioids  in  workers’   compensa3on   –  Overall  use  of  opioids   –  Longer-­‐term  use  of  opioids  
  • 6. Opioids  In  Workers’  Compensa3on:     Key  Findings  From  WCRI  Studies  •  Most  injured  workers  received  opioids  for  pain  relief,   over  80%  in  some  states  studied  •  Amount  of  opioids  received  per  claim  unusually  high  in   several  study  states  •  1  in  6  or  7  injured  workers  in  Louisiana  and  New  York   who  received  opioids  had  them  on  a  longer-­‐term  basis    •  Few  longer-­‐term  users  of  opioids  received    services  for   monitoring  and  management  •  Longer-­‐term  opioid  use  in  MA  fell  a_er     pain  guidelines  
  • 7. Opioids  Commonly  Received  By  Injured   Workers,  Paid  Under  WC   Generic  Name  (Brand  Name)   Federal   %  Claims  w/   Schedule   Pain  Meds   (Median  State)   Hydrocodone-­‐Acetaminophen  (Vicodin®)   3*   58%   Oxycodone  w/Acetaminophen  (Percocet®)   2   28%   Propoxyphene-­‐N  w/APAP  (Darvocet-­‐N®)   4   18%   Tramadol  HCL  (Ultram®)   -­‐   17%   Oxycodone  HCL  (OxyCon3n®)   2   4%   Fentanyl  (Duragesic®)     2   1%   *  The  FDA  And  DEA  Are  Currently  Considering  Rescheduling  Hydrocodone  Products  (e.g.,  Vicodin®)  From  Schedule  3  To  Schedule  2.   Claims  With  >  7  Days  Of  Lost  Time,  Injuries  From  October  2005    To  September  2006,  Opioid  Prescrip?ons  Filled  Through  March  2008  (Data   From  2011  Prescrip?on  Benchmarks,  2nd  Edi?on)  
  • 8. Opioids  Commonly  Received  By  Injured   Workers,  Paid  Under  WC  (Cont.)   Generic  Name  (Brand  Name)   Federal   %  Of  Rx  For   Schedule   Pain  Meds   (Median  State)   Hydrocodone-­‐Acetaminophen  (Vicodin®)   3*   36%   Oxycodone  w/Acetaminophen  (Percocet®)   2   10%   Tramadol  HCL  (Ultram®)   -­‐   6%   Propoxyphene-­‐N  w/APAP  (Darvocet-­‐N®)   4   6%   Oxycodone  HCL  (OxyCon3n®)   2   2%   Fentanyl  (Duragesic®)     2   <1%   *  The  FDA  And  DEA  Are  Currently  Considering  Rescheduling  Hydrocodone  Products  (e.g.,  Vicodin®)  From  Schedule  3  To  Schedule  2.   Claims  With  >  7  Days  Of  Lost  Time,  Injuries  From  October  2005    To  September  2006,  Opioid  Prescrip?ons  Filled  Through  March  2008  (Data   From  2011  Prescrip?on  Benchmarks,  2nd  Edi?on)  
  • 9. Most  Injured  Workers  With  Pain   Medica3ons  Received  Opioids   * Nonsurgical  Claims  With  >  7  Days  Of  Lost  Time,  Injuries  From  October   2008  To  September  2009,  Prescrip?ons  Filled  Through  March  2011      *  Texas  Closed  Formulary  Went  Into  Effect  On  September  1,  2011,  Which   Is  Expected  To  Reduce  Use  And  Longer-­‐Term  Use  Of  Opioids  
  • 10. Amount  Of  Opioids  Received  Per  Claim   Unusually  High  In  NY,  LA,  PA  &  MA   Nonsurgical  Claims  With  >  7  Days  Of  Lost  Time,  Injury  Year  2006,  Prescrip?ons  Filled  Through  March  2008  (Data  From  2011  Narco?cs  Study)   *  Texas  Closed  Formulary  Went  Into  Effect  On  September  1,  2011,  Which  Is   Expected  To  Reduce  Use  And  Longer-­‐Term  Use  Of  Opioids  
  • 11. Database  Suppor3ng  Latest  WCRI   Study  On  Opioids  •  300,000+  claims,  1.1  million  pain  medica3on  Rx   filled  through  March  2011    •  Nonsurgical  claims  with  >  7  days  of  lost  3me  •  21  states  represen3ng  two-­‐thirds  of  workers’   compensa3on  medical  benefits  in  the  U.S.   –  20–47%  of  claims  in  each  state  •  Snapshots  of  an  average  24-­‐month  experience  
  • 12. Prescrip3ons  For  Opioids  •  Rx  for  opioids   –  Dispensed  by  physicians  or  pharmacies   –  Paid  under  workers’  compensa3on  •  Excluded       –  Hospital-­‐dispensed  opioids   –  Opioids  administered  by  medical  providers   (e.g.,  injectables,  infusions,  etc.)  
  • 13. Opioids  In  Workers’  Compensa3on:     Key  Findings  From  WCRI  Studies  •  Most  injured  workers  received  opioids  for  pain  relief,   over  80%  in  some  states  studied  •  Amount  of  opioids  received  per  claim  unusually  high  in   several  study  states   1  in  6  or  7  injured  workers  in  Louisiana  and  New  York   who  received  opioids  had  them  on  a  longer-­‐term  basis     Few  longer-­‐term  users  of  opioids  received    services  for   monitoring  and  management  •  Longer-­‐term  opioid  use  in  MA  fell  a_er     pain  guidelines  
  • 14. Longer-­‐Term  Use  Of  Opioids  •  Study  defini3on   –  First  opioid  Rx  filled  within  first  3  months  a_er   injury   –  Opioids  con3nued  a_er  6  months  pos3njury   –  3+  Rx  fills  during  months  7–12    •  Nonsurgical  cases  
  • 15. One  In  6  Or  7  Workers  With  Opioids  In   LA  And  NY  Had  Longer-­‐Term  Use       *Nonsurgical  Claims  With  >  7  Days  Of  Lost  Time,  Injuries  From  October  2008   To  September  2009,  Narco?c  Prescrip?ons  Filled  Through  March  2011      *  Texas  Closed  Formulary  Went  Into  Effect  On  September  1,  2011,  Which  Is   Expected  To  Reduce  Use  And  Longer-­‐Term  Use  Of  Opioids  
  • 16. Longer-­‐Term  Use  Of  Opioids  Also   Prevalent  In  Several  Other  States   *Nonsurgical  Claims  With  >  7  Days  Of  Lost  Time,  Injuries  From  October  2008   To  September  2009,  Narco?c  Prescrip?ons  Filled  Through  March  2011      *  Texas  Closed  Formulary  Went  Into  Effect  On  September  1,  2011,  Which  Is   Expected  To  Reduce  Use  And  Longer-­‐Term  Use  Of  Opioids  
  • 17. Medical  Treatment  Guidelines  For  Chronic   Opioid  Management  Recommend   •  Urine  drug  tes3ng   •  Psychological  and  psychiatric  evalua3ons  and   treatment   •  Ac3ve  physical  therapy     Note:  Guideline  recommenda3ons  are  based  on  widely-­‐accepted  medical   treatment  guidelines,  including  ACOEM,  APS/AAPM,  ODG,  and  state   guidelines  (CO,  UT,  WA).  See  Appendix  A  of  WCRI’s  Longer-­‐Term  Use  of   Opioids.  
  • 18. Frequency  Of  Drug  Tes3ng  Was  Low,   Even  A_er  Considerable  Increases     %  Of  Claims  With  Longer-­‐Term   21-­‐State   Most   Use  Of  Opioids  That  Received   Median   States   Drug  Tes3ng  In…   (Range)        2007/2009   14%   9–24%        2009/2011   24%   18–30%  Nonsurgical  Claims  With  >  7  Days  Of  Lost  Time  That  Were  Iden?fied   As  Longer-­‐Term  Users  Of  Opioids,  Injury  Years  2007  &  2009,   Prescrip?ons  Filled  Through  March  2011,  Average  24-­‐Month   Snapshots    
  • 19. Psychological  Evalua3ons  And   Treatment  Performed  Infrequently       %  Of  Claims  With  Longer-­‐Term  Use   21-­‐State   Most  States   Of  Opioids  That  Received…   Median   (Range)   Psychological  Evalua3ons        2007/2009   6%   4–9%        2009/2011   7%   3–9%   Psychological  Treatment        2007/2009   6%   3–7%        2009/2011   4%   2–6%  Nonsurgical  Claims  With  >  7  Days  Of  Lost  Time  That  Were  Iden?fied  As  Longer-­‐Term  Users  Of  Opioids,  Injury  Years  2007  &  2009,  Prescrip?ons   Filled  Through  March  2011,  Average  24-­‐Month  Snapshots    
  • 20. Opioids  In  Workers’  Compensa3on:     Key  Findings  From  WCRI  Studies  •  Most  injured  workers  received  opioids  for  pain  relief,   over  80%  in  some  states  studied  •  Amount  of  opioids  received  per  claim  unusually  high  in   several  study  states  •  1  in  6  or  7  injured  workers  in  Louisiana  and  New  York   who  received  opioids  had  them  on  a  longer-­‐term  basis    •  Few  longer-­‐term  users  of  opioids  received    services  for   monitoring  and  management   Longer-­‐term  opioid  use  in  MA  fell  a_er     pain  guidelines  
  • 21. Longer-­‐Term  Opioid  Use  In  MA  Fell  A_er   Pain  Guidelines   2007/2009  To  2009/2011  Nonsurgical  Claims  With  >  7  Days  Of  Lost  Time,  Injury  Years  2007  To  2009,   Prescrip?ons  Filled  Through  March  2011,  24-­‐Month  Maturi?es  *  Texas  Closed  Formulary  Went  Into  Effect  On  September  1,  2011,  Which  Is   Expected  To  Reduce  Use  And  Longer-­‐Term  Use  Of  Opioids  
  • 22. Conclusions  •  Opioid  problem  is  BIG  in  workers’   compensa3on,  especially  in  some  states  •  Doctors  prescribe  opioids  more  o_en  in  some   states  than  others,  overall  and  on  longer-­‐term   basis  •  Opportuni3es  to  eliminate  unnecessary  opioid   prescrip3ons  
  • 23. Right  Drug,  Right  Test,  Right  Time.  
  • 24. Discussion  Points  •  Chronic  opioid  therapy  management    •  Prescrip3on  drug  monitoring  guidelines  &  protocol   development  •  Prescrip3on  drug  monitoring  result  trends  •  Balancing  costs  
  • 25. Management  of  chronic  pain  pa?ents  –   10  steps  of  universal  precau?ons     Make  a  diagnosis  with  appropriate  differen3al  and  a  plan  for  further  evalua3on  and   1   inves3ga3on  of  underlying  condi3ons  to  try  to  address  the  medical  condi3on  that  is   responsible  for  the  pain   2   Psychologic  assessment,  including  risk  of  addic3ve  disorders   3   Informed  consent   4   Treatment  agreement   5   Pre-­‐/post-­‐treatment  assessment  of  pain  level  and  func3on   6   Appropriate  trial  of  opioid  therapy  +/-­‐  adjunc3ve  medica3on   7   Reassessment  of  pain  score  and  level  of  func3on   8   Regularly  assess  the  “Four  As”  of  pain  medicine   •  Analgesia,  Ac3vity,  Adverse  reac3ons,  and  Aberrant  behavior   9   Periodically  review  management  of  the  underlying  condi3on  that  is  responsible  for  the   pain,  the  pain  diagnosis  and  comorbid  condi3ons  rela3ng  to  the  underlying  condi3on,   and  the  treatment  of  pain  and  comorbid  disorders   10   Documenta3on  of  medical  management  and  of  pain  management  according  to  state   guidelines  and  requirements  for  safe  prescribing  Gourlay DL, Heit HA, Almahrezi A. Universal Precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-112.Gourlay DL, Heit HA. Universal precautions revisited: managing the inherited pain patient.  Pain  Med. 2009;10(suppl 2):S115-S123. |   25  
  • 26. Prescrip?on  drug  monitoring  –  objec?ve  evidence  to   assist  in  pa?ent  management  Prescrip3on  Drug  Monitoring  Urine  drug  tes3ng  which  is  used  to  detect  the  presence  of  the  prescribed  drug  in  the  urine,  specifically  controlled  medica3ons,  as  an  indicator  of  the  pa3ent’s  adherence  or  compliance  to  their  treatment  plan    Presence  of  the  drug  or  the  drug’s  metabolites  indicates  that  the   pa3ent  is  taking  the  drug    Absence  of  the  drug  or  the  drug’s  metabolites  indicates  that  the   pa3ent  is  probably  not  taking  the  drug    Presence  of  an  illicit  drug  or  prescrip3on  drug  not  prescribed  by   the  physician  indicates  that  the  pa3ent  is  supplemen3ng  his   treatment   Confidential – Do not copy or distribute | 26
  • 27. Tes?ng  Road  Map   Science  and  What’s  Supported  by  Data   Local  Coverage  State  Laws,  Rules  &  Professional  Standards   Determina?ons  and   Medical  Policies   Other  Regulatory   Pain   Addic?on/Recovery   Requirements   and  Policies   2 7
  • 28. Guidelines  have  common  themes  but  are  not   defini?ve    APS/AAPM  Guidance  ¹   ACOEM  Guidelines     Universal  Precau?ons  High  risk  pa3ents  or  who   “There  is  evidence  that   MODERATE  TO  HIGH  Risk  have  engaged  in  aberrant   urine  drug  screens  can   of  Misuse  drug-­‐related  behaviors,   iden3fy  aberrant  opioid   May  be  periodically  clinicians  should  periodically   use  and  other  substance   eligible  for  monitoring  at  obtain  urine  drug  screens  or   use  that  otherwise  is  not   each  visit,  with  a  other  informa3on  to  confirm   apparent  to  the  trea3ng   minimum  of  one  test  adherence  to  the  COT  plan  of   physician.”   conducted  every  three  care.   months  (4x/year)  Pa3ents  not  at  high  risk  and   Screening  is   LOW  Risk  of  Misuse  not  known  to  have  engaged   recommended:  in  aberrant  drug-­‐related   -­‐  At  baseline   May  be  periodically  behaviors,  clinicians  should   -­‐  Randomly  at  least  2-­‐4   eligible  for  monitoring  at  consider  periodically   3mes/year   each  visit,  with  a  obtaining  urine  drug  screens   -­‐  At  termina3on  “for   minimum  of  one  test  or  other  informa3on  to   cause”   conducted  every  six  confirm  adherence  to  the   months  (2x/year).  COT  plan  of  care  ¹Chou R, Fanciullo GJ, et al. (2009) Clinical Guidelines for the Use of Chronic|    28     Therapy in OpioidChronic Noncancer Pain. The Journal of Pain, 10 (2): 113-130.
  • 29. Protocol  must  be  defined  by  prac?ce  Who to test? Which drugs? How Clinical frequently? response to test results? Goal: Patient, Practice & Community Safety 2 9
  • 30. What to order Practice Protocol Broad Initial PDM Test Prior to _____RX spectrum testing: pain Risk Assessment using ___________tool medication, illicit drugs,potential drug Low-Risk High-Risk interactions Perform random PDM Perform random PDM testing testing minimum of minimum of Targeted ______ times per______ ______ times per______testing based on results & other risk Consistent Inconsiste Consistent Inconsisten factors Result nt Result t Result Result Continue Modify Continue Modify testing Testing at testing testing frequency to low-risk frequency to frequency for ______ times rate ______ times _______ per _____ per _____ period
  • 31. Most  pa?ent  drug  tests  are  inconsistent  with  expecta?ons   •  The  majority  of  pa3ents  tested  misused  their   prescrip3on  medica3ons  (60%)   •  Many  pa3ents  took  drugs  or  combined  drugs   without  physician  oversight     •  A  large  number  of  pa3ents  showed  no  drug  in   their  specimen   •  Recrea3onal  marijuana  users  are  more  likely   than  non-­‐users  to  misuse  other  drugs   •  Anyone  is  at  risk  of  misuse.   70%  Medicaid,  58%  Medicare,  59%  Private     •  Inconsistent  results  declined  by  10%    in  pa3ents   tested  30  days  or  more  a_er  ini3al  screen  Quest Diagnostics Health Trends, Prescription Drug Monitoring Report 2013 | 31
  • 32. Inconsistent  results  driven  by  a  number  of  factors  •  One-­‐third  (33%)  of   inconsistent  results  showed   presence  of    drug(s)  not   specified  by  the  ordering   physician  in  addi3on  to   prescribed  medica3on.    •  25%  showed  presence  of  a   drug  different  than  the  one   prescribed  by  the  ordering   physician.    •  In  42%  of  inconsistent  cases,   no  drug  was  detected.     | 32
  • 33. Marijuana  was  the  most  frequently  detected    non-­‐prescribed  drug  •  Non-­‐prescribed  marijuana  was   the  most  frequently  detected   drug,  found  in  26%  of  pa3ent   specimens  with  inconsistent   results.  •  These  findings  confirm  other   data  sugges3ng  marijuana  is  the   most  commonly  abused  illicit   drug  in  the  United  States.    •  The  next  most  frequently   misused  drugs  detected  in   tes3ng  were  opiates  (22%)  and   benzodiazepines  (16%).  
  • 34. Recrea?onal  marijuana  users  were  more  likely  to  use   other  non-­‐prescribed  medica?ons  than  non-­‐users  •  45%  of  specimens  posi3ve  for  non-­‐ prescribed  marijuana  were  also   posi3ve  for  at  least  one  other  non-­‐ prescribed  drug  –  10%  higher  than   non-­‐users  (36%).  •  Pa3ents  who  used  marijuana   illicitly  are  1.3  3mes  more  likely  to   use  drugs  not  prescribed  by  an   ordering  physician.  •  Among  illicit  marijuana  users,   seda3ve  medica3ons  and  narco3c   pain  killers  were  the  most   frequently  detected  non-­‐ prescribed  drugs.   | 34
  • 35. Cost  of  tes?ng  can  vary  widely  based  on  provider  prac?ce   Scenario  1  26 year old female patient Assumptions •  Neck pain – post accident •  Screen reimbursement - CA WC schedule •  5 mg Hydrocodone 4 times (120% of MC) day •  Use of G0434 for POCT & G0431 for lab- •  20 mg Adderall daily based immunoassay •  Moderate Risk- consistent •  Quantitative reimbursement - opiate CPT results code Provider  A   Jan.   April   Jul.   Oct.   Annual   12  Drug  POC  Test  Cup   1*$24   1*$24   1*$24   1*$24   $96   12  Quant.  Confirma3ons   12*$32   12*$32   12*$32   12*$32   $1,536   Delta  per   Total   $408   $408   $408   $408   $1,632   Pa?ent   $792   Provider  B   Jan.   April   Jul.   Oct.   Annual   annually   10  Drug  Lab  Test  +  SVT   1*$146   1*$146   1*$146   1*$146   $584   2  Quant.  Confirma3ons   2*$32   2*$32   2*$32   2*$32   $256   Total   $210   $210   $210   $210   $840   |    35    
  • 36. Cost  of  tes?ng  can  vary  widely  based  on  provider  prac?ce   Scenario  2  40 year old male patient Assumptions •  Lower back pain – post work •  Screen reimbursement - CA WC schedule injury (120% of MC) •  100 mg Tapentadol 4 times/day •  Use of G0434 for POCT & G0431 for lab- •  0.5 mg Clonazepam daily based immunoassay •  Moderate Risk- consistent •  Quantitative reimbursement - opiate CPT results code Provider  A   Jan.   April   Jul.   Oct.   Annual   12  Drug  POC  Test  Cup   1*$24   1*$24   1*$24   1*$24   $96   10  Quant.  Confirma3ons  +   $26  +   $26  +   $26  +   $26  +  15* $2,024   SVT  +  5  Direct  to  Quant.   15*$32   15*$32   15*$32   $32   Delta  per   Pa?ent   Total   $530   $530   $530   $530   $2,120   $1,280   Provider  B   Jan.   April   Jul.   Oct.   Annual   annually   10  Drug  Lab  Test  +  SVT   1*$146   1*$146   1*$146   1*$146   $584   2    Direct  to  Quant.     2*$32   2*$32   2*$32   2*$32   $256   Total   $210   $210   $210   $210   $840   |    36    
  • 37. Providers  and  payers  must  work  together  to  op?mize   outcomes  and  minimize  cost  to  system  •  Educate  physicians  on  state   rules,  regula3ons  &  guidelines  •  Implement  reasonable  tes3ng   frequency  &  reimbursement   policies  •  Link  pharmacy  and  laboratory   data  •  U3liza3on  evalua3ons  &  clinical   interven3on,  as  appropriate   |    37    
  • 38. Next  fron?er:    using  gene?cs  to  individualize  pain  drug   selec?on  Cytochrome  P450  enzymes  are  commonly  associated  with  drug  metabolism.  Approximately  90%  of  individual  differences  in  liver  CYP  3A  ac3vity  are  from  gene3c  varia3on  The  P450  variants  can  drama3cally  alter  enzyma3c  ac3vity.   Gene3c  varia3ons  in  the  DNA  can   affect  rate  and  extent  of  cytochrome   Drug P450  enzyme  metabolism:  CYP 3A metabolism CYP  2D6   CYP 2D, 2C metabolism CYP  2C19   Glucuronida?on     CYP  3A4   CYP  3A5  
  • 39. Right  Drug,  Right  Test,  Right  Time.  Tron  Emptage,  RPh,  Chief  Clinical  Officer  Progressive  Medical,  Inc.  
  • 40. Learning  Objec?ves  •  Outline  how  clinical  programs  can  iden3fy   excessive  use  or  misuse  of  opioid.  •  Describe  the  impact  of  behavioral  interven3ons   in  chronic  opioid  cases.  •  Explain  the  value  of  urine  and  drug  screening  
  • 41. Discussion  Points  •  Pharmacy  Benefit  Management  Solu3ons  •  Prevent  through  Connec3vity  •  Monitor  U3liza3on  •  Intervene  through  Clinical  Review  •  Leverage  Analy3cs  
  • 42. Workers’  Compensa?on  Facts   Top  1%  account  for  ~40%     of  all  narco3c  costs   Top  10%  account  for  ~80%     of  all  workers’  compensa3on  narco3c  costs    Source:  NCCI  Narco3cs  in  Workers’  Compensa3on  
  • 43. U?liza?on   Medica?on  Quan?ty  x  Length  of  Use   1-­‐2  year  old  claims  =  3%  of  total  medical  costs   11 year old claims = 40% of total medical costsSource:  NCCI  Drug  Study:  2011  Update  
  • 44. Right  Drug,  Right  Test,  Right  Time  Prevent   Alert   Monitor   Intervene  
  • 45. Case  Study:    The  Beginning  A framer with a construction company was injured whenpulling a pallet of bricks on the job from one site toanother for use of the materials.His injury, a low back strain, occurred in August of 1989and in 1990 had a percutaneous 3-level lumbardiscectomy. He continued with residual pain and thefollowing therapies were initiated:•  TENS therapy – effective•  Nerve blocks – ineffective•  OT/PT with Activity Restriction•  Biofeedback and Counseling•  Medication Therapy – minimally effective
  • 46. PHARMACY  BENEFIT  MANAGEMENT     SOLUTIONS  
  • 47. Total  Pharmacy  Management   ONGOING  COMMUNICATION   U?liza?on     Clinical  &  Diagnos?c   Educa?on  &    Management   Interven?ons   Analy?cs   NETWORK  PENETRATION  
  • 48. Follow  the  Prescrip?on  in  Workers’   Compensa?on   Retail     Injured  Worker   Pharmacy   NO   Iden?fy   YES   Out  of   PBM   In  Network   Network   Alternate   PBM  Billing  Agent   Filling  Site   Payor  
  • 49. Processing  and  Eligibility  Solu?ons  Capture  Rx  at   Reduce  OON   Home     First  Fill   Bills   Delivery  
  • 50. Capture  Rx  at  First  Fill  •  Nearly  65,000  retail  pharmacies  •  PBMs  contract  with  these  pharmacies  to  bring  efficiencies  •  First  fills  are  the  beginning  to  network  penetra3on  and   guideline  adherence  •  Early  fill  capture  allows  for  early  aler3ng  of  poten3al  problems  
  • 51. In  Network  Processing   Increases  Informa?on  •  Monitor  for  guideline  adherence  •  Direct-­‐to-­‐pharmacy  connec3vity  processing  brings   conflict  alerts  to  the  pharmacist  •  Reduces  risk  of  duplicate  therapy  •  Alert  for  high  dose  •  Mul3ple  prescribers  •  Reduce  informa3on  delay  associated  with  paper   claims  
  • 52. Home  Delivery  •  Offer  convenience  to  injured  workers  •  Order  online,  via  phone  and  mail  •  Offers  physician  increase  in  control  of  maintenance   medica3ons  •  Brings  claims  professional  and  payor  prescrip3on   informa3on  on  long-­‐term  claims  •  Follows  long-­‐term  claims  more  closely  
  • 53. Mul?faceted  Approach  Prevent   Alert   Monitor   Intervene  
  • 54. Prevent  •  First  fill  plans  developed  with  guidelines  at  First   No3ce  of  Loss  •  High  retail  network  penetra3on  means  more   prescrip?ons  through  program  at  point  of  sale  •  Iden?fy  claims  needing  early  Urine  Drug  Screening  •  Con3nual  drug  informa?on  review  through  analy3cs  
  • 55. Alert  •  Applica3on  of  guidelines  through  medica3on  plans   based  on  injury  type,  date  of  injury  and  body  part  •  Drive  point-­‐of-­‐sale  informa3on  to  dispensing   pharmacist  to  alert  to  dispensing  problems  •  Clinical  audits  and  triggers  alert  claims  professional,   prescriber  and  injured  worker  to  addi3onal  cau3ons   within  the  claim  based  on  analy3cs  •  Injured  worker  alerts  can  be  set  to  allow  for  Urine   Drug  Screening  
  • 56. Formulary  Development  •  Use  of  evidence-­‐based  medica3on  prac3ces  •  Na3onal  and  state-­‐specific  guideline  applica3on  •  Injury  and  disease  treatments  •  Use  of  body  part  and  nature  of  injury  •  Dura3on  of  use  limits  •  Quan3ty  limits  •  Step  therapy  allowances  for  proper  medica3on   allowance  •  Off-­‐label  prescribing    
  • 57. Dispensing  Edits  and  Alerts  •  Industry  standards  from  Na3onal  Council  of   Prescrip3on  Drug  Programs,  D.0  standards  •  Alerts  and  edits   –  Therapeu3c  duplica3on   –  Early  refills   –  Drug  –  drug  interac3ons   –  Drug  –  disease  interac3ons   –  Mul3ple  prescriber  alerts   –  High  dose,  over  use  alerts  
  • 58. Follow  the  Prescrip?on  in  Workers’   Compensa?on   Retail     Injured  Worker   Pharmacy   NO   Iden?fy   YES   Out  of   PBM   In  Network   Network   Alternate   PBM  Billing  Agent   Filling  Site   Payor  
  • 59. Opioid  Strategies  •  Ini3a3on  of  narco3c  therapy  no3fies  medical  and   claims  professionals  when  injured  workers  receive   mul3ple  opioid  medica3ons  especially  when  mul3ple   physicians  are  involved  •  Targeted  alerts  inform  claims  professionals  of:   o  Specific  prescrip3ons  that  may  not  be  appropriate  for   severity  or  chronicity  of  injury   o  When  morphine  equivalents  exceed  a  set  amount     o  Narco3c  duplica3on   o  Excessive  APAP  
  • 60. Case  Study:    More  Informa?on  •  Medica3on  regimen  in  late  2007  included:   o  Venlafaxine  75mg  -­‐  3  per  day   o  Lyrica  150mg  -­‐  3  per  day   o  Clonazepam  1mg  -­‐  4  per  day   o  Carisoprodol  350mg  -­‐  3  per  day   o  OxyCon3n  80mg  ER  -­‐  8  per  day   o  Oxycondone  30mg  IR  -­‐  6  per  day  
  • 61. Case  Study:  Concerns  •  Claimant  receiving  well  above  1,000mg  morphine   equivalents  per  day  •  Claimant  consistently  reported  pain  scores  of  7-­‐9  out   of  10  •  Claimant  began  to  have  high  blood  pressure  readings  •  Urine  drug  monitoring  was  ini3ated  and  compounds   represen3ng  illicit  drugs  were  found  present  in  the   urine,  as  well  as  opioid  compounds    •  Claimant  was  discharged  from  physician                                     due  to  broken  opioid  medica3on  contract  
  • 62. Monitor  •  Monthly  clinical  audits  assist  in  physician  monitoring   to  find  misuse  •  Urine  drug  screening  program  to  find  claims  that  may   benefit  from  regular  analysis      •  Narco3c  use  and  overu3liza3on  reports  using   analy3cal  tools  and  processes  to  find  poten3al   problems  early  
  • 63. Monitoring  Strategies  •  Ini3a3on  of  urine  drug  screening  and  monitoring  •  Guidelines  suggest:   o  Baseline  tes3ng   o  Randomized  tes3ng   o  Daily  morphine  equivalents  requirements   o  Therapy  guidelines  •  Opioid  contract  implica3ons  •  Prescrip3on  drug  monitoring  programs  •  Other  screening  tools  
  • 64. Intervene  •  Con3nual  clinical  pharmacist  reviews  allow  for  iden3fica3on   of  the  need  for  interven3on  •  Drug  u?liza?on  evalua?ons  allow  for  the  pinpoin3ng  of  early   drug  regimen  changes  •  Pharmacists  at  point  of  dispense  help  inform  injured  workers   of  poten3al  issues  •  Use  of  Le:ers  of  Medical  Necessity    •  Pharmacist  reviews  and  consulta?on  recommending   poten3al  treatment  changes  •  Peer-­‐to-­‐peer  consulta?on  assists  in  making                                             therapy  regimen  changes  
  • 65. Clinical  Interven?on  Reports  •  Pharmacist  Only  Review   –  Review  of  medica3ons   –  Summary  of  past  and  current  medical  history   –  Medica3on  therapy  recommenda3ons  •  Physician  Review   –  Above,  with  physician  review  and  comment  •  Peer-­‐to-­‐Peer  Reviews   –  Above,  with  conversa3on  
  • 66. Interven?on  Results   CASE STUDY: 628 INTERVENTION CLAIMS  •  Compared  six  months  pre-­‐  and  post-­‐interven3on  •  Prescribing  physicians  reviewed  therapies  and  made  changes   with  the  following  results   -­‐   24%   -­‐   22%   -­‐   28%    #  of  Prescrip3ons   Morphine    Spend  per  Claim   Equivalency  
  • 67. Case  Study:  Results  •  Claimant  referred  for  medica3on  review  in  early  2009  •  Results  of  successful  peer-­‐to-­‐peer  consulta3on  and  weaning   of  medica3ons:   o  Lyrica  600mg  per  day   o  OxyCon3n  80mg  ER  –  2  per  day   o  Oxycondone  5mg  IR  -­‐  6  per  day  •  While  s3ll  well  above  many  guidelines,  morphine  equivalents   reduced  by  more  than  1,000mg  per  day  •  Claimant  has  increased  func3onality  and  decreased  pain   scores  •  Urine  drug  monitoring  has  been  con3nued  and                             claimant  has  been  adherent  to  therapy  
  • 68. Thank  you  

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