A Paradigm Shift of Payer Strategy April 10-12, 2012 Walt Disney World Swan Resort
Learning Objectives:1. Analyze the scope of the payers’ role in the prescription drug abuse problem.2. Identify specific best practice methodologies that can be implemented by payers to reduce fraud, waste and abuse through member and prescriber interventions/ education and support3. Describe the “drug seeker” profile and how it has changed.
Disclosure Statement• All presenters for this session, Dr. Kathryn Mueller, Dr. Brian K. Solow and Dr. Beverly Franklin-Thompson have disclosed no relevant, real or apparent personal or professional financial relationships.
A Paradigm Shift of Payer StrategyBeverly Franklin-Thompson, PharmD Director, Regional Pharmacy BlueCross BlueShield Tennessee
The Issues• Tennessee is one of the top three states for per capita prescription drug use – about 18 Rx’s per person each year• According to the Tennessee Controlled Substance Database, 275,496,939 hydrocodone tablets were dispensed in 2010• Admissions to drug abuse treatment programs increased seven-fold between 2000 and 2010.• In 2010, more people died in Tennessee from drug overdoses than from auto accidents, homicide or suicide.Sources: Kingsport Times-News and Knoxville News SentinelNashville Tennessean, Novartis Pharmacy Benefit Report 2011
Distribution of Prescription Pain Killers 8.5-12.6 7.3-8.4 6.0-7.2 3.7-5.9 in Kg/10,000 peopleDrug Enforcement Administration, 2010
Healthcare Costs• Annual medical costs for opioid abuser are $14,054 higher than the non-abuser with private insurance: – 4X more likely to visit ER – 11X more likely to visit outpatient mental health – 12X more likely to have an inpatient hospitalization• $72.5 Billion=Estimated direct health care costs related to nonmedical use of prescription painkillers(McAdam‐Marx et al., 2010; White et al., 2005)
Managed Care Tools• Review/monitor prescription claims• Prescriber notification• Patient outreach/case management• Quantity limits for certain drugs• Limiting refills• ID check/DOB Matching• Assign patients to single pharmacy
The Next LevelAdvanced Safety and Monitoring Program• Multidisciplinary team reviews, identifies and addresses excessive medication use in high- risk patients• Promotes member safety and reduces avoidable prescription and medical costs
The Next Level• Academic Detailing Pharmacist visits prescribers who write high numbers of controlled substances prescriptions to discuss rationale and alternatives• Prescriber Toolkit Educational information and questionnaires helps prescriber manage patients with chronic pain• Clinical Risk/Credentialing Identifies and investigates practitioners for quality of care concerns if there is evidence or possibility to harm a member.
Prescriber Tools• Health Care Plan’s Expectations• Treatment Guidelines• Opioid Dosing Calculators• Pain Management Contracts• Urine Drug Screens• Questionnaires-Addiction Risk Assessment, Pain and Function