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

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. 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. 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. 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. 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. 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
America's
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. 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. Case
Management
Strategies
in
Workers’
Compensa3on
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate

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. 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. 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. MaladapFve
Cycle
Illness conviction
Maladaptive Catastrophizing
Fear avoidance
Coping Quick fix seeking
Lack of objective
measures
Quick fixes
Trial and error
Maladaptive
approach Treatment
Poly-pharmacy
Escalating
interventions

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. 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. 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. 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. 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. 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. 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. 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. 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. Can
a
Popula3on
be
Managed?
Managed
Care
OrganizaFons
and
PrescripFon
Drug
Abuse
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate

23. Centene
Managed
Care
101

27. Start
Smart
for
Your
Baby
Health
Steps
IniFaFve

34. 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

37. Kentucky
Spirit
Health
Plan
Controlled
Substance
Pilot

42. “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