Third-Party Payer: FInancial Toll of Rx Addiction

1. Third-Party Payer Track:
Financial Toll of Rx Addiction
Presenters:
• Chao Zhou, PhD, Economist, National Center for Injury
Prevention and Control, CDC
• Stephen N. Fisher, MD, PhD, Medical Advisor to the CEO,
Chesapeake Employers’ Insurance Company
• Asheley Cockrell Skinner, PhD, Associate Professor, Injury
Prevention Research Center, UNC - Chapel Hill
Moderator: Grant T. Baldwin, PhD, MPH, Director, Division of
Unintentional Injury Prevention, National Center for Injury
Prevention and Control, CDC, and Member, Rx Summit
National Advisory Board

2. Disclosures
Chao Zhou, PhD; Stephen N. Fisher, MD, PhD; Asheley
Cockrell Skinner, PhD; and Grant T. Baldwin, PhD, MPH,
have disclosed no relevant, real, or apparent personal
or professional financial relationships with proprietary
entities that produce healthcare goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Identify national trends in opioid use and
expenditures.
2. Outline strategies to identify and manage
high-risk claims within the workers’
compensation population.
3. Describe the North Carolina Medicaid Lock-In
Program.

5. The PowerPoint presented by
Chao Zhou, PhD,
has been removed
at presenter’s request.

6. Third-Party Payer Track:
Financial Toll of Rx Addiction
Stephen Fisher, M.D., Ph.D.
Medical Advisor to the CEO
Director of Health Services
Chesapeake Employers’ Insurance Company
April 8, 2015

7. Disclosure
• Stephen Fisher, MD., Ph.D., has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services.

8. Learning Objectives
1. Identify national trends in opioid use and
expenditures.
2. Outline strategies to identify and manage
high-risk claims within the workers’
compensation population.
3. Describe the North Carolina Medicaid Lock-In
Program.

9. Drug and Alcohol-Related Intoxication
Deaths in Maryland, 2013
Maryland Department of Health and Mental Hygiene
http://dhmh.Maryland.gov/data/Documents/2013%20final%20intoxication%20report.pdf

10. Opiate Prescribing by State
Source: http://www.riskandinsurance.com/wc-narcotics-abuse/

11. Chesapeake Employers’ Overview
• Insures primarily small to medium employers- approx. 21,000
policy holders
• Large percentage of policyholders in construction and the
trades
• Insures 70% of all Maryland municipalities and counties
• Third party administrator for the State of Maryland

12. Why a Work Comp Problem?
Higher amounts of narcotics in treating acute work-related
low back pain cause injured workers to be:
• away from work longer (up to 69 days longer)
• have higher medical costs
• be 3X more likely to have surgery
• have a 6X greater chance of using narcotics beyond
the recommended time
WorkComp Central 7/20/09

13. Chesapeake Employers / IWIF
Top 10 Manual Class Codes Associated with Top 10 Drug Cost
STATE EMPLOYEE -- NON-HAZARDOUS WORK
CARPENTRY PRIVATE RESIDENCES
TOWNSHIP, MUNICIPALITY; ALL EMP EXCL CLERICAL, POLICE & FIRE
CLERICAL OFFICE EMPLOYEES N O C
COUNTIES, ALL EMPLOYEES EXCLUDING POLICE AND FIREFIGHTERS
PLUMBING NOC & DRIVERS
GAS STATION-FULL SERVICE/AUTO REPAIR
TRUCKING: LOCAL HAULING ONLY-ALL EMPLOYEES
CONVAL NURSE HOMES-ALL EMPLOYEES
ELECT WIRING WITHIN BLDGS & DRIVERS

14. Chesapeake Employers / IWIF
2014 Rx Count by State and Private Business
All Drugs
All Groups By Group State By Group Private
Age # Rxs Age # Rxs Age # Rxs
54 2126 54 889 54 1237
53 1919 60 888 55 1143
50 1844 53 886 50 1070
55 1751 48 869 51 1066
51 1637 50 774 53 1033
60 1591 49 652 56 955
48 1567 63 638 46 919
49 1527 59 637 49 875
44 1495 45 634 44 862
52 1471 44 633 52 854
Source: ExpressScripts

15. Prescription Drug Problem in Maryland
Workers’ Comp
• There is a guaranteed payer, no co-pays, and freedom to
choose practitioner
• Opioids make up to 3 percent of costs in shorter term claims
and between 15 and 20 percent of all medical costs in longer
term claims
• Travelers estimates medical costs currently make up 60
percent of workers’ comp claim costs and are projected to
increase to 67 percent by 2019
• Narcotics account for 25% of drug costs (NCCI, September 26,
2013)
• Utilization is a major driver in cost changes (NCCI, September
26, 2013)
Insurance Business May 17, 2013- Opioid Epidemic Plagues Workers’ Comp

16. Key Cost Areas for
Workers’ Compensation
• Epidemic of opioid use, overuse and abuse (prescribing,
utilization)
• Physician dispensing
• Costs associated with compound medications
• Converting brand opioids to generic alternatives

17. Chesapeake Employers-Prescribers by Specialty
Rank by
Cost Specialty
% of
Rxs
% of
Cost
# of Rxs
with MED
> 90
1 Physical Medicine & Rehabilitation 10.9% 14.4% 662
2 Internal Medicine 12.9% 13.9% 195
3 Physician Assistant 12.6% 11.5% 687
4 Nurse Practitioner 9.8% 10.2% 595
5 Family Medicine 8.4% 8.0% 220
6 Specialist 6.1% 5.9% 198
7 Psychiatry & Neurology 5.7% 5.8% 73
8 Pain Medicine 3.6% 5.8% 274
9 Anesthesiology 4.5% 4.9% 271
10 Orthopaedic Surgery 6.5% 3.2% 220
11 Registered Nurse 1.1% 2.2% 96
12 General Practice 1.5% 1.4% 291
13 Clinical Nurse Specialist 0.2% 0.8% 23
14 Neurological Surgery 1.4% 0.8% 55
15 Emergency Medicine 1.2% 0.6% 30
16 Surgery 0.7% 0.6% 24

18. Chesapeake Employers
Pharmacy/ Opioids - Interventions
• Early opioid utilization 60-90 days following injury
• Narcotic alert reporting
• Evidence-based-guidelines
• Alerts for MED > 120
• Narcotic scripts continuing 90 days following the
injury
• Houston cocktail report
• Formulary control using days from injury,
duration and number of refills
• Red flags in duplicate therapy, early refills,
multiple prescribers, poly-pharmacies
• Peer reviews, Independent Medical Evaluations

19. Chesapeake Employers’
Program Initiatives
• Pharmacy Benefit Manager (PBM) partnership on Fraud, Waste and
Abuse
• Pain Management group
• Pharmacy Nurse
• Behavioral Health Assessments
• Functional Restoration Programs
• Multidisciplinary Back Program
• State Regulatory Health Agency
• Identifying groups prescribing and or dispensing inappropriately
• Education of injured workers of the dangers of long term opioids
• Soft tissue algorithm to prevent medical and drug over utilization

20. RESULTS OF PHARMACY
INITIATIVES

21. Chesapeake Employers
2014 Percentage and Average of Narcotics Rxs
% Narcotics to total rxs Average narcotic rxs/claim
13
12 11
10
2011 2012 2013 2014
69%
66%
65%
61%
56%
58%
60%
62%
64%
66%
68%
70%
2011 2012 2013 2014

22. Chesapeake Employers’
Pharmacy Cost to Medical Cost
• 2014= 7.8%
• 2013= 11.8%
• 2012= 11.6%
• 2011= 11.4%
According to NCCI, national workers’ comp pharmacy spend is 19%
of total medical cost.

23. Chesapeake Employers -Top Therapy
Classes by % of plan cost & Rx count
0%
5%
10%
15%
20%
25%
30%
35%
% of
Plan Cost
% Rx Count

24. Chesapeake Employers - Top 10 Drugs By Percentage
of Plan Cost and Script Count in 2014
0%
2%
4%
6%
8%
10%
12%
% of
Plan Cost
% Rx Count
Express Scripts

25. Chesapeake Employers' Results-
Brand to Generic Initiative
Started in 2014
% generic
Rx count
% generic
cost
%
brand
Rx count
%
brand
cost
2014 82% 49% 18% 51%
2013 76% 38% 24% 62%

26. Chesapeake Employers
Drug Therapy Class Percentage of Yearly
Cost Variance
YEAR
2011 to
2012
2012 to
2013
2013 to
2014
OPIOID AGONISTS 14.32% -0.12% 4.34%
ANTICONVULSANTS-MISC 0.67% -15.42% 0.22%
OPIOID COMBINATIONS 9.77% 2.14% -6.89%
CENTRAL MUSCLE RELAXANTS 7.72% -8.26% 0.91%
NSAIDS- ANTI-INFLAMMATORY -8.68% -21.54% 6.76%

27. Chesapeake Employers
Top Five Drugs
Percentage of Yearly Cost Variance
YEAR
2011 to
2012
2012 to
2013
2013 to
2014
Oxycontin 13.84% 1.97% 3.07%
Lyrica 3.53% -19.36% -1.44%
Oxycodone HCL 1.60% -8.52% -40.67%
Oxycodone-
Acetaminophen 13.47% -9.51% -43.21%
Gabapentin 4.48% -15.60% -4.00%

28. Chesapeake Employers’
Office Dispensing Strategy
Office Dispensing- Maryland has no pharmacy fee schedule
• Re-pricing of dispensed drugs to PBM pricing
• Data analytics - prescribing data and by medical specialty
• PBM educational mailings to injured workers regarding
prescription drugs
• Direct outreach to injured worker by adjuster or nurse case
managers

29. 2014 Office Dispensing for a
Pain Management Practice
• Large pain management practice with large number of
physician extenders
• # distinct claims - 187 # of overall office visits - 1,208
office visits
• # of visits with a drug dispensed - 155 of the visits (238
scripts)
• 13% of visits with drug dispensed
• 1.5 scripts per visits

30. Chesapeake Employers
2014 Office Drug Dispensing
All Office Dispensing
0%
5%
10%
15%
20%
25%
30%
% cost
% scripts
Select office group
0%
5%
10%
15%
20%
25%
30%
35%
40%
% cost
% scripts

31. Select Office Group - Prescribers
Designation
% of Total Rx
Count
% of Total Plan
Cost
CRNP 77.52% 87.27%
MD/DO 21.28% 11.80%
PA 1.20% 0.94%

32. Chesapeake Employers’
Compound Drugs Initiatives
• Implementation of Chesapeake Employers’ evidence-based
Medical Policy
• Re-price each drug in compound mixture back to original
NDC#
• Peer reviews/ Independent Medical Evaluations
• Evaluate continued therapy upon pain reduction or
improvement in function

33. Chesapeake Employers’
Compound Drug Results
Year Rx Count Plan Cost
2014 148 $ 122,896.45
2013 233 $ 190,582.61
2012 194 $ 100,021.24
2011 311 $ 101,699.59

34. Conclusion-Key Points
• Build pain management expertise
• Provide early intervention!!!!
• Identify cost drivers
• Implement strategies to mitigate drug use, costs and abuse
• Reduce legacy claims
• Utilize evidence-based-medicine
• Identify red flags for at risk workers and prescribers
• Partner with Pharmacy Benefit Manager
• Explore Data Analytics
• Increase number of appropriate settlements

35. THANK YOU!
Stephen Fisher, M.D., Ph.D.
Sfisher@ceiwc.com
410-494-2173
8722 Loch Raven Blvd.
Towson, MD 21286

36. Using a PDMP
to Understand the True Effects
of a Medicaid Program
Targeting Opioid Misuse
Asheley Cockrell Skinner, PhD
Associate Professor
Injury Prevention Research Center
University of North Carolina at Chapel Hill

37. Disclosure Statement
Asheley Cockrell Skinner, PhD, has
disclosed no relevant, real, or apparent
personal or professional relationships with
proprietary entities that produce health
care goods and services.

38. Learning Objectives
• Identify national trends in opioid use and
expenditures.
• Outline strategies to identify and manage high-risk
claims within the workers’ compensation population.
• Describe the North Carolina Medicaid Lock-In
Program.

39. History: North Carolina
Medicaid Lock-In Program
• Medicaid-based programs are used to
minimize controlled substance misuse and
abuse, and improve continuity of care
– Mortality from overdose in Medicaid-eligible
populations is 5-7 times that of the general
population
– Medicaid Lock-In Programs are one such effort
• Recommended by the Center for Medicare and
Medicaid Services

40. History: North Carolina
Medicaid Lock-In Program
• Medicaid Lock-In Programs
– Constrain patients to a single pharmacy and/or
provider for their controlled substance
medications
• Improves the monitoring of controlled substance use
across multiple points in the health care system
– Virtually all states have them, though their design
varies widely

41. NC Medicaid Lock-In Program
• 2009 GAO audit showed NC as 1 of 5 states
with an unusually large number of controlled
substance claims
• North Carolina MLIP developed in response
– Implemented in October 2010

42. NC MLIP Eligibility Details
• Eligibility - In 2 consecutive months:
– Fill 6 or more opioid or benzodiazepine
prescriptions;
– Receive opioid or benzodiazepine prescriptions
from 3 or more unique providers; and/or
– Receive a direct provider referral
• Locked in for 12 months
– May utilize only 1 prescriber and 1 pharmacy, self-
specified, for all opioid or benzodiazepine
prescriptions

43. The MLIP Loophole:
Circumvention
• If there is no Medicaid claim associated with a
purchase (cash payment), prescriptions may
be obtained without being monitored
– Minimizes clinical and economic impact of Lock-In
programs
• Prescriptions may be misused, abused, or diverted
• Wastes Medicaid resources devoted to MLIP
administration

44. Research Objectives
1. Determine the effect of enrollment in the NC
MLIP on opioid prescriptions, including
volume, prescribers, and costs.
2. Determine the effect of enrollment in the NC
MLIP on circumvention of opioid
prescriptions.

45. Study Design
• Pre-post MLIP enrollment comparison
– October 2009 – June 2013
• One year prior to the initiation of the MLIP through the
first two years of implementation
• Controls
– Multiple observations used to minimize the effects
of regression to the mean
– Enrollment in the MLIP occurs for a group of
individuals each month, minimizing temporal
effects

46. Data Sources
1. North Carolina Medicaid Claims
2. North Carolina Controlled Substance Reporting
System (CSRS)
– State Prescription Drug Monitoring Program (PDMP)
– Does not capture Medicaid ID or other shared
identifiers
Records between these two systems were matched by
hand at the NC Division of Medical Assistance (DMA)
– Used names, addresses, dates of birth
– De-identified prior to acquisition by UNC

47. Analytic Approach
• Statistical models took advantage of
longitudinal nature of data
• Analysis based on restricted maximum
likelihood (REML) estimation mixed effects
regression model
– Controlled for within-individual correlations and
time effects

48. Population
4352 individuals | 99,798 months of data
Demographics
(n=4352)
AGE 35.23
SEX
Female 69.18
Male 30.82
RACE
White 77.91
Black 16.78
Other 5.31

49. Medicaid Claims Results
4352 individuals | 99,798 months of data
Opioid Claims Averages for MLIP Cohort
(by whether or not enrolled that month)
Overall Not Enrolled Enrolled p
Opioids
Any opioid claim 57.5 64.8 37.9 <0.001
Number of prescriptions 1.44 1.64 0.84 <0.001
Number of prescribers 0.51 0.56 0.35 <0.001
Total days supply received 22.67 23.72 19.48 <0.001
Total units received 86.1 91.97 68.32 <0.001
Total Medicaid payments 104.07 101.12 113.01 <0.001

50. Medicaid Claims Results
4352 individuals | 99,798 months of data
Multivariable Analysis of the Effect of MLIP Enrollment on Opioid Use
Unadjusted Adjusted
OR SE p OR SE p
Any prescription 0.19 0.002 <0.001 0.12 0.002 <0.001
B SE p B SE p
Number of prescriptions -1.16 0.012 <0.001 -1.16 0.012 <0.001
Number of prescribers -0.48 0.006 <0.001 -0.48 0.006 <0.001
Total days supply received -10.02 0.19 <0.001 -9.96 0.19 <0.001
Total units received -41.62 0.88 <0.001 -41.52 0.88 <0.001
Total Medicaid payments -23.75 2.56 <0.001 -23.85 2.58 <0.001

51. Multivariable Analysis of the Effect of MLIP Enrollment
on Opioid Circumvention
Unadjusted Adjusted
OR SE p OR SE p
Any circumvention 5.07 0.09 <0.001 5.11 0.14 <0.001
B SE p B SE p
Number of prescriptions 0.58 0.01 <0.001 0.58 0.01 <0.001
Prescribers 0.47 0.01 <0.001 0.48 0.01 <0.001
Units 23.33 0.80 <0.001 23.36 0.80 <0.001
Days supply 5.77 0.15 <0.001 5.76 0.15 <0.001
Circumvention Results
4352 individuals | 99,798 months of data

52. Potential MLIP Benefits
• Appropriate use of controlled substances -
reduced number of prescriptions and volume
per prescription
– Improved quality of care
– Cost savings

53. Potential MLIP Limitations
• Enrollees may be denied access to needed
medications
• Circumvention may have a significant impact
on the effectiveness of the MLIP
– Medicaid covers medical care related to
circumvented prescriptions

54. Lessons Learned
• Integrating PDMP and Medicaid claims allows
for a different picture of the effect of
Medicaid-based programs
– Future improvement to PDMPs should consider
shared identifiers to permit linkages

55. Conclusions
• Limited evaluation of MLIPs
– Appear to reduce opioid prescriptions
– Many opioids are relatively inexpensive – enrollees
may attempt to circumvent the system by paying cash
• Limited information sharing between Medicaid
and PDMPs
– Need PDMPs to collect and share payment methods
– Need the sharing of a random unique identifier for
linking purposes

56. Third-Party Payer Track:
Financial Toll of Rx Addiction
Presenters:
• Chao Zhou, PhD, Economist, National Center for Injury
Prevention and Control, CDC
• Stephen N. Fisher, MD, PhD, Medical Advisor to the CEO,
Chesapeake Employers’ Insurance Company
• Asheley Cockrell Skinner, PhD, Associate Professor, Injury
Prevention Research Center, UNC - Chapel Hill
Moderator: Grant T. Baldwin, PhD, MPH, Director, Division of
Unintentional Injury Prevention, National Center for Injury
Prevention and Control, CDC, and Member, Rx Summit
National Advisory Board