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Tpp 2 eadie wood_baumgartner


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Third-Party Payer: PDMP Coordination with Third-Party Administrators - Chris Baumgartner, John Eadie and Bruce Wood

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Tpp 2 eadie wood_baumgartner

  1. 1. PDMP COORDINATION WITH THIRD PARTY PAYERS   John L. Eadie Director, Prescription Drug Monitoring Program Center of Excellence, Brandeis University Bruce C. Wood Associate General Counsel & Director, Workers’ Compensation American Insurance Association Chris Baumgartner PMP Director, Washington State Department of Health Atlanta Marriott Marquis Atlanta, Georgia April 22, 2014
  2. 2. Disclosure Statements   •  John  Eadie  has  no  financial  rela0onships  with   proprietary  en00es  that  produce  health  care  goods   and  services.   •  Bruce  Wood  has  no  financial  rela0onships  with   proprietary  en00es  that  produce  health  care  goods   and  services.   •  Chris  Baumgartner  has  no  financial  rela0onships   with  proprietary  en00es  that  produce  health  care   goods  and  services.  
  3. 3. Learning Objectives   1.  State  the  basis  for  broad  access  to  PDMP  database,   including  third-­‐party  administrators.   2.  Iden0fy  specific  strategies  for  third-­‐party   administrators  to  u0lize  their  state  PDMP  data.   3.  Outline  approaches  to  data  sharing  among  states.  
  4. 4. Prescrip)on  Drug  Monitoring   Programs  and   Third  Party  Payers  Mee)ng  Report   Working  Together  to  Assure  Safe  Prescribing  and     Interdict  the  Prescrip9on  Drug  Abuse  Epidemic    Tuesday,  April  22nd  from  1:45  pm  –  3:00  pm   Atlanta,  GA  
  5. 5. PDMP  Provision  of  data  to     3rd  Party  Payers   As  of  2012    #  of  States  Data  shared  with    28      Medicaid  and/or  Medicare    8        Workers  Compensa0on      1      Private  3rd  Party  Payer  Program   Data  are  from  the  PDMP  Training  and  Technical  Assistance  Center     2012  survey  of  state  PDMPs.  
  6. 6. There  is  room  for  expansion  of  PDMPs   sharing  data  with  Third  Party  Payers.  
  7. 7. How  to  find  contact  informa)on     for  a  state’s  PDMP?   •   Go  to  -­‐  website  of  PDMP   Training  &  Technical  Assistance  Center  at  Brandeis   University   •   Go  to  the  leY  column  of  Homepage;  under  “State   Contact  Informa0on  and  click  on  the  link  for  “State   Contacts”   •   That  will  bring  up  the  name  of  the  primary  PDMP   contact(s)  in  each  state.     •   Click  on  a  name  and  the  individual’s  contact   informa0on  will  appear.    
  8. 8.  
  9. 9. How  to  find  other  informa)on     about  a  state’s  PDMP   •   On  the  homepage  of,  click  the  top   tab  marked  “Resources”     •   On  drop  down  menu,  click  “State  Profiles”   •   On  the  next  webpage,  click  the  state’s  name.   •   For  each  state,  there  is:     –  The  state  agency  administering  the  PDMP     –  Informa0on  about  the  state     –  Drug  schedules  monitored   –  Who  may  request  pa0ent  informa0on   –  Legisla0on  and  regula0ons    
  11. 11. II.  Tracking  and  Monitoring   Evaluate  exis0ng  programs  that  require  doctor  shoppers  and   people  abusing  prescrip0on  drugs  to  use  only  one  doctor  and   one  pharmacy.  The  PMP  Center  of  Excellence  at  Brandeis   University  will  convene  a  mee0ng  in  2011  with  private   insurance  payers  to  begin  discussions  on  these  topics.   (ONDCP/DOJ/HHS/SAMHSA)     Page  6   hhp://­‐ content/prescrip0on-­‐drugs/rx_abuse_plan_0.pdf    
  12. 12. PDMPs    &  Third  Party  Payers     First  Mee9ng   PDMPs     PBMs     Privately  Funded  3rd  Party  Payers     Publicly  Funded  3rd  Party  Payers   Workers  Compensa0on   Federal  Agencies  –  ONDCP,  BJA,  CDC,  CMS,  DEA,  FDA,   NIDA,  SAMHSA     Na0onal  Organiza0ons   Researchers  
  13. 13. Workgroups  at  Mee)ng  -­‐  1   Overview:  Sharing  Prescrip0on  Histories  with  Third   Party  Payers     Protec0ng  PDMP  Data  and  Ensuring  Appropriate   Use   Iden0fying  and  Overcoming  Barriers  to  Data  Sharing   Evalua0ng  Data  Sharing  Collabora0ons  
  14. 14. Workgroups  at  Mee)ng  -­‐  2   Sharing  Data  with  Health  Care  Systems   Iden0fying  Ques0onable  Ac0vity  by  Providers   Third  Party  Payer  Support  for  PDMPs   Enhancing  Drug  Abuse  Referral  and  Treatment  
  15. 15. PDMPs  should  be  authorized  to  share   prescrip)on  data  with  third  party  payers.   Insurers  have  a  central  role  to  play  in  assuring  quality   health  care  and  addressing  the  prescrip0on  drug  abuse   epidemic;  their  use  of  PDMP  data  is  key  to  an  effec0ve   response.     Without  it,  insurers  do  not  have  a  complete  picture  of   the  prescribing  and  dispensing  carried  out  by  network   prac00oners  and  provided  to  their  enrollees.  
  16. 16. Safeguards  are  essen)al   Providing  PDMP  data  to  third  party  payers  is  feasible   and  worthwhile  so  long  as  appropriate  safeguards  are   put  in  place  to  assure  use  is  appropriate,  data  are  kept   secure,  and  pa0ent  confiden0ality  is  maintained.     Insurers  must  address  concerns  about  denying   coverage  based  on  viewing  PDMP  data.  
  17. 17. Barriers  to  data  sharing     can  be  overcome.   Facilita0ng  insurers’  access  to  PDMP  data  requires   collabora0ve  efforts  on  the  part  of  all  stakeholders  to   modify  legisla0ve  and  regulatory  language  to  permit   such  access.     It  will  also  require  developing  policies  and  procedures   on  data  security,  standardiza0on,  and  interoperability.  
  18. 18. Data  sharing  policies  &  procedures  need   evalua)on  to  maximize  effec)veness.   Research  is  needed  to  iden0fy  process  and  outcome   measures  relevant  to  assessing  the  impact  of  third   party  payer  use  of  PDMP  data.     Research  could  also  focus  on  the  wider  public  health   impact  of  PDMP  u0liza0on  by  insurers,  helping  to  make   the  case  for  data  sharing  ini0a0ves.    
  19. 19. PDMPs  should  be  authorized  to   provide  data  to  health  care  systems.   Sharing  PDMP  data  with  health  care  systems  (e.g.,   the  VA,  Indian  Health  Service,  Tricare,  Kaiser   Permanente)  can  help  improve  medical  care  and   iden0fy  appropriate  paherns  of  prescribing  and  use   of  controlled  substances.     Such  sharing  can  also  permit  quality  assurance   programs  to  earlier  iden0fy  and  intervene  in   problema0c  prescribing.  
  20. 20. Insurers  should  use  PDMP  data  to  iden)fy   ques)onable  prescribing  &  dispensing.   PDMP  data  on  medical  providers  can  be  used  to  help   iden0fy  fraud,  monitor  provider  performance,  and   detect  pharmacy  non-­‐compliance  with  insurance   regula0ons.     Third  party  payers  and  the  wider  public  would  benefit   from  use  of  PDMP  data  to  monitor  prescriber  and   dispenser  behavior.  
  21. 21. Third  party  payers  should     support  PDMPs.   Since  PDMP  data  can  play  an  important  role  in  insurers’   efforts  to  improve  medical  care  and  reduce  costs,  they   should  consider  assis0ng  PDMPs  by  means  such  as:     – educa0ng  policy  makers,     – direct  contribu0ons,  or     – collabora0ve  efforts  to  secure  stable  sources  of   funding.    
  22. 22. Providers  should  be  encouraged  to   refer  pa)ents  to  treatment.   A  primary  goal  of  use  of  PDMP  data,  including  by  third   party  payers,  should  be  the  iden0fica0on  of  individuals   in  need  of  substance  abuse  treatment  or  beher  pain   management.       Providers  need  educa0on  and  training  in  the  use  of  the   PDMP  and  tools  such  as  SBIRT  (screening,  brief   interven0on,  referral  to  treatment).     Insurers  can  help  assure  that  these  objec0ves  are  met.  
  23. 23. PDMPs    &  Third  Party  Payers     Next  Steps:   Formally  release  report   Present  at  Na3onal  Summit  on  Rx  Drug  Abuse   Distribute  report  to  interested  par3es   Provide  informa3on  and  assistance  to  states  interested  in   adop3ng  recommenda3ons   Possible  next  steps,  for  example:   –  Plan  tests  of  data  sharing  in  some  states   –  Plan  steps  to  make  tests  feasible   –  Plan  evalua3on  of  tests    
  24. 24. Contact  Informa)on   John  Eadie,  MPA   Director   PMP  Center  of  Excellence   Brandeis  University   518-­‐429-­‐6397     Website:            
  25. 25. PDMP COORDINATION WITH THIRD PARTY PAYERS   Bruce C. Wood Associate General Counsel & Director, Workers’ Compensation American Insurance Association Atlanta Marriott Marquis Atlanta, Georgia April 22, 2014
  26. 26. PDMP COORDINATION WITH THIRD PARTY PAYERS   Disclosure  Statement   Bruce  Wood  has  no  financial  rela0onships  with   proprietary  en00es  that  produce  health  care   goods  and  services  
  27. 27. PDMP COORDINATION WITH THIRD PARTY PAYERS   2014 LEARNING OBJECTIVES 1.  State  the  basis  for  broad  access  to  PDMP  database,   including  third-­‐party  administrators.   2.    Iden)fy  specific  strategies  for  third-­‐party   administrators  to  u)lize  their  state  PDMP  data.   3.    Outline  approaches  to  data  sharing  among  states.  
  29. 29. I    Discussion/history  of  workers’   compensa)on  •  Evolu)on  of  this  social  insurance  program  over  the   past  century  =  first  w.c.  program  enacted  in  1911   (Wisconsin)   •  Subs)tute  for  tort  =  quid  pro  quo   •  Trauma)c/occupa)onal  diseases   •  Na)onal  Commission  on  State  Workmen’s   Compensa)on  Laws  (1972)  =  watershed  event/   states’  response     •  Post-­‐Na)onal  Commission  history  =  benefit   expansion;  financial  crisis  (later  ‘80s-­‐mid-­‐’90s)  
  30. 30. II    Key  Program  Elements   •  All  medical  treatment  “reasonable  and  necessary”  (w/o  co-­‐ pays,  deduc)bles,  exclusions,  dura)on  limits)  =  1st  dollar   coverage.   •  Indemnity  benefits  =  commonly  2/3  of  gross  “average  weekly   wages”  =  Paid  for:    Temporary  total  disability  (TTD),  temporary  par)al   disability  (TPD),  permanent  par)al  disability  (PPD),   permanent  total  disability  (PTD)   •  Voca)onal  rehabilita)on  benefits  =  evalua)on  and  re-­‐training   •  Survivor/dependents’  benefits  =  payable  for  life  or  un)l   remarriage;  dependents  un)l  18  or  22  if  enrolled  in  college  
  31. 31. 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  compensa)on   scheme?  Did  the  employer  intend  to  injure  the   worker?      
  32. 32. 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,  li)ga)on,  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?    Restric)ons?   Accommoda)ons?      
  33. 33. IV    The  Role  of  Workers’   Compensa)on  Medical  Treatment   Workers’  compensa)on  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  objec)ve  in  workers’  compensa)on  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  =  coordina)ng   medical  treatment  and  indemnity.      
  34. 34. The  Role  of  Workers’  Compensa)on   Medical  Treatment  –  cont’d  Because  workers’  compensa)on  medical  treatment  remains  first-­‐ dollar  coverage  –  with  no  demand-­‐side  controls  on  cost  and   u)liza)on  –  it  reinforces  need  of  payers  to  use  administra)ve  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  –  na)onal  =  ACOEM/ODG    Unit  price  controls  (fee  schedules)  =  Medicare  RBRVS/DRGs    Impairment  guidelines  =  AMA  Guides  to  the  Evalua)on  of   Permanent  Impairment  
  35. 35. The  Role  of  Workers’  Compensa)on   Medical  Treatment  –  cont’d  Delivering  medical  treatment,  )mely,  and  of  the  nature  and  intensity   needed,  requires  an  unimpeded  exchange  of  medical  informa)on   with  providers  and  evaluators.       •  No  authoriza)ons/releases  required  in  workers’   compensa)on.     •  System  is  intended  to  be  less  formal  than  civil  li)ga)on,  to   promote  quick  exchange  of  informa)on  in  the  employee’s   interest  in  receiving  necessary  and  )mely  medical   treatment,  in  evalua)ng  return-­‐to-­‐work  restric)ons  and   accommoda)ons  necessary,  and  in  an  employer’s   understanding  of  poten)al  health  and  safety  risks  posed  by   the  injury.      
  36. 36. The  Role  of  Workers’  Compensa)on   Medical  Treatment  –  cont’d   In  workers’  compensa)on,  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.    The  employer/insurer  is  obligated   under  statute  to  pay  benefits  w/in  a  specified  )me.  For  this   reason,  the  employee,  who  puts  his  condi)on  at  issue,  does  not   have  the  same  confiden)ality  expecta)ons  as  do  claimants  in  a   group  health  selng.    The  claimant  is  in  control  of  informa)on   that  legally  obligates  another  party  to  pay  benefits.        
  37. 37. The  Role  of  Workers’  Compensa)on   Medical  Treatment  –  cont’d   The  special  informa)onal  needs  of  workers’  compensa)on   payers  is  recognized  under  HIPAA:        “A  covered  en)ty  may  disclose  protected  health   informa)on  as  authorized  by  and  to  the  extent  necessary   to  comply  with  laws  rela)ng  to  workers’  compensa)on  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  authoriza)on,  or  opportunity  to   agree  or  object  is  not  required;  45  CFR  164.512(l)].      
  38. 38. The  Role  of  Workers’  Compensa)on   Medical  Treatment  –  cont’d    Where  state  law,  itself,  mandates  disclosure  without  authoriza)on,   disclosure  is  permired  under  HIPAA  rules  and  exempt  from  the   “minimum  necessary”  informa)on  disclosure  standard.    “A  covered   en)ty  may  use  or  disclose  protected  health  informa)on  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  en)ty  under  HIPAA  rules  also  may  disclose  informa)on   to  any  en)ty  as  necessary  for  payment,  although  the  covered  en)ty   may  disclose  the  amount  and  types  of  informa)on  necessary  for   payment.    
  39. 39. The  Role  of  Workers’  Compensa)on   Medical  Treatment  –  cont’d   In  brief,  HIPAA  does  not  erect  barriers  to  a  workers’  compensa)on   payer  obtaining  protected  health  informa)on,  whether  without  an   authoriza)on,  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  informa)on  from  medical  providers.     Some  states  =  explicit  mandates  to  release  informa)on  to   employer/insurer.    Other  states  impose  ex  parte  rules  on  physician   communica)ons  with  carrier  that  slow  evalua)on/ decisions.  
  40. 40. The  Role  of  Workers’  Compensa)on   Medical  Treatment  –  cont’d   To  the  Point:  It  is  essen9al  for  workers’  compensa)on  payors  to   obtain  access  to  prescrip)on  monitoring  program  data,  to   properly  assess  an  injured  worker’s  use  of  prescrip)on   medica)ons  and,  broadly,  to  provide  all  reasonable  and   necessary  medical  treatment  and  effec)vely  manage  disability.   Without  access,  it  is  not  possible  for  a  workers’  compensa)on   payer  to  know  the  full  extent  of  prescrip)on  drug  use,  because   a  worker  may  be  obtaining  prescrip)ons  under  other  benefit   systems  (e.g.,  Medicaid,  group  health,  Veterans)  or  has   prescrip)ons  through  other  providers  not  otherwise  reported.    
  41. 41. AIA  POLICY  POSITION   AIA  endorses  robust  PDMPs  as  one  key  element  for   comba)ng  opioid  abuse.        Mandatory  prescribing  and  dispensing  checking   of  database,  with  data  entry      Ac)ve  PDMPs  pushing  informa)on  to  prescribers   and  dispensers    Broad  access  to  PDMP  database,  including  3rd   party  payers  and  law  enforcement    Interstate  operability  
  42. 42. Use  of  opioids,  especially  long-­‐ac)ng  medica)on,  for   treatment  of  chronic  pain  in  workers’  compensa)on  can   increase  chances  of  a  “catastrophic  claim  ($100,000+)  by   almost  four  )mes.    Use  of  short-­‐ac)ng  opioids  raises   chances  by  almost  twice.    Average  claim  not  involving   opioids  =  $13,000.      -­‐-­‐  “The  Effects  of  Opioid  Use  on  Workers’  Compensa)on  Claim  Cost  in  the   State  of  Michigan;  Bernacki,  et.  al;  Journal  of  Occupa)onal  and  Environmental   Medicine,  August  2012.   OPIOID  ABUSE:     THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION    
  43. 43.  Average  claim  costs  of  workers  receiving  7+  opioid  prescrip)ons  for   back  problems  without  spinal  cord  involvement  =     –  3X  greater  than  for  workers  receiving  0  or  1  opioid  prescrip)on    Workers  receiving  mul)ple  opioid  prescrip)ons  =     –  2.7X  more  likely  to  be  off  work     –  4.7X  as  many  days  off  work     (Swedlow  et  al.,  CWCI  Special  Report  2008)   OPIOID  ABUSE:     THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION    
  44. 44. Prevalence  of  Fentanyl  in  California’s  Workers’  Compensa)on  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’   compensa)on  prescrip)ons  for  these  drugs,  which  represents  87%  of   the  morphine  equivalents  provided  to  injured  workers  accoun)ng  for   88%  of  all  Schedule  II  pharmacy  payments  in  the  CA  WC  system.   Nearly  half  of  Schedule  II  prescrip)ons  =  minor  back  injuries.      [CWCI  Research  Bulle)n  11-­‐05;  April  28,  2011]   OPIOID  ABUSE:     THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION    
  45. 45. AIA  endorses  robust  PDMPs  as  one  key  element  for   comba)ng  opioid  abuse.        Mandatory  prescribing  and  dispensing  checking   of  database,  with  data  entry      Ac)ve  PDMPs  pushing  informa)on  to  prescribers   and  dispensers    Broad  access  to  PDMP  database,  including  3rd   party  payers  and  law  enforcement    Interstate  operability       OPIOID  ABUSE:     THE  MOST  URGENT  ISSUE  FACING  WORKERS’   COMPENSATION    
  46. 46. Brandeis  3rd  party  payer  conference  agreed  unanimously  in   merit  of  access  to  PDMP  data    “Insurers  have  a  central  role  to  play  in  assuring  quality   health  care  and  addressing  the  prescrip)on  drug  abuse   epidemic;  their  use  of  PDMP  data  is  key  to  an  effec)ve   response.  Without  it,  insurers  do  not  have  a  complete   picture  of  the  prescribing  and  dispensing  carried  out  by   network  prac))oners  and  provided  to  their  enrollees.”     THIRD  PARTY  PAYER  ACCESS  
  47. 47. WHY  IS  THIS  SO  IMPORTANT  FOR  WC?    WC  Medical  Costs  are  about  2-­‐3%  of  na)onal  spend    Overwhelming  share  of  medical  costs  not  captured    WC   payers   have   no   ability   to   know   otherwise   what   is   being  paid  under  systems    WC   Prescrip)on   Drug   Costs   are   about   20%   of   WC   Medical  Costs;  Opioids  comprise  about  13%  -­‐-­‐  65%  of   Overall  Drug  Costs.      Numbers  mask  far  greater  impact  =  delayed  RTW   THIRD  PARTY  PAYER  ACCESS  
  48. 48. Brandeis  report  states:    “Safeguards  are  essen)al.  Providing  PDMP  data  to  third   party  payers  is  feasible  and  worthwhile  so  long  as  appropriate   safeguards  are  put  in  place  to  assure  use  is  appropriate,  data   are  kept  secure,  and  pa)ent  confiden)ality  is  maintained.   Insurers  must  address  concerns  about  denying  coverage  based   on  viewing  PDMP  data.”     THIRD  PARTY  PAYER  ACCESS  
  49. 49. WHAT  ARE  THE  IMPLICATIONS  FOR  WC?    WC   =   strong   safeguards   for   claimant   informa)on.   Claim   files  are  comprised  of  adjustor/arorney  work  product  =   policyholder  (employer)  against  whom  a  legal  claim  has   been  filed  and  to  whom  insurer  owes  defense  under  the   policy.     These   are   privileged   files.     No   release   of   informa)on  except  pursuant  to  process,  for  purposes  of   either   defending   claim   or   in   complying   with   claimant/ arorney  request/subpoena.         THIRD  PARTY  PAYER  ACCESS  
  50. 50.  Can  WC  Insurers  Deny  Coverage  Based  on  PDMP  Data?    No    Workers  are  not  policyholders;  employers  are.    Insurers  do  not  know  iden)ty  of  who  is  employed    WC   is   underwriren   based   on   employer’s   nature   of   business,  size,  number  of  employees,  and  experience.    WC  ra)ng  plans  do  not  inquire  into  individual  claims.    Role   of   ra)ng   plans:   Unit   Sta)s)cal   Plan,   Uniform   Classifica)on  System,  Uniform  Experience  Ra)ng  Plan     THIRD  PARTY  PAYER  ACCESS  
  51. 51. Brandeis  Report  States:    “Barriers  to  data  sharing  can  be  overcome.  Facilita)ng   insurers’  access  to  PDMP  data  requires  collabora)ve   efforts  on  the  part  of  all  stakeholders  to  modify  legisla)ve   and  regulatory  language  to  permit  such  access.  It  will  also   require  developing  policies  and  procedures  on  data   security,  standardiza)on,  and  interoperability.  “   THIRD  PARTY  PAYER  ACCESS  
  52. 52. IMPLICATIONS  FOR  WC    Policy  ra)onale  for  permilng  access  is  same   regardless  of  nature  of  3rd  party  payer    No   jus)fiable   dis)nc)on   between   public   and  private  payers    Sole  criterion  is  whether  purpose  of  access   and  use  of  data  meets  policy  objec)ves   THIRD  PARTY  PAYER  ACCESS  
  53. 53. Brandeis  Report  States:    “Data  sharing  policies  and  procedures  need  evalua)on   to  maximize  effec)veness.  Research  is  needed  to  iden)fy   process  and  outcome  measures  relevant  to  assessing  the   impact  of  third  party  payer  use  of  PDMP  data.  Research   could  also  focus  on  the  wider  public  health  impact  of   PDMP  u)liza)on  by  insurers,  helping  to  make  the  case  for   data  sharing  ini)a)ves.”     THIRD  PARTY  PAYER  ACCESS  
  54. 54. IMPLICATIONS  FOR  WC    Agree.        Extensive   WC   research   capabili)es   already   exist  to  measure  impact    -­‐-­‐  WCRI,  CWCI,  NCCI    CWCI   report   (2013)   measured   impact   of   California  WC  insurers’  access  to  CURES  data  =   significant   impact.     15:1   ROI   even   with   WC   insurers’  full  funding  of  CURES.       THIRD  PARTY  PAYER  ACCESS  
  55. 55. Brandeis  Report  States:    “PDMPs  should  be  authorized  to  provide  data  to   health  care  systems.  Sharing  PDMP  data  with  health  care   systems  (e.g.,  the  VA,  Indian  Health  Service,  Tricare,  Kaiser   Permanente)  can  help  improve  medical  care  and  iden)fy   appropriate  parerns  of  prescribing  and  use  of  controlled   substances.  Such  sharing  can  also  permit  quality  assurance   programs  to  earlier  iden)fy  and  intervene  in  problema)c   prescribing.”     THIRD  PARTY  PAYER  ACCESS  
  56. 56. IMPLICATIONS  FOR  WC    Agree.     CWCI   Study   iden)fied   considerable   misuse   of   opoids  in  CA  WC  system  =       High  rate  of  inappropriate  opioid  use;     Limits  in  statutes/rules/regs  make  it  difficult  to  regulate  within        tradi)onal  workers’  comp  controls     Graduated  use  associated  with  adverse  injured  worker  outcomes     Small  number  of  physicians  associated  with  high  prescribing  parerns     Rapid  increase  in  drug  tes)ng  associated  to  high  opioid  use  with  no   na)onal  guidelines  for  tes)ng     CURES  has  significant  poten)al  to  increase  QOC  and  lower  cost   THIRD  PARTY  PAYER  ACCESS  
  57. 57. Brandeis  Report  States:    “Insurers  should  use  PDMP  data  to  iden)fy   ques)onable  prescribing  and  dispensing.  PDMP  data   on  medical  providers  can  be  used  to  help  iden)fy   fraud,  monitor  provider  performance,  and  detect   pharmacy  non-­‐compliance  with  insurance  regula)ons.   Third  party  payers  and  the  wider  public  would  benefit   from  use  of  PDMP  data  to  monitor  prescriber  and   dispenser  behavior.”     THIRD  PARTY  PAYER  ACCESS  
  58. 58. IMPLICATIONS  FOR  WC    Agree.    See  CWCI  Study:    “CWCI  has  es)mated  that  almost  half  of  all  claims  with   Schedule  II  opioids  fall  outside  the  pain  management  medica)on   recommenda)ons  included  in  the  evidence-­‐based  medical   literature.    Many  workers’  compensa)on  payers,  as  well  as  other   stakeholders,  believe  that  access  to  the  CURES  system,  coupled   with  enhanced  medical  cost  containment  strategies  including   medical  provider  networks  (MPN)  monitoring  and  u)liza)on   review  (UR)  –could  significantly  reduce  the  average  number  of   prescrip)ons  and  the  average  dose  levels  of  workers’   compensa)on  claims  that  u)lize  opioids.”  Es9mated  Savings  from  Enhanced   Opioid  Management  Controls  through  3rd  Party  Payer  Access  to  the  Controlled  Substance  U9liza9on  Review   and  Evalua9on  System  (CURES);  Swedow;  Ireland,  January  2013.   THIRD  PARTY  PAYER  ACCESS  
  59. 59. Brandeis  Report  States:    “Third  party  payers  should  support  PDMPs.  Since   PDMP  data  can  play  an  important  role  in  insurers’   efforts  to  improve  medical  care  and  reduce  costs,  they   should  consider  assis)ng  PDMPs  by  means  such  as   educa)ng  policy  makers,  direct  contribu)ons,  or   collabora)ve  efforts  to  secure  stable  sources  of   funding.”     THIRD  PARTY  PAYER  ACCESS  
  60. 60. IMPLICATIONS  FOR  WC    AIA  =  No  official  policy  –  yet.    No  predisposi)on  to  object    CWCI  study  of  CURES  suggests  significant  cost-­‐ effec)veness  to  access  to  PDMP  data   THIRD  PARTY  PAYER  ACCESS  
  61. 61. •  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. •  Funding cut in 2010; SB 809 restores funding for operations; limits on use and access CURES Background Pain  Management  in  the  California  Workers’  Comp  System   Controlled  Substance  U0liza0on  Review     &  Evalua0on  System    (CURES)   CWCI  2012.    All  Rights  Reserved  
  62. 62. Claims  w/   Opioid  Scripts CA  Claim  Count   (2010) Pcnt  of   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% 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 Pain  Management  in  the  California  Workers’  Comp  System   Controlled  Substance  U0liza0on  Review     &  Evalua0on  System    (CURES)   CWCI  2012.    All  Rights  Reserved  
  63. 63. Controlled  Substance  U0liza0on  Review  and  Evalua0on  System            CURES:  ROI  for  California  Workers’  Compensa0on  (2012)   Claims  w/   Opioid  Scripts Avg  Cost/  Claim   (2010) Total  Payments Est  %   Savings Total  Es0mated   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     Actual  savings  will  depend  upon  several  factors  including:   •  Medical  &  Rx  trends,  Injury  mix;   •  Appropriate  statutes,  rules  and  regs.   CURES  Opera0ng  Budget  (Est.):  $3,700,000   ROI  for  CA  WC:  $15.5  :  $1 Pain  Management  in  the  California  Workers’  Comp  System   CWCI  2012.    All  Rights  Reserved  
  64. 64. Brandeis  Report  States:    “Providers  should  be  encouraged  to  refer  pa)ents   to  treatment.  A  primary  goal  of  use  of  PDMP  data,   including  by  third  party  payers,  should  be  the   iden)fica)on  of  individuals  in  need  of  substance   abuse  treatment  or  berer  pain  management.   Providers  need  educa)on  and  training  in  the  use  of   the  PDMP  and  tools  such  as  SBIRT  (screening,  brief   interven)on,  referral  to  treatment).  Insurers  can  help   assure  that  these  objec)ves  are  met.”     THIRD  PARTY  PAYER  ACCESS  
  65. 65. IMPLICATIONS  FOR  WC    Agree.     Objec)ve   is   inherent   to   the   disability   management   focus   of   workers’   compensa)on   =   providing   evidence-­‐based   medical   treatment   of   proper  nature  and  intensity  to  expedite  recovery  and   return  to  work.     THIRD  PARTY  PAYER  ACCESS  
  66. 66. CONCLUSION    3rd  party  payer  access  is  jus)fied  by  the   seriousness  of  opioid  abuse  and  its  impact  on   society  and  the  workforce    3rd  party  payer  access  can  be  accomplished   with  necessary  privacy  protec)ons  while   providing  payers  with  the  informa)on   necessary  to  curb  unnecessary  and   inappropriate  treatment  and  to  deter  fraud   and  criminal  ac)vity.   THIRD  PARTY  PAYER  ACCESS  
  68. 68. April  22  –  24,  2014   Atlanta  Marrioh  Marquis   PDMP  Workshops:    PDMP  Coordina)on  with   Third-­‐Party  Administrators   Chris Baumgartner PMP Director Washington State Department of Health
  69. 69. Disclosure  Statement   Chris  Baumgartner  has  no  financial  rela0onships   with  proprietary  en00es  that  produce  health   care  goods  and  services.  
  70. 70. Learning  Objec)ves   1.  State  the  basis  for  broad  access  to  PDMP   database,  including  third-­‐party   administrators.   2.  Iden0fy  specific  strategies  for  third-­‐party   administrators  to  u0lize  their  state  PDMP   data.   3.  Outline  approaches  to  data-­‐sharing  among   states.  
  71. 71. Public  Insurer  Access   •  PDMP  Statute:  Allows  PDMP  data  to  be   provided  to  Medicaid  and  Workers’   Compensa0on   •  Primary  Goal:  To  provide  for  beher  pa0ent   care  and  promote  pa0ent  safety.   •  Secondary  Goal:  To  assist  our  public  insurers   in  preven0ng  fraud  and  saving  state  funding.    
  72. 72. Two  Types  of  Access   1.  Healthcare  Prac00oners  within  the  Health  Care  Authority   (HCA  -­‐  Medicaid)  and  Department  of  Labor  and  Industries   (LNI  –  Workers’  Compensa0on)  can  login  with  individual   account  access  and  request  a  pa0ent  history  report.   2.  Once  a  month  each  agency  provides  a  file  through  secure   file  transfer  of  all  their  clients/pa0ents  (names,  DOB).    Our   vendor  then  provides  matching  data  for  each  client/pa0ent   in  a  file  that  is  returned  through  secure  file  transfer.  
  73. 73. LNI  Early  Opioid  Interven0on  Pilot   •  Iden0fy  claims  that  are  15  -­‐  45  days  old  AND   received  ≥ 1  opioid  prescrip0ons  within  60   days  before  the  injury   •  Clinical  review  and  interven0on  by  a  nurse  or   pharmacist  as  necessary   •  Beher  coordina0on  of  medical  care  and   management  of  claims,  promote  use  of  PDMP   and  reduce  cost  and  disability  
  74. 74. LNI  -­‐  Early  Opioid  Interven0on  Pilot   •  350  –  500  new  claims  meet  this  criteria  each   month  (3-­‐4%  of  all  claims  allowed)   •  Priori0za0on  Criteria     –  Chronic  opioid  use  (≥  3  prescrip0ons  in  previous  3  months)   –  High  dose  opioid  (>  120mg/d  MED)   –  Other  controlled  substances  (e.g.  benzodiazepines,  seda0ve-­‐hypno0cs   –  Timeloss  (wage  replacement)   •  Clinical  review  is  priori0zed  by  the  number  of   criteria  met  
  75. 75. LNI  Opioid  Guidelines  (July  2013)   •  Opioids  in  the  Acute  Phase  (0-­‐6  weeks  aYer  injury  or   surgery)   –  Should  check  PDMP  before  prescribing  opioids     •  Opioids  in  the  Sub  Acute  Phase  (between  6  and  12   weeks)     –  Access  PDMP  to  ensure  CS  history  is  consistent   •  Ongoing  Chronic  Opioid  Therapy  (every  12  weeks)     –  No  aberrant  behavior  iden0fied  by  PDMP  or  UDT  
  76. 76. LNI  Opioid  Guidelines  (July  2013)   •  Opioids  for  Catastrophic  Injuries   –  Injuries  in  which  significant  recovery  of  physical  func0on  is   not  expected  (e.g.  severe  burns,  crush  or  spinal  cord   injury)   –  No  aberrant  behavior  iden0fied  by  PDMP  or  UDT   •  Before  Surgery  -­‐  Surgeon  and  Ahending  Provider   should:     –  Access  the  PDMP  and  review  worker’s  controlled   substance  history  to  get  accurate  informa0on  on  opioid   dose   •  For  more  informa0on:   –   hhp://    
  77. 77. HCA  –  Pa0ent  Review  &  Coordina0on  (PRC)   •  Aimed  at  over-­‐u0lizing  clients   •  Decrease  and  control  over-­‐u0liza0on  and  inappropriate  use  of   health  care  services   •  Minimize  medically  unnecessary  services  and  addic0ve  drug  use   •  Client  and  provider  educa0on  and  coordina0on  of  care   •  Assist  providers  in  managing  PRC  clients  by  providing  available   resource  informa0on  to  facilitate  coordina0on  of  care   •  Reduce  overall  expenditures  
  78. 78. PDMP  Assistance  to  PRC  to  Date   •  As  of  May  2012  the  PDMP  has  assisted  in  iden0fying   20  clients  for  the  PRC  program  to  date  (through  5   months  of  using  just  the  individual  query  site)   •  The  minimum  0me  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.   78  
  79. 79. 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  PDMP   prescrip0on.   •  Of  the  1,170  clients  filling  prescrip0ons     –  489  Clients  paid  cash  for  2,470  prescrip0ons.  And  243  addi0onal   clients  are  listed  as  paid  by  04  private  insurance  with  an   addi0onal  2,059  prescrip0ons.  This  would  be  a  total  of  732  clients   filling  4,529  total  prescrip0ons   –  By  contrast  898  clients  filled  12,240  prescrip0ons  paid  for  by   Medicaid  during  this  same  period.   79  
  80. 80. Future  HCA  Plans   •  HCA  will  look  to  use  bulk  data  to  augment  the  lock-­‐in  PRC   program   •  HCA  will  explore  providing  data  to  managed  care  plans   they  contract  with   •  HCA  will  look  to  use  the  data  to  monitor  Subxone  use   among  clients   •  HCA  is  considering  sending  threshold  reports  to:   –  Prescribers  with  clients  prescrip0on  informa0on   –  Pharmacies  who  accept  cash  from  Medicaid  clients  in   viola0on  of  their  core  provider  agreement   –  Inform  their  managed  care  plans  of  provider  outliers   80  
  81. 81. •  Chris  Baumgartner,  PMP  Director   –  Washington  State  Department  of  Health   –  Phone:  360.236.4806   –  Email:   –  Website:  hhp://   Program  Contact