This document discusses opioid dependence issues faced by health plans and strategies to address them. It identifies barriers to responsible pain management like lack of provider information, skills, and external incentives. Health plans have data on total costs across settings that can identify population problems and inform practices. Strategies for health plans include using data to educate providers, changing policies, and working with providers on care coordination, prior approvals, pharmacy management, and innovative payment models. The best approaches coordinate objective patient information, expert collaboration, and payment reform focused on total cost of care.

1. Opioid Dependence: Health
Plan Problems and Strategies
Kelly J. Clark, MD, MBA, DFAPA, FASAM
Medical Director of Behavioral Health
CDPHP, Albany NY

2. Disclosure Statement
• All presenters for this session, Dr. Kelly J.
Clark and Dr. Nathaniel P. Katz, have
disclosed no relevant, real or apparent
personal or professional financial
relationships.

3. Learning Objectives:
• 1. Identify barriers to responsible pain management that
does not contribute to an addiction or to diversion
activities.
• 2. Outline best practice strategies for patient monitoring
to prevent over-prescribing and dispensing.
• 3. Explain the importance of coordinating care between
health care providers and facilities.

4. Health Plan concerns:
• Value = Quality / Cost
• Behavioral Health = Mental Health, SUDs and
Health Behaviors
• Total Cost of Care:
– Primary Care Physician - Hospital
– Specialist - non-MD providers
– Pharmacy - Imaging
– ER and Urgent care - labs

5. Barriers to responsible pain management,
or
Why might MD s overprescribe?
• Lack of information
• Lack of skill
• External reinforcement

6. Lack of information
- What are proper prescription patterns
- Which patients are at risk for problems
- Whether a patient has demonstrated a problem
- Where they can access expert consultation

7. Lack of skill
– Managing patient expectations
– Confronting problematic patient behaviors
– Working collaboratively with other providers
– Using a biopsychosocial approach

8. External reinforcement
- Payment models rewarding more quickly
writing pills than talking with patients
- The Fifth Vital Sign quality metric
- Pay for high patient satisfaction

9. Health Plans:
Keepers of the Data
• Claims data from all areas:
– Primary Care Physician - Hospital
– Specialist - Labs
– Pharmacy - Imaging
– ER and Urgent care - non-MD providers
• These can be used by individual providers and
larger systems to improve care and decrease
cost

10. Uses of plan data:
population management issues
• Health plan data can show the range of practice
patterns in a community
• UDS claims study
• Example emergency department utilization to
obtain controlled drug rx

11. Trust, but Verify: the UDS
• Urine Drugs Screens should be like a blood
glucose level
• Clinicians need to understand what yields false
positives and false negatives
• Who is at risk for substance misuse?
– humans

12. CDPHP
• Regional, non-profit, physician-directed health plan
(Albany, NY)
• 350,000 covered lives
• All LOB (Medicare, Medicaid, Commercial, ACO)

13. Rates of Drug and/or
alcohol screenings
– Continuously enrolled for 12 months
– 275 days of fill of any controlled substance (75%)
– drug screening code 80100/80101,G0434,G0431

14. Results : 1 year controlled drug use
and UDS
• Medicaid population = 16.8% members
• Medicaid population = 27.9% 1 year Rx
• 7.6% of all members with chronic prescriptions
had a drug screen within the year

15. Use of ER to obtain
controlled drug Rx
• Claims data from first 6 months of 2011
• ER claims
• Fills for controlled drugs within 2 days of ER visit
• Voluntary inpatient admissions for detoxification or
substance abuse rehabilitation

16. 1 visit with a prescription

17. 3 visits with a prescription

18. If an ER doc gives
a controlled drug prescription:
• 1/58 of our commercial members they give it to use the
ER three times January to July
• 1/9 of our Medicaid/FHP members they give it to use the
ER three times January to July for controlled drugs.
• Or, 1/37 of the Medicaid/FHP members in an ER right
now use the ER 3 times for controlled drug from
January to July

19. Addiction admissions who
obtained rx from ER

22. Intermittent Schedule of Reinforcement
- 4.1 pills per rx is the average of the top 10 ER
prescribers
- 20 pills or more are given in 1/15 total ER prescription
- The variability in practice pattern is high, and inversely
related to numbers of prescriptions written

23. Plan data can drive education
and policy
-Educating ER prescribers on practice patterns
-Altering policies measuring quality in ERs
-Educating all prescribers on need for UDS
(including ER docs)
-provider systems can work with plans to get the
data needed

24. Plan strategies: working with
providers to improve monitoring and
decrease over-prescribing
• Information exchange
• Care Coordination
• Prior Approval
• Pharmacy management
• Innovative payment programs

25. Health plan tools:
Information exchange
Primary Care Physician could get info if:
• Pt seen in ER
• Pt admitted to hospital
• Pt filled Prescriptions
• Pt seen by specialists
• Pt had imaging

26. Health Plan tools:
Care Coordination
• calls between providers
• calls to patients
• helping support adherence
• helping support access to ancillary services
– (often social services or behavioral health)

27. Health Plan tools:
Prior Approval
• Stops unnecessary re-imaging for pain complaints
• Pharmacy management
– Can be a quality reinforcer

28. Health Plan tools:
Pharmacy management
• Monitors for abuse/diversion
– # of prescriptions, # of prescribers, # of pharmacies, # of pills, #
of meds in each class
• Quantity limits (# pills, # Rxs)
• Block payments for prescriptions
– Restrict pharmacy, prescribers, pills, facilities
• Feedback to prescribers

29. Health plan tools:
Innovative payment programs
- bundled payments for multidisciplinary pain programs
- buprenorphine spoke-and-wheel
- behavioral medicine and/or care coordination as part of
PCMH

30. Best Strategies:
• Obtain objective information on your patients:
– UDS
– where they are seen, by whom, with what treatment
• Obtain collaboration with addictionist experts:
– ASAM
– PCSS
• As payment reform happens, work with payers:
– Develop the programs your community needs
– Look at total cost of care ( ER, inpatient, Labs,
pharmacy, imaging, as all related to MH/SUDs)

31. Network for assistance
• www.asam.org
Addiction physician s medical society
• http://www.pcssprimarycare.org/
Provides addictionist mentors for PCPs