Addressing Medical Necessity Denials and RecoupmentsPYA, P.C.
With increased denials and recoupments related to medical necessity at the forefront of discussions at this year’s American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues, PYA was prepared to inform and assist providers instituting best practices to address medical necessity denials. PYA Principal Denise Hall-Gaulin co-presented “Medical Status-Current Status/Key Best Practices in Prevention of Medical Necessity Denials and Recoupments” with Michael Spake, VP of External Affairs and Chief Compliance and Integrity Officer at Lakeland Regional Health.
The presentation included:
A discussion of medical necessity—what it means and what it affects
Information regarding medical necessity determinations and criteria for determination
Definitions for categorically excluded services
Criteria for admission (skilled nursing facilities and inpatient rehabilitation facilities included)
This document provides an overview of e-prescribing requirements, incentives, and penalties related to Meaningful Use and the e-Prescribing Incentive Program. It summarizes proposed changes to Meaningful Use Stage 2 objectives that relate more directly to e-prescribing. It also outlines the criteria for avoiding penalties in 2013 and 2014, including qualifying for incentives, reporting a minimum number of e-prescriptions, or applying for a hardship exemption. The document concludes with best practices for e-prescribing.
This document discusses the advantages of an integrated managed pharmacy solution for health systems. It begins with an introduction of the presenter, Mike Medel, and his background in helping health systems leverage pharmacy programs. It then discusses the traditional PBM model and how the PBM landscape has changed. The main portion explains how fully integrating the pharmacy benefit allows health systems to better manage costs, drive revenue, and improve care for employees and risk partners. It provides examples of how integration across specialties within a health system can optimize the pharmacy benefit management model.
The Physician Quality Reporting Initiative (PQRI) was established by Congress in 2006 to improve quality reporting in healthcare. It provides incentives for eligible professionals to satisfactorily report data on quality measures for their Medicare patients. Professionals can report either through claims-based reporting using CPT codes or registry-based reporting which involves submitting data to a registry. While the program aims to encourage adoption of electronic health records, participation is currently voluntary though incentives are in place.
The document summarizes changes to the Meaningful Use Stage 2 rules for electronic health record incentive programs. Key changes include allowing a 90-day reporting period in 2017 for first-time participants and those choosing to implement Stage 3 in 2017. It modifies measures related to patient engagement, public health reporting, and thresholds for Stage 3 objectives like computerized provider order entry and electronic prescribing. The final rule also changes the 2015 reporting period to 90 days and aligns future periods with the calendar year. It streamlines programs by removing redundant measures and modifies several objectives and measures for Stages 1, 2 and 3.
E-Prescribing Controlled Substances: Opportunities and Experiences - May 2014...Forward360 LLC
Electronic prescribing of controlled substances (EPCS) provides opportunities to improve safety and reduce fraud compared to paper prescriptions. EPCS is now legal in all but two states, though adoption has been limited due to lack of awareness, competing IT priorities, and geographic disparities between enabled pharmacies and providers. Experiences from providers and pharmacies already using EPCS show benefits like increased accountability, accuracy, and reduced costs. Widespread adoption could save up to $700 million annually through improved medication management.
Understanding the Physician Quality Reporting System (PQRS) Requirements in 2014Practice Fusion
This webinar, Understanding the Physician Quality Reporting System (PQRS) Requirements in 2014, goes over which reporting options are available, what the incentives and penalties are for participating, reporting requirements, and how to choose quality measure for reporting.
Addressing Medical Necessity Denials and RecoupmentsPYA, P.C.
With increased denials and recoupments related to medical necessity at the forefront of discussions at this year’s American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues, PYA was prepared to inform and assist providers instituting best practices to address medical necessity denials. PYA Principal Denise Hall-Gaulin co-presented “Medical Status-Current Status/Key Best Practices in Prevention of Medical Necessity Denials and Recoupments” with Michael Spake, VP of External Affairs and Chief Compliance and Integrity Officer at Lakeland Regional Health.
The presentation included:
A discussion of medical necessity—what it means and what it affects
Information regarding medical necessity determinations and criteria for determination
Definitions for categorically excluded services
Criteria for admission (skilled nursing facilities and inpatient rehabilitation facilities included)
This document provides an overview of e-prescribing requirements, incentives, and penalties related to Meaningful Use and the e-Prescribing Incentive Program. It summarizes proposed changes to Meaningful Use Stage 2 objectives that relate more directly to e-prescribing. It also outlines the criteria for avoiding penalties in 2013 and 2014, including qualifying for incentives, reporting a minimum number of e-prescriptions, or applying for a hardship exemption. The document concludes with best practices for e-prescribing.
This document discusses the advantages of an integrated managed pharmacy solution for health systems. It begins with an introduction of the presenter, Mike Medel, and his background in helping health systems leverage pharmacy programs. It then discusses the traditional PBM model and how the PBM landscape has changed. The main portion explains how fully integrating the pharmacy benefit allows health systems to better manage costs, drive revenue, and improve care for employees and risk partners. It provides examples of how integration across specialties within a health system can optimize the pharmacy benefit management model.
The Physician Quality Reporting Initiative (PQRI) was established by Congress in 2006 to improve quality reporting in healthcare. It provides incentives for eligible professionals to satisfactorily report data on quality measures for their Medicare patients. Professionals can report either through claims-based reporting using CPT codes or registry-based reporting which involves submitting data to a registry. While the program aims to encourage adoption of electronic health records, participation is currently voluntary though incentives are in place.
The document summarizes changes to the Meaningful Use Stage 2 rules for electronic health record incentive programs. Key changes include allowing a 90-day reporting period in 2017 for first-time participants and those choosing to implement Stage 3 in 2017. It modifies measures related to patient engagement, public health reporting, and thresholds for Stage 3 objectives like computerized provider order entry and electronic prescribing. The final rule also changes the 2015 reporting period to 90 days and aligns future periods with the calendar year. It streamlines programs by removing redundant measures and modifies several objectives and measures for Stages 1, 2 and 3.
E-Prescribing Controlled Substances: Opportunities and Experiences - May 2014...Forward360 LLC
Electronic prescribing of controlled substances (EPCS) provides opportunities to improve safety and reduce fraud compared to paper prescriptions. EPCS is now legal in all but two states, though adoption has been limited due to lack of awareness, competing IT priorities, and geographic disparities between enabled pharmacies and providers. Experiences from providers and pharmacies already using EPCS show benefits like increased accountability, accuracy, and reduced costs. Widespread adoption could save up to $700 million annually through improved medication management.
Understanding the Physician Quality Reporting System (PQRS) Requirements in 2014Practice Fusion
This webinar, Understanding the Physician Quality Reporting System (PQRS) Requirements in 2014, goes over which reporting options are available, what the incentives and penalties are for participating, reporting requirements, and how to choose quality measure for reporting.
Did you know that ALL of your Medicare reimbursements will be docked if you don't participate in the PQRS reporting program? This applies to mental / behavioral heath and substance abuse providers - get the full scoop in our guide.
This slide deck provides a detailed overview of the PQRS program, including helpful information on how to report for PQRS using the claims-based reporting method. Learn how to report Quality Data Codes for PQRS on Medicare claims and avoid penalties!
NCQA’s Accreditation process provides payers with a comprehensive framework to improve quality of care and services. It allows members and employers to compare health plan performance across various plans and against industry benchmarks. NCQA accreditation has 3 parts – HEDIS, Patient experience CAHPS measures and NCQA standards
1. Behavioral health providers can participate in the Connecticut Medicaid EHR Incentive Program by having their rendering providers reassign incentive dollars back to the agency.
2. To participate, providers must have an individual Connecticut Medical Assistance Program provider ID and attest that they have adopted, implemented, or upgraded to a certified EHR system.
3. Eligible provider types include physicians, nurse practitioners, certified nurse-midwives, dentists, and physician assistants working in federally qualified health centers. Providers must also meet patient volume requirements related to Medicaid patients.
The document provides an overview of the Part D Senior Savings Model proposed by CMS Innovation Center. The model aims to lower out-of-pocket costs for insulin by establishing a stable $35 copay for eligible insulins through the deductible, initial coverage, and coverage gap phases of Part D plans. The model would be voluntary for manufacturers, Part D plans, and beneficiaries. It also outlines the application process and timelines for manufacturers and Part D plans to participate in the 2021 plan year.
The document summarizes the Medicare Access and CHIP Reauthorization Act (MACRA) which repeals the Sustainable Growth Rate formula and shifts Medicare payments to value-based and alternative payment models. MACRA establishes two payment tracks - the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). MIPS consolidates existing quality programs and provides payment incentives or penalties based on a performance score. APMs offer additional rewards for physicians meeting thresholds for payments or patients in eligible models.
This document discusses several topics related to healthcare finance and quality reporting systems:
1) It summarizes the goals of the Physician Quality Reporting System (PQRS) and Value-Based Purchasing System (VBPS), including improving quality of care and tying reimbursement to quality metrics.
2) It outlines the roles of Health Information Management professionals in supporting these programs through data analytics and quality reporting.
3) It describes the roles of Quality Improvement Organizations in ensuring accurate medical coding and documentation for reimbursement.
4) It provides an overview of several laws and acts aimed at reducing healthcare fraud, including the Anti-Kickback statute and their effects on providers.
The document discusses commissioning for outcomes in mental health in the UK. It covers identifying and prioritizing high-level outcomes, using outcomes-based research to focus commissioning plans, specifying outcomes in service contracts, and monitoring outcomes to evaluate service delivery. OptumHealth's approach is presented as an example that uses patient questionnaires, algorithms, and predictive modeling to monitor outcomes and improve quality of care.
HRS provides healthcare executive relationship services and solution assessments focused on improving the patient experience and addressing challenges caused by ACA mandates. There are several challenges impacting the patient-provider relationship, including patient experience metrics that impact reimbursement, an increasing number of uninsured patients, constraints on caregiver capacity, becoming a data-driven organization, delivering integrated care throughout the patient lifecycle, accurate ordering and revenue cycle management, quickly implementing ACA requirements, transitioning to a value-based and patient-centric model with price transparency, and accelerating accurate claims cycles. HRS' solutions aim to address these challenges through approaches like accelerated learning, virtual offices, data analytics platforms, communication and workflow solutions, performance management, and improving order accuracy
Impact of the Government Shutdown on Synchrogenix FDA-regulated ClientsDarshan Kulkarni
The document summarizes how the US government shutdown in January 2019 impacted operations at the FDA and activities related to drug and medical device development. It notes that some FDA activities could continue using carryover user fees, including reviewing certain submissions and advancing some policies. However, the FDA could not accept new application submissions requiring fees or conduct all planned activities like issuing some guidances. Key FDA divisions were impacted differently depending on their funding sources. The document aims to help biopharma clients understand how the shutdown affected FDA operations and timelines.
Gates Healthcare Associates is a consulting firm that provides extensive clinical, regulatory, real estate, contract evaluation and business development services and expertise to pharmacies, medical practices, hospitals, and healthcare organizations
This document provides an overview of compliance and regulatory topics related to medical coding and billing. It discusses Medicare parts A through D, private insurance plans, coding guidelines, place of service codes, fraud and abuse, National Correct Coding Initiative edits, coverage determinations, the Health Insurance Portability and Accountability Act, relative value units, medical necessity, and managed care plans like HMOs, POS, and PPOs. The goal is to correctly code and bill medical claims according to rules and avoid improper billing practices.
This document discusses telemedicine and remote patient monitoring in the United States. It provides an overview of the growth and policies around telemedicine in the US. It specifically highlights Teladoc as the largest and first telemedicine company to have an IPO. Teladoc provides virtual visits via internet, phone or video chat and aims to provide care within 10 minutes. It has over 6,000 business customers and 11.5 million members. The document summarizes Teladoc's business model, revenue sources, and recent acquisition of HealthiestYou.
The document discusses proposed expedited pathways for prescription medicines in Australia, including a Priority Review pathway. It outlines proposed eligibility criteria focusing on serious conditions with unmet needs where the medicine provides a major therapeutic advantage.
A draft designation process is presented involving assessment of eligibility criteria within 6-8 weeks. Designations would lapse if no registration submission is made within 3 months. Appeals of designation decisions are proposed.
Priority Review is aimed to complete assessments in 150 working days through flexible business processes and expert advice. Provisional Approval could grant earlier conditional registration based on early safety and efficacy data, with enhanced post-market monitoring required. Public consultation on
This document summarizes a presentation on the financial toll of prescription drug addiction from the perspective of third-party payers. It includes presentations from experts at the CDC, a private insurance company, and a university. The presentations outline national trends in opioid use and expenditures, strategies used by an insurance company to identify and manage high-risk opioid claims, and a description of North Carolina's Medicaid Lock-In Program aimed at curbing prescription drug misuse. The document provides disclosure statements for each presenter and learning objectives for the session.
The Medicare Diabetes Prevention Program (MDPP) Model Expansion Medicare Learning Network (MLN) Call was held from 1:30 p.m. – 3:00 p.m. EST on November 30, 2016. During this call, CMS experts provided a high-level overview of the finalized policies in the CY 2017 Medicare Physician Fee Schedule (PFS) final rule (the CY 2017 Medicare PFS final rule includes the expansion of the MDPP Model beginning January 1, 2018), reviewed the steps necessary for enrollment into Medicare as an MDDPP supplier, and answered some of the audiences most pressing questions.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document outlines a proposal for a new generation of Prescription Monitoring Programs (PMPs) to more proactively address the prescription drug abuse epidemic. Key aspects of the proposal include standardizing and speeding up data collection; identifying who picks up prescriptions; integrating with electronic prescribing; improving data quality; linking prescription records; providing online access to reports and automated alerts; and performing analyses to identify problematic prescribing patterns to target interventions. The goal is to move PMPs from a reactive to proactive role in confronting drug abuse and diversion.
Summary -- Patient Centered Medical Home the Necessary Foundation for Accountable Care and Population Management.
In the next 10 years, we will be living in 1) mobile world 2) in the middle of an aging and chronic disease epidemic and 3) data. But , we will also have the ability to analyze data in a cognitive way this will do for doctors’ minds what X-ray and medical imaging have done for their vision. How? By turning data into actionable information. Take, for instance, IBM’s intelligent supercomputer, Watson. Watson can analyze the meaning and con-text of human language and quickly process vast amounts of information. With this in-formation, it can suggest options targeted to a patient’s specific circumstances.
We need the basic foundation to support this transformation a system integrator where data at the level of a patients flows and is held accountable and that model is the Patient Centered Medical Home. (PCMH) starts to happen when clinicians/ healers step up to comprehensive relationship based care empowered by tools to manage the data and communicate effectively. This move to PCMH level care requires the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system and all of that is power by data made into meaningful information.
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The Patient-Centered Medical Home (PCMH) lies at the center of the effort to get at population health, integrated and coordinated care. PCMH is where the Primary care healer leads an organization that delivers clinician-led primary care, with comprehensive, accessible, holistic, coordinated, evidence-based coordination and management. In the USA this is now the standard in the US Veterans Administration and the US Military and under the ACA.
Providers know that successful care coordination is key to enhancing patient outcomes and better personalizing their experience. At its root, care coordination starts with effective communication, and healthcare organizations are increasingly turning to innovative technology solutions to solve their needs. To improve their care teams’ communication, coordination, and data capture capabilities, two of New York City’s leading healthcare organizations worked with two cutting edge tech solutions providers to design and implement innovative pilots as a part of the New York Digital Health Accelerator program. Utilizing real-life case studies, the panelists will discuss the design and implementation of the pilots, and lessons learned from their participation in the program.
• Anuj Desai - Vice President of Market Development, New York eHealth Collaborative
• Joseph Mayer, MD - Founder & CEO, Cureatr Inc.
• Patricia Meisner, MS, MBA - CEO & Co-Founder, ActualMeds
• Ken Ong, MD, MPH - Chief Medical Informatics Officer, New York Hospital Queens
• Victoria Tiase, MSN, RN - Director, Informatics Strategy, NewYork-Presbyterian Hospital
New York eHealth Collaborative Digital Health Conference
November 17, 2014
A Seven Step Approach to a Clinically Integrated Network.pdfPatWilson13
This document outlines a seven-step approach to building a clinically integrated network (CIN). The steps include: 1) gathering interested stakeholders; 2) creating a value proposition; 3) developing governance and participation agreements; 4) selecting quality measures; 5) recruiting physicians; 6) measuring and improving programs; and 7) engaging payers. The presentation emphasizes using data to benchmark quality, utilization, and costs in order to develop a sustainable incentive structure for the CIN. Yale New Haven Health System's experience in establishing its CIN, called the Total Health Network, is discussed as a case study.
Please share this video with anyone who may be interested!
Watch all our webinars: https://www.youtube.com/playlist?list=PL4dDQscmFYu_ezxuxnAE61hx4JlqAKXpR
In this webinar:
● Background to the role of private drug insurance plans in Canada
● Impact on access of recent developments in private insurance plan programs
● Future directions of private insurance in Canada
View the video: https://youtu.be/rik50CrMffY
Follow our social media accounts:
Twitter - https://twitter.com/survivornetca
Facebook - https://www.facebook.com/CanadianSurvivorNet
Pinterest - https://www.pinterest.com/survivornetwork
YouTube - https://www.youtube.com/user/Survivornetca
Surviving the Therapy Caps and Manual Medical Review with Nancy Beckley and C...Clinicient
How to Survive Therapy Caps and the Manual Medical Review with Physical Therapy and Rehab compliance expert Nancy Beckley and Clinicient, a proven leader in physical therapy EMR and practice Management solutions.
Did you know that ALL of your Medicare reimbursements will be docked if you don't participate in the PQRS reporting program? This applies to mental / behavioral heath and substance abuse providers - get the full scoop in our guide.
This slide deck provides a detailed overview of the PQRS program, including helpful information on how to report for PQRS using the claims-based reporting method. Learn how to report Quality Data Codes for PQRS on Medicare claims and avoid penalties!
NCQA’s Accreditation process provides payers with a comprehensive framework to improve quality of care and services. It allows members and employers to compare health plan performance across various plans and against industry benchmarks. NCQA accreditation has 3 parts – HEDIS, Patient experience CAHPS measures and NCQA standards
1. Behavioral health providers can participate in the Connecticut Medicaid EHR Incentive Program by having their rendering providers reassign incentive dollars back to the agency.
2. To participate, providers must have an individual Connecticut Medical Assistance Program provider ID and attest that they have adopted, implemented, or upgraded to a certified EHR system.
3. Eligible provider types include physicians, nurse practitioners, certified nurse-midwives, dentists, and physician assistants working in federally qualified health centers. Providers must also meet patient volume requirements related to Medicaid patients.
The document provides an overview of the Part D Senior Savings Model proposed by CMS Innovation Center. The model aims to lower out-of-pocket costs for insulin by establishing a stable $35 copay for eligible insulins through the deductible, initial coverage, and coverage gap phases of Part D plans. The model would be voluntary for manufacturers, Part D plans, and beneficiaries. It also outlines the application process and timelines for manufacturers and Part D plans to participate in the 2021 plan year.
The document summarizes the Medicare Access and CHIP Reauthorization Act (MACRA) which repeals the Sustainable Growth Rate formula and shifts Medicare payments to value-based and alternative payment models. MACRA establishes two payment tracks - the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). MIPS consolidates existing quality programs and provides payment incentives or penalties based on a performance score. APMs offer additional rewards for physicians meeting thresholds for payments or patients in eligible models.
This document discusses several topics related to healthcare finance and quality reporting systems:
1) It summarizes the goals of the Physician Quality Reporting System (PQRS) and Value-Based Purchasing System (VBPS), including improving quality of care and tying reimbursement to quality metrics.
2) It outlines the roles of Health Information Management professionals in supporting these programs through data analytics and quality reporting.
3) It describes the roles of Quality Improvement Organizations in ensuring accurate medical coding and documentation for reimbursement.
4) It provides an overview of several laws and acts aimed at reducing healthcare fraud, including the Anti-Kickback statute and their effects on providers.
The document discusses commissioning for outcomes in mental health in the UK. It covers identifying and prioritizing high-level outcomes, using outcomes-based research to focus commissioning plans, specifying outcomes in service contracts, and monitoring outcomes to evaluate service delivery. OptumHealth's approach is presented as an example that uses patient questionnaires, algorithms, and predictive modeling to monitor outcomes and improve quality of care.
HRS provides healthcare executive relationship services and solution assessments focused on improving the patient experience and addressing challenges caused by ACA mandates. There are several challenges impacting the patient-provider relationship, including patient experience metrics that impact reimbursement, an increasing number of uninsured patients, constraints on caregiver capacity, becoming a data-driven organization, delivering integrated care throughout the patient lifecycle, accurate ordering and revenue cycle management, quickly implementing ACA requirements, transitioning to a value-based and patient-centric model with price transparency, and accelerating accurate claims cycles. HRS' solutions aim to address these challenges through approaches like accelerated learning, virtual offices, data analytics platforms, communication and workflow solutions, performance management, and improving order accuracy
Impact of the Government Shutdown on Synchrogenix FDA-regulated ClientsDarshan Kulkarni
The document summarizes how the US government shutdown in January 2019 impacted operations at the FDA and activities related to drug and medical device development. It notes that some FDA activities could continue using carryover user fees, including reviewing certain submissions and advancing some policies. However, the FDA could not accept new application submissions requiring fees or conduct all planned activities like issuing some guidances. Key FDA divisions were impacted differently depending on their funding sources. The document aims to help biopharma clients understand how the shutdown affected FDA operations and timelines.
Gates Healthcare Associates is a consulting firm that provides extensive clinical, regulatory, real estate, contract evaluation and business development services and expertise to pharmacies, medical practices, hospitals, and healthcare organizations
This document provides an overview of compliance and regulatory topics related to medical coding and billing. It discusses Medicare parts A through D, private insurance plans, coding guidelines, place of service codes, fraud and abuse, National Correct Coding Initiative edits, coverage determinations, the Health Insurance Portability and Accountability Act, relative value units, medical necessity, and managed care plans like HMOs, POS, and PPOs. The goal is to correctly code and bill medical claims according to rules and avoid improper billing practices.
This document discusses telemedicine and remote patient monitoring in the United States. It provides an overview of the growth and policies around telemedicine in the US. It specifically highlights Teladoc as the largest and first telemedicine company to have an IPO. Teladoc provides virtual visits via internet, phone or video chat and aims to provide care within 10 minutes. It has over 6,000 business customers and 11.5 million members. The document summarizes Teladoc's business model, revenue sources, and recent acquisition of HealthiestYou.
The document discusses proposed expedited pathways for prescription medicines in Australia, including a Priority Review pathway. It outlines proposed eligibility criteria focusing on serious conditions with unmet needs where the medicine provides a major therapeutic advantage.
A draft designation process is presented involving assessment of eligibility criteria within 6-8 weeks. Designations would lapse if no registration submission is made within 3 months. Appeals of designation decisions are proposed.
Priority Review is aimed to complete assessments in 150 working days through flexible business processes and expert advice. Provisional Approval could grant earlier conditional registration based on early safety and efficacy data, with enhanced post-market monitoring required. Public consultation on
This document summarizes a presentation on the financial toll of prescription drug addiction from the perspective of third-party payers. It includes presentations from experts at the CDC, a private insurance company, and a university. The presentations outline national trends in opioid use and expenditures, strategies used by an insurance company to identify and manage high-risk opioid claims, and a description of North Carolina's Medicaid Lock-In Program aimed at curbing prescription drug misuse. The document provides disclosure statements for each presenter and learning objectives for the session.
The Medicare Diabetes Prevention Program (MDPP) Model Expansion Medicare Learning Network (MLN) Call was held from 1:30 p.m. – 3:00 p.m. EST on November 30, 2016. During this call, CMS experts provided a high-level overview of the finalized policies in the CY 2017 Medicare Physician Fee Schedule (PFS) final rule (the CY 2017 Medicare PFS final rule includes the expansion of the MDPP Model beginning January 1, 2018), reviewed the steps necessary for enrollment into Medicare as an MDDPP supplier, and answered some of the audiences most pressing questions.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
This document outlines a proposal for a new generation of Prescription Monitoring Programs (PMPs) to more proactively address the prescription drug abuse epidemic. Key aspects of the proposal include standardizing and speeding up data collection; identifying who picks up prescriptions; integrating with electronic prescribing; improving data quality; linking prescription records; providing online access to reports and automated alerts; and performing analyses to identify problematic prescribing patterns to target interventions. The goal is to move PMPs from a reactive to proactive role in confronting drug abuse and diversion.
Summary -- Patient Centered Medical Home the Necessary Foundation for Accountable Care and Population Management.
In the next 10 years, we will be living in 1) mobile world 2) in the middle of an aging and chronic disease epidemic and 3) data. But , we will also have the ability to analyze data in a cognitive way this will do for doctors’ minds what X-ray and medical imaging have done for their vision. How? By turning data into actionable information. Take, for instance, IBM’s intelligent supercomputer, Watson. Watson can analyze the meaning and con-text of human language and quickly process vast amounts of information. With this in-formation, it can suggest options targeted to a patient’s specific circumstances.
We need the basic foundation to support this transformation a system integrator where data at the level of a patients flows and is held accountable and that model is the Patient Centered Medical Home. (PCMH) starts to happen when clinicians/ healers step up to comprehensive relationship based care empowered by tools to manage the data and communicate effectively. This move to PCMH level care requires the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system and all of that is power by data made into meaningful information.
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The Patient-Centered Medical Home (PCMH) lies at the center of the effort to get at population health, integrated and coordinated care. PCMH is where the Primary care healer leads an organization that delivers clinician-led primary care, with comprehensive, accessible, holistic, coordinated, evidence-based coordination and management. In the USA this is now the standard in the US Veterans Administration and the US Military and under the ACA.
Providers know that successful care coordination is key to enhancing patient outcomes and better personalizing their experience. At its root, care coordination starts with effective communication, and healthcare organizations are increasingly turning to innovative technology solutions to solve their needs. To improve their care teams’ communication, coordination, and data capture capabilities, two of New York City’s leading healthcare organizations worked with two cutting edge tech solutions providers to design and implement innovative pilots as a part of the New York Digital Health Accelerator program. Utilizing real-life case studies, the panelists will discuss the design and implementation of the pilots, and lessons learned from their participation in the program.
• Anuj Desai - Vice President of Market Development, New York eHealth Collaborative
• Joseph Mayer, MD - Founder & CEO, Cureatr Inc.
• Patricia Meisner, MS, MBA - CEO & Co-Founder, ActualMeds
• Ken Ong, MD, MPH - Chief Medical Informatics Officer, New York Hospital Queens
• Victoria Tiase, MSN, RN - Director, Informatics Strategy, NewYork-Presbyterian Hospital
New York eHealth Collaborative Digital Health Conference
November 17, 2014
A Seven Step Approach to a Clinically Integrated Network.pdfPatWilson13
This document outlines a seven-step approach to building a clinically integrated network (CIN). The steps include: 1) gathering interested stakeholders; 2) creating a value proposition; 3) developing governance and participation agreements; 4) selecting quality measures; 5) recruiting physicians; 6) measuring and improving programs; and 7) engaging payers. The presentation emphasizes using data to benchmark quality, utilization, and costs in order to develop a sustainable incentive structure for the CIN. Yale New Haven Health System's experience in establishing its CIN, called the Total Health Network, is discussed as a case study.
Please share this video with anyone who may be interested!
Watch all our webinars: https://www.youtube.com/playlist?list=PL4dDQscmFYu_ezxuxnAE61hx4JlqAKXpR
In this webinar:
● Background to the role of private drug insurance plans in Canada
● Impact on access of recent developments in private insurance plan programs
● Future directions of private insurance in Canada
View the video: https://youtu.be/rik50CrMffY
Follow our social media accounts:
Twitter - https://twitter.com/survivornetca
Facebook - https://www.facebook.com/CanadianSurvivorNet
Pinterest - https://www.pinterest.com/survivornetwork
YouTube - https://www.youtube.com/user/Survivornetca
Surviving the Therapy Caps and Manual Medical Review with Nancy Beckley and C...Clinicient
How to Survive Therapy Caps and the Manual Medical Review with Physical Therapy and Rehab compliance expert Nancy Beckley and Clinicient, a proven leader in physical therapy EMR and practice Management solutions.
5 Eligibility and Benefits Verification Challenges that Most Medical Practice...Billingparadise1
Practices can use either real-time computerized eligibility checks or manual checks to verify a patient's eligibility verification.
In order to ensure that patients are eligible for the services they are seeking, medical practices have a few options for validation. One way to verify eligibility is through the use of computerized real-time eligibility checks. This method utilizes electronic systems to instantly check a patient's insurance coverage and benefits, providing the practice with immediate confirmation of the patient's eligibility.
Due to popular demand, the Comprehensive Primary Care Plus (CPC+) team hosted a repeat of the webinar that was originally held on Thursday, April 21, 2016. During this webinar Model team members provided an overview of the model specifically for health IT vendors.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The document provides an overview of the Comprehensive Primary Care Initiative (CPC Initiative) which aims to establish a new model for purchasing and delivering comprehensive primary care. It discusses the goals of better health outcomes, better care experiences, and lower costs. Practices will receive care management fees and have opportunities for shared savings. They will be required to meet milestones related to care management, access, patient experience, use of data, care coordination, and meaningful use of EHRs. The webinar invites primary care practices to apply and outlines the application process and requirements.
1. The document outlines seven best practices for reducing frequent emergency department use. These include adopting an electronic health information system to coordinate care plans across providers for high-need patients, disseminating patient education materials, and identifying and developing case management for frequent users.
2. It also recommends developing patient care plans for frequent users, implementing opioid prescribing guidelines to reduce drug-seeking behaviors, enrolling emergency physicians in the state's prescription monitoring program, and designating staff to review interventions for frequent users.
The document discusses population health and value-based care. It provides information on how providers are approaching population health management, including tackling the transition in-house, engaging third-party managed services, or using third-party consulting. Data shows most provider mindshare is focused on managed services. A poll found most providers believe population health management will surpass fee-for-service in 3-5 years. The document also discusses the current state of population health solutions and key capabilities needed around data aggregation.
Commercial health plans and PBMs are responding to the coronavirus pandemic by offering extended prescription supplies, waived copays, and early refills. They are also allowing mail order prescriptions in some cases and supporting cross-state licensing of pharmacy staff. The DEA has agreed to allow controlled substances to be prescribed via telemedicine without an initial in-person visit during the public health emergency. However, state rules and the medical purpose of the prescription still apply. Payment and reimbursement issues may arise regarding prescriptions for anti-malarial drugs prescribed for COVID-19 treatment, as their use for this purpose is still investigational. Pharmacies may face auditing and recoupment later for invalid prescriptions issued during
Patient Centered Medical Homes are providing a pathway for healthcare delivery organizations pursuing value-based initiatives. As reimbursement models continue to transition at an accelerated pace, PCMH practices are well-positioned to achieve clinical targets and qualify for the associated financial incentives.
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1. PDMP
Workshops:
PDMP
Coordina2on
with
Third-‐Party
Payers
Chris
Baumgartner
PMP
Director,
Washington
State
Prescrip4on
Drug
Monitoring
Program
Bruce
Wood
Associate
General
Counsel
and
Director,
Workers’
Compensa4on,
American
Insurance
Associa4on
Alex
Swedlow
Execu4ve
Vice
President,
Research,
California
Workers’
Compensa4on
Ins4tute
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate
2. Learning
Objec2ves
1. State
the
basis
for
broad
access
to
PDMP
database,
including
third-‐party
payers.
2. Iden4fy
specific
strategies
to
avoid
risky
prescribing
to
help
physicians
avoid
trouble
with
their
Boards
or
the
DEA.
3. Outline
approaches
to
data-‐sharing
among
states.
3. Disclosure
Statement
Chris
Baumgartner
has
no
financial
rela4onships
with
proprietary
en44es
that
produce
health
care
goods
and
services.
4. Public
Insurer
Access
• PDMP
Statute:
Allows
PDMP
data
to
be
provided
to
Medicaid
and
Workers’
Compensa4on
• Primary
Goal:
To
provide
for
beUer
pa4ent
care
and
promote
pa4ent
safety.
• Secondary
Goal:
To
assist
our
public
insurers
in
preven4ng
fraud
and
saving
state
funding.
5. Two
Types
of
Access
1. Healthcare
Prac44oners
within
the
Health
Care
Authority
(HCA
-‐
Medicaid)
and
Department
of
Labor
and
Industries
(LNI
–
Workers’
Compensa4on)
can
login
with
individual
account
access
and
request
a
pa4ent
history
report.
2. Once
a
month
each
agency
provides
a
file
through
secure
file
transfer
of
all
their
clients/pa4ents
(names,
DOB).
Our
vendor
then
provides
matching
data
for
each
client/pa4ent
in
a
file
that
is
returned
through
secure
file
transfer.
6. LNI
-‐
PDMP
Bulk
Transfer
• PDMP
bulk
transfer
uses:
– Iden4fying
pre-‐exis4ng
opioid
use
– Iden4fying
duplica4ve
prescrip4ons
(in
process)
– Iden4fying
prescribing
outliers
(future)
• Bulk
transfer
available
in
May
2012
7. LNI
Early
Opioid
Interven4on
Pilot
• Iden4fy
claims
that
are
15
-‐
45
days
old
AND
received
≥ 1
opioid
prescrip4ons
within
60
days
before
the
injury
• Clinical
review
and
interven4on
by
a
nurse
or
pharmacist
as
necessary
• BeUer
coordina4on
of
medical
care
and
management
of
claims,
promote
use
of
PMP
and
reduce
cost
and
disability
8. LNI
-‐
Early
Opioid
Interven4on
Pilot
• 350
–
500
new
claims
meet
this
criteria
each
month
(3-‐4%
of
all
claims
allowed)
• Priori4za4on
Criteria
– Chronic
opioid
use
(≥
3
prescrip4ons
in
previous
3
months)
– High
dose
opioid
(>
120mg/d
MED)
– Other
controlled
substances
(e.g.
benzodiazepines,
seda4ve-‐hypno4cs
– Timeloss
(wage
replacement)
• Clinical
review
is
priori4zed
by
the
number
of
criteria
met
9. Future
LNI
Ini4a4ves
• Complete
the
Early
Opioid
Interven4on
Pilot
• Require
L&I’s
providers
to
access
PDMP
before
prescribing
opioids
for
a
work-‐related
injury
(new
guideline)
• Iden4fy
duplica4ve
prescrip4ons
and
create
a
process
to
intervene
• Iden4fy
prescribing
outliers
to
improve
L&I’s
new
provider
network
10. HCA
–
Pa4ent
Review
&
Coordina4on
(PRC)
• Aimed
at
over-‐u4lizing
clients
• Decrease
and
control
over-‐u4liza4on
and
inappropriate
use
of
health
care
services
• Minimize
medically
unnecessary
services
and
addic4ve
drug
use
• Client
and
provider
educa4on
and
coordina4on
of
care
• Assist
providers
in
managing
PRC
clients
by
providing
available
resource
informa4on
to
facilitate
coordina4on
of
care
• Reduce
overall
expenditures
11. PDMP
Assistance
to
PRC
to
Date
• As
of
May
2012
the
PDMP
has
assisted
in
iden4fying
20
clients
for
the
PRC
program
to
date
(through
5
months
of
using
just
the
individual
query
site)
• The
minimum
4me
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.
11
12. 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
PMP
prescrip4on.
• Of
the
1,170
clients
filling
prescrip4ons
– 489
Clients
paid
cash
for
2,470
prescrip4ons.
And
243
addi4onal
clients
are
listed
as
paid
by
04
private
insurance
with
an
addi4onal
2,059
prescrip4ons.
This
would
be
a
total
of
732
clients
filling
4,529
total
prescrip4ons
– By
contrast
898
clients
filled
12,240
prescrip4ons
paid
for
by
Medicaid
during
this
same
period.
12
13. PDMP
Bulk
Data
use
by
PRC
• Client
Iden4fica4on
analysis
• Allows
improved
algorithms
with
clients.
– Iden4fied
>2000
Clients
in
2012
with
Cash
and
Medicaid
paid
schedule
prescrip4ons
on
the
same
day.
– Iden4fied
478
clients
where
cash
and
Medicaid
fills
were
<
10
days
apart,
the
scripts
were
overlapping,
for
the
same
drug
and
from
different
prescribers.
– Currently
reviewing
the
top
u4lizers
of
the
478
for
PRC
placement.
13
14. HCA
-‐
Narco4c
Review
Program
• The
Narco4c
Review
Program
(NRP)
evaluates
Medicaid
clients
who
are
receiving
high
doses
of
opioid
narco4cs
to
verify
the
medical
need
for
these
excep4onal
doses.
It
only
applies
to
client
with
chronic
non-‐cancer
pain.
• Each
narco4c
prescrip4on
for
these
clients
requires
authoriza4on
as
long
as
the
client
is
in
the
narco4c
review
program.
A
client’s
narco4c
use
will
be
adjusted
to
minimize
pain
and
maximize
func4on.
The
lowest
effec4ve
dose,
or
zero
use
is
determined
by
medical
necessity
and
clinical
considera4ons.
• PDMP
Data
found
that
83%
of
clients
in
the
NRP
had
scripts
that
were
not
paid
for
by
Medicaid.
14
15. Future
HCA
Ini4a4ves
• HCA
will
be
using
bulk
data
to
augment
our
lock-‐in
PRC
program.
• HCA
has
already
been
working
on
threshold
reports
to
go
to
managed
care
plans
concerning
clients
using
cash.
• HCA
will
be
sending
threshold
reports
to:
– Prescribers
with
clients
prescrip4on
Informa4on
– Pharmacies
who
accept
cash
from
Medicaid
clients
in
viola4on
of
their
core
provider
agreement
15
16. Refining
the
Bulk
Transfer
• Key
Areas
that
were
fine
tuned:
– Data
Fields:
NPI,
Payment
Type,
etc…
– Handling
reversals,
voids,
duplicates
– Provide
back
in
return
file
LNI
pa4ent
name
for
matching
• Key
Areas
for
improvement:
– Payment
Type
–
entered
more
accurately
– NPI
#
-‐
require
is
to
be
reported
– Pa4ent
ID
–
more
reliable
matching
17. Program
Contact
• Chris
Baumgartner,
PMP
Director
– Washington
State
Dept.
of
Health
– Phone:
360.236.4806
– Email:
prescrip4onmonitoring@doh.wa.gov
– Website:
hUp://www.doh.wa.gov/hsqa/PMP/default.htm
18. PDMP
Coordina2on
with
Third-‐
Party
Payers
Bruce
C.
Wood
Associate
General
Counsel
&
Director,
Workers’
Compensa4on
American
Insurance
Associa4on
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate
19. Learning
Objec2ves
• State
the
basis
for
broad
access
to
PDMP
database,
including
third-‐party
payers.
• Iden4fy
specific
strategies
to
avoid
risky
prescribing
to
help
physicians
avoid
trouble
with
their
Boards
or
the
DEA.
• Outline
approaches
to
data-‐sharing
among
states.
20. Disclosure
Statement
• Bruce
Wood
has
no
financial
rela4onships
with
proprietary
en44es
that
produce
health
care
goods
and
services.
23. I
Discussion/history
of
workers’
compensa2on
• Evolu2on
of
this
social
insurance
program
over
the
past
century
=
first
w.c.
program
enacted
in
1911
(Wisconsin)
• Subs2tute
for
tort
=
quid
pro
quo
• Trauma2c/occupa2onal
diseases
• Na2onal
Commission
on
State
Workmen’s
Compensa2on
Laws
(1972)
=
watershed
event/
states’
response
• Post-‐Na2onal
Commission
history
=
benefit
expansion;
financial
crisis
(later
‘80s-‐mid-‐’90s)
24. II
Key
Program
Elements
• All
medical
treatment
“reasonable
and
necessary”
(w/o
co-‐
pays,
deduc2bles,
exclusions,
dura2on
limits)
=
1st
dollar
coverage.
• Indemnity
benefits
=
commonly
2/3
of
gross
“average
weekly
wages”
=
Paid
for:
Temporary
total
disability
(TTD),
temporary
par2al
disability
(TPD),
permanent
par2al
disability
(PPD),
permanent
total
disability
(PTD)
• Voca2onal
rehabilita2on
benefits
=
evalua2on
and
re-‐training
• Survivor/dependents’
benefits
=
payable
for
life
or
un2l
remarriage;
dependents
un2l
18
or
22
if
enrolled
in
college
25. 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
compensa2on
scheme?
Did
the
employer
intend
to
injure
the
worker?
26. 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,
li2ga2on,
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?
Restric2ons?
Accommoda2ons?
27. IV
The
Role
of
Workers’
Compensa2on
Medical
Treatment
Workers’
compensa2on
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
objec2ve
in
workers’
compensa2on
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
=
coordina2ng
medical
treatment
and
indemnity.
28. The
Role
of
Workers’
Compensa2on
Medical
Treatment
–
cont’d
Because
workers’
compensa2on
medical
treatment
remains
first-‐
dollar
coverage
–
with
no
demand-‐side
controls
on
cost
and
u2liza2on
–
it
reinforces
need
of
payers
to
use
administra2ve
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
–
na2onal
=
ACOEM/ODG
Unit
price
controls
(fee
schedules)
=
Medicare
RBRVS/DRGs
Impairment
guidelines
=
AMA
Guides
to
the
Evalua2on
of
Permanent
Impairment
29. The
Role
of
Workers’
Compensa2on
Medical
Treatment
–
cont’d
Delivering
medical
treatment,
2mely,
and
of
the
nature
and
intensity
needed,
requires
an
unimpeded
exchange
of
medical
informa2on
with
providers
and
evaluators.
• No
authoriza2ons/releases
required
in
workers’
compensa2on.
• System
is
intended
to
be
less
formal
than
civil
li2ga2on,
to
promote
quick
exchange
of
informa2on
in
the
employee’s
interest
in
receiving
necessary
and
2mely
medical
treatment,
in
evalua2ng
return-‐to-‐work
restric2ons
and
accommoda2ons
necessary,
and
in
an
employer’s
understanding
of
poten2al
health
and
safety
risks
posed
by
the
injury.
30. The
Role
of
Workers’
Compensa2on
Medical
Treatment
–
cont’d
In
workers’
compensa2on,
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.
For
this
reason,
the
employee,
who
puts
his
condi2on
at
issue,
does
not
have
the
same
confiden2ality
expecta2ons
as
do
claimants
in
a
group
health
sekng.
31. The
Role
of
Workers’
Compensa2on
Medical
Treatment
–
cont’d
The
special
informa2onal
needs
of
workers’
compensa2on
payers
is
recognized
under
HIPAA:
“A
covered
en2ty
may
disclose
protected
health
informa2on
as
authorized
by
and
to
the
extent
necessary
to
comply
with
laws
rela2ng
to
workers’
compensa2on
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
authoriza2on,
or
opportunity
to
agree
or
object
is
not
required;
45
CFR
164.512(l)].
32. The
Role
of
Workers’
Compensa2on
Medical
Treatment
–
cont’d
Where
state
law,
itself,
mandates
disclosure
without
authoriza2on,
disclosure
is
permiqed
under
HIPAA
rules
and
exempt
from
the
“minimum
necessary”
informa2on
disclosure
standard.
“A
covered
en2ty
may
use
or
disclose
protected
health
informa2on
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
en2ty
under
HIPAA
rules
also
may
disclose
informa2on
to
any
en2ty
as
necessary
for
payment,
although
the
covered
en2ty
may
disclose
the
amount
and
types
of
informa2on
necessary
for
payment.
33. The
Role
of
Workers’
Compensa2on
Medical
Treatment
–
cont’d
In
brief,
HIPAA
does
not
erect
barriers
to
a
workers’
compensa2on
payer
obtaining
protected
health
informa2on,
whether
without
an
authoriza2on,
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
informa2on
from
medical
providers.
Some
states
=
explicit
mandates
to
release
informa2on
to
employer/insurer.
Other
states
impose
ex
parte
rules
on
physician
communica2ons
with
carrier
that
slow
evalua2on/
decisions.
34. The
Role
of
Workers’
Compensa2on
Medical
Treatment
–
cont’d
It
is
essen?al
for
workers’
compensa2on
payors
to
obtain
access
to
prescrip2on
monitoring
program
data,
to
properly
assess
an
injured
worker’s
use
of
prescrip2on
medica2ons
and,
broadly,
to
provide
all
reasonable
and
necessary
medical
treatment
and
effec2vely
manage
disability.
Without
access,
it
is
not
possible
for
a
workers’
compensa2on
payer
to
know
the
full
extent
of
prescrip2on
drug
use,
because
a
worker
may
be
obtaining
prescrip2ons
under
other
benefit
systems
(e.g.,
Medicaid,
group
health,
Veterans)
or
has
prescrip2ons
through
other
providers
not
otherwise
reported.
35. The
Role
of
Workers’
Compensa2on
Medical
Treatment
–
cont’d
Washington
State’s
Department
of
Labor
&
Industry
has
access
to
PMP
data.
The
Department’s
role
in
providing
workers’
compensa2on
benefits
is
no
different
from
that
of
other
private
market
insurers
and
self-‐insured
employers.
Arizona
enacted
legisla2on
last
year
providing
access
for
IMEs
to
that
state’s
PDMP
database
and
the
right
to
disclose
that
informa2on
to
“the
employee,
employer,
insurance
carrier
and
the
[Industrial]
commission.”
[H
2155;
Chp.
156,
Laws
of
2012;
eff.
1-‐1-‐13].
36. OPIOID
ABUSE:
THE
MOST
URGENT
ISSUE
FACING
WORKERS’
COMPENSATION
37. OPIOID
ABUSE:
THE
MOST
URGENT
ISSUE
FACING
WORKERS’
COMPENSATION
Use
of
opioids,
especially
long-‐ac2ng
medica2on,
for
treatment
of
chronic
pain
in
workers’
compensa2on
can
increase
chances
of
a
“catastrophic
claim
($100,000+)
by
almost
four
2mes.
Use
of
short-‐ac2ng
opioids
raises
chances
by
almost
twice.
Average
claim
not
involving
opioids
=
$13,000.
-‐-‐
“ The
Effects
of
Opioid
Use
on
Workers’
Compensa2on
Claim
Cost
in
the
State
of
Michigan;
Bernacki,
et.
al;
Journal
of
Occupa2onal
and
Environmental
Medicine,
August
2012.
38. OPIOID
ABUSE:
THE
MOST
URGENT
ISSUE
FACING
WORKERS’
COMPENSATION
Average
claim
costs
of
workers
receiving
7+
opioid
prescrip2ons
for
back
problems
without
spinal
cord
involvement
=
– 3X
greater
than
for
workers
receiving
0
or
1
opioid
prescrip2on
Workers
receiving
mul2ple
opioid
prescrip2ons
=
– 2.7X
more
likely
to
be
off
work
– 4.7X
as
many
days
off
work
(Swedlow
et
al.,
CWCI
Special
Report
2008)
39. OPIOID
ABUSE:
THE
MOST
URGENT
ISSUE
FACING
WORKERS’
COMPENSATION
Prevalence
of
Fentanyl
in
California’s
Workers’
Compensa2on
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’
compensa2on
prescrip2ons
for
these
drugs,
which
represents
87%
of
the
morphine
equivalents
provided
to
injured
workers
accoun2ng
for
88%
of
all
Schedule
II
pharmacy
payments
in
the
CA
WC
system.
Nearly
half
of
Schedule
II
prescrip2ons
=
minor
back
injuries.
[CWCI
Research
Bulle2n
11-‐05;
April
28,
2011]
40. OPIOID
ABUSE:
THE
MOST
URGENT
ISSUE
FACING
WORKERS’
COMPENSATION
AIA
endorses
robust
PDMPs
as
one
key
element
for
comba2ng
opioid
abuse.
Mandatory
prescribing
and
dispensing
checking
of
database,
with
data
entry
Ac2ve
PDMPs
pushing
informa2on
to
prescribers
and
dispensers
Broad
access
to
PDMP
database,
including
3rd
party
payers
and
law
enforcement
Interstate
operability
41. OPIOID
ABUSE:
THE
MOST
URGENT
ISSUE
FACING
WORKERS’
COMPENSATION
FINALLY:
Comprehensive,
well-‐designed
prescrip2on
drug
monitoring
programs
can
serve
a
cri2cal
role
in
thwar2ng
opioid
abuse,
as
well
as
illegal
drug
diversion.
It
is
essen2al
for
there
to
be
broad
access
to
PDMP
data
–
by
those
with
a
legi2mate
purpose
in
such
data
–
and
as
essen2al
for
PDMP
programs
to
ac2vely
monitor
their
databases
for
suspicious
ac2vity,
thereby
providing
a
cri2cal
check
on
prescribers
and
dispensers
and
facilita2ng
data-‐
sharing.
42. Prescrip2on
Drug
Monitoring
Program
Workshop:
PDMP
Coordina2on
with
Third-‐Party
Payers
Managing
Pain
Management
in
the
California
Workers’
Compensa2on
System
Alex
Swedlow
California
Workers’
Compensa4on
Ins4tute
www.cwci.org
43. Disclosure
Statement
• Alex
Swedlow
has
no
financial
rela4onships
with
proprietary
en44es
that
produce
health
care
goods
and
services.
44. Pain
Management
in
the
California
Workers’
Comp
System
Agenda
• Pain Management in the California Workers’
Compensation System
• Controlled Substance Utilization Review and Evaluation
System (CURES)
45. Pain
Management
in
the
California
Workers’
Comp
System
Areas
of
CWCI
Rx
Research
1. Changing
Role
of
Rx
in
Workers’
Compensa4on
2. Repackaged
Drugs
3. Sole
Source
(Brand)
v.
Mul4-‐source
(Generic)
4. Opioids
&
Schedule-‐II
Rx
5. Compound
Drugs
6. Drug
Tes4ng
46. Pain
Management
in
the
California
Workers’
Comp
System
Changing
Role
of
Rx
in
CA
Workers’
Compensa4on
1. Growing
use
of
pharmaceu4cals
2002:
5%
of
medical
benefits
2010:
10%
of
medical
benefits
2.
Reforms
in
pricing
and
fee
schedules
3.
Growing
influence
of
pain
management
prac4ces
4.
Legisla4ve,
administra4ve
and
payer
responses
47. Pain
Management
in
the
California
Workers’
Comp
System
Managing
Pain
Management
Rules
and
Regula4ons
and
Medical
Management
• Pain
Mgt
Guidelines
Implemented
July
2009
-‐
Compe4ng
MTUS
defini4ons
and
triggers
-‐ Hierarchy
of
medical
evidence
-‐ Different
levels
of
specificity
• Limits
to
Workers
Comp
Medical
Management
-‐ Few
supply-‐
and
demand-‐side
controls
-‐ Liens
(2012)
-‐ No
3rd
party
payer
access
to
PDMP
48. Pain
Management
in
the
California
Workers’
Comp
System
Opioid
Prescrip4on
&
Payments
in
CA
Workers’
Comp
(2012)
49. Pain
Management
in
the
California
Workers’
Comp
System
Pharmaceu4cal
U4liza4on
&
Cost
Schedule-‐II
Opioid
Drugs1
321%
345%
1
CWCI
2012.
Calcula4ons
are
on
a
calendar
year
basis
50. Pain
Management
in
the
California
Workers’
Comp
System
Rx
&
Pain
Management
Report
to
the
Industry
What
is
the
associa4on
between
the
use
of
opioids
on
low
back
pain
on:
•
Average
Benefit
Costs
-‐
Medical
-‐
Indemnity
•
Loss
of
Produc4vity/Return
To
Work
CWCI
2008
Exhibit
50
51. Pain
Management
in
the
California
Workers’
Comp
System
Pain
Mgt
and
the
Use
of
Opioids
Data
&
Methods
• 166,336
California
injured
workers
• Medical
back
condi4ons
without
spinal
cord
involvement
• A
total
of
854,244
opioid
prescrip4ons
were
dispensed
• Controls
(morphine
equivalents)
for
different
types
of
opioids
• Case-‐mix
adjusted
outcomes
CWCI
2008
52. Pain
Management
in
the
California
Workers’
Comp
System
Background
on
Pain
Management
Opioid
Prescrip4ons
on
Medical
Back
Injuries
Not
Involving
the
Spine
Medical
back
injuries
w/
opioids
typically
receive
5.9
prescrip4ons
per
injury
CWCI
2008
Exhibit
52
53. Pain
Management
in
the
California
Workers’
Comp
System
Evidence-‐based
Medicine
&
Compara4ve
Effec4veness
Research
on
Opioids
ACOEM
Insights
on
Opioids
• Opioid
use
is
the
most
important
factor
impeding
recovery
of
func4on
in
pa4ents
referred
to
pain
clinics
• Opioids
do
not
consistently
and
reliably
relieve
pain
and
can
decrease
quality
of
life
and
func4onal
status
• The
use
of
opioids
during
the
sub-‐acute
and
chronic
phases
of
an
injury,
especially
in
the
absence
of
an
objec4vely
iden4fiable
pain
generator,
cannot
be
recommended.
Genovese,
Harris,
Korevaar
2007
54. Pain
Management
in
the
California
Workers’
Comp
System
Morphine
Equivalents
Categories
Average
Range of MEs in
MEs in
Category
Category Category
No MEs 0 0
Level 1 124 3-240
Level 2 406 241-650
Level 3 1,207 651-2100
Level 4 14,870 2,101 and up
ME
conversions
based
on
American
Pain
Society
Conversion
Tables
CWCI
2008
Exhibit
54
55. Pain
Management
in
the
California
Workers’
Comp
System
Adverse
Outcomes:
Increased
Costs
+203%
+196%
+209%
CWCI
2008
Exhibit
55
56. Pain
Management
in
the
California
Workers’
Comp
System
Adverse
Outcomes:
Reduced
Produc2vity
Paid
Time
Off
Work
+365%
CWCI
2008
Exhibit
56
57. Pain
Management
in
the
California
Workers’
Comp
System
Adverse
Outcomes:
Higher
Likelihood
of
Lost
Time
and
Li2ga2on
+131%
+60%
CWCI
2008
Exhibit
57
58. Pain
Management
in
the
California
Workers’
Comp
System
Pain
Mgt
and
the
Use
of
Opioids
Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids
Analysis
of:
1. Injury
Characteris4cs
2. Physician
Prescribing
PaUerns
3. Injured
Worker
Characteris4cs
PBM
and
ICIS
Data:
• 16,890
Claims
• 9,174
Prescribing
physician
DEA
code
• 233,276
Prescrip4ons
• Script,
dosage
and
days
CWCI
March
2011
• Pharmaceu4cal
characteris4cs
• DOS,
billed
and
paid
amount
• ER
and
EE
characteris4cs
Exhibit
58
59. Pain
Management
in
the
California
Workers’
Comp
System
Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids
Top
Injury
Categories
w/
Schedule
II
Opioids
Pcnt of S-II Pcnt of S-II Pcnt of S-
Opioid Opioid II Opioid
Diagnostic Category Claims Scrips Pymnts
Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2%
Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1%
Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5%
Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4%
Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8%
Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7%
Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8%
Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6%
Mental Disturbances 1.2% 1.7% 1.5%
Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%
CWCI
March
2011
Exhibit
59
60. Pain
Management
in
the
California
Workers’
Comp
System
Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids
Top
Injury
Categories
w/
Schedule
II
Opioids
Pcnt of S-II Pcnt of S-II Pcnt of S-
Opioid Opioid II Opioid
Diagnostic Category Claims Scrips Pymnts
Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2%
Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1%
Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5%
Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4%
Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8%
Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7%
Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8%
Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6%
Mental Disturbances 1.2% 1.7% 1.5%
Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%
CWCI
March
2011
Exhibit
60
61. Pain
Management
in
the
California
Workers’
Comp
System
Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids
Top
Injury
Categories
w/
Schedule
II
Opioids
Pcnt of
Pcnt of S-II Pcnt of S- S-II
Opioid II Opioid Opioid
Diagnostic Category Claims Scrips Pymnts
Outside
EBM
Guidelines:
Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2%
Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1%
•
51%
of
Claims
Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5%
Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4%
Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8%
Ruptured
Bursitis
Tendon, Tendonitis, Myositis &
6.0% 3.6% 2.7% •
60%
of
Prescrip4ons
Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8%
Wound, FX of Shoulder, Arm, Knee or Lower
Leg 6.3% 2.7% 1.6% •
62%
of
Payments
Other Mental Disturb 1.2% 1.7% 1.5%
Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%
CWCI
March
2011
Exhibit
61
62. Pain
Management
in
the
California
Workers’
Comp
System
Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids
Cumula2ve
Percentage
of
Schedule
II
Prescrip2ons
(Top
10%
of
S-‐II
Prescribing
Physicians)
CWCI
March
2011
Exhibit
62
63. Pain
Management
in
the
California
Workers’
Comp
System
Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids
Cumulative Percentage of Schedule II Payments
(Top 10% of S-II Prescribing Physicians)
CWCI
March
2011
Exhibit 63
64. Pain
Management
in
the
California
Workers’
Comp
System
Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids
Average
S-‐II
Opioid
Prescribing
Physicians
per
Claim
(Injured
Worker)
Median:
1.5
CWCI
March
2011
Exhibit
64
65. Pain
Management
in
the
California
Workers’
Comp
System
Pain
Management
Drug
Tes4ng:
• High
levels
of
tes4ng
associated
with
increasing
opioid
and
S-‐
II
u4liza4on
• Ra4onale
for
drug
tes4ng:
-‐
Protocols?
-‐
Type
of
test?
-‐
Timing
and
frequency?
-‐
Medical
necessity?
•
Consequences:
-‐
Injured
worker
-‐
Physician
-‐
Employer
-‐
Claims
administrator
66. Pain
Management
in
the
California
Workers’
Comp
System
Drug Testing: Calendar Year Payments ($M)
CWCI
2012
Exhibit 66
67. Pain
Management
in
the
California
Workers’
Comp
System
Controlled
Substance
U4liza4on
Review
and
Evalua4on
System
(CURES)
CURES Background
• 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.
• Now dormant and absent a funding source, the CURES program
shuts down on July 1, 2013.
68. Pain
Management
in
the
California
Workers’
Comp
System
Controlled
Substance
U4liza4on
Review
and
Evalua4on
System
(CURES)
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
Claims
w/
CA
Claim
Count
Pcnt
of
Opioid
Scripts (2010) 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%
69. Pain
Management
in
the
California
Workers’
Comp
System
Controlled
Substance
U4liza4on
Review
and
Evalua4on
System
CURES:
ROI
for
California
Workers’
Compensa4on
Claims
w/
Avg
Cost/
Claim
Total
Payments
Est
%
Total
Es4mated
(2010) Savings
Opioid
Scripts 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
CURES
Opera4ng
Budget
(Est.):
$3,700,000
ROI
for
CA
WC:
$15.5
:
$1
Actual
savings
will
depend
upon
several
factors
including:
• Medical
&
Rx
trends,
Injury
mix;
• Appropriate
statutes,
rules
and
regs.
70. Pain
Management
in
the
California
Workers’
Comp
System
Summary
• High rate of inappropriate opioid use;
• Limits in statutes/rules/regs make it difficult to regulate within
traditional workers’ comp controls
• Graduated use associated with adverse injured worker outcomes
• Small number of physicians associated with high prescribing
patterns
• Rapid increase in drug testing associated to high opioid use with
no national guidelines for testing
• CURES has significant potential to increase QOC and lower cost