Tpp 2 eadie wood_baumgartner

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

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.

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.

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

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.

There
is
room
for
expansion
of
PDMPs

sharing
data
with
Third
Party
Payers.

How
to
ﬁnd
contact
informa)on

for
a
state’s
PDMP?

• 
Go
to

www.pdmpassist.org
-‐
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.

How
to
ﬁnd
other
informa)on

about
a
state’s
PDMP

• 
On
the
homepage
of
www.pdmpassist.org,
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

EPIDEMIC:

RESPONDING
TO
AMERICA’S

PRESCRIPTION

DRUG
ABUSE
CRISIS

2011

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://www.whitehouse.gov/sites/default/ﬁles/ondcp/issues-‐
content/prescrip0on-‐drugs/rx_abuse_plan_0.pdf

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

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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

Contact
Informa)on

John
Eadie,
MPA

Director

PMP
Center
of
Excellence

Brandeis
University

518-‐429-‐6397

jeadie@Brandeis.edu

Website:
www.pmpexcellence.org

THIRD PARTY PAYERS

Bruce C. Wood
Associate General Counsel &
Director, Workers’ Compensation
American Insurance Association
Atlanta Marriott Marquis
Atlanta, Georgia
April 22, 2014

THIRD PARTY PAYERS

Disclosure
Statement

Bruce
Wood
has
no
ﬁnancial
rela0onships
with

proprietary
en00es
that
produce
health
care

goods
and
services

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.

THIRD PARTY PAYERS

LET’S
REVIEW
.
.
.

WORKERS’
COMPENSATION:

THE
BASICS

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)

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

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?

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?

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.

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

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.

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.

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)].

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.

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.

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.

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

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

 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

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

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

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

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

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

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

 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

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

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

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

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

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

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

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

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

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

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

•  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

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

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

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

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

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

QUESTIONS?

THIRD PARTY PAYERS

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

Disclosure
Statement

Chris
Baumgartner
has
no
ﬁnancial
rela0onships

with
proprietary
en00es
that
produce
health

care
goods
and
services.

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.

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.

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.

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

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

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

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://www.opioids.lni.wa.gov/

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

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

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

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

•  Chris
Baumgartner,
PMP
Director

–  Washington
State
Department
of
Health

–  Phone:
360.236.4806

–  Email:
prescrip0onmonitoring@doh.wa.gov

–  Website:
hhp://www.doh.wa.gov/PMP

Program
Contact

Tpp 2 eadie wood_baumgartner

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