Opioid Dependence: Health Plan Problems and Strategies National Rx Drug Abuse Summit 4-11-12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

16. 1 visit with a prescription

17. 3 visits with a prescription

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

19. Addiction admissions who
obtained rx from ER

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

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

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

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

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

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

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

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

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

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