Third-Party Payer Track, National Rx Drug Abuse Summit, April 2-4, 2013. Right Drug, Right Test, Right Time presentation by Dongchung Wang, Dr. Lennox Abbott and Tron Emptage

1. Right
Drug,
Right
Test,
Right
Time
Ms.
Dongchun
Wang
Economist,
Workers’
Compensa3on
Research
Ins3tute
Dr.
Lenox
Abbo:
Director,
Laboratory
Opera3ons
and
Na3onal
Standards,
Quest
Diagnos3cs
Tron
Emptage
Chief
Clinical
Officer,
Progressive
Medical
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate

2. Learning
Objec?ves
• Outline
how
clinical
programs
can
iden3fy
excessive
use
or
misuse
of
opioids
• Describe
the
impact
of
behavioral
interven3ons
in
chronic
opioid
cases
• Explain
the
value
of
urine
and
drug
screening

3. Disclosure
Statement
• Ms.
Dongchun
Wang
has
no
rela3onships
with
proprietary
en33es
that
produce
health
care
goods
and
services.
• Dr.
Lenox
AbboS
has
no
rela3onships
with
proprietary
en33es
that
produce
health
care
goods
and
services.
• Tron
Emptage
has
no
rela3onships
with
proprietary
en33es
that
produce
health
care
goods
and
services.

4. Opioids
In
Workers’
Compensa3on
WCRI
Annual
Conference
February
2013

5. Today’s
Discussion
• Prescribing
paSerns
of
opioids
in
workers’
compensa3on
– Overall
use
of
opioids
– Longer-­‐term
use
of
opioids

6. Opioids
In
Workers’
Compensa3on:
Key
Findings
From
WCRI
Studies
• Most
injured
workers
received
opioids
for
pain
relief,
over
80%
in
some
states
studied
• Amount
of
opioids
received
per
claim
unusually
high
in
several
study
states
• 1
in
6
or
7
injured
workers
in
Louisiana
and
New
York
who
received
opioids
had
them
on
a
longer-­‐term
basis
• Few
longer-­‐term
users
of
opioids
received
services
for
monitoring
and
management
• Longer-­‐term
opioid
use
in
MA
fell
a_er
pain
guidelines

7. Opioids
Commonly
Received
By
Injured
Workers,
Paid
Under
WC
Generic
Name
(Brand
Name)
Federal
%
Claims
w/
Schedule
Pain
Meds
(Median
State)
Hydrocodone-­‐Acetaminophen
(Vicodin®)
3*
58%
Oxycodone
w/Acetaminophen
(Percocet®)
2
28%
Propoxyphene-­‐N
w/APAP
(Darvocet-­‐N®)
4
18%
Tramadol
HCL
(Ultram®)
-­‐
17%
Oxycodone
HCL
(OxyCon3n®)
2
4%
Fentanyl
(Duragesic®)
2
1%
*
The
FDA
And
DEA
Are
Currently
Considering
Rescheduling
Hydrocodone
Products
(e.g.,
Vicodin®)
From
Schedule
3
To
Schedule
2.
Claims
With
>
7
Days
Of
Lost
Time,
Injuries
From
October
2005
To
September
2006,
Opioid
Prescrip?ons
Filled
Through
March
2008
(Data
From
2011
Prescrip?on
Benchmarks,
2nd
Edi?on)

8. Opioids
Commonly
Received
By
Injured
Workers,
Paid
Under
WC
(Cont.)
Generic
Name
(Brand
Name)
Federal
%
Of
Rx
For
Schedule
Pain
Meds
(Median
State)
Hydrocodone-­‐Acetaminophen
(Vicodin®)
3*
36%
Oxycodone
w/Acetaminophen
(Percocet®)
2
10%
Tramadol
HCL
(Ultram®)
-­‐
6%
Propoxyphene-­‐N
w/APAP
(Darvocet-­‐N®)
4
6%
Oxycodone
HCL
(OxyCon3n®)
2
2%
Fentanyl
(Duragesic®)
2
<1%
*
The
FDA
And
DEA
Are
Currently
Considering
Rescheduling
Hydrocodone
Products
(e.g.,
Vicodin®)
From
Schedule
3
To
Schedule
2.
Claims
With
>
7
Days
Of
Lost
Time,
Injuries
From
October
2005
To
September
2006,
Opioid
Prescrip?ons
Filled
Through
March
2008
(Data
From
2011
Prescrip?on
Benchmarks,
2nd
Edi?on)

9. Most
Injured
Workers
With
Pain
Medica3ons
Received
Opioids
*
Nonsurgical
Claims
With
>
7
Days
Of
Lost
Time,
Injuries
From
October
2008
To
September
2009,
Prescrip?ons
Filled
Through
March
2011
*
Texas
Closed
Formulary
Went
Into
Effect
On
September
1,
2011,
Which
Is
Expected
To
Reduce
Use
And
Longer-­‐Term
Use
Of
Opioids

10. Amount
Of
Opioids
Received
Per
Claim
Unusually
High
In
NY,
LA,
PA
&
MA
Nonsurgical
Claims
With
>
7
Days
Of
Lost
Time,
Injury
Year
2006,
Prescrip?ons
Filled
Through
March
2008
(Data
From
2011
Narco?cs
Study)
*
Texas
Closed
Formulary
Went
Into
Effect
On
September
1,
2011,
Which
Is
Expected
To
Reduce
Use
And
Longer-­‐Term
Use
Of
Opioids

11. Database
Suppor3ng
Latest
WCRI
Study
On
Opioids
• 300,000+
claims,
1.1
million
pain
medica3on
Rx
filled
through
March
2011
• Nonsurgical
claims
with
>
7
days
of
lost
3me
• 21
states
represen3ng
two-­‐thirds
of
workers’
compensa3on
medical
benefits
in
the
U.S.
– 20–47%
of
claims
in
each
state
• Snapshots
of
an
average
24-­‐month
experience

12. Prescrip3ons
For
Opioids
• Rx
for
opioids
– Dispensed
by
physicians
or
pharmacies
– Paid
under
workers’
compensa3on
• Excluded
– Hospital-­‐dispensed
opioids
– Opioids
administered
by
medical
providers
(e.g.,
injectables,
infusions,
etc.)

13. Opioids
In
Workers’
Compensa3on:
Key
Findings
From
WCRI
Studies
• Most
injured
workers
received
opioids
for
pain
relief,
over
80%
in
some
states
studied
• Amount
of
opioids
received
per
claim
unusually
high
in
several
study
states
 1
in
6
or
7
injured
workers
in
Louisiana
and
New
York
who
received
opioids
had
them
on
a
longer-­‐term
basis
 Few
longer-­‐term
users
of
opioids
received
services
for
monitoring
and
management
• Longer-­‐term
opioid
use
in
MA
fell
a_er
pain
guidelines

14. Longer-­‐Term
Use
Of
Opioids
• Study
defini3on
– First
opioid
Rx
filled
within
first
3
months
a_er
injury
– Opioids
con3nued
a_er
6
months
pos3njury
– 3+
Rx
fills
during
months
7–12
• Nonsurgical
cases

15. One
In
6
Or
7
Workers
With
Opioids
In
LA
And
NY
Had
Longer-­‐Term
Use
*
Nonsurgical
Claims
With
>
7
Days
Of
Lost
Time,
Injuries
From
October
2008
To
September
2009,
Narco?c
Prescrip?ons
Filled
Through
March
2011
*
Texas
Closed
Formulary
Went
Into
Effect
On
September
1,
2011,
Which
Is
Expected
To
Reduce
Use
And
Longer-­‐Term
Use
Of
Opioids

16. Longer-­‐Term
Use
Of
Opioids
Also
Prevalent
In
Several
Other
States
*
Nonsurgical
Claims
With
>
7
Days
Of
Lost
Time,
Injuries
From
October
2008
To
September
2009,
Narco?c
Prescrip?ons
Filled
Through
March
2011
*
Texas
Closed
Formulary
Went
Into
Effect
On
September
1,
2011,
Which
Is
Expected
To
Reduce
Use
And
Longer-­‐Term
Use
Of
Opioids

17. Medical
Treatment
Guidelines
For
Chronic
Opioid
Management
Recommend
• Urine
drug
tes3ng
• Psychological
and
psychiatric
evalua3ons
and
treatment
• Ac3ve
physical
therapy
Note:
Guideline
recommenda3ons
are
based
on
widely-­‐accepted
medical
treatment
guidelines,
including
ACOEM,
APS/AAPM,
ODG,
and
state
guidelines
(CO,
UT,
WA).
See
Appendix
A
of
WCRI’s
Longer-­‐Term
Use
of
Opioids.

18. Frequency
Of
Drug
Tes3ng
Was
Low,
Even
A_er
Considerable
Increases
%
Of
Claims
With
Longer-­‐Term
21-­‐State
Most
Use
Of
Opioids
That
Received
Median
States
Drug
Tes3ng
In…
(Range)
2007/2009
14%
9–24%
2009/2011
24%
18–30%
Nonsurgical
Claims
With
>
7
Days
Of
Lost
Time
That
Were
Iden?fied
As
Longer-­‐Term
Users
Of
Opioids,
Injury
Years
2007
&
2009,
Prescrip?ons
Filled
Through
March
2011,
Average
24-­‐Month
Snapshots

19. Psychological
Evalua3ons
And
Treatment
Performed
Infrequently
%
Of
Claims
With
Longer-­‐Term
Use
21-­‐State
Most
States
Of
Opioids
That
Received…
Median
(Range)
Psychological
Evalua3ons
2007/2009
6%
4–9%
2009/2011
7%
3–9%
Psychological
Treatment
2007/2009
6%
3–7%
2009/2011
4%
2–6%
Nonsurgical
Claims
With
>
7
Days
Of
Lost
Time
That
Were
Iden?fied
As
Longer-­‐Term
Users
Of
Opioids,
Injury
Years
2007
&
2009,
Prescrip?ons
Filled
Through
March
2011,
Average
24-­‐Month
Snapshots

20. Opioids
In
Workers’
Compensa3on:
Key
Findings
From
WCRI
Studies
• Most
injured
workers
received
opioids
for
pain
relief,
over
80%
in
some
states
studied
• Amount
of
opioids
received
per
claim
unusually
high
in
several
study
states
• 1
in
6
or
7
injured
workers
in
Louisiana
and
New
York
who
received
opioids
had
them
on
a
longer-­‐term
basis
• Few
longer-­‐term
users
of
opioids
received
services
for
monitoring
and
management
 Longer-­‐term
opioid
use
in
MA
fell
a_er
pain
guidelines

21. Longer-­‐Term
Opioid
Use
In
MA
Fell
A_er
Pain
Guidelines
2007/2009
To
2009/2011
Nonsurgical
Claims
With
>
7
Days
Of
Lost
Time,
Injury
Years
2007
To
2009,
Prescrip?ons
Filled
Through
March
2011,
24-­‐Month
Maturi?es
*
Texas
Closed
Formulary
Went
Into
Effect
On
September
1,
2011,
Which
Is
Expected
To
Reduce
Use
And
Longer-­‐Term
Use
Of
Opioids

22. Conclusions
• Opioid
problem
is
BIG
in
workers’
compensa3on,
especially
in
some
states
• Doctors
prescribe
opioids
more
o_en
in
some
states
than
others,
overall
and
on
longer-­‐term
basis
• Opportuni3es
to
eliminate
unnecessary
opioid
prescrip3ons

23. Right
Drug,
Right
Test,
Right
Time.

24. Discussion
Points
• Chronic
opioid
therapy
management
• Prescrip3on
drug
monitoring
guidelines
&
protocol
development
• Prescrip3on
drug
monitoring
result
trends
• Balancing
costs

25. Management
of
chronic
pain
pa?ents
–
10
steps
of
universal
precau?ons
Make
a
diagnosis
with
appropriate
differen3al
and
a
plan
for
further
evalua3on
and
1
inves3ga3on
of
underlying
condi3ons
to
try
to
address
the
medical
condi3on
that
is
responsible
for
the
pain
2
Psychologic
assessment,
including
risk
of
addic3ve
disorders
3
Informed
consent
4
Treatment
agreement
5
Pre-­‐/post-­‐treatment
assessment
of
pain
level
and
func3on
6
Appropriate
trial
of
opioid
therapy
+/-­‐
adjunc3ve
medica3on
7
Reassessment
of
pain
score
and
level
of
func3on
8
Regularly
assess
the
“Four
As”
of
pain
medicine
•
Analgesia,
Ac3vity,
Adverse
reac3ons,
and
Aberrant
behavior
9
Periodically
review
management
of
the
underlying
condi3on
that
is
responsible
for
the
pain,
the
pain
diagnosis
and
comorbid
condi3ons
rela3ng
to
the
underlying
condi3on,
and
the
treatment
of
pain
and
comorbid
disorders
10
Documenta3on
of
medical
management
and
of
pain
management
according
to
state
guidelines
and
requirements
for
safe
prescribing
Gourlay DL, Heit HA, Almahrezi A. Universal Precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-112.
Gourlay DL, Heit HA. Universal precautions revisited: managing the inherited pain patient.
Pain
Med. 2009;10(suppl 2):S115-S123.
|
25

26. Prescrip?on
drug
monitoring
–
objec?ve
evidence
to
assist
in
pa?ent
management
Prescrip3on
Drug
Monitoring
Urine
drug
tes3ng
which
is
used
to
detect
the
presence
of
the
prescribed
drug
in
the
urine,
specifically
controlled
medica3ons,
as
an
indicator
of
the
pa3ent’s
adherence
or
compliance
to
their
treatment
plan
 Presence
of
the
drug
or
the
drug’s
metabolites
indicates
that
the
pa3ent
is
taking
the
drug
 Absence
of
the
drug
or
the
drug’s
metabolites
indicates
that
the
pa3ent
is
probably
not
taking
the
drug
 Presence
of
an
illicit
drug
or
prescrip3on
drug
not
prescribed
by
the
physician
indicates
that
the
pa3ent
is
supplemen3ng
his
treatment
Confidential – Do not copy or distribute | 26

27. Tes?ng
Road
Map
Science
and
What’s
Supported
by
Data
Local
Coverage
State
Laws,
Rules
&
Professional
Standards
Determina?ons
and
Medical
Policies
Other
Regulatory
Pain
Addic?on/Recovery
Requirements
and
Policies
2
7

28. Guidelines
have
common
themes
but
are
not
defini?ve
APS/AAPM
Guidance
¹
ACOEM
Guidelines
Universal
Precau?ons
High
risk
pa3ents
or
who
“There
is
evidence
that
MODERATE
TO
HIGH
Risk
have
engaged
in
aberrant
urine
drug
screens
can
of
Misuse
drug-­‐related
behaviors,
iden3fy
aberrant
opioid
May
be
periodically
clinicians
should
periodically
use
and
other
substance
eligible
for
monitoring
at
obtain
urine
drug
screens
or
use
that
otherwise
is
not
each
visit,
with
a
other
informa3on
to
confirm
apparent
to
the
trea3ng
minimum
of
one
test
adherence
to
the
COT
plan
of
physician.”
conducted
every
three
care.
months
(4x/year)
Pa3ents
not
at
high
risk
and
Screening
is
LOW
Risk
of
Misuse
not
known
to
have
engaged
recommended:
in
aberrant
drug-­‐related
-­‐ At
baseline
May
be
periodically
behaviors,
clinicians
should
-­‐ Randomly
at
least
2-­‐4
eligible
for
monitoring
at
consider
periodically
3mes/year
each
visit,
with
a
obtaining
urine
drug
screens
-­‐ At
termina3on
“for
minimum
of
one
test
or
other
informa3on
to
cause”
conducted
every
six
confirm
adherence
to
the
months
(2x/year).
COT
plan
of
care
¹Chou R, Fanciullo GJ, et al. (2009) Clinical Guidelines for the Use of Chronic|
28
Therapy in
Opioid
Chronic Noncancer Pain. The Journal of Pain, 10 (2): 113-130.

29. Protocol
must
be
defined
by
prac?ce
Who to test? Which drugs? How Clinical
frequently? response to
test results?
Goal: Patient, Practice & Community Safety
2
9

30. What to order Practice
Protocol
Broad Initial PDM Test Prior to _____RX
spectrum
testing: pain Risk Assessment using
___________tool
medication,
illicit drugs,
potential drug Low-Risk High-Risk
interactions Perform random PDM Perform random PDM testing
testing minimum of minimum of
Targeted ______ times per______ ______ times per______
testing based
on results &
other risk Consistent Inconsiste Consistent Inconsisten
factors Result nt Result t
Result Result
Continue Modify Continue Modify testing
Testing at testing testing frequency to
low-risk frequency to frequency for ______ times
rate ______ times _______ per _____
per _____ period

31. Most
pa?ent
drug
tests
are
inconsistent
with
expecta?ons
• The
majority
of
pa3ents
tested
misused
their
prescrip3on
medica3ons
(60%)
• Many
pa3ents
took
drugs
or
combined
drugs
without
physician
oversight
• A
large
number
of
pa3ents
showed
no
drug
in
their
specimen
• Recrea3onal
marijuana
users
are
more
likely
than
non-­‐users
to
misuse
other
drugs
• Anyone
is
at
risk
of
misuse.
70%
Medicaid,
58%
Medicare,
59%
Private
• Inconsistent
results
declined
by
10%
in
pa3ents
tested
30
days
or
more
a_er
ini3al
screen
Quest Diagnostics Health Trends, Prescription Drug Monitoring Report 2013
| 31

32. Inconsistent
results
driven
by
a
number
of
factors
• One-­‐third
(33%)
of
inconsistent
results
showed
presence
of
drug(s)
not
specified
by
the
ordering
physician
in
addi3on
to
prescribed
medica3on.
• 25%
showed
presence
of
a
drug
different
than
the
one
prescribed
by
the
ordering
physician.
• In
42%
of
inconsistent
cases,
no
drug
was
detected.
| 32

33. Marijuana
was
the
most
frequently
detected
non-­‐prescribed
drug
• Non-­‐prescribed
marijuana
was
the
most
frequently
detected
drug,
found
in
26%
of
pa3ent
specimens
with
inconsistent
results.
• These
findings
confirm
other
data
sugges3ng
marijuana
is
the
most
commonly
abused
illicit
drug
in
the
United
States.
• The
next
most
frequently
misused
drugs
detected
in
tes3ng
were
opiates
(22%)
and
benzodiazepines
(16%).

34. Recrea?onal
marijuana
users
were
more
likely
to
use
other
non-­‐prescribed
medica?ons
than
non-­‐users
• 45%
of
specimens
posi3ve
for
non-­‐
prescribed
marijuana
were
also
posi3ve
for
at
least
one
other
non-­‐
prescribed
drug
–
10%
higher
than
non-­‐users
(36%).
• Pa3ents
who
used
marijuana
illicitly
are
1.3
3mes
more
likely
to
use
drugs
not
prescribed
by
an
ordering
physician.
• Among
illicit
marijuana
users,
seda3ve
medica3ons
and
narco3c
pain
killers
were
the
most
frequently
detected
non-­‐
prescribed
drugs.
| 34

35. Cost
of
tes?ng
can
vary
widely
based
on
provider
prac?ce
Scenario
1
26 year old female patient Assumptions
• Neck pain – post accident • Screen reimbursement - CA WC schedule
• 5 mg Hydrocodone 4 times (120% of MC)
day • Use of G0434 for POCT & G0431 for lab-
• 20 mg Adderall daily based immunoassay
• Moderate Risk- consistent • Quantitative reimbursement - opiate CPT
results code
Provider
A
Jan.
April
Jul.
Oct.
Annual
12
Drug
POC
Test
Cup
1*$24
1*$24
1*$24
1*$24
$96
12
Quant.
Confirma3ons
12*$32
12*$32
12*$32
12*$32
$1,536
Delta
per
Total
$408
$408
$408
$408
$1,632
Pa?ent
$792
Provider
B
Jan.
April
Jul.
Oct.
Annual
annually
10
Drug
Lab
Test
+
SVT
1*$146
1*$146
1*$146
1*$146
$584
2
Quant.
Confirma3ons
2*$32
2*$32
2*$32
2*$32
$256
Total
$210
$210
$210
$210
$840
|
35

36. Cost
of
tes?ng
can
vary
widely
based
on
provider
prac?ce
Scenario
2
40 year old male patient Assumptions
• Lower back pain – post work • Screen reimbursement - CA WC schedule
injury (120% of MC)
• 100 mg Tapentadol 4 times/day • Use of G0434 for POCT & G0431 for lab-
• 0.5 mg Clonazepam daily based immunoassay
• Moderate Risk- consistent • Quantitative reimbursement - opiate CPT
results code
Provider
A
Jan.
April
Jul.
Oct.
Annual
12
Drug
POC
Test
Cup
1*$24
1*$24
1*$24
1*$24
$96
10
Quant.
Confirma3ons
+
$26
+
$26
+
$26
+
$26
+
15* $2,024
SVT
+
5
Direct
to
Quant.
15*$32
15*$32
15*$32
$32
Delta
per
Pa?ent
Total
$530
$530
$530
$530
$2,120
$1,280
Provider
B
Jan.
April
Jul.
Oct.
Annual
annually
10
Drug
Lab
Test
+
SVT
1*$146
1*$146
1*$146
1*$146
$584
2
Direct
to
Quant.
2*$32
2*$32
2*$32
2*$32
$256
Total
$210
$210
$210
$210
$840
|
36

37. Providers
and
payers
must
work
together
to
op?mize
outcomes
and
minimize
cost
to
system
• Educate
physicians
on
state
rules,
regula3ons
&
guidelines
• Implement
reasonable
tes3ng
frequency
&
reimbursement
policies
• Link
pharmacy
and
laboratory
data
• U3liza3on
evalua3ons
&
clinical
interven3on,
as
appropriate
|
37

38. Next
fron?er:
using
gene?cs
to
individualize
pain
drug
selec?on
Cytochrome
P450
enzymes
are
commonly
associated
with
drug
metabolism.
Approximately
90%
of
individual
differences
in
liver
CYP
3A
ac3vity
are
from
gene3c
varia3on
The
P450
variants
can
drama3cally
alter
enzyma3c
ac3vity.
Gene3c
varia3ons
in
the
DNA
can
affect
rate
and
extent
of
cytochrome
Drug P450
enzyme
metabolism:
CYP 3A metabolism
CYP
2D6
CYP 2D, 2C metabolism
CYP
2C19
Glucuronida?on
CYP
3A4
CYP
3A5

39. Right
Drug,
Right
Test,
Right
Time.
Tron
Emptage,
RPh,
Chief
Clinical
Officer
Progressive
Medical,
Inc.

40. Learning
Objec?ves
• Outline
how
clinical
programs
can
iden3fy
excessive
use
or
misuse
of
opioid.
• Describe
the
impact
of
behavioral
interven3ons
in
chronic
opioid
cases.
• Explain
the
value
of
urine
and
drug
screening

41. Discussion
Points
• Pharmacy
Benefit
Management
Solu3ons
• Prevent
through
Connec3vity
• Monitor
U3liza3on
• Intervene
through
Clinical
Review
• Leverage
Analy3cs

42. Workers’
Compensa?on
Facts
Top
1%
account
for
~40%
of
all
narco3c
costs
Top
10%
account
for
~80%
of
all
workers’
compensa3on
narco3c
costs
Source:
NCCI
Narco3cs
in
Workers’
Compensa3on

43. U?liza?on
Medica?on
Quan?ty
x
Length
of
Use
1-­‐2
year
old
claims
=
3%
of
total
medical
costs
11 year old claims = 40% of total medical costs
Source:
NCCI
Drug
Study:
2011
Update

44. Right
Drug,
Right
Test,
Right
Time
Prevent
Alert
Monitor
Intervene

45. Case
Study:
The
Beginning
A framer with a construction company was injured when
pulling a pallet of bricks on the job from one site to
another for use of the materials.
His injury, a low back strain, occurred in August of 1989
and in 1990 had a percutaneous 3-level lumbar
discectomy. He continued with residual pain and the
following therapies were initiated:
• TENS therapy – effective
• Nerve blocks – ineffective
• OT/PT with Activity Restriction
• Biofeedback and Counseling
• Medication Therapy – minimally effective

46. PHARMACY
BENEFIT
MANAGEMENT
SOLUTIONS

47. Total
Pharmacy
Management
ONGOING
COMMUNICATION
U?liza?on
Clinical
&
Diagnos?c
Educa?on
&
Management
Interven?ons
Analy?cs
NETWORK
PENETRATION

48. Follow
the
Prescrip?on
in
Workers’
Compensa?on
Retail
Injured
Worker
Pharmacy
NO
Iden?fy
YES
Out
of
PBM
In
Network
Network
Alternate
PBM
Billing
Agent
Filling
Site
Payor

49. Processing
and
Eligibility
Solu?ons
Capture
Rx
at
Reduce
OON
Home
First
Fill
Bills
Delivery

50. Capture
Rx
at
First
Fill
• Nearly
65,000
retail
pharmacies
• PBMs
contract
with
these
pharmacies
to
bring
efficiencies
• First
fills
are
the
beginning
to
network
penetra3on
and
guideline
adherence
• Early
fill
capture
allows
for
early
aler3ng
of
poten3al
problems

51. In
Network
Processing
Increases
Informa?on
• Monitor
for
guideline
adherence
• Direct-­‐to-­‐pharmacy
connec3vity
processing
brings
conflict
alerts
to
the
pharmacist
• Reduces
risk
of
duplicate
therapy
• Alert
for
high
dose
• Mul3ple
prescribers
• Reduce
informa3on
delay
associated
with
paper
claims

52. Home
Delivery
• Offer
convenience
to
injured
workers
• Order
online,
via
phone
and
mail
• Offers
physician
increase
in
control
of
maintenance
medica3ons
• Brings
claims
professional
and
payor
prescrip3on
informa3on
on
long-­‐term
claims
• Follows
long-­‐term
claims
more
closely

53. Mul?faceted
Approach
Prevent
Alert
Monitor
Intervene

54. Prevent
• First
fill
plans
developed
with
guidelines
at
First
No3ce
of
Loss
• High
retail
network
penetra3on
means
more
prescrip?ons
through
program
at
point
of
sale
• Iden?fy
claims
needing
early
Urine
Drug
Screening
• Con3nual
drug
informa?on
review
through
analy3cs

55. Alert
• Applica3on
of
guidelines
through
medica3on
plans
based
on
injury
type,
date
of
injury
and
body
part
• Drive
point-­‐of-­‐sale
informa3on
to
dispensing
pharmacist
to
alert
to
dispensing
problems
• Clinical
audits
and
triggers
alert
claims
professional,
prescriber
and
injured
worker
to
addi3onal
cau3ons
within
the
claim
based
on
analy3cs
• Injured
worker
alerts
can
be
set
to
allow
for
Urine
Drug
Screening

56. Formulary
Development
• Use
of
evidence-­‐based
medica3on
prac3ces
• Na3onal
and
state-­‐specific
guideline
applica3on
• Injury
and
disease
treatments
• Use
of
body
part
and
nature
of
injury
• Dura3on
of
use
limits
• Quan3ty
limits
• Step
therapy
allowances
for
proper
medica3on
allowance
• Off-­‐label
prescribing

57. Dispensing
Edits
and
Alerts
• Industry
standards
from
Na3onal
Council
of
Prescrip3on
Drug
Programs,
D.0
standards
• Alerts
and
edits
– Therapeu3c
duplica3on
– Early
refills
– Drug
–
drug
interac3ons
– Drug
–
disease
interac3ons
– Mul3ple
prescriber
alerts
– High
dose,
over
use
alerts

58. Follow
the
Prescrip?on
in
Workers’
Compensa?on
Retail
Injured
Worker
Pharmacy
NO
Iden?fy
YES
Out
of
PBM
In
Network
Network
Alternate
PBM
Billing
Agent
Filling
Site
Payor

59. Opioid
Strategies
• Ini3a3on
of
narco3c
therapy
no3fies
medical
and
claims
professionals
when
injured
workers
receive
mul3ple
opioid
medica3ons
especially
when
mul3ple
physicians
are
involved
• Targeted
alerts
inform
claims
professionals
of:
o Specific
prescrip3ons
that
may
not
be
appropriate
for
severity
or
chronicity
of
injury
o When
morphine
equivalents
exceed
a
set
amount
o Narco3c
duplica3on
o Excessive
APAP

60. Case
Study:
More
Informa?on
• Medica3on
regimen
in
late
2007
included:
o Venlafaxine
75mg
-­‐
3
per
day
o Lyrica
150mg
-­‐
3
per
day
o Clonazepam
1mg
-­‐
4
per
day
o Carisoprodol
350mg
-­‐
3
per
day
o OxyCon3n
80mg
ER
-­‐
8
per
day
o Oxycondone
30mg
IR
-­‐
6
per
day

61. Case
Study:
Concerns
• Claimant
receiving
well
above
1,000mg
morphine
equivalents
per
day
• Claimant
consistently
reported
pain
scores
of
7-­‐9
out
of
10
• Claimant
began
to
have
high
blood
pressure
readings
• Urine
drug
monitoring
was
ini3ated
and
compounds
represen3ng
illicit
drugs
were
found
present
in
the
urine,
as
well
as
opioid
compounds
• Claimant
was
discharged
from
physician
due
to
broken
opioid
medica3on
contract

62. Monitor
• Monthly
clinical
audits
assist
in
physician
monitoring
to
find
misuse
• Urine
drug
screening
program
to
find
claims
that
may
benefit
from
regular
analysis
• Narco3c
use
and
overu3liza3on
reports
using
analy3cal
tools
and
processes
to
find
poten3al
problems
early

63. Monitoring
Strategies
• Ini3a3on
of
urine
drug
screening
and
monitoring
• Guidelines
suggest:
o Baseline
tes3ng
o Randomized
tes3ng
o Daily
morphine
equivalents
requirements
o Therapy
guidelines
• Opioid
contract
implica3ons
• Prescrip3on
drug
monitoring
programs
• Other
screening
tools

64. Intervene
• Con3nual
clinical
pharmacist
reviews
allow
for
iden3fica3on
of
the
need
for
interven3on
• Drug
u?liza?on
evalua?ons
allow
for
the
pinpoin3ng
of
early
drug
regimen
changes
• Pharmacists
at
point
of
dispense
help
inform
injured
workers
of
poten3al
issues
• Use
of
Le:ers
of
Medical
Necessity
• Pharmacist
reviews
and
consulta?on
recommending
poten3al
treatment
changes
• Peer-­‐to-­‐peer
consulta?on
assists
in
making
therapy
regimen
changes

65. Clinical
Interven?on
Reports
• Pharmacist
Only
Review
– Review
of
medica3ons
– Summary
of
past
and
current
medical
history
– Medica3on
therapy
recommenda3ons
• Physician
Review
– Above,
with
physician
review
and
comment
• Peer-­‐to-­‐Peer
Reviews
– Above,
with
conversa3on

66. Interven?on
Results
CASE STUDY: 628 INTERVENTION CLAIMS
• Compared
six
months
pre-­‐
and
post-­‐interven3on
• Prescribing
physicians
reviewed
therapies
and
made
changes
with
the
following
results
-­‐
24%
-­‐
22%
-­‐
28%
#
of
Prescrip3ons
Morphine
Spend
per
Claim
Equivalency

67. Case
Study:
Results
• Claimant
referred
for
medica3on
review
in
early
2009
• Results
of
successful
peer-­‐to-­‐peer
consulta3on
and
weaning
of
medica3ons:
o Lyrica
600mg
per
day
o OxyCon3n
80mg
ER
–
2
per
day
o Oxycondone
5mg
IR
-­‐
6
per
day
• While
s3ll
well
above
many
guidelines,
morphine
equivalents
reduced
by
more
than
1,000mg
per
day
• Claimant
has
increased
func3onality
and
decreased
pain
scores
• Urine
drug
monitoring
has
been
con3nued
and
claimant
has
been
adherent
to
therapy

68. Thank
you