In 2011 workers' comp industry sources such as NCCI published studies highlighting how prescription drug costs have increased to represent 19 percent of total medical spend, with the estimates of opioid use accounting for a large chunk--approximately 25 percent--of a payer's total prescription drug costs.
More than ever before, the need to use a proven, comprehensive opioid management strategy to address these complex issues is necessary. But it's not as simple as pressing an "easy button" to fix it all. According to Daryl Corr, president of Healthesystems, a specialty provider of pharmacy and ancillary benefits management programs for the workers' compensation industry, chipping away at the opioid challenge is no easy matter. But, by using a strategic and flexible approach, a targeted opioid management program can start to turn the tables on this critical problem in workers' compensation. "There are no panaceas or silver bullets to immediately change opioid prescribing in comp," Corr said. "But the combination of several tools have proven to positively impact this ever-expanding problem." The key is it must be a comprehensive, proactive and measurable solution.
For many payers, the strategy to control prescription opioid use has been solely focused on the older portion of the claims population since these legacy claims typically comprise the majority of drug costs. The challenge, however, is that this only addresses one element of the larger problem. When you consider that upward of 60 percent of claimants being prescribed opioids after 90 days of treatment will likely still be on opioids one year later, the need for controlling and intervening somewhere within the first 45 to 60 days is crucial for altering the cost trajectory of long-term opioid use. Early detection and intervention is critical. Between the first and second year of opioid treatments, the opioid cost per claim can increase over 200 percent due to the incremental increases in utilization, dosage amounts and drug potency--and it continues to skyrocket from there, with costs after five years increasing by over 800 percent in some cases.
Therapeutically, it's also a challenge when you take into account how some doctors are frequently prescribing more powerful opioids such as oxymorphone (OpanaŽ). This highly potent drug has a Morphine Equivalent Dose that is three times more powerful than morphine and is approximately two times more potent than Oxycontin, raising more safety concerns over how these therapies are being applied. (Morphine Equivalent Dose, or MED, is a method of comparing the strength of opioids in relation to the drug morphine.) When you combine these cost and safety-related issues, time is the critical factor and an opioid management program must be capable of addressing these issues regardless of the time period of the treatment lifecycle.
In addition, the strategy must go beyond monitoring individual prescription transactions at the pharmacy counter and keep a vigilant eye on the bigger picture. Over the past two years several new opioid drugs have been introduced to the market including Oxycontin OP, a new abuse deterrent formulation (crush resistant) created to replace the highly abused Oxycontin OC. While this was positive news from the perspective of controlling abuse, in some instances prescribing activity has actually shifted away from the abuse deterrent formulation and over to nonabuse deterrent Oxycodone IR and Opana ER. This shift in opioid prescribing is a great example of how quickly the game can change and how critical it is to immediately make changes or develop new strategies within the PBM program. Data analytics and automated program triggers or alerts play a key role in staying ahead of these issues. A successful opioid management program closely looks at every potential factor within the data. That can mean monitoring script activity, as well as uncovering anomalies and red flags such as morphine dosage escalations, opioid use within compounds, and multiple, overlapping medical providers prescribing opioids to a single patient.
The best approach, Corr said, analyzes treatment data both in real time and retrospectively, to identify any anomalies and present them to the claims management stakeholders, working with the provider, and in some cases notifying the patient, especially if there is a safety risk.
"It is a continuum that includes constant monitoring, alerting, educating, following up, and engaging in discussions to create a more definitive, concrete plan," Corr said.
Corr offered the example of an injured worker receiving multiple prescriptions from multiple prescribers, which can have serious potential for things to go wrong for both payer and patient.
When converting new clients onto the Healthesystems program, there have been instances where large percentages of claimants regularly receiving opioid prescriptions were seeing three or more prescribers. With multiple prescribers there is a much greater probability for patient confusion and therapeutic misadventure, including adverse drug interactions, duplicate prescriptions, and a higher likelihood of abuse, misuse or diversion. Not only does this practice place claimants at risk for medication-related issues, the monthly prescription costs can be at least 25 percent higher when compared to claimants seeing a single provider.
To reduce the chances of this happening, payers and their PBM partners must continually develop and improve fraud, waste and abuse programs that target claims with identified risks. The Healthesystems VigilantRx clinical program, for example, proactively identifies patients with targeted characteristics such as multiple prescribers and high-dose opioid prescriptions as these risk factors occur. Subsequently, the payer is alerted and information is provided to address the situation immediately and mitigate the risk.
Communication with prescribers is also essential for ensuring patient safety and optimal clinical outcomes, Corr said, for example in cases where multiple prescribers must be involved, and especially when opioids are being used, it is important to establish a lead prescriber. This provider should coordinate not only the care plan but also the drug therapy, including discussing the patient's choice of pharmacy to prevent possible miscommunication and overlap in therapy. All strategies should be developed with the end-goal in mind. "This is a team effort between our pharmacists and our clients," Corr said. "The more we can collaborate, even down to the case level, the better the outcome." A great tool for coordinating this, Corr explains, is the use of the Healthesystems Therapeutic Advisory Group (H-TAG) program, where the client's medical staff and claims professionals, along with the Healthesystems clinical services team meet regularly to collaborate and jointly develop strategies specifically to address the client's unique challenges.
"It has been great to see the success we have been able to achieve by implementing these types of tools into our clinical program," Corr said. More importantly, it has been very interesting to see how the program keeps evolving since its inception many years ago.
"We designed our clinical program to ensure we have the flexibility to easily make changes, especially since drug trends are changing so quickly," Corr said. "It is also critical to accommodate the uniqueness of each customer." Claims populations and claims management philosophies can vary significantly--no two clients tend to be identical and there needs to be room for customization. Having the clinical pharmacist staff analyze the claims population and develop and present new strategies to the client has had a big impact.
There is clear evidence that the Healthesystems clinical program tools have achieved significant reductions in overall drug spend. When analyzing the results from claims where these tools have been applied, successes include a reduction in annualized drug spend of more than 40 percent, a 40 percent reduction in the number of prescriptions, and a significant reduction in the number of prescribing physicians.
"By no means are we saying these opioid issues are solved. There are so many other contributing claim factors that need to be taken into account," Corr said. "The crucial piece is for the PBM to continually evolve and collaborate with its clients. Strategize and make sure you are considering all the factors so the outcomes can be positive for payers, patients and providers."
(The above piece is part of our continuing Perspectives series designed to highlight key products and services to our readers. This paid-for Perspective was written and edited by Risk & InsuranceŽ
on behalf of our marketing partner. Additional Perspectives can be found on our Web site at www.riskandinsurance.com/.)
May 1, 2012
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