By Anne Freedman
Every state in the country, but one, has a prescription drug monitoring program, and increasingly, compliance with such programs is becoming mandatory.
At their best, PDMPs prevent doctor shopping, multiple refills of a single prescription and theft of paper prescription pads. But the voluntary nature of most programs hampers effectiveness, and the lack of a national structure leaves too many gaps.
For the programs to be effective, doctors and pharmacies should be mandated to check the programs' databases for red flags before addictive and powerful medications are prescribed or filled.
"If it's optional, nobody does it," said Mark Walls, senior vice president-Workers' Compensation Market Research leader at Marsh.
"What we are seeing happening in workers' comp is a symptom of a much bigger problem," he said. "We have a national crisis around prescription drug abuse, and specifically opioids."
Theories vary as to what sparked this deadly and debilitating situation, which has led to more deaths from prescription drug overdoses than from cocaine or heroin. It's also led to prescription drug overdoses overtaking all other causes of death in the United States, except for automobile accidents, according to the U.S. Centers for Disease Control and Prevention.
Someone dies from prescription drug abuse every 19 minutes.
Many think it began with the development of stronger pain medications -- drugs that were developed for end of life cancer patients but are now being prescribed for back pain. Some think it sprung from the federal government's focus on pain control and research over the past decade.
Others blame the influence of big pharma on medical providers, in combination with a lack of knowledge on the part of too many treating physicians.
Regardless, the issue is finally getting the national attention it needs. The flames have been burning for much too long, and have snuffed out too many lives.
And the cost isn't just the ruination of lives and families, drug diversion costs health insurers up to $72.5 billion a year in illegal schemes and the cost of treating patients who develop serious medical problems due to narcotics abuse, according to the Coalition Against Insurance Fraud.
A study in the Clinical Journal of Pain in 2011 estimated that the total cost of nonmedical use of prescription opioids in 2006 was $53.4 billion, the bulk of which ($42 billion) was attributed to lost productivity.
"It's an absolutely huge problem," said Dr. Robert L. Goldberg, chief medical officer at Healthesystems, a workers' compensation medical cost management company.
"As people become more dependent on medication, they become less functional and become less likely to return to work," he said. "That impacts not only themselves but their families, and it certainly impacts their employers, who typically lose what was otherwise a productive employee."
Dr. Goldberg also noted that the longer employees are on prolonged disability, the less likely it is they will ever return to the level of employment they had before getting hurt.
Studies have shown, he said, that in most cases, that last job "was probably the best job they ever held in their life." If they ever reach gainful employment again, they will likely be less well paid, with fewer benefits, he said.
"Ultimately, as a society, we all end up paying those costs," Goldberg said.
Some States Lead the Way
Experts point to New York, Kentucky and Texas as examples of programs that other states may want to emulate.
To be effective, said Stephen Festa, chief claims officer at EMPLOYERS, compliance with a prescription drug monitoring program needs to be mandatory for physicians and pharmacies, it needs to be in real time and it needs to be adequately funded.
Too many states -- and he points to California's program as a poor example -- have voluntary PDMPs with nominal funding.
"Funding is critical," Festa said. "Without the appropriate funding, these states are paying lip service to this particular issue."
Every state but Missouri has some type of monitoring program, all of them with varying rules and potential challenges.
It comes down to "sounding good in theory versus execution," said Walls. "Whether or not they work depends totally on how the states implement them."
One of the most robust prescription drug monitoring programs is in New York, where the I-STOP (Internet System for Tracking Over-Prescribing) Act was signed into law on Aug. 27, 2012. It requires physicians to consult a database of a patient's prescription history before prescribing an opioid and requires real-time reporting by pharmacists when filling prescriptions.
By December 2014, I-STOP's mandate for universal e-prescribing of controlled substances will go into effect as well. Also key to the legislation is the ability of payers and PBMs to access database information.
"I think it will have a very significant impact on prescriptions and dispensing in New York," said Joseph Paduda, principal of Health Strategy Associates, author of the popular blog, ManagedCareMatters.com, and president of CompPharma, a consortium of pharmacy benefit managers.
"It eliminates the doctor shopping and it also eliminates the chance that the claimant or that individual duplicates the script and takes it to multiple pharmacies," he said.
"A lot of PDMPs are voluntary. Doctors, protest, 'Oh, it's too much work to not kill my patients so I am not going to do this.' To their credit, most pharmacies are in step with PDMPs."
The New York law is still in the midst of being rolled out and regulations are still being written, however, so its performance is still unknown, Paduda said.
In Kentucky, he said, the state PDMP has already shown some good results.
When that state upgraded its program from voluntary to mandatory, he said, the number of drug conflicts caught by the physicians and retail pharmacies more than tripled.
In addition to database monitoring being required of physicians and pharmacies, the state requires independent medical evaluations every time an opioid is prescribed, said Dr. Teresa Bartlett, senior vice president and medical director at Sedgwick Claims Management Services.
Paduda also noted that Kentucky put into place an interoperability agreement with Ohio -- something that more states should be doing until the federal government steps into a leadership role.
The southeast and southwest corners of Ohio, he said, are "hotbeds of prescription drug use," and before the new agreement took effect, the users would get their prescriptions written in Ohio, but get them filled in Kentucky.
Eastern Kentucky, Walls said, used to be the "epicenter" of prescription drug abuse. "The amount of drugs being prescribed in this area was phenomenal," he said. "The amount of death was tragic."
The Texas program went a slightly different route, requiring precertification before opioid prescriptions can be written for new injuries.
That requirement -- which will be extended to all legacy claims beginning in September -- reduced the number of such prescriptions by 80 percent for claims handled by Sedgwick, Bartlett said.
"It was very effective," she said.
Some other states have also modified their formulary rules. Tennessee, for example, requires precertification for all opioid prescriptions longer than 90 days. Washington State -- which created a five-question opioid risk tool for physicians -- requires patients receiving more than 120 doses for six months to be referred to pain specialists and undergo drug testing and psychological screening.
There is no shortage of variation. All of which points to the need for interstate operability of such programs, as prescription drug abuse is definitely an issue that crosses state lines.
Prescription drug abusers in Kentucky, for example, get 60 percent of their pills from Florida, said Kentucky Attorney General Jack Conway, testifying last fall before the U.S. House Energy and Commerce Subcommittee on Commerce, Manufacturing, and Trade.
One raid by Florida law enforcement of a Broward County medical clinic found that, of the 1,700 medical records, 1,100 patients were from Kentucky, he said.
Interstate operability is "definitely an issue that still needs to be addressed," said Walls. "You go up in the Northeast and you can be in five different states in an hour. It's very easy to get around one state's laws by going to another state.
"Ultimately, the answer is a federal database on these issues and there are discussions going on with that," he said.
But, Festa said, nothing of substance is likely to happen any time soon.
"Until the federal government steps up to the plate on these issues, even if every state in the union did what New York was doing, it's still an issue about the sharing of information across states," he said.
Until that happens, he said, there needs to be enhanced training of physicians, beginning in medical school, and an increased focus by employers on making sure health providers in their networks are trained on this issue.
When long-acting opioids are prescribed as part of workers' comp claims, they are nearly four times as likely to turn into catastrophic claims, with costs reaching more than $100,000, according to a study in the Journal of Occupational and Environmental Medicine.
Another study finds that claims costs are four to eight times higher when workers are prescribed even one opioid, compared to injured workers who are not prescribed such drugs.
Even worse is the impact on the individual.
"The costs of the drugs are not insignificant but it's their impact on the ability of the worker to have a productive life," he said.
ANNE FREEDMAN is senior editor of Risk & Insurance®. She can be reached at firstname.lastname@example.org.
May 1, 2013
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