Smart Care California: Multi-Stakeholder Strategies for Reducing Opioid Overuse. Jennifer Wong, MPH IHA Stakeholders Meeting September 19, 2017

Transcription

1 Smart Care California: Multi-Stakeholder Strategies for Reducing Opioid Overuse Jennifer Wong, MPH IHA Stakeholders Meeting September 19, 2017

2 Why Measure Opioid Use? NATIONAL EPIDEMIC 400% Increase in opioid-related deaths in last two decades 12 Californians die from drug overdose every day and two thirds of these deaths involve opioids 1 ACCOUNTABILITY Measuring opioid usage at high dosage or in combination with benzodiazepines in the commercial VBP4P population Enables providers and health plans to hold each other accountable. 3 $$$$ HIGH COST Opioid overuse in North America is estimated to have $78.5B an annual cost of $78.5B 2 produces resources for patients, payers providers, health plans, and purchasers to support the reduction of the use of opioids. VBP4P Measurement compliments Smart Care CA s efforts Curtis S. Florence, Chao Zhou, Feijun Luo, Likang Xu. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, Medical Care, 2016; 54 (10): 901 DOI: /MLR Use of opioids at high dose or use of opioids and benzodiazepines increase the risk of opioid overdose deaths 2016 Integrated Healthcare Association. All rights reserved. 2

3 Opioid Kill People Source: Leonard J. Paulozzi, Karin A. Mack, and Christopher M. Jones, Vital Signs: Risk for Overdose from Methadone Used for Pain Relief United States, , Morbidity and Mortality Weekly Report 61, no. 26 (July 6, 2012): , Integrated Healthcare Association. All rights reserved.. 3

4 Variation Across California: Opioid Overdose Deaths Source: California Opioid Overdose Surveillance Dashboard 2017 Integrated Healthcare Association. All rights reserved.. 4

5 Variation Across California: Morphine milligram equivalents (MME) by County Lake County: 1420 MME per resident per year CA average: 496 MME per resident per year Alpine County: 83 MME per resident per year CA average: 496 MME per resident per year Source: California Opioid Overdose Surveillance Dashboard 2017 Integrated Healthcare Association. All rights reserved.. 5

6 Statewide Problems Require Statewide Solutions 2017 Integrated Healthcare Association. All rights reserved.. 6

7 Today s Presenters Lance Lang, MD, Covered California Smart Care California and the role of purchasers on reducing opioid overuse Jean Shahdadpuri, MD, MBA, Health Net Health plan perspective on reducing opioid overuse Parag Agnihotri, MD, Sharp Rees-Stealy Medical Group Provider perspective on reducing opioid overuse 2017 Integrated Healthcare Association. All rights reserved.. 7

8 Questions? 2017 Integrated Healthcare Association. All rights reserved. 8

9 Smart Care California and the Role of Purchasers IHA Stakeholders Lance Lang, MD September 19, 2017

10 About Smart Care California Public-private partnership working to promote safe, affordable health care in California Co-chaired by the state s largest health care purchasers: Department of Health Care Services (DHCS) Covered California California Public Employees' Retirement System (CalPERS) With participation by Pacific Business Group on Health (PBGH) Collectively, Smart Care California co-chairs purchase or manage care for more than 16 million Californians or 40 percent of the state IHA convenes and coordinates the partnership CHCF provides funding and thought leadership Multi-stakeholder in the best California tradition

11 Smart Care California Participants

12 Smart Care California: Three Focus Areas Initial Focus: Overuse C-section for Low Risk First Time Births (Lead: Covered California) Opioid (Lead: DHCS) Multi-Stakeholder Collaboration Low Back Pain (Lead: CalPERS) Initial Guidelines: Choosing Wisely Found it was not enough to define what not to do Need multi-stakeholder alignment and focus on best practices

13 Variation starts with purchasers

14 Multi-Lever Model for Change Payment Data/ Transparency Purchaser Requirements Public Policy Reduce Opioid Overuse Workforce Consumer Engagement Quality Improvement

15 Covered California Drive for Delivery System Reform: Key Buckets of Requirements 1. Narrow Disparities in Care 2. Integration and Coordination of Care Patient Centered Medical Home (PCMH) Accountable Care Organizations (ACOs) 3. Network Design Based on Value Best Current Data for Hospitals (maternity & safety) Not a narrow network strategy Rather: a QI strategy with a deadline (YE 2019) Comprehensive Data not yet available for physicians 3. Adopt Best Practices Smart Care California

16 Summary: The Power of Aligning Purchaser Requirements Providers are hungry for a consistent set of expectations and consistent business model with revenue aligned with quality goals Primary Care important to but distinct from ACO IHA/PBGH ACO metrics Smart Care Agenda: Maternity Establish Honor Roll sponsored by Secretary Dooley Define Payment Menu Develop Opioid and Back Pain programs Establish best practices Evaluate benefit and payment strategies for alignment

17 Smart Care California: Four Core Priorities for Opioids PREVENT MANAGE TREAT STOP overdose deaths Decrease the number of new starts fewer prescriptions, lower doses, shorter durations Identify patients on risky regimens (highdose opioids, or opioids and sedatives) and work with them to taper to safer doses Streamline access to buprenorphine and methadone to treat opioid addiction Streamline access to naloxone for overdose reversal 8

18 Smart Care California: Opioid Activities to Date Online resources* Dashboard of measures Health plan and purchaser checklist Payer and provider recommendations (in development) * 9

19 Opioid Overutilization Management Program IHA Stakeholders Meeting Jean Shahdadpuri MD MBA Senior Medical Director Health Net Sep 19 th

20 Opioid Overutilization Management Program GOAL Reduce opioid overutilization and to promote appropriate opioid utilization through coordination of care between prescribers and their patients. Provide prescribers with strategies and resources for proper pain assessment and treatment of their Health Net members. Promote the safe use of opioids by sending educational flyer to members To identify members who have a fill of an opioid on or after the fill date of a medication for opioid dependence (exclude Medi-Cal/ CalViva, carved out) INTERVENTION Intervention criteria: Members must meet one or more of the following criteria over a fourmonth period (current age is 20 or older) to be included: 90 morphine milligram equivalents (MME)/day 2

21 Opioid Overutilization Management Program Concurrent benzodiazepine and Soma use and 50 morphine milligram equivalents (MME)/day Concurrent medications for opioid dependence and opioids with 30 or more days of overlap (exclude Medi-Cal/ CalViva, carved out) Visited more than 3 physicians or pharmacies Member opioid outreach: Educational flyer (without a letter): Do You Take a Drug That Contains Opioids? Also known as pain killers, opiates or narcotics 3

22 Opioid Overutilization Management Program Prescriber intervention: Cover letter that explains the Opioid Utilization Program and refers to various resources such as MHN, Be In Charge! (Decision Power s outreach for Medi-Cal and CalViva Health members), and Decision Power (outreach for Commercial and Medicare members), plus the following inserts: Patient profiles Utilize PDMP databases to confirm opioid history and concurrent prescribing by other providers Guide to appropriate opioid prescribing with resources for opioid prescribers Optional medication contract that may be customized, signed by patient and prescriber, and kept in patient s chart Fax-back survey to confirm that opioid medications listed are appropriate, medically necessary, and safe or the regimen should be adjusted. 4

23 Opioid Overutilization Management Program GOAL Adhere to CMS mandates that Medicare Part D plan sponsors implement intensive management programs to address the overuse of opioid analgesics. COMMUNICATIONS MTM pharmacists conduct utilization reviews and receive Member Services transfers to speak with members and their prescribers. INTERVENTIONS Intervention criteria: Members are included in this program when they meet any of the following: 120 mg morphine equivalent dose per day for > 90 days, and are receiving opiates from > 3 pharmacies and prescriptions from > 3 prescribers Any member identified by CMS Any member referred through Medicare Drug Integrity Contractors (MEDICs), case management, MHN, or other organization 5

24 Opioid Overutilization Management Program 2016 RESPONSE REPORT BDS No further review planned: Beneficiary dis-enrolled from contract or lacks Part D eligibility due to any reason except disenrollment due to death. BOR Beneficiary level POS edit not determined necessary: Beneficiary's overutilization resolved. BXD No further review planned: Beneficiary has exempt diagnosis. DMN Beneficiary level POS edit not determined necessary: Drug(s) and dose(s) are deemed medically necessary. INC Review in progress. PS1 Beneficiary level POS edit determined necessary: No drugs allowed in the class. PS2 Beneficiary level POS edit determined necessary: One or more drugs in class allowed. 6

25 Opioid Overutilization Management Program 2016 OUTCOMES 42 cases total. We successfully closed 13 cases (30%) 9 members (21%) deemed the regimens medically necessary (DMN) 2 members required POS edits. (PS2) 28 of the cases (66%) are certain follow-ups. (INC) Count of HICN Column Labels Row Labels BDS BOR DMN INC PS2 Grand Total H H H H H H H Grand Total

26 Opioid High Dosage Monitored Metric 8

27 Opioid Multiple Providers Monitored Metric 9

28 Opioid Safe Med LA collaborative The Safe Med LA coalition includes County health agencies (e.g., Departments of Health Services, Mental Health, and Public Health), health plans, physicians, pharmacists, substance use providers, law enforcement, medical associations, hospitals, community clinics, prevention coalitions, educators, and other community stakeholders. It is comprised of a lead Steering Committee and various goal-specific Action Teams that focus on the 6 priorities and 10 key objectives of the strategic plan. The Safe Med LA Steering Committee will lead the coalition and collaborative implementation of this plan through the 9 Action Teams. Action Teams are each comprised of coalition members that will focus their expertise on specific action items within the key objectives of the strategic plan. 10

29 Opioid Safe Med LA collaborative 11

30 Opioid Safe Med LA collaborative The Safe Med LA coalition includes County health agencies (e.g., Departments of Health Services, Mental Health, and Public Health), health plans, physicians, pharmacists, substance use providers, law enforcement, medical associations, hospitals, community clinics, prevention coalitions, educators, and other community stakeholders. It is comprised of a lead Steering Committee and various goal-specific Action Teams that focus on the 6 priorities and 10 key objectives of the strategic plan. The Safe Med LA Steering Committee will lead the coalition and collaborative implementation of this plan through the 9 Action Teams. Action Teams are each comprised of coalition members that will focus their expertise on specific action items within the key objectives of the strategic plan. 12

31 Opioid Smart Care CA collaborative Smart Care California Smart Care California is a public-private partnership working to promote safe, affordable health care in California. The group currently focuses on three issues: C-sections, opioid overuse and low back pain. Collectively, Smart Care California participants purchase or manage care for more than 16 million Californians or 40 percent of the state. Smart Care California is co-chaired by the state s leading health care purchasers: DHCS, which administers Medi-Cal; Covered California, the state s health insurance marketplace; and CalPERS. IHA convenes and coordinates the partnership with funding from CHCF. 13

32 Our learnings on promoting safe opioid prescribing practices Parag Agnihotri MD Medical Director for Population Health & Post Acute care Sharp Rees-Stealy Medical Group, San Diego

33 How do you address this in a large multispecialty medical group with 1.4 million visits 500+ Physicians 60+ NP/PA 2200 Clinic staff 21 Clinic locations

34 Internal problem A segment of population was prescribed million hydrocodone at an average cost of $4M 570,000 oxycodone at average cost of $2M Key Objectives 1. Reduce by 10% inappropriate use of Opioids Rx 2. Reduce overall Morphine Milligram Equivalent (MME) 3. Preventing overdose: increased use of Naloxone 4. Promote holistic approach for pain management

35 Universal Safe Opioid prescribing committee Pain Specialist Physiatrist Primary care Pharmacist Surgeon Data analyst Medical Director

36 Registry on Opioid prescribing Practice variation reports MME calculation Top 10% of Prescribers for claims where SHC MME > Dr. A Dr. B Dr. C Dr. D Dr. E Dr. F Dr. G Dr. H Dr. I Dr. J Dr. K Dr. L Dr. M

37 Morphine Milligram Equivalent (MME) calculation

38 Informed Prescribing decisions Reduce new starts Prescriber education Prescribing patterns Pain control agreements Easy Access to CURES Choosing wisely material

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40 Reducing overall MME/high dose Opioid Safe tapering of high dose of Opioids How to calculate MME? Access to pain specialist EHR embedded Opioid assessment tool Urine Drug screen Targeted outreach to high volume prescribers Personal experience of Physician with MBC

41 Safe opioid tapering handouts

42 Opioid assessment tool embedded in EHR

43 Site Claims per 1000 for MME > 90 Practice Variation reports for high dose Opioid prescribing Peer to Peer shared experiences Provider Region, Provider Site

44 Early access to Naloxone Retail Pharmacist able to prescribe Sharp McDonald Center Offering Addiction treatment

45 HMO Turning the tide on opioid prescribing.. 14, Opioid Type Supply Count per 1,000 HMO Patients 11.50% 12, , % 8, , , % 2, % Fentanyl Patch Hydrocodone Oxycodone Grand Total

46 New starts 1 st prescription for quantity pills % reduction pills

47 High dose prescriptions trending down Morphine Milligram Equivalent 90 Rate Prescriptions written per 1, MME> YTD 2.16

48 Challenges towards safe opioid prescribing Ongoing provider education Consumer participation Access to Medication Assisted Treatment? Telehealth options for MAT Holistic approach to pain and available options

49 Lessons learned Key Objectives 1. Reduce by 10% inappropriate use of Opioids Rx 2. Reduce overall Morphine Milligram Equivalent (MME) 3. Preventing overdose: increased use of Naloxone Reduce new starts by Provider and Consumer education. Consider using Choosing Wisely material Practice variation reports Promote CURES Peer to Peer experience Engage pharmacist Promote holistic approach for pain management