An Integrated Healthcare System s Approach to Chronic Pain

Transcription

1 An Integrated Healthcare System s Approach to Chronic Pain Presbyterian Health Plan (PHP) Charles Baumgart M.D., Chief Medical Officer Louanne Cunico PharmD, Pharmacy Director September 20, 2011

2 Medical Group Delivery System Presbyterian Healthcare Services Established 1908 Health Plan

3 Presbyterian Healthcare Services Over 37% of New Mexicans rely on PHS for the financing and/or delivery of health care services PHS is comprised of Presbyterian Health Plan (PHP) and the Presbyterian Delivery System (PDS) PHP is the largest health plan in the state with approximately 400,000 Commercial, Medicare and Medicaid members

4 Presbyterian Healthcare Services (PHS) Espanola Hospital Holy Cross Miners Colfax Union County San Juan Regional Rehoboth McKinley Cibola General Hosp. Los Alamos Med. Ctr. St. Vincent Northeastern Regional Medical Ctr. Guadalupe City Hospital Dan C. Trigg 8 Hospitals 650+ Physician multispecialty group Socorro General Lincoln County Medical Center Eastern NM Medical Ctr. Roosevelt General 43 clinic locations 400,000 member health plan Sierra Vista Lea Regional Gila Regional Mountain View Memorial Gerald Champion Columbia Medical Ctr. North Lea Regional Mimbres Memorial Memorial Medical Artesia General

5 Drivers of Healthcare Cost Musculoskeletal Osteoarthritis Injury Chronic pain OB Gyn Cardiology Diabetes GI Cancer

6 Five or More ED Visits/year Urinary tract infection site not specified Nondependent alcohol abuse unspec drunkenness Fever unspecified Unspecified Otitis Media/Acute uris Unspecified disorder teeth&supporting structures Vomiting Alone Acute Pharyngitis Unspecified backache/lumbago Abdominal Pain Migraine/Headache Unspecified backache/lumbago Unspecified Otitis Media/Acute uris Abdominal Pain Urinary tract infection site not specified Migraine/Headache Nondependent alcohol abuse unspec drunkenness Fever unspecified Unspecified disorder teeth&supporting structures Vomiting Alone Acute Pharyngitis

7 Top 50 patients Unspecified disorder teeth&supporting structures Nondependent alcohol abuse unspec drunkenness Urinary tract infection site not specified Vomiting Alone Unspecified backache/lumbago Unspecified Otitis Media/Acute uris Acute Pharyngitis Fever unspecified Migraine/Headache Abdominal Pain Abdominal Pain Unspecified backache/lumbago Migraine/Headache Unspecified disorder teeth&supporting structures Nondependent alcohol abuse unspec drunkenness Urinary tract infection site not specified Vomiting Alone Unspecified Otitis Media/Acute uris Acute Pharyngitis Fever unspecified

8 Cost Per Episode Pain Management Narcotic Analgesics Cost Per Episode $50.00 $45.00 $40.00 $35.00 $30.00 $25.00 $20.00 $15.00 $10.00 $5.00 $- Osteoarthritis Diabetes Spinal/Back Disord, Low Back Arthropathies/Joint Disord NEC Rheumatoid Arthritis Condition Cost per Episode 2010 Cost per Episode 2009

9 Chronic pain Multi-faceted approach Core case management Lists of members accessing ED three or more times to PCP Access to pain specialists Control of advanced imaging CT, MRI Pharmacy management

10 Radiology Utilization

11 Background Review pharmacy utilization Top 25 medications by cost & volume are reviewed monthly. Trends Identified. Research conducted. 11

12 Utilization Opportunity Identified Increased utilization of narcotic analgesics OxyContin identified as cost saving initiative Escalating dosages identified Multiple combinations of narcotics being used Multiple providers and pharmacies being used

13 Build of Pain Management Program Identify patients that are outliers Process for referring to case management Process to identify specialists to manage patients Create tools for primary care providers Create treatment guidelines for primary care providers Create formulary to meet the needs of the specialists and members

14 What Are We Trying to Accomplish? Create a comprehensive program that encompasses the best practice standards for treating chronic pain. Process for referring to case management Process to identify specialists to manage patients Create tools and treatment guidelines for primary care providers Reduce cost and barriers. Create a formulary that meets the needs of the providers and members Remove OxyContin from the formulary.

15 Recognizing the Need To Make A Change Increases in PA volume for second line and non covered sustained release narcotics when members had tried and failed first line formulary alternatives. Corresponding increase in PA burden for providers and provider dissatisfaction. Feedback from PMG Pain & Spine Group that we needed to develop a more sustentative formulary to manage chronic pain. Utilization patterns began to emerge that were concerning related to OxyContin; Increases in dosing frequency Overall dose escalation including members who were on more than one prescription and strength of OxyContin. Increasing incidence of lost medication and refill too soon situations All of the above were driving significant cost increases

16 PMG Pain & Spine Collaboration Collaborated for over 6 months in 2007 with the ABMS certified pain management specialists at PMG Pain & Spine to re-design the formulary and pain management criteria. Worked together in the re-design of a more sustentative, yet cost effective PHP sustained release narcotic formulary. Replace PA management tools with step therapy requirements. PA would result in point of service pharmacy rejections only when the step therapy requirements were not met. Created tools for primary care providers to utilize when members were transitioned back.

17 Historical Overview Preceding Formulary Changes Sustained release narcotic formulary options before 3Q 2007 Morphine Sulfate ER first line (no restrictions) Fentanyl patches; OxyContin (Oxycodone ER); and MS Contin (morphine sulfate ER) second line required PA. Avinza (morphine sulfate ER); Kadian (morphine sulfate ER) and Opana ER (Oxymorphone ER) were not covered and could only be obtained through medical exception.

18 Formulary Changes September 2007 Sustained release narcotic formulary options after Q Morphine Sulfate ER (first line no restrictions) Fentanyl patches and Opana ER were added to the formulary with a step-therapy requirement requiring documentation of morphine sulfate ER prior use in the claims history (second line requiring step therapy). Avinza and Kadian were added to the formulary with a step therapy requirement for prior use of morphine sulfate ER and either Opana ER or Fentanyl Patches. (third line requiring step therapy). OxyContin remained not covered and could only be obtained through medical exception.

19 Formulary Transition Plan Developed A 90 day transition plan was developed which involved coordinated referrals to PMG Pain & Spine and assignment to a PHP case manager. And eventually, transition to a new Presbyterian provider. Letters were sent to members and providers notifying them of the formulary change PHP clinical pharmacists and Medical Directors were key to coordinating transitions.

20 Sustained Release Narcotic Utilization Overview

21 Long Acting Opioid Cost Trend By Drug $450, $400, $350, $300, $250, $200, $150, $100, $50, $0.00 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Duragesic (Fentanyl) Morphine Sulfate ER Opana ER Oxycontin (Oxycodone ER)

22 Axis Title Long Acting Opioid Rx Trend By Drug Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Duragesic (Fentanyl) Morphine Sulfate ER Opana ER Oxycontin (Oxycodone ER)

23 Long Acting Opioid Quantity Per Rx By Drug Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Duragesic (Fentanyl) Morphine Sulfate ER Opana ER Oxycontin (Oxycodone ER)

24 Documented Outcomes Improvement in the cost trend without imposing increased formulary restrictions. Increasing the number of formulary options for Presbyterian providers. Gave them access to more options to switch to other sustained release narcotics rather than escalating doses on a restricted few. Established a referral process to pain management specialists with case manager, clinical pharmacist and medical director support. Over 62 of the members who were on a higher dose of OxyContin were successfully transitioned to new providers and to other formulary alternatives at appropriate dosing.

25 THANK YOU QUESTIONS COMMENTS