WA PMP Access by Public Payers. PDMP North Regional Meeting St. Louis, MO April 23-24

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1 WA PMP Access by Public Payers PDMP North Regional Meeting St. Louis, MO April 23-24

2 Public Insurer Access PDMP Statute: Allows PDMP data to be provided to Medicaid and Workers Compensation Primary Goal: To provide for better patient care and promote patient safety. Secondary Goal: To assist our public insurers in preventing fraud and saving state funding.

3 Two Types of Access 1. Healthcare Practitioners within the Health Care Authority (HCA - Medicaid) and Department of Labor and Industries (LNI Workers Compensation) can login with individual account access and request a patient history report. 2. Once a month each agency provides a file through secure file transfer of all their clients/patients (names, DOB). Our vendor then provides matching data for each client/patient in a file that is returned through secure file transfer.

4 LNI - PDMP Bulk Transfer PDMP bulk transfer uses: Identifying pre-existing opioid use Identifying duplicative prescriptions (in process) Identifying prescribing outliers (future) Bulk transfer available in May 2012

5 LNI Early Opioid Intervention Pilot Identify claims that are days old AND received 1 opioid prescriptions within 60 days before the injury Clinical review and intervention by a nurse or pharmacist as necessary Better coordination of medical care and management of claims, promote use of PMP and reduce cost and disability

6 LNI - Early Opioid Intervention Pilot new claims meet this criteria each month (3-4% of all claims allowed) Prioritization Criteria Chronic opioid use ( 3 prescriptions in previous 3 months) High dose opioid (> 120mg/d MED) Other controlled substances (e.g. benzodiazepines, sedativehypnotics Timeloss (wage replacement) Clinical review is prioritized by the number of criteria met

7 Future LNI Initiatives Complete the Early Opioid Intervention Pilot Require L&I s providers to access PDMP before prescribing opioids for a work-related injury (new guideline) Identify duplicative prescriptions and create a process to intervene Identify prescribing outliers to improve L&I s new provider network

8 HCA Patient Review & Coordination (PRC) Aimed at over-utilizing clients Decrease and control over-utilization and inappropriate use of health care services Minimize medically unnecessary services and addictive drug use Client and provider education and coordination of care Assist providers in managing PRC clients by providing available resource information to facilitate coordination of care Reduce overall expenditures

9 PDMP Assistance to PRC to Date As of May 2012 the PDMP has assisted in identifying 20 clients for the PRC program to date (through 5 months of using just the individual query site) The minimum time that a client is in PRC is 2 years and they can be 3 years or 5 years. These 20 clients represent 67 PRC client lock-in years at $6,000 per year. This amounts to over $400,000 in savings. 9

10 PDMP Bulk Data use by PRC PRC Program compliance analysis Of 3,800 PRC clients 1,900 are currently Fee For Service Of these 1,900, 1,170 clients have at least 1 PMP prescription. Of the 1,170 clients filling prescriptions 489 Clients paid cash for 2,470 prescriptions. And 243 additional clients are listed as paid by 04 private insurance with an additional 2,059 prescriptions. This would be a total of 732 clients filling 4,529 total prescriptions By contrast 898 clients filled 12,240 prescriptions paid for by Medicaid during this same period. 10

11 PDMP Bulk Data use by PRC Client Identification analysis Allows improved algorithms with clients. Identified >2000 Clients in 2012 with Cash and Medicaid paid schedule prescriptions on the same day. Identified 478 clients where cash and Medicaid fills were < 10 days apart, the scripts were overlapping, for the same drug and from different prescribers. Currently reviewing the top utilizers of the 478 for PRC placement. 11

12 HCA - Narcotic Review Program The Narcotic Review Program (NRP) evaluates Medicaid clients who are receiving high doses of opioid narcotics to verify the medical need for these exceptional doses. It only applies to client with chronic non-cancer pain. Each narcotic prescription for these clients requires authorization as long as the client is in the narcotic review program. A client s narcotic use will be adjusted to minimize pain and maximize function. The lowest effective dose, or zero use is determined by medical necessity and clinical considerations. PDMP Data found that 83% of clients in the NRP had scripts that were not paid for by Medicaid. 12

13 Future HCA Initiatives HCA will be using bulk data to augment our lock-in PRC program. HCA has already been working on threshold reports to go to managed care plans concerning clients using cash. HCA will be sending threshold reports to: Prescribers with clients prescription Information Pharmacies who accept cash from Medicaid clients in violation of their core provider agreement 13

14 Refining the Bulk Transfer Key Areas that were fine tuned: Data Fields: NPI, Payment Type, etc Handling reversals, voids, duplicates Provide back in return file LNI patient name for matching Key Areas for improvement: Payment Type entered more accurately NPI # - require is to be reported Patient ID more reliable matching

15 Program Contact Chris Baumgartner, PMP Director Washington State Dept. of Health Phone: Website:

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