Clinical concerns and medication alternatives in workers' comp and auto no-fault claims

Transcription

1 Clinical concerns and medication alternatives in workers' comp and auto no-fault claims A workers compensation and auto no-fault continuing education course May 10, 2018

2 If you have any questions regarding your continuing education credits received from Optum webinars, please contact This course has been approved for 1-hour of CE for the following license types: Pre-approved Adjuster (AK, AL, CA, DE, FL, GA, ID, IN, KY, LA, MS, NC, NM, OK, OR, TX, UT, WY); Certified Case Manager (CCM); National Nurse (all states except Iowa); Certification of Disability Management Specialists (CDMS); Commission on Rehabilitation Counselor (CRC); and Certified Medicare Secondary Payer (CMSP) for CE accreditation. For states that do not require prior approval, the adjuster is responsible for submitting their attendance certificate to the appropriate state agency to determine if continuing education credits can be applied. Please note: Adjuster credits for NH are pending. 3

3 Administrative details

4 To receive continuing education credit 1. Remain logged on for the entire webinar. 5

5 To receive continuing education credit 1. Remain logged on for the entire webinar. 2. Answer all three poll questions. 6

6 To receive continuing education credit 1. Remain logged on for the entire webinar. 2. Answer all three poll questions. 3. You will receive an from the CEU Institute on our behalf approximately 24 hours after the webinar. This will contain a link that you will use to submit for your CE credits. You will need to complete this task within 72 hours. 7

7 Ask a question Questions will be answered at the end of the presentation as time allows. 8

8 Technical issues? Let us know if you experience an issue that causes you to: Miss a poll question Have audio problems Log out Any other technical issue Send a message using the webinar controls question panel or ceprogram@optum.com The sooner we know about an issue, the faster we can take the steps needed to make sure you get the continuing education credits you require. 9

9 Disclosure No planner, presenter or content expert has a conflicting interest affecting the delivery of this continuing education activity. Optum does not receive any commercial advantage nor financial remittance through the provided continuing education activities. 10

10 Medical disclaimer Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, new treatment options and approaches are developed. The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at time of publication. However, in view of the possibility of human error or changes in medical sciences, neither Optum nor any other party involved in the preparation or publication of this work warrants the information contained herein is in every respect accurate or complete, and are not responsible for errors or omissions or for the results obtained from the use of such information. Readers are encouraged to confirm the information contained herein with other sources. This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the Food and Drug Administration (FDA). We do not promote the use of any agent outside of approved labeling. Statements made in this presentation have not been evaluated by the FDA. 11

11 Disclaimer The display or graphic representation of any product or description of any product or service within this presentation shall not be construed as an endorsement of that product by the presenter or any accrediting body. Rather, from time to time, it may facilitate the learning process to include/use such products or services as a teaching example. Accreditation of this continuing education activity refers to recognition of the educational activity only and does not imply endorsement or approval of those products and/or services by any accrediting body. CE credits for this course are administered by the CEU Institute. If you have any issues or questions regarding your credits, please contact rosters@ceuinstitute.net. 12

12 Presenters Matthew Foster, PharmD Clinical Pharmacist, Product Dr. Robert Hall Medical Director Susan Martin, R.Ph. Clinical Pharmacist 13

13 Learning objectives Review medication issues/concerns with the American workforce Describe potential cost issues among various treatment options Identify lower cost alternatives for high cost medications Understand the impact of a formulary on overall claim cost Gain insight into why providers sometimes do not follow practice guidelines Understand what you can do to help make sure a claimant receives the right medication at the right time All pricing listed in this presentation is sourced from: RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

14 Clinical concerns Claimant age Increase risk of injury Chronic diseases Side effects Comorbidities Pill burden Polypharmacy

15 Aging American workforce 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% (projected) American Society on Aging. Issues, Impacts, and Implications of an Aging Workforce. February 6, Available at: 16

16 Complicated medication regimens can drive up costs Dose too high Duplication of therapy Excessive duration of therapy Non-optimal dosing Adding new medication to treat side effect of another medication Nonadherence 17

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18 High-cost combination products Combination products significantly more expensive than each of its individual ingredients May reduce pill burden for some claimants while increasing cost to payer Active ingredients may be available in generic, by prescription and over-thecounter Consider prescribing separate medications at low doses for shortest period of time Reduce unnecessary risk to claimants Reduce costs to clients and healthcare system 19

19 Examples of high-cost combination products Up to 99 $ $1.00-$10.00 $$ $10.01-$50.00 $$$ $50.01-$ $$$$ $ $1000 $$$$$ $ and up Medication Strength Rx/OTC AWP/ unit Vimovo Naproxen / Esomeprazole AWP/ month 500 mg 20 mg Rx $$ $$$$$ 60 Naproxen 500 mg Rx $ $$$ 60 Qty Esomeprazole 20 mg Rx $ $$$$ 60 Naproxen 220 mg OTC $ 60 Esomeprazole 20 mg OTC $$ 60 RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

20 Brand vs. generic Required to be proven safe and effective by FDA Generic medications contain same active ingredients as brand name counterparts Claimant perceptions of generics Brand samples and continuation of prescribing Some generics are made in same facilities using same formulations as brand name counterparts 22

21 Examples of brand vs. generic medications Up to 99 $ $1.00-$10.00 $$ $10.01-$50.00 $$$ $50.01-$ $$$$ $ $1000 $$$$$ $ and up Medication Strength Brand/Generic AWP/ unit AWP/ month Percocet 10 mg/325 mg Brand $$ $$$$$ 120 Endocet 10 mg/325 mg Branded generic $ $$$$ 120 Qty Oxycodone / Acetaminophen 10 mg/325 mg Generic $ $$$$ 120 Medication Strength Brand/Generic AWP/ unit AWP/ month Norco 10 mg/325 mg Brand $ $$$$ 120 Lortab 10 mg/325 mg Brand $ $$$$ 120 Qty Hydrocodone / Acetaminophen 10 mg/325 mg Generic $ $$$ 120 RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

22 Tablet vs. capsule Some companies make new/different formulations of the same medication Example: Tizanidine (Zanaflex ) capsules vs. tablets Tizanidine is FDA approved to reduce muscle tone associated with spasticity Tablets approved by the FDA in 1996 Capsules approved by the FDA in 2002 Capsules and tablets are bioequivalent in fasting state (on empty stomach) Differences in rate and extent of absorption following a meal 24

23 Examples of tablet vs. capsule Medication Strength Brand/Generic AWP/Capsule AWP/Tablet 2 mg + 4 mg Zanaflex 2 mg Brand $3.01 N/A Tizanidine 2 mg Generic $2.71 $1.35 Zanaflex 4 mg Brand $3.82 $2.84 Tizanidine 4 mg Generic $3.44 $ (6 mg) Zanaflex 6 mg Brand $5.73 N/A Tizanidine 6 mg Generic $5.15 N/A RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

24 Prescription vs. over-the-counter OTC alternatives for prescription medications in different therapeutic classes Analgesics (lidocaine patches, acetaminophen) Nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen) Histamine blockers (famotidine) Proton pump inhibitors (omeprazole, esomeprazole) Laxatives (senna, MiraLAX ) 26

25 Examples of prescription vs. over-the-counter Up to 99 $ $1.00-$10.00 $$ $10.01-$50.00 $$$ $50.01-$ $$$$ $ $1000 $$$$$ $ and up Medication Strength Brand/Generic Rx/OTC AWP/ unit AWP/ month Lidoderm 5% patch Brand Rx $$ $$$$ 30 Lidocaine 5% patch Generic Rx $ $$$$ 30 Lidocaine 4% patch Various brands OTC $ $$$ 30 Qty Medication Strength Brand/Generic Rx/OTC AWP/ unit AWP/ month Naprosyn 500 mg Brand Rx $ $$$$ 60 Naproxen 500 mg Generic Rx $ $$$ 60 Aleve 220 mg Brand OTC $ 60 Naproxen 220 mg Generic OTC $ 60 Qty 27

26 Immediate-release vs. extended-release Extended-release formulations often cost more than immediate-release formulations May enter market prior to new generic immediate-release versions becoming available Example Lyrica (pregabalin) Immediate-release - indicated to treat nerve (neuropathic) pain associated with spinal cord injury Lyrica CR does not have all the same indications as immediate-release 29

27 Examples of immediate-release vs. extended-release Medication Brand/Generic Formulation First available AWP/unit Lyrica Brand Immediate-release 2005 $9.36 Lyrica CR Brand Extended-release 2018 $15.32 Pregabalin Generic Immediate-release Late Early 2019 TBD RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

28 Dose optimization Some medications can be dosed less frequently - Same therapeutic effect - Better adherence (reduces pill burden) - Less cost Example - Lyrica (pregabalin) used to treat nerve (neuropathic) pain 31

29 Examples of dose optimization Medication Dosing Total daily dose AWP/unit AWP/month Qty Lyrica 100 mg Three per day 300 mg $9.36 $ Lyrica 150 mg Two per day 300 mg $9.36 $ RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

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31 Formulary management Provides more control and better outcomes for medications Establishes standard for using first-line therapy and appropriate medications for injuries Ensures claimant receives the right medication at the right time at the right cost for payer Promotes the use of generics and lower cost medications Encourages client to pause/ask questions before approving potentially inappropriate medications 34

32 Impact on a claim when taking brand name medication Percocet 10mg/325mg Cost per tablet $24.44 Per month $2,933 One year $35,196 Two years $70, years $351, years $1,055,880 36

33 Impact on a claim when taking generic medication Percocet 10mg/325mg Oxycodone/APAP 10mg/325mg Cost per tablet $24.44 $3.55 Per month $2,933 $430 One year $35,196 $5,160 Two years $70,392 $10, years $351,960 $51, years $1,055,880 $154,800 Projected cost savings with generic medication $901,080 37

34 Compounded medications Contains multiple ingredients in one formulation to be applied topically (i.e., cream, ointment, gel) May contain mixture of anti-inflammatory agents, muscle relaxants, anticonvulsants, anesthetics Majority of the active ingredients are commercially available Not considered first-line therapy Little-to-no evidence to support topical use of many of the ingredients used in compounds Typically require prior authorization Average cost of compounded prescription can range from $500 to $5000 Compound kits have single NDC even though multiple ingredients may be contained in package 38

35 Examples of compounded medications Medication Class Cost/month Oral formulation AWP/month Gabapentin Anticonvulsant Yes $ (300 mg) Amitriptyline Antidepressant Yes $69.30 (100 mg) Ketamine Local anesthetic $ No -- Bupivacaine Local anesthetic No -- PCCA Lipoderm cream Base No -- RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

36 Therapeutic alternatives Medications with different chemical structures but same pharmacological and/or therapeutic class Has similar therapeutic effects and adverse reaction profiles when given in therapeutically equivalent doses Prescriber needs to authorize therapeutic alternatives, when clinically appropriate 40

37 Example of therapeutic alternatives Up to 99 $ $1.00-$10.00 $$ $10.01-$50.00 $$$ $50.01-$ $$$$ $ $1000 $$$$$ $ and up Medication Strength Brand/Generic Formulation AWP/ unit Pennsaid 2% Brand Topical Solution AWP/ month Size $$ $$$$$ 112 gm Diclofenac 1.5% Generic Topical Solution $ $$$$ 150 ml Flector 1.3% Brand Transdermal Patch Voltaren 1% Brand Topical Gel Diclofenac 1% Generic Topical Gel $$ $$$$ 30 patches $$$ 100 gm $$$ 100 gm RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

38 Step therapy Medications with different chemical structures but same pharmacological and/or therapeutic class Provides way to initially prescribe lower cost, clinically appropriate medication for an injury After adequate trial period or if not effective, consider step up to another medication Prescriber needs to write new prescription, if clinically appropriate Cost can be much less depending on dose 42

39 Example of step therapy Medication Strength Brand/Generic Formulation AWP/unit AWP/month Qty Gabapentin 300 mg Generic Immediaterelease Lyrica 150 mg Brand Immediaterelease $1.69 $ $9.36 $ RED BOOK Average Wholesale Price. Truven Health Analytics, an IBM Company. April

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41 Why some providers do not follow practice guidelines Knowledge Familiarity Awareness Behavioral Factors Claimant Guidelines Environmental Attitudes Outcome expectation Self efficacy Motivation Agreement with specific guidelines Agreement with guidelines in general Cabana MD, Rand CS, Powe NR, et al. Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement. JAMA. 1999;282(15):

42 Why some providers do not follow guidelines Facilitator of recommendation Barrier to recommendation Evidence-based Discussion of benefits Discussion of harm and risks Easy to follow Immediate effects Compatible with existing norms Complex decision tree New knowledge required New skills required Organizational changes Changes to existing habits Claimants reacted negatively Burgers JS, Grol RP, Zaat JO, Spies TH, van der Bij AK, Mokkink HG. Characteristics of effective clinical guidelines for general practice. Br J Gen Pract Jan;53(486):15-9.

43 Communicating the message of medication alternatives Discuss cost savings with claimants regarding their care (Outreach and education) Educate prescribers about high cost medications and alternatives - Generic and over-the-counter options (example: lidocaine patch) - Combination products (examples: Vimovo and Duexis ) - Dose optimization (example: pregabalin) - Compounded medications (examples: topical compounds and compound kits) - Guideline-based prescribing 47

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45 Summary Understand that treatment with medications may be complicated Determine what medical conditions are (are not) related to an injury Ensure the right formulary is in place for your claimant Ask prescriber what condition a medication is being used to treat in relation to injury Ask questions prior to approving medications that require Prior Authorization Inquire with clinician if there is a lower cost alternative for a higher priced medication Obtain Medication Review or Peer Outreach to identify and resolve therapeutic concerns Encourage the use of generics and lower cost alternatives 49

46 Thank you! Questions? You will receive an from the CEU Institute on our behalf approximately 24 hours after the webinar. This will contain a link that you will use to submit for your CE credits. You must complete this task within 72 hours. Register for additional Continuing Education opportunities HeliosComp.com/Resources/Continuing-Education CE credits for this course are administered by the CEU Institute. If you have any issues or questions regarding your credits, please contact rosters@ceuinstitute.net.