Managing Opioid Overutilization Challenges
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- Laureen Conley
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1 One Source. Lower Cost. Better Care. Managing Opioid Overutilization Challenges A LOOK AT REDUCING OPIOID OVERUTILIZATION BY 36 PERCENT Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Healthcare Systems, Inc. maintains the sole and exclusive ownership, right, title, and interest in and to this document.
2 Contents The Challenge: A Nation in Pain... 1 Goal: Helping Resolve Opioid Misuse, Abuse & Overutilization Implementing a Case Management Program... 2 Identifying Potential Issues... 2 Conducting Interventions... 3 Surveying Prescribers... 3 Questionnaire Outcomes... 4 Evaluation & Claims Findings Successful Member Outcomes... 6 Results... 7 Looking Forward MedImpact s Overutilization and Safety Controls Program About MedImpact... 8
3 The Challenge: A Nation in Pain Our nation s unprecedented opioid epidemic has been called the worst drug crisis in U.S. history. More Americans died of drug overdoses in 2016 than in the entirety of the Vietnam War, with preliminary death estimates exceeding 64,000 a 22 percent annual increase and the largest jump ever recorded. 1 Opioids prescription and illicit are the main driver of drug overdose fatalities, 2 which now surpass automobile accidents as the leading cause of accidental deaths in the United States. 3 By the Numbers 2016 Our nation s unprecedented opioid epidemic claims 64,000+ American lives annually 1 22% annual increase 1 ~2 Million: # of Americans addicted to pain killers 4 ~3,900: # of people who start taking pain killers every day for non-medical reasons 8 650,000+ opioid prescriptions are dispensed every day in the U.S. 9 91: # of people who die every day from opioid-related overdoses 10 More than 2 million Americans are addicted to narcotic pain killers, such as Vicodin, OxyContin and morphine, contributing to increased heroin use and the spread of HIV and hepatitis. 4 The opioid epidemic has taken a particularly devastating toll on managed care patients and plans. Medicare patients have some of the fastest-growing rates of opioid use disorder, currently at more than six out of every 1,000 beneficiaries. 5 Medicaid members are at the highest risk for opioid abuse and are 10 times more likely to suffer from addiction and substance abuse than privately insured members. 6 The Centers for Medicare & Medicaid Services (CMS) announced in its 2018 Final Call Letter plans to modify the Overutilization Monitoring System (OMS) established in 2013 to better assist plan sponsors with overutilization compliance and to identify members potentially misusing or abusing opioids in Government programs and healthcare organizations nationwide are working hard to turn the tide on opioid abuse by launching numerous initiatives to combat America s opioid crisis from The Comprehensive Addiction and Recovery Act (CARA) to the Surgeon General s Call Letter urging 2.3 million U.S. prescribers to help end the opioid epidemic to President Donald Trump s Commission on Combatting Drug Addiction and the Opioid Crisis. Some initiatives slated for 2019: Individual states are implementing electronic prescribing of controlled substances The Centers for Disease Control (CDC) has updated its opioid prescribing guidelines CMS announced plans to initiate updated OMS criteria in 2018, including: - Reducing morphine equivalent dose (MED) limits from 120 mg to 90 mg - Lock-ins to specific pharmacies to assist providers in monitoring potential misuse, abuse and overutilization The opioid epidemic continues to escalate. Government programs and regulations are only part of the solution. Phamacy Benefit Managers (PBM) can make an impact by offering solutions to manage opioid overutilization and safety, and provide advanced case management PBMs can help plan sponsors: Manage appropriate access to opioids to prevent overutilization Increase patient safety Mitigate fraud, waste and abuse Reduce unnecessary costs Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. 1
4 Goal: Helping Resolve Opioid Misuse, Abuse & Overutilization Opioid misuse and abuse affects people of all ages and walks of life. However, managed care plans face some of the greatest challenges as Medicare and Medicaid members misuse and abuse opioids at increasingly higher and faster rates than other patient populations. The goals of the MedImpact program were to: Reduce opioid overutilization, limiting potential opioid overuse and abuse Manage safe and appropriate use of opioids to provide better care for members Reconcile use of multiple providers and pharmacies to reduce opioid overutilization, misuse and abuse Improve CMS-reported calendar year 2016 opioid summary rates per 1,000 members for high dose (HD), multiple providers (MP), and high dose and multiple providers (HDMP) Action: Implementing a Case Management Program MedImpact sent intervention materials and implemented an advanced, aggressive opioid management solution to help reconcile opioid use and to coordinate with multiple prescribers. MedImpact used multiple identification techniques to detect potential opioid overutilization before members reached patient safety thresholds. MedImpact surveyed more than 600 prescribers to limit potential opioid overuse for two large national Medicare Part D Prescription Drug Plans that included more than 200,000 members from the individual and employer group markets. MedImpact continues to regularly monitor current and future opioid-related quality measures. Action: Identifying Potential Issues MedImpact identified 617 Medicare members for potential drug-seeking behavior. The study also found that the average MED utilization was 276 mg from a range of 120 mg to 1,218 mg. MedImpact analyzed monthly claims from April 2013 to October 2016 to identify members potentially using opioids unsafely based on the following MedImpact criteria: MED dose, recently changed to morphine milligram equivalents (MME), exceeding 120 mg for 90 consecutive days or more Three or more prescribers and three or more pharmacies contributing to opioid claims during the most recent 12 months. (Figure 1) Figure 1: Claims Analysis to Identify Potential Issues Daily morphine equivalent dose (MED) exceeding 120 mg 90 consecutive days Opioid claims from 3 prescribers 3 pharmacies in a 12-month period The opioids included in the MedImpact program were those defined by the CDC and their respective MME conversion factors. However, narcotic cough and cold products and addiction treatments containing buprenorphine were excluded. Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. 2
5 Action: Conduct Interventions MedImpact sent intervention materials monthly to more than 600 providers prescribing the highest volume of opioids. Communications included: Cover letter detailing the purpose of the intervention (CMS-required drug utilization review) Member s opioid medication profile (claim history and total opioid utilization) Questionnaire to confirm opioid usage was appropriate, medically necessary and safe Figure 2: Case Management Members identified monthly by claims analysis Intervention materials (letter and survey) sent to prescriber Calls made if no response to faxed survey Case management pharmacist reconciles case (Case Resolution) Previously case managed members that were identified again were reevaluated every six months 100% of Prescribers Responded by Fax or Phone Action: Survey Prescribers MedImpact surveyed prescribers to help ensure appropriate utilization. Questions and assistance included: Were opioids prescribed for cancer, post-surgery, severe pain (due to what condition) or other reason? Was the prescriber aware that the patient was seeing multiple providers or on high doses of opioids? Was the patient referred to a pain management clinic? If they did not prescribe the prescription, they were asked to provide the patient s primary care physician. Would they be interested in having the plan assist in managing the patient s opioid use by limiting the quantity or type of opioid medication the patient receives through his or her Medicare drug coverage?? Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. 3
6 Questionnaire Outcomes The most common outcomes based on the questionnaire responses and case managers clinical evaluations were: Appropriate therapy for severe pain (48.1%) Overutilization resolved (36.3%). (Figure 3) Figure 3: Questionnaire Outcomes Resolution (n = 617) 4 Member Deceased or Terminal 1% 12 Referred to Pain Management 2% 17 Member No Longer Enrolled 3% 23 Appropriate for Post-Surgery Treatment 4% 40 Appropriate for Cancer Treatment 6% 224 Overutilization Resolved 36% 297 Appropriate for Severe Pain 48% Outcomes Showed 36% Overutilization Resolution 100% PRESCRIBER RESPONSE RATE Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. 4
7 Questionnaire Outcomes Overutilization resolutions included: High Dosage Rate Prescribers decreased dosage to ensure safe and appropriate opioid use Advanced case management resolved members seeing multiple providers and/or pharmacies (per claims review) Intervention assisted members in no longer meeting CMS overutilization criteria The following charts compare CMS 2016 national averages to the plans in the MedImpact program. In addition, MedImpact implemented a more proactive approach to include members seeing three or more prescribers and using three or more pharmacies in comparison to the current CMS criteria of four or more prescribers and pharmacies. Opioid HIgh Dose Rate Daily MED > 120mg for 90 consecutive days or more Rate is per 1000 member-years Mar Apr May Jun Jul Aug Sep Oct Nov Dec MedImpact 2016 Plan 2016 National PDP Average Plans High Dosage Rates Multiple Provider Rate High Dosage and Multiple Provider Rate Change Multiple Providers Rate 4 or more prescribers AND 4 or more pharmacies Rate is per 1000 member-years 18.1 MedImpact National Action: Evaluation & Claims Findings Opioid Multiple Providers Rate Mar Apr May Jun Jul Aug Sep Oct Nov Dec MedImpact worked to improve the safe and appropriate use of opioids to provide better care for members. The process included: MedImpact 2016 Plan 2016 National PDP Average High Dosage and Multiple Providers Rate All members identified as an opioid overutilizer were entered into a proprietary case management program and were evaluated and monitored by a case management pharmacist (Figure 2) Prescriber responses were clinically evaluated by the case manager to reconcile final case outcomes Opioid HIgh Dose & Multiple Providers Daily MED > 120mg for 90 consecutive days or more AND 4 or more prescribers and 4 or more pharmacies Rate is per 1000 member-years Mar Apr May Jun Jul Aug Sep Oct Nov Dec MedImpact 2016 Plan 2016 National PDP Average Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. 5
8 Successful Member Outcomes The following are only a snapshot of the many member cases that our opioid solution was able to help successfully resolve: Member Opioid Abuse: 10 Percocet and two Nucynta daily (MED 161 mg) from three prescribers and three pharmacies over the past 12 months. MedImpact reached out to the member s rheumatologist and neurosurgeon and determined that neither physician was aware of the other s opioid prescribing. Both prescribers agreed the member should be referred to a pain management specialist. Resolution: Follow up with the member s new pain management specialist determined that the member s new therapy was appropriate and ensured that the member stayed with one provider for all opioid prescriptions. Member Opioid Abuse: 23 OxyContin tablets daily (MED 177 mg) from eight different prescribers and three pharmacies within the past 12 months. MedImpact contacted the member s most recent opioid prescriber, who explained that the member was a new patient and advised the member s medications would be decreased. Resolution: The member sought help for opioid abuse and entered opioid addiction treatment three months later. Member Opioid Abuse: Multiple prescriptions for 30-day supply of 60 oxycodone tablets and 90 oxycodone tablets with a total daily dose of 85 mg (MED 137 mg) from eight prescribers and five pharmacies over the past 12 months. MedImpact reached out to member s current opioid prescriber. The prescriber decreased the member s dosage and continued to reduce it slowly, tapering the patient down to six tablets per day to fall below the overutilization qualification criteria. Resolution: The member now sees just one prescriber and uses one pharmacy for much safer opioid treatment. Follow-up claims history review showed that the member s opioid usage was tapered to below 120 mg MED and no longer qualified for case management. Member Opioid Abuse: 16 tablets of Dilaudid and two tablets of Percocet daily, (MED 220 mg) from five prescribers and five pharmacies within the past 12 months. MedImpact reached out to both the member s internal medicine and pain management providers, who were both unaware of each other s opioid prescribing and expressed concern. The pain management provider requested that we implement an opioid restriction so that the member only received two specific opioid prescriptions. Resolution: After four months of having an opioid restriction placed on the member s benefits, the prescriber no longer felt that opioid overutilization with multiple providers was a concern with this member and requested we terminate the restriction as the member no longer qualified for case management. Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. 6
9 Results MedImpact s Overutilization and Safety Controls Program and advanced case management resulted in: Lower opioid prescribed dosage Resolved members who were seeing multiple prescribers and using multiple pharmacies Reduced opioid overutilization by 36 percent Identified 617 Medicare members for potential drugseeking behavior Reduced opioid overutilization by 36% Helping Plans Save Millions By using actionable data to combat member opioid abuse, MedImpact has been able to save these clients potentially $6.35 million dollars in prescription and medical costs over the three-year case study period, which ranged from Looking Forward Based on experience from compliance activities, additional analyses and the CDC guidelines, CMS announced plans to investigate modifying OMS criteria for implementation in 2018 to improve the identification of current opioid overutilizers and to align with the recently published CDC guidelines to the following: 11 Revised opioid overutilization criteria: In modifying the criteria, CMS seeks to: 12 During the most recent six months: - Use of opioids with an average daily MED equal to or exceeding 90 mg for any duration, AND - Received opioids from more than three prescribers and more than three pharmacies - OR from more than five prescribers regardless of the number of dispensing pharmacies Beneficiaries with cancer diagnoses and beneficiaries in hospice are excluded Prescribers within the same practice are counted as a single prescriber Improve the identification of inappropriate opioid use (i.e., reduce false positives related to overutilization that resolved recently and to better identify the most egregious cases of overuse) Align with the CDC guideline on opioid prescribing Define a target population for which the caseload would be manageable for Part D sponsors Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. 7
10 MedImpact s Overutilization and Safety Controls Program MedImpact s Overutilization and Safety Controls Program and case management offers an advanced solution that meets current CMS recommendations and helps prepare plans for the forthcoming revised criteria in Our aggressive opioid management solution supports efforts to reconcile opioid use and coordinates care with multiple prescribers. Multiple identification techniques, such as measuring daily MED and number of providers, allows health plans to detect opioid overutilization before members reach CMS patient safety thresholds and to regularly monitor current and future opioid-related quality measures. The opioid epidemic translates to massive healthcare costs for plans, but even more importantly, patients and their families are suffering and struggling with opioid abuse. MedImpact s opioid case management solution helps address opioid misuse before it escalates to help prevent tragic outcomes for your members. To see how MedImpact can help your plan manage and reduce opioid overutilization, misuse and abuse to improve member health, please contact your account representative for more information. If you don t have an account, us at info@medimpact.com. You can also see more information at About MedImpact MedImpact, an independent, trend-focused pharmacy benefit manager (PBM), is the nation s largest privately held PBM, serving health plans, self-insured employers and government entities. Our business model is unique: avoiding conflicts by not owning a fulfillment pharmacy. Instead, we focus on effectively managing client pharmacy benefits for Lower Cost and Better Care through One Source. We work with clients to promote prescribing to the lowest-net cost, medically appropriate drug. Our number one goal is client satisfaction by providing solutions and patient-centric products with a focus on lowest-net cost and quality outcomes. Founded in 1989, MedImpact manages pharmacy programs for more than 50 million lives in the U.S. and abroad. For more information, go to pbm.medimpact.com. References 1. New York Times. Drug Deaths in America Are Rising Faster Than Ever. Katz, Jason, June 5, 2017: Statistical information about casualties of the Vietnam War: 2. Centers for Disease Control and Prevention: 3. American Society of Addiction Medicine: 4. National Institute on Drug Abuse: 5. Centers for Medicare & Medicaid Services. Opiod Misuse Strategy, Centers for Medicare & Medicaid Services. Opiod Misuse Strategy, Centers for Medicare & Medicaid Services. Opiod Misuse Strategy, Department of Health and Human Services: 9: Department of Health and Human Services: 10: Centers for Disease Control and Prevention, Understanding the Epidemic: Centers for Medicare & Medicaid Service. Analysis of Proposed Opioid Overutilization Criteria Modifications in Medicare Part D Centers for Medicare & Medicaid Service. Analysis of Proposed Opioid Overutilization Criteria Modifications in Medicare Part D. Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. 8
11 MedImpact Services Drive Your Clinical Pharmacy Programs Member Engagement Tools Quality Measurement, Interventions & Outcomes Reporting Management Reporting Tailored PBM Solutions Single, Proprietary PBM Platform Plan Design Expertise & Predictive Modeling Fraud, Waste & Abuse Prevention Utilization Management & Prior Authorization Highly Managed Specialty & Mail Fulfillment Formulary Design & Rebate Optimization Broad, Narrow & Performance-Based Networks To learn more about managing drug spend and trend, join us at the MedImpact Annual Conference 2018 in San Diego March us today at
12 Independent, Trend-Focused Pharmacy Benefit Manager One Source. Lower Cost. Better Care. Managing Trend Before It Happens Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Healthcare Systems, Inc. maintains the sole and exclusive ownership, right, title, and interest in and to this document.
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