Transcript Eichler Louisiana ODG Formulary Presentation

Workers Compensation Drug
Formulary: The Basics
Louisiana WCAC
August 2015
Ken Eichler; Director
Regulatory & Outcome Initiatives
Work Loss Data Institute / ODG
[email protected]
917-270-3921
Improving Quality of Care & Outcomes
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Improving the way opioids are prescribed through clinical practice
guidelines can ensure patients have access to safe, effective
treatment while reducing the number of people who misuse,
abuse, or overdose from these powerful drugs.
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Informing agencies, providers, and medical/professional
organizations about evidence-based practices that can improve
patient outcomes.
Content source: Centers for Disease Control and Prevention, National Center for Injury Prevention
and Control, Division of Unintentional Injury Prevention
Page last updated: June 12, 2014
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Workers Compensation
Research Institute
http://www.wcrinet.org/whats_new.html
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New WCRI Publications
– WCRI Medical Price Index for Workers'
Compensation, Sixth Edition (MPI-WC)
– Impact of a Texas-Like Formulary in Other States
– Interstate Variations in Use of Narcotics, 2nd
Edition
– Longer-Term Use of Opioids, 2nd Edition
– Higher costs of doctor-dispensed drugs draw
state reform efforts
Impacts of Texas Adoption of
ODG Guidelines & Formulary
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2014 Workers Compensation Research Institute Study
“Impact of a Texas-Like Formulary in Other States”
http://www.wcrinet.org/whats_new.html
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70 % Reduction in Non-Formulary Prescriptions
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Physicians infrequently substitute formulary drugs for non-formulary
drugs.
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Medical/drug costs both down 30% (opioid costs down 81%)
NASI Study: Texas new lowest cost state in the U.S.
WCRI Findings
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Workers Compensation
Versus Group Health Coverage
GROUP HEALTH
“YOU GET WHAT YOU PAY FOR”
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Coverage is purchased for pre-set defined services and benefits
on a plan & premium specific, by option basis.
Cost based with predefined set benefits, coverage, co-pays and
deductibles knowingly purchased and factored into premium
pricing.
Insurer costs and profits are factored into determination of
Covered Services and Formulary.
Minimal opportunity to address case specific needs & variences.
Workers Compensation
Versus Group Health Coverage
WORKERS COMPENSATION
“MEDICALLY APPROPRIATE & CAUSALLY RELATED”
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Coverage affords treatment & services required to restore the
Patient to MMI and/or ongoing care as medically necessary.
Evidence Based reflecting medical appropriateness; NOT costs,
discounts, rebates or incentives from providers, manufacturers
and distributors.
“Traditionally” consistent coverage for all Workers on a
jurisdictional basis without co-pays or deductibles paid by the
Injured Worker.
All Formularies Are Not A Good Fit for
Workers Compensation
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EBM Based versus Business Model Based
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Workers Comp versus Group Health
• Ease of use by all Stakeholders,
decreasing the need for pre-authorization
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Use in the Authorization, Utilization Review
and Appeals processes
Integration into Claims & PBM programs/systems
Evidence Based Medicine (EBM)
Guidelines & Formularies Can Afford:
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Safeguards for Patients against risky, questionable
inappropriate care and prescription medications
and
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User friendly framework to address Patient & case specific needs
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Improved Patient outcomes, quality of life and function
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Decreased disabilities, substance abuse, overdoses & deaths
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Identification of “pre-approved” care and medications versus
those requiring expedited pre-authorization with substantiation of
need, thereby DECREASING the volume of UR & IMR
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Improved reserve setting, cost containment and MSA’s
EBM Formularies
Empower Medical Providers
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Decrease adversarial relationship with Patients
and enable Physicians to “Just Say No”
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Expedite authorizations and medical reviews
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Consider the picture within the picture within
the picture; the specific drug versus the
alternative drug options versus the alternatives
to drugs.
Consider Treatment Options
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Isolated Treatments & Medication is a small
but costly and potentially dangerous piece of
the treatment plan puzzle.
Look at the picture within the picture within the
picture; i.e. - the specific drug versus the
alternative drug options versus the alternatives
to drugs.
Scope of the Drug Formulary
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FDA Orange Book: FDA Approved Drug Products with
Therapeutic Equivalence Evaluations
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Front line recommendations versus required pre-authorization
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Compounds
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Access by Class, Generic, Brand & NDC Code
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Opioid MED (Morphine Equivalent Dose) Calculators
Looking At The Options
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NDC ADVISOR
“Look-up” Tool
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NDC ADVISOR
Recommendation with Hyperlinks
to Supporting Evidence
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Excerpt of Evidence Based Supporting
Documentation with Hyperlinks
This topic is covered under multiple headings. See more specific entries, as follows: Opioids, criteria for use;
Opioids for chronic pain; Opioids for neuropathic pain; Opioids for osteoarthritis; Opioids, cancer pain vs.
nonmalignant pain; Opioids, dealing with misuse & addiction; Opioids, dosing; Opioids, indicators for addiction;
Opioids, long-acting; Opioids, long-term assessment; Opioids, pain treatment agreement; Opioid provider outreach;
Opioids, psychological intervention; Opioids, specific drug list; Opioids, screening for risk of addiction (tests);
Opioids, state medical boards guidelines; Detoxification; Substance abuse (tolerance, dependence, addiction); Urine
Drug Testing (UDT) in patient-centered clinical situations; Weaning of medications; Implantable drug-delivery
systems (IDDSs); Methadone; Buprenorphine; Rapid detox; Testosterone replacement for hypogonadism (related to
opioids); Opioid hyperalgesia; Opioid-induced constipation treatment; & Opioids, specific drug list. Opioid drugs are
also referred to as opiate analgesics, narcotic analgesics, or schedule C (II -IV) controlled substances. Opioid
analgesics are a class of drugs (e.g., morphine, codeine, and methadone) that have a primary indication to relieve
symptoms related to pain. Opioid drugs are available in various dosage forms and strengths. They are considered
the most powerful class of analgesics that may be used to manage both acute and chronic pain. These medications
are generally classified according to potency and duration of dosage duration.
Overall Classification:
Pure-agonists: include natural and synthetic opioids such as morphine sulfate (MS Contin®), hydromorphone
(Dilaudid®), oxymorphone (Numorphan®), levorphanol (Levo-Dromoran®), codeine (Tylenol w/Codeine 3®),
hydrocodone (Vicodin®), oxycodone (OxyContin®), methadone (Dolophine HCl®), and fentanyl (Duragesic®). This
group of opioids does not have a ceiling effect for their analgesic efficacy nor do they antagonize (reverse) the
effects of other pure opioids. (Baumann, 2002) Morphine is the most widely used type of opioid analgesic for the
treatment of moderate to severe pain due to its availability, the range of doses offered, and its low cost.
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Morphine Equivalent
Dose Calculator
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Nearly 15,000 people die every year of overdoses
involving prescription painkillers.
In 2010, 1 in 20 people in the US (age 12 or older)
reported using prescription painkillers for nonmedical
reasons in the past year.
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Enough prescription painkillers were prescribed in
2010 to medicate every American adult around-theclock for a month.
Drug Overdoses in the USA: 2012
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Leading cause of injury death, exceeding motor
vehicle traffic crashes or firearms
117% increase from 1999 to 2012
account for 9 out of 10 poisoning deaths
114 people died daily as a result of an overdose
6,748 people were treated in emergency
departments (ED) daily for the misuse or abuse
of drugs; approximately 2.5 million
Drug Overdoses in the USA: 2012
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41,502 drug overdose deaths
33,175 (79.9%) unintentional
5,465 (13.2%) suicidal intent
80 (0.2%) homicides
2,782 (6.7%) undetermined intent
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Some deaths include more than one type of drug
22,114 (53%) were related to pharmaceuticals
16,007 (72%) involved opioid analgesics
6,524 (30%) involved benzodiazepines
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Drug Overdoses in the USA: 2011
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Drug misuse and abuse caused about 2.5
million emergency department (ED) visits
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1.4 million were related to non-medical use of
pharmaceuticals.
501,207 visits related to anti-anxiety and insomnia
medications
420,040 visits were related to opioid analgesics
Female Overdoses in the USA
Nearly 48,000 women died of prescription
painkiller overdoses between 1999 and 2010.
Deaths from prescription painkiller overdoses
among women have increased more than 400%
between 1999 and 2013, compared to 265%
among men.
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Child Drug Overdoses in the USA
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Between 2004 and 2005, an estimated 71,000
children (18 or younger) were seen in EDs
each year because of medication overdose
(excluding self-harm, abuse and recreational
drug use).
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Among children under age 6, pharmaceuticals
account for about 40% of all exposures
reported to poison centers.
Who Consumes the Prescribed Drugs?
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Over 50% of prescribed medications are
consumed by individuals other than those they
have been prescribe for.
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Points of access other than Prescribers:
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The generous helping hand
The medicine cabinet
Let’s “party”
Guns get locked up, but medications do not.
How do they get the drugs?
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Studies show that over 80% of patients get
what they want…drugs, testing, referrals, etc.
Why don’t docs “Just Say NO”?
Over 80% of narcotics are prescribed by less
than 10% of the prescribers.
Legitimate injured workers in need of meds
Injured workers bolstering their claims
Drug seekers – need vs. addiction vs. diversion
Knowing the Street Value
www.streetrx.com
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The Soaring Cost of the Opioid Economy
New York Times: June 22, 2013
The stronger the opioid, the higher the expense.
Average claim cost without use of opioids: $13,000
Cost with short-acting opioid like Percocet: $39,000
Cost with long-acting opioid like OxyContin: $117,000
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The Soaring Cost of the Opioid Economy
New York Times: June 22, 2013
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Between 2001 and 2008, narcotics
prescriptions as a share of all drugs used to
treat workplace injuries jumped 63 percent.
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In California, workplace insurers spent $252
million on opioids in 2010, which represented
about 30 percent of all prescription costs; in
2002, opioids accounted for 15 percent of drug
expenditures.
Louisiana “Regulatory Review”
Complementary ODG Trial Access
URL: www.odgtreatment.com
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Username: LAWCAC
Passcode: ODG
THANK YOU FOR THE
OPPORTUNITY TO PRESENT
Ken Eichler
Director, Regulatory & Outcome Initiatives
Work Loss Data Institute / ODG
[email protected]
917-270-3921
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