Transcript Working with a PBM 2014 04 30

Opioids in Workers’ Compensation:
PBM Solutions
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The material in today’s presentation is
based on the training and professional
experience of the presenters, and is not
intended to represent the opinions or
policies of the City of Denver or Midwest
Employers Casualty Company.
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Ray Sibley
• Director of Risk Management
• City and County of Denver
Marcos Iglesias MD, MMM, FAAFP, FACOEM
• Medical Director
• Midwest Employers Casualty Company
• Broad WC experience as treater, medical
director, PBM director and others
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What to Expect
A review of the opioid problem in WC
Latest developments - Zohydro ER, Moxduo CR
PBM as gatekeeper
Opioid strategies
Patient opioid education as part of the strategy
What to look for in a PBM
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Opioids
Opium (1500 BC)
Morphine (1804)
Codeine (1832)
Heroin (1874)
Dihydrocodeine (1908)
Oxycodone (1916)
Hydrocodone (1920)
Hydromorphone (1924)
Methadone (1937)
Fentanyl (1960)
Tramadol (1977)
Buprenorphine (1980)
Oxycodone ER (1996)
Zohydro ER (March 2014)
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Daily MED
Morphine equivalence dose (MED)
Fentanyl 100X more potent than morphine
10 morphine
= 10 hydrocodone
=7 oxycodone
= 70 codeine
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Scope of the problem
254 M opioid prescriptions: Enough to “medicate every
American adult around the clock for a month”
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16,500 deaths from overdose
More than for all illegal drugs combined
285% increase (2000 – 2010)
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32 ED visits for adverse effects per death
CDC, 2011
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Costs: WC
% Total Cost
Indemnity
40%
Opioid
4%
Other
medical
48%
Other drug
8%
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Costs: WC
Use of a short acting opioid: 3X cost
Use of a long acting opioid: 9X cost
Older claims: up to 40% of medical cost
NCCI, 2011
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Costs: California
Off work 3.6X longer
60% higher litigation rates
Claim costs 2X more expensive
WCRI, 2013
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Adverse effects
Itching
Nausea/Vomiting
Drowsiness
Euphoria
Constipation
Bowel obstruction
Depression
Addiction
Immune system
Endocrine system
Decreased sex drive
Hyperalgesia
Respiratory depression
Death
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Safety: MED
Many have chosen 120 mg as a “red flag”
• Washington State: 120 mg
• Connecticut: 90 mg
• Ohio: 80 mg
• ACOEM Opioid Guidelines (2014): 50 mg
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Safety: Other drugs
Central nervous system (CNS) depressants
Alcohol
Benzodiazepines
Sedatives
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Evidence for use
Little-to-none
Short-term studies (1 to 4 months)
Most are funded by industry
High dropout rates
Studies exclude patients with mental and
substance abuse disorders
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Zohydro ER
Zogenix, Inc.
Extended release pure hydrocodone – no APAP
No abuse deterrent properties
Capsules: 10, 15, 20, 30, 40 and 50 mg
AWP $7.02 to $8.58
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Zohydro ER
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Black Box Warning
Abuse potential
Life threatening respiratory depression
Accidental fatal overdose, esp. in children
Potential for neonatal opioid withdrawal
syndrome
Avoid alcohol
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Zohydro ER: Concerns
Do we need another opioid?
No abuse deterrent properties
Under the direction of Dr Margaret Hamburg
the FDA went against its own advisory
committee recommendation (11 to 2) when it
approved Zohydro ER
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Zohydro ER: Clinical Trials
• 302 subjects randomized to Zohydro ER or
placebo
• 12 weeks
• Looking for 30% reduction in pain
• 67.5% vs. 31.1%
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Other
Purdue developing an extended release
hydrocodone to compete with Zohydro ER
Moxduo CR
Combination morphine – oxycodone
Rejected last week by an FDA advisory
committee
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Multi-stakeholder solutions
IW
MD
PBM
PAYER
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PBM: Gatekeeper
Formulary design
Step therapy
Real-time DUR (prospective)
Prior authorization process
Drug review (retrospective)
Monitoring and identification of risk
Data
Education
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Formulary
Right drug for the right patient
List of drugs that will be automatically
filled
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State specific
Acute vs chronic
Injury specific
Claimant specific
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Step therapy
Requires the use of a certain drug before
escalating to another, more expensive or
dangerous drug
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Drug utilization review (DUR)
Correct doses
Early refills
Duplicate fills
Quantities
Dangerous
combinations
Multiple or
unauthorized
prescribers or
pharmacies
Formulary
Step therapy
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Prior authorization
Rx at pharmacyTriggerRejection
P/A alert to payerDecisionAction
• Time-sensitive
• Requires knowledge on part of the
adjuster
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Time sensitive
Avoid frustration at pharmacy
Avoid use of a third party payer
• P/A to NCM or UR department?
• Is the p/a alert truly real time?
• Is it batched (30+ minute delay)?
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Knowledge and decision support
Adjusters are not pharmacists or clinicians
Educational and informational support
Internal (NCM, MD, UR) and external
Does the PBM help the payer make a good
decision?
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Prior authorization
BENEFITS:
• Multiple user roles streamline the process
• Team collaboration
• Increased efficiency for nurses who data sift for potential abuse cases
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E-Prescribing
Point of care management
Formulary integration
Medication history
Letter of medical necessity
BENEFITS:
• Can eliminate prior authorizations at the pharmacy
• Patient safety
• Lower drug costs
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PBM: Opioid interventions
Risk identification
Patterns
Long acting opioids
MED threshold
Injured worker education
Prescriber intervention
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PBM: Prescriber education
Assessment of function
Use of PDMP
Prescription Drug Monitoring Program
Opioid agreement
Urine drug screening
Weaning
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PBM: Peer interventions
Pharmacist and peer review
Peer interaction
Alternatives
Weaning
Opioid detox
Other interventions: CBT / FRP
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Case Study: Alerts
Alerts triggered
• Excessive duration of
use
• Concurrent use of opioid
and sedative
Action
• Opioid program
enrollment
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Case Study: Clinical Interventions
• Letter sent to physician
• IW education sent
• Client enrolled in opioid
management program
• Physician letter, opioid
progress report, pain
agreement, drug testing
and medication history
sent
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Case Study: Outcomes
• Opioid and zolpidem
discontinued
• Reduced risk of sedation
• Reduced risk of OD risk
• Savings > $2,500 annually
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Typical results
38% reduction in opioid utilization (MED)
19% reduction in cost
12-13% of IWs are weaned
14% referral to an appropriate pain
specialist
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Main cost drivers in WC pharmacy
1.Cost of the drug
2.UTILIZATION – especially opioids
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PBM strategy
Medical network
Utilization review
Physician education and intervention
Injured worker education
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What to look for in a PBM
1.What type of clinical programs do you have to
monitor utilization management?
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Alerts
Prospective review
Retrospective review
Patient education
Prescriber education
Opioid management programs
Clinician reviews
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What to look for in a PBM
2. Are your prior authorization alerts truly real
time?
3. Can we customize who you send them to?
4. Do you have mobile apps for these?
5. How do you alert the adjuster about
potential abuse?
6. How do you communicate with prescribers?
With injured workers?
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What to look for in a PBM
7. What tools do you use in managing opioids
and other potentially harmful medications?
8. How will you educate my staff?
9. How will you keep me up to date on clinical
and regulatory issues that affect my ability to
manage opioids and other prescriptions?
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Questions, Final Comments and
Contact Information
Ray Sibley – [email protected]
Marcos Iglesias MD – [email protected]
ask for patient education brochure
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KEEP THIS SLIDE FOR EVALUATION
INFORMATION/MOBILE APP ETC.
Please complete the session survey on the RIMS14 mobile application.
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