Transcript Best Practices: Prescription Drugs and Chronic Pain

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A Prescription for Mitigating MSA Settlement Costs
Your Speaker
Mark Pew, Senior Vice President
PRIUM (www.prium.net)
Medical Intervention on Clinically Complex Claims
Mr. Pew brings over 30 years of expertise in the property and casualty and healthcare
industries, strategic planning, and technology to his presentations. He has worked with
PRIUM in a variety of roles since 1989 including IT, operations, product and service
development, and executive management. Other experience includes CoreSpeed,
MedicaView International, ChoicePoint and Equifax.
Mr. Pew has been following the prescription drug issue since 2003 and created PRIUM’s
Medical Intervention Program. He is a member of the medical issues committee of
International Association of Industrial Accident Boards and Commissions (IAIABC).
Current responsibilities at PRIUM include educational outreach, product development and
marketing.
MSA Basics
MSA 101
The Problem
CMS and WCMSA
• Used for lump-sum settlements with future medical costs
• Protect Medicare’s financial interest
• Protect the claimant’s Medicare coverage
• They want the proposal at MMI
• Biggest issues …
• No defined appeal process
• Response can be unpredictable and inconsistent
• Pharmacy costs can be as much as 70% of a WCMSA proposal
MSA 101
Enormous Costs
• Medication costs over a 30-year expectancy:
Drug
Purpose
Dosage
Total Cost
Abilify
Depression,
schizophrenia
10mg
$251,521
Duragesic
Fentanyl (opioid) patch
for pain
100mcg
$173,052
Butrans
Buprenorphine (opioid)
patch for pain
20mcg
$165,984
Imitrex
Migraine treatment
20mg
$164,628
OxyContin
Oxycodone (opioid) for
pain
80mg
$147,606
MSA 101
The Drug Problem
• The logic …
• If the treating physician said it …
• Or the payer paid for it …
• Within the past 2 years …
• It’s the treatment * the rated life expectancy
• The AHA … now … OMG moment
• Settlement
MSA 101
Some Reasons
• AWP pricing is required
• Nobody pays AWP
• No generic substitutions for brand-name drugs
• DAW doesn’t matter if the brand-name drug was dispensed
• Only the treating physician’s opinion / actions matter
• Even if they just mention it
• Reluctance to accept “projected” prescription drug reductions or tapering
• Only “actual” reductions matter
• Generalized calculations often based on unrealistic assumptions about
future medical care
• The same dosage/frequency forever? Really?
Treatment Red Flags
Treatment Red Flags
Polypharmacy
• Variety of definitions:
• Concurrent use of multiple drugs, with some researchers
discriminating between minor (two drugs) and major (more than
four drugs)
• The use of more drugs than are clinically indicated
• Too many inappropriate drugs
• Two or more medications to treat the same condition
• Two or more drugs of the same clinical class
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000563/
• Risk Factors
• Treatment of side effects
• Multiple prescribers, uncoordinated care
• Co-morbidities that complicate care
• Patient non-adherence
• The Enemy of Function … And Cost
Treatment Red Flags
Polypharmacy
PAIN
Opioid
fentanyl?
• Insomnia
zolpidem
• Lethargy
modafinil
• Atrophy
carisoprodol
• Depression
duloxetine
• Sexual dysfunction
sildenafil
• Constipation
stool softener
• Addiction
buprenorphine
All of this makes
the pain harder to
identify and treat
Treatment Red Flags
Inappropriate Patterns
Treatment Red Flags
• Opioid dosage exceeding 120mg MED per day
• ACOEM’s new guidelines say 50mg MED/day
• Acetaminophen dosage exceeding 4000mg per day
• NSAID dosage exceeding 3200mg per day
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Opioids used for more than 2 contiguous months after surgery
Muscle relaxants used for more than 2 contiguous months
NSAIDs used for more than 6 contiguous months
Benzodiazepines used for more than 4 contiguous weeks
• No exit strategy by the prescriber
Treatment Red Flags
Inappropriate Patterns
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Topical analgesics
Anti-narcoleptic drugs (Provigil, Nuvigil)
Hormonal supplements
Spinal Cord Stimulator / Intrathecal Pump and topical / oral analgesics
Drug regimen that has automatic refills
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More than one prescribing physician involved in the overall drug regimen
No opioid treatment agreement
No urine drug monitoring
No liver / kidney toxicity tests where applicable
• Prescriber not utilizing the state’s PDMP
Treatment Red Flags
Developing a Strategy
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Opinions are not enough
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Standard of Care is not enough
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MMI < > Polypharmacy
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With no appeal process, it needs to be your “best offer”
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Incorporate services and procedures that create that “best offer”
The Package of Evidence
Optimizing a MSA
Package of Evidence
1. Assess the clinical appropriateness of ongoing treatment
• If clinically questionable, STOP THE MSA PROCESS
Optimizing a MSA
Package of Evidence
1. Assess the clinical appropriateness of ongoing treatment
• If clinically questionable, STOP THE MSA PROCESS
2. Intervene collegially with treating physician(s)
• EV1: Proves the treating physician agrees with changes
Optimizing a MSA
Intervention
Creating an Epiphany
• Must be collegial
• Don’t start with Utilization Review or IME
• Sometimes a prescriber will only respond to a peer
• PM&R specialty that focuses on function
• Diligent
• 3 calls over 3 days does not constitute reasonable effort
• Recommendations should be from Evidence Based Medicine
• Even if the jurisdiction doesn’t mandate it
• Get the agreement in writing
• For CMS, the decision needs to come from the treating physician
Optimizing a MSA
Package of Evidence
1. Assess the clinical appropriateness of ongoing treatment
• If clinically questionable, STOP THE MSA PROCESS
2. Intervene collegially with treating physician(s)
• EV1: Proves the treating physician agrees with changes
3. Have a plan ready for a non-cooperative physician and/or patient
• Options are jurisdictionally driven
Optimizing a MSA
Package of Evidence
1. Assess the clinical appropriateness of ongoing treatment
• If clinically questionable, STOP THE MSA PROCESS
2. Intervene collegially with treating physician(s)
• EV1: Proves the treating physician agrees with changes
3. Have a plan ready for a non-cooperative physician and/or patient
• Options are jurisdictionally driven
4. Initiate consistent oversight with treating physician(s) to
implement changes
• EV2: You weren’t just lucky
Optimizing a MSA
Intervention
Accountability
• Must be consistent
• The treating physician should be expecting the call
• Must include accountability
• Not just checking … Verifying
• Must provide flexibility
• If Plan A isn’t working, help determine a Plan B
• Must connect the dots
• Ensure all stakeholders know the plan and concur
Optimizing a MSA
Intervention
Tapering Basics
1. Motivation of the patient
• Identify how patient will manage pain with less/no dosage
• Recovery lifestyle
• Coping skills
• Function
2. Competence of the provider
• Can the treating physician facilitate the weaning?
• In-patient / out-patient?
• Is the goal reduction in dosage or removal of drugs?
Optimizing a MSA
Package of Evidence
5. Utilize the PBM (and bill review) to create a customized
formulary
• EV3: Enforce the changes
Optimizing a MSA
Intervention
Customization
• Create a customized formulary per patient
• As drugs/dosages change, edit the formulary
• Determine Prior Auth or Block
• How will exceptions be handled?
• Edits + Transactions = Strategy
• Active engagement tells a good story to CMS
In Summary …
Collegial, evidence-based
Leverage PBM system,
customize the formulary
Consistent, coordinated, teambased follow up on changes
Optimizing a MSA
Package of Evidence
5. Utilize the PBM (and bill review) to create a customized formulary
• EV3: Enforce the changes
6. Create a story to show the strategic effort to remove
inappropriate drugs
• Reviewing physician’s assessment
• Treating physician’s agreement
• Ongoing interaction with treating physician during tapering
• Transactional record from PBM shows dosage reduced / drugs
removed
• This is compelling to CMS
Optimizing a MSA
Package of Evidence
5. Utilize the PBM (and bill review) to create a customized formulary
• EV3: Enforce the changes
6. Create a story to show the strategic effort to remove inappropriate
drugs
• Reviewing physician’s assessment
• Treating physician’s agreement
• Ongoing interaction with treating physician during tapering
• Transactional record from PBM shows dosage reduced / drugs
removed
• This is compelling to CMS
7. RESTART THE MSA PROCESS
Optimizing a MSA
In Summary
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Your first calculation may not be your best offer
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Identify triggers for when to delay the WCMSA proposal
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Create a compelling case to CMS that history does not predict future
• And document everything …
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This all requires patience
Mark Pew
Senior Vice President
(678) 735-7309 Office
[email protected]
LinkedIn: markpew
Twitter: @RxProfessor
Our Evidence Based blog
www.priumevidencebased.com