Transcript VIII. MAT among Medicaid Programs

Concrete Efforts to Address Barriers
to MAT among Medicaid Programs
Dr. Don Teater, National Safety Council
Joe Moser, Indiana Medicaid
Dr. Joe Parks, MO HealthNet
Medicaid National Meeting on Prescription Drug Abuse and Overdose
February 1, 2016
Concrete Efforts to Address Barriers
to MAT among Medicaid Programs
Joe Moser
Director, Indiana Medicaid
Indiana Initiatives
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Scott County Opana Epidemic
Needle Exchange Program
Governor’s Drug Task Force
Medicaid Section 1115 Waiver
Gold Card Program
CleanSlate
Legislation with Medicaid impacts
Opioid Treatment Programs
– Methadone Coverage
• Access and Provider Recruitment
Scott County
Governor’s Task Force on Drug
Enforcement, Treatment and Prevention
• Created by Executive Order on September 1, 2015
• 34 Members
 Medical Professionals
 State Leaders
 Law Enforcement
• Public Meetings
• Tasked with statewide assessment and making
recommendations for reforms
Medicaid 1115 SUD Waiver
• Recommendation of Governor’s Taskforce on Drug
Enforcement, Treatment, and Prevention
• Exploring services currently not covered in
Medicaid for the treatment of substance use
disorder
• 1115 demonstration waiver allows for Medicaid to
broaden coverage and outline a comprehensive
strategy for improving access and quality of care
• Services currently being explored include increased
inpatient detoxification and residential services
Indiana Health Care Programs (IHCP)
“Gold Card” Program
Exempting Providers from PA Requirements for
Buprenorphine and Buprenorphine/Naloxone in the
Treatment of IHCP members with Opioid Dependence
“Gold Card” Prescriber Licensure and
Certifications
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Board certified Psychiatrist
Licensed to practice medicine in Indiana
Possesses one of the following certifications:
• Certified in addiction psychiatry from the American Board of
Psychiatry and Neurology (ABPN)
• Certified in addiction medicine from the American Board of
Addiction Medicine (ABAM)
“Gold Card” Prescriber Requirements
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IHCP enrolled prescribing provider
Providing direct care of opioid dependent member
Certified to prescribe buprenorphine or
buprenorphine/naloxone
Meets Federal and State requirements for
prescribing controlled substances and
buprenorphine products
Agrees to the provisions and receives approval
from the Indiana Family and Social Services
Administration
IHCP Requirements
• Agrees to comply with current IHCP buprenorphine
and buprenorphine/naloxone criteria
• Maintains complete medical records for individual
IHCP members documenting criteria compliance
• Consents to IHCP audits
• Informs FSSA immediately of any change in
qualification status
• FSSA reserves the right to withdraw the prescriber
from participation in this program
CleanSlate
• Physicians certified in Addiction Medicine
• Comprehensive Assessments
• Initial and Ongoing Treatment Planning
• Compliance Testing
• Screening for Comorbidities
• Treatment for Other Dependencies
• Care Coordination with PMPs
• Reporting
Legislation
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Aaron’s Law
– - Lay persons administer injectable naloxone
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Enhanced Lifeline Law
– - First responders carry and administer nasal naloxone
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Good Samaritan Law
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Immunity from arrest when reporting alcohol overdose
Adding opioids under consideration
Jennifer’s Law
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Training on involuntary civil commitment and medication
assisted treatment options
Opioid Treatment Programs (OTP)
• 13 certified in Indiana
• Division for Mental Health and Addiction
(DMHA) may authorize 5 additional OTPs
before June 30, 2018
• DMHA to determine areas of need
• Medicaid reimbursement for methadone
• Barrier: Reimbursement
Neuro-Diagnostic Institute
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Focus will be on diagnosis and treatment of brain-based
disorders, including:
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acute and chronic mental illness
chronic addictions
intellectual and developmental disabilities
traumatic brain injury
neuro-degenerative illnesses such as Alzheimer’s disease
Related Websites
www.indianamedicaid.com
www.bitterpill.in.gov
www.in.gov/gtfdetp/
Medicaid’s Role in Medication
Assisted Treatment Access and
Population Management Of Opiate
Misuse
Dr. Joe Parks
Director, MO HealthNet
Missouri Opiate Situation
• Weaknesses
– Only state without a PDMP
– Underutilization of MAT
• Strategies
– Open access to MAT medications
– Population care management with respect to opiates audit and feedback to high-volume prescribers
regarding high risk patients
• Next Steps
– Encouraging her utilization of MAT by non-SUD
treatment specialists
Vivitrol Cost Efficiency Evaluation
• Adult consumers served in CSTAR General
Population and CSTAR Women & Children in FY
2014 with alcohol or opioid primary drug of abuse
(n=12,527).
• Limited to those consumers who were Medicaid
eligible during FY 2013, FY 2014, and FY 2015
(n=3,691).
• Identified consumers who:
– received Vivitrol in FY 2014 (n=161) and
– those who did not receive Vivitrol in FY 2014 (n=3,311).
• Calculated SUD Treatment costs (including MAT
medications) and other Medicaid costs.
Identifying High Risk Prescribers
• Percent of opioid patients flagged for substance
use diagnosis
• Monthly average number of opiate prescriptions
per opioid patient
• Average daily methadone equivalent of opioid
prescriptions to SUD flagged patients
Costs of Those Receiving Vivitrol
Received Vivitrol in FY 2014
Medical Costs
FISCAL_YEAR
Average per
Person
# Persons
SUD Tx Costs
Average
per
Person
# Persons
Total
Average per
Person
2013
$20,538
159
$6,712
89
$24,295
2014
$19,998
161
$9,605
161
$29,603
2015
$16,551
160
$6,198
96
$20,269
Change 20152013
-$3,987
-$514
-$4,025
Costs of Those Not Receiving Vivitrol
Did Not Receive Vivitrol in FY 2014
Medical Costs
FISCAL_YEAR
Average per
Person
# Persons
SUD Tx Costs
Average
per
Person
# Persons
Total
Average per
Person
2013
$13,778
3,247
$3,597
1,336
$15,258
2014
$16,104
3,311
$3,197
3,110
$19,106
2015
$15,334
3,258
$3,812
1,436
$17,014
Change 20152013
$1,556
$214.70
$1,756
Conclusions
• In general, consumers that received Vivitrol in FY 2014
had higher SUD treatment and medical costs during the
three year period. This is not all that surprising because
we have seen that consumers prescribed MAT tend to
have more severe addictions, co-occurring issues, etc.
• With Vivitrol - $4025 reduction per person in Medicaid
costs from FY 2013 ($24,295) to FY 2015 ($20,269)
• Without Vivitrol -$1756 increase in Medicaid costs ( from
$15,258 in FY 2013 to $17,014 in FY 2015).
• Total net change over 2 years = $5781 reduction
• Longer Retention in Treatment 98 vs 190 days
Abstinence: No Use in Past 30 Days
Valid Cases
Intake
Discharge
Vivitrol
326
20.25%
76.07%
No Vivitrol
19,032
31.13%
60.22%
Employed in Past 30 Days
Valid Cases
Intake
Discharge
Vivitrol
405
20.74%
40.49%
No Vivitrol
22,641
31.43%
35.09%
Had Stable Housing in Past 30 Days
Valid Cases
Intake
Discharge
Vivitrol
436
89.91%
96.10%
No Vivitrol
23,282
91.32%
92.96%
No Arrests in Past 30 Days
Valid Cases
Intake
Discharge
Vivitrol
382
86.39%
94.24%
No Vivitrol
21,599
92.19%
94.26%
Participation in Self-Help Groups in Past 30 Days
Valid Cases
Intake
Discharge
Vivitrol
348
24.14%
44.25%
No Vivitrol
21,024
17.42%
33.28%
Applying Population Health Management
to Prescription Drug Abuse
• Use claims to identify patients who appear to be
at high risk for prescription drug abuse
• Identify prescribers with high portions of their
patients at risk for prescription drug abuse
• Identify high risk patients to the prescribers
involve and provide benchmark feedback and
recommendations for change
• Report selected high risk prescribers who did
not respond to feedback for regulatory
investigation
Applying Population Health Management
to Prescription drug abuse
• Pharmacy Data Alone
– Multiple opiates or benzodiazepines for over 60 days
– High-dose benzodiazepines
– Multiple opiates prescribers
• Pharmacy and Claims Data
– Multiple pharmacies filling opiates or benzodiazepines
– SUD Related diagnoses
– Co-prescribed benzodiazepines and opiates
Quality Indicator™ Overview
Behavioral Pharmacy
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Age Banded – Child, Adult, Elderly
Opioid Pharmacy
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Age Banded – Child, Adult, Elderly
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Audit and Feedback
• Cochrane Review:
– More efficacious than academic detailing
– Best value when:
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Includes peer comparisons
Communicated by a peer-verbally and in writing
Targeted goals and action plans
Patient specific information tied to outcomes
Reflective of CMT’s Core Quality
Indicator Approach
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Quality Indicators™ Common
Foundation
• Evidence or consensus based.
• Involve significant cost and/or health and safety.
• A small proportion of providers responsible for a
large proportion of suspected errors.
• Compelling empirical support for the indicator.
• Are actionable.
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Sample Opioid
Clinical Consideration™
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Peer Comparator
Unsolicited Report
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Overview
Original Mailing QIs
• Use of Buprenorphine with another Opioid (prescribed by
another physician).
• Use of Buprenorphine with a Benzodiazepine (prescribed by
another physician).
• Patient’s use of 5 or more prescribers for Opioid prescriptions.
• Use of Opioids for 60 or more days with a diagnosis
suggesting Opioid, alcohol or other substance abuse in the
last year.
• Use of Opioids for 60 or more days with two or more
diagnoses of malingering, somatization or factitious disorder.
Overview
New Mailing QIs (6/13 Initiation) Following Expansion
• Use of cough and cold medications containing Opioids Adult / Child / Elderly
• Patient's use of 4 or more pharmacies for Opioid Rxs –
Adult
• Patient's use of 5 or more prescribers for Opioid Rxs Child / Elderly
• Use of Opioids for 60 or More Days in Absence of a
Diagnosis Supporting Chronic Use - Adult / Child /
Elderly
Overview
Mailing Statistics - Overview
Mailing Date
Patients
Providers
2/25/2013
2,627
1,786
4/22/2013
3,219
1,273
6/27/2013
33,780
1,675
8/30/2013
28,422
1,594
10/30/2013
27,238
1,566
12/20/2013
26,093
1,585
2/14/2014
25,900
1,646
4/21/2014
27,572
1,603
6/20/2014
27,897
1,756
Phase
Original 5 QIs
5 Original QIs
+
Expansion QIs
Overview
After mailing summary reports:
• Following each mailing, summary reports are
emailed to Missouri administrative staff.
• Those reports include:
– OPI QI Summary (list of QIs with patient and prescriber
counts and percentages)
– High Risk Substance Abuse Patient Report
– Prescriber Identified High Risk Patients Report
– Prescribers More Likely to Treat Patients with SA Report
– OPI Intervention Report (selected QIs and counts of
patients and prescribers)
– OPI CMHC and CMHC-Prescriber Benchmark Reports
Overview – Three Month Pre/Post
Analysis
Successes of the current OPI program in Missouri – Original QIs:
• Estimated savings of $217,034 in opioid pharmacy cost
avoidance – an average of $20.69 per intervened patient per
month for 3,496 individuals eligible for 3 months follow-up.
• Significant decrease of emergency department visits by
37.84%* and hospital admits decreased by 37.82%*
• Average patient usage of 37.1%* fewer opioid prescribers and
31.2%* fewer opioid pharmacies
• Average monthly dose of opioids (in morphine equivalents)
dispensed fell 17.9%*
• Three Month Pre/Post analysis includes MO HealthNet clients
from the eight OPI mailing interventions from 2/25/2013
through 4/21/14.
* comparing 3 months pre-intervention to 3 months post-intervention | p<.001
Multiple Baseline Regression Analyses
Methodology
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Study included eligible adult/child/elderly first intervened in 2013/2014.
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Patient/Months in the analysis included where spend is greater than zero or
subject is Medicaid-eligible for the entire month.
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Study excludes subjects who:
– Were part of a BPM intervention in this report
– Were included in any BPM or OPI intervention in 2012
– Are dual eligibles
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End date for claims analysis was 8/22/2014.
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Cost avoidance related to Hospitalizations, ER and Opioid Rx estimate is
$40 million.
Note: A multiple baseline analysis has multiple cohorts and multiple study periods, hence no single
reporting period applies to all cohorts.
Multiple Baseline Regression Analyses
Cohort
Successes of the current OPI program in Missouri – Original QIs:
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Multiple Baseline Analysis includes multiple cohorts with variable amounts
of follow-up based on eligibility and claims activity.
Dataset includes up to 12 months of pre/post for each cohort.
Mailing Date
Cohort Total
Eligible Patient-Months
After Mailing Date
2/25/2013
4/22/2013
6/27/2013
8/30/2013
10/30/2013
12/20/2013
2/14/2014
4/21/2014
6/20/2014
Total
788
810
659
403
311
320
306
246
328
4,171
8,155
8,574
6,894
4,093
2,645
2,216
1,665
921
615
35,778
Overview – Multiple Baseline Analysis
FY2014
Successes of the current OPI program in Missouri – Original QIs:
Combined Hospital, ER and Opioid Spend PMPM | Original 5 QIs | Adults
$3,000
PharmacyTotalPaid_Cost_Hosp_Cost_ER (method 2) PRE
$2,500
y = 81.59x + 559.33
PharmacyTotalPaid_Cost_Hosp_Cost_ER (method 2) POST
PharmacyTotalPaid_Cost_Hosp_Cost_ER (method 2) PROJECTED
$2,000
Linear (PharmacyTotalPaid_Cost_Hosp_Cost_ER (method 2) PRE)
$1,500
$1,000
$500
$0
-11 -10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
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4
5
6
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8
9
10
11
12
Overview – Multiple Baseline Analysis
FY2014
Successes of the current OPI program in Missouri – Original QIs:
Opioid Spend PMPM | Original 5 QIs | Adults
$250
PharmacyTotalPaid_OPI PRE
y = 8.0306x + 31.423
PharmacyTotalPaid_OPI POST
$200
PharmacyTotalPaid_OPI PROJECTED
Linear (PharmacyTotalPaid_OPI PRE)
$150
$100
$50
$0
-11 -10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
7
8
9
10
11
12
Overview
Successes of the current OPI program in Missouri – Original QIs:
QI 883: Use of Opioids for 60 or More days with a diagnosis suggesting Opioid, alcohol or other substance abuse in
the last year
Triggering % Change| July 2013 Data | August 2013 Mailing
Initial QI Triggering Resulted in Intervention
100%
201307
201309
201311
201401
201403
201405
90%
%Patients Triggering QI per month
80%
70%
60%
50%
40%
30%
20%
10%
0%
201307
201309
201311
201401
201403
Data Year Month
201405
201407
201409
201411
Overview
Successes of the expanded OPI program in Missouri –New QIs:
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Expansion started with mailings in June 2013
• Substantial increase in mailing volume
• Approximately 20x as many clients impacted as before per
mailing
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Estimated $454K savings on Opioids for FY 2013-2014
• Adult: $7.16 PMPM x 17,142 individuals x 3 Months = $368K
• Child: $16.54 PMPM x 1,530 individuals x 3 Months = $76K
• Elderly: $1.36 PMPM x 2,439 individuals x 3 Months = $10K
• Cost avoidance related to Hospitalizations, ER and
Opioid Rx estimate is $15.3 million
Overview
Successes of the expanded OPI program in Missouri –New QIs:
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Significant decrease of emergency department visits by 10.2%* for adults and a
decrease of 45.3%* for children.
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Significant decrease in hospitalizations by 43.7%* for children.
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Average usage of opioid prescribers dropped by 12.6%* for adults, 11.8%* for elderly
and 77.6%* for children
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Average number of pharmacies used to obtain opioids decreased 13.1%* for adults,
77.1%* for children and 10.0%* for elderly.
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Average monthly dose of opioids (in morphine equivalents) dispensed fell 8.1%* for
adults, 52.3%* for children and 11.3%* for elderly.
* comparing 3 months pre-intervention to 3 months post-intervention | p<.001
Questions
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