Proprietary and Confidential

Dave Erlich, LCSW, LISACBehavioral Health ManagerMercy Care Plan & Mercy Care Advantage

August 4, 2017

High risk controlled medication misuse and abuse

Proprietary and Confidential

Mercy Care Plan 2Proprietary and Confidential

Our values

Mercy Care Plan 3Proprietary and Confidential

Objectives

• Understand the origin of controlled medication use

• Be able to identify warning sign behaviors to look out for

• Identify patients with high risk controlled medication utilization

• Have strategies to reduce member risk

Mercy Care Plan 4Proprietary and Confidential

Patient introduction to controlled medications• Acute pain or injury

• Chronic pain and pain management

• Anxiety related behavioral health conditions

Mercy Care Plan 5Proprietary and Confidential

Types of pain

Acute Pain• Surgery• Broken bones• Dental work• Burns or cuts• Labor and childbirth

Chronic Pain• Headache• Lower back pain• Cancer pain• Arthritis• Neurogenic pain• Psychogenic pain

Mercy Care Plan 6Proprietary and Confidential

Chronic pain vs. other conditions

10025.8

16.3

11.97

Number of people suffering (in millions)

Chronic painDiabetesCoronary heart diseaseCancerStroke

Mercy Care Plan 7Proprietary and Confidential

Chronic pain and depression

• 77% of chronic pain patients being treated with opiates report depression related symptoms

• 75% of people in primary care settings with depression also complain of pain related symptoms

0%50%

100%

Anti-depressants

Anti-anxietymedications

Other medication

84%

41%

17%

Patients with chronic pain being treated for

depression

Mercy Care Plan 8Proprietary and Confidential

Anxiety disorders

• General anxiety disorder

• Panic disorder

• Social anxiety disorder

Mercy Care Plan 9Proprietary and Confidential

Benzodiazepine use

• Highest long-term utilization is with older adults ages 65-80

• In all age groups, women are twice as likely as men to be prescribed benzodiazepines

• Most benzodiazepine prescriptions are written by non-psychiatrists

• Diazepam as a muscle relaxant

Mercy Care Plan 10Proprietary and Confidential

United states loves opioids

• 4.6% of the world’s population

• Use 80% of the world’s opioids

• Use 99% of the world’s hydrocodone supply

Mercy Care Plan 11Proprietary and Confidential

Opioid epidemic

• Nearly 50% of people using opioids long-term are only taking short acting opioids

• Primary care physicians are the leading prescribers of opioid prescriptions

• Almost 60% of opioid medication users were taking dangerous combinations of medications

• 27.5% of long-term opioid users were taking two or more short-acting opioids at the same time

Mercy Care Plan 12Proprietary and Confidential

Opioid epidemic

• Over 47,000 deaths resulting from opioid overdose in 2014

• Over 650,000 opioid prescriptions dispensed daily

• $55 billion in health and social costs each year

• $20 billion in emergency department and inpatient care for opioid poisonings

Mercy Care Plan 13Proprietary and Confidential

Interventions

• Prescription drug monitoring programs

• Provider outreach

• Restriction programs

Mercy Care Plan 14Proprietary and Confidential

Prescription drug monitoring programs

• Currently individually managed by each state

• 49 of 50 states currently have a PDMP

Mercy Care Plan 15Proprietary and Confidential

Provider outreach and coordination

Mercy Care Plan High Risk Opioid and Benzodiazepine Intervention Program

Members are identified based on criteria set forth by Arizona’s Medicaid program, known as Arizona Health Care Cost Containment System (AHCCCS) based on a, now closed, performance improvement project designed for all contractors

Mercy Care Plan 16Proprietary and Confidential

Provider outreach and coordination

Mercy Care Plan 17Proprietary and Confidential

Provider outreach and coordination

Notification to all opioid and/or benzodiazepine prescribers• A letter is sent to each prescriber of each

member identified in the high risk categories

• Notification of identified potential risk to the member

• Encourage coordination• Each letter lists the following:

1. Member name2. Member ID3. Member DOB4. Medication label name5. Days supply6. Fill date7. Prescriber’s name8. Prescriber’s phone number

intervention

Mercy Care Plan 18Proprietary and Confidential

Provider outreach and coordination

• Quarterly run report

• Allows for claims run out of about 3 months

• July 2016 report included data from Q1 2016 (January 2016-March 2016)

• Letters are sent out to prescribers of high risk members

Timelines

Mercy Care Plan 19Proprietary and Confidential

Provider outreach and coordination

High risk benzodiazepine and opioid members

Outcomes

Mercy Care Plan 20Proprietary and Confidential

Provider outreach and coordination

Adding a component that focuses on the members moving to a lower risk group and having their opioids or benzodiazepines reduced:

• Explore impact of reduced controlled medication

• Identify members needing additional support

next steps

Mercy Care Plan 21Proprietary and Confidential

Restriction programs

Different criteria depending on the state and/or health plan

Identify members based on particular criteria

Restrict controlled medication fills by locking the member into a particular pharmacy and/or a particular prescriber

Mercy Care Plan 22Proprietary and Confidential

Mercy Care Plan’s programReferrals via:• 10 scripts/10 prescribers/10 ED visit (aka "Poly" report)• Pain management providers - violated contract• Case managers• Pharmacies (cash customers)• State of Arizona• Emergency departments• Urgent cares• Prescribers• Other

Mercy Care Plan 23Proprietary and Confidential

Red flags we look for

• Dispensing of controlled substances from multiple providers• Use of multiple pharmacies to fill the same medications• Treatment from multiple providers for the same medical

conditions• Diagnosis of poisoning or overdose • Diagnosis of alcohol or other psychoactive substance use

disorders• Multiple ED or Urgent Care visits related to pain• Early fills of medication due to “lost” or “stolen” scripts

Mercy Care Plan 24Proprietary and Confidential

Mercy Care Plan’s programOur Process:• Confirm with provider who will be prescribing controlled substances,

PCP, BH, or pain management specialist• Request medical records• After review of the medical information

• Staff with medical director for determination to enroll in Exclusive Prescriber Program

• Restrict approved member to PCP, BH provider, pain management, or specialist

• Enroll into care management• All members will be reviewed annually or upon request of the member

and or the prescribing physician

EXCLUDE any active cancer diagnosis; if pain is associated with the malignancy

Mercy Care Plan 25Proprietary and Confidential

Exclusive prescriber program care coordination

• Identify barriers to treatment• Coordinate with the restricted prescriber• Review utilization of services and share with prescribers• Facilitate discharge planning with both medical/behavioral

health providers as requested• Educate on high risk behaviors with the aim to modify risk

factors• Screen members to identify gaps in medically necessary

services• Monitor progress and track outcomes• Evaluate for more intensive care management needs and

assign accordingly

Mercy Care Plan 26Proprietary and Confidential

Exclusive prescriber program graduation criteria

• Controlled substances obtained consistently from one medical provider and/or one behavioral health provider

• Appropriate use of ED or urgent care facilities

• Absence of poisoning and/or overdose

• No apparent psychoactive substance abuse

*NOTE: This should be sustained over a 6 month period

Mercy Care Plan 27Proprietary and Confidential

Demographics for Q1 2017

Mercy Care Plan 28Proprietary and Confidential

Average prescribers

28

Mercy Care Plan 29Proprietary and Confidential

Average prescriptions

29

Mercy Care Plan 30Proprietary and Confidential

Average emergency department visits

30

Mercy Care Plan 31Proprietary and Confidential

Average poisonings

31

Mercy Care Plan 32Proprietary and Confidential

ReferencesThe Cleveland Clinic Foundation. (2014, July 7). Acute vs. Chronic Pain. Retrieved from https://my.clevelandclinic.org/services/anesthesiology/pain-management/diseases-conditions/hic-acute-vs-chronic-pain

(2016, November 30). AAPM Facts and Figures on Pain. Retrieved from http://www.painmed.org/patientcenter/facts_on_pain.aspx

Michaelson, D. & Company, LLC. (2006, May). Voices of Chronic Pain. A national study conducted for: American Pain Foundation

Kleiber, B., Jain, S., and Trivedi, M.H. (2005, May). Depression and Pain: Implications for Symptomatic Presentation and Pharmacological Treatments. Psychiatry (Edgemont). 2(5): 12-18.

National Institute of Mental Health. (March, 2016). Anxiety Disorders. Retrieved from https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

Billioti de Gage, S. et al. (2014, September 9). Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ. 349: g5205.

Manchikanti L, Singh A. (2008, March 11). Therapeutic opioids: a ten-year perspective on the complexities and complications of escalating use, abuse, and non-medical use of opioids. Pain Physician. 11(2 Suppl): S63-S88.

Rudd, R.A. et al. (2016, January 1). Increases in Drug and Opioid Overdose Deaths – United States, 2000-2014. Morbidity and Mortality Weekly Report. 64(50); 1378-82.

Department of Health & Human Services. (June 2016). The Opioid Epidemic: By the Numbers. Retrieved from: https://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf

Mercy Care Plan 33Proprietary and Confidential

Thank you