A Paradigm Shift of Payer Strategy

April 10-12, 2012 Walt Disney World Swan Resort

Learning Objectives: 1.  Analyze the scope of the payers’ role in the

prescription drug abuse problem.

2.  Identify specific best practice methodologies that can be implemented by payers to reduce fraud, waste and abuse through member and prescriber interventions/education and support

3.  Describe the “drug seeker” profile and how it has changed.

Disclosure Statement

•  All presenters for this session, Dr. Kathryn Mueller, Dr. Brian K. Solow and Dr. Beverly Franklin-Thompson have disclosed no relevant, real or apparent personal or professional financial relationships.

A Paradigm Shift of Payer Strategy

Beverly Franklin-Thompson, PharmD Director, Regional Pharmacy

BlueCross BlueShield Tennessee

The Issues

•  Tennessee is one of the top three states for per capita prescription drug use – about 18 Rx’s per person each year

•  According to the Tennessee Controlled Substance Database, 275,496,939 hydrocodone tablets were dispensed in 2010

•  Admissions to drug abuse treatment programs increased seven-fold between 2000 and 2010.

•  In 2010, more people died in Tennessee from drug overdoses than from auto accidents, homicide or suicide.

Sources: Kingsport Times-News and Knoxville News Sentinel Nashville Tennessean, Novartis Pharmacy Benefit Report 2011

0 1 2 3 4 5 6 7 8 9

2006 2007 2008 2009 2010 2011

$5.8 $6.8 $6.8 $7.4

$8.1 $8.4 ($ billions)

U.S. Annual Opioid Sales

Source: IMS Data

8.5-12.6 7.3-8.4 6.0-7.2 3.7-5.9 in Kg/10,000 people

Drug Enforcement Administration, 2010

Distribution of Prescription Pain Killers

Healthcare Costs

•  Annual medical costs for opioid abuser are $14,054 higher than the non-abuser with private insurance: –  4X more likely to visit ER –  11X more likely to visit outpatient mental health –  12X more likely to have an inpatient

hospitalization

•  $72.5 Billion=Estimated direct health care costs related to nonmedical use of prescription painkillers

(McAdam‐Marx et al., 2010; White et al., 2005)

Managed Care Tools

•  Review/monitor prescription claims

•  Prescriber notification •  Patient outreach/case

management •  Quantity limits for certain drugs •  Limiting refills •  ID check/DOB Matching •  Assign patients to single

pharmacy

The Next Level

Advanced Safety and Monitoring Program •  Multidisciplinary team reviews, identifies and

addresses excessive medication use in high-risk patients

•  Promotes member safety and reduces avoidable prescription and medical costs

The Next Level •  Academic Detailing

Pharmacist visits prescribers who write high numbers of controlled substances prescriptions to discuss rationale and alternatives

•  Prescriber Toolkit Educational information and questionnaires helps prescriber manage patients with chronic pain

•  Clinical Risk/Credentialing Identifies and investigates practitioners for quality of care concerns if there is evidence or possibility to harm a member.

Prescriber Tools

•  Health Care Plan’s Expectations •  Treatment Guidelines •  Opioid Dosing Calculators •  Pain Management Contracts •  Urine Drug Screens •  Questionnaires-Addiction Risk

Assessment, Pain and Function

Scre

en

H&P

Lab

Risk

Depression A

sse

ss P

rog

ress

Pain

Function

AE’s Mo

nito

r Pill Count

UDS

Misuse