A Prescription for Mitigating MSA Settlement Costs

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Your Speaker

Mark Pew, Senior Vice PresidentPRIUM (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 101The 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 101Enormous 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 101The 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 101Some 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 FlagsPolypharmacy

• 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 FlagsPolypharmacy

• Insomnia

• Lethargy

• Atrophy

• Depression

• Sexual dysfunction

• Constipation

• Addiction

PAIN

zolpidem

modafinil

carisoprodol

duloxetine

sildenafil

stool softener

buprenorphine

Opioid

All of this makes the pain harder to identify and treat

fentanyl?

Treatment Red FlagsInappropriate 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

• 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 FlagsInappropriate Patterns

• Topical analgesics• Anti-narcoleptic drugs (Provigil, Nuvigil)• Hormonal supplements• Spinal Cord Stimulator / Intrathecal Pump and topical / oral analgesics• Drug regimen that has automatic refills

• 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 FlagsDeveloping a Strategy

• Opinions are not enough

• Standard of Care is not enough

• MMI < > Polypharmacy

• With no appeal process, it needs to be your “best offer”

• Incorporate services and procedures that create that “best offer”

The Package of Evidence

Optimizing a MSAPackage of Evidence

1. Assess the clinical appropriateness of ongoing treatment• If clinically questionable, STOP THE MSA PROCESS

Optimizing a MSAPackage 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 MSAIntervention

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 MSAPackage 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 MSAPackage 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 MSAIntervention

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 MSAIntervention

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 MSAPackage of Evidence

5. Utilize the PBM (and bill review) to create a customized formulary• EV3: Enforce the changes

Optimizing a MSAIntervention

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, team-

based follow up on changes

Optimizing a MSAPackage 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 MSAPackage 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 MSAIn Summary

• Your first calculation may not be your best offer

• Identify triggers for when to delay the WCMSA proposal

• Create a compelling case to CMS that history does not predict future• And document everything …

• This all requires patience

Mark PewSenior Vice President

(678) 735-7309 Officempew@prium.netLinkedIn: markpew

Twitter: @RxProfessor

Our Evidence Based blogwww.priumevidencebased.com