Opioid Dependence: Health Plan Problems and Strategies

Kelly J. Clark, MD, MBA, DFAPA, FASAM Medical Director of Behavioral Health

CDPHP, Albany NY

Disclosure Statement

•  All presenters for this session, Dr. Kelly J. Clark and Dr. Nathaniel P. Katz, have disclosed no relevant, real or apparent personal or professional financial relationships.

Learning Objectives: •  1. Identify barriers to responsible pain management that

does not contribute to an addiction or to diversion activities.

•  2. Outline best practice strategies for patient monitoring to prevent over-prescribing and dispensing.

•  3. Explain the importance of coordinating care between health care providers and facilities.

Health Plan concerns: •  Value = Quality / Cost

•  Behavioral Health = Mental Health, SUDs and Health Behaviors

•  Total Cost of Care: –  Primary Care Physician - Hospital –  Specialist - non-MD providers –  Pharmacy - Imaging –  ER and Urgent care - labs

Barriers to responsible pain management, or

Why might MD’s overprescribe?

•  Lack of information

•  Lack of skill

•  External reinforcement

- What are proper prescription patterns

- Which patients are at risk for problems

- Whether a patient has demonstrated a problem

- Where they can access expert consultation

Lack of information

–  Managing patient expectations

–  Confronting problematic patient behaviors

–  Working collaboratively with other providers

–  Using a biopsychosocial approach

Lack of skill

External reinforcement

- Payment models rewarding more quickly writing pills than talking with patients

- “The Fifth Vital Sign” “quality” metric

- Pay for high patient satisfaction

Health Plans: Keepers of the Data

•  Claims data from all areas: –  Primary Care Physician - Hospital –  Specialist - Labs –  Pharmacy - Imaging –  ER and Urgent care - non-MD providers

•  These can be used by individual providers and larger systems to improve care and decrease cost

Uses of plan data: population management issues

•  Health plan data can show the range of practice patterns in a community

•  UDS claims study

•  Example emergency department utilization to obtain controlled drug rx

Trust, but Verify: the UDS •  Urine Drugs Screens should be like a blood

glucose level

•  Clinicians need to understand what yields false positives and false negatives

•  Who is at risk for substance misuse? –  humans

CDPHP

•  Regional, non-profit, physician-directed health plan (Albany, NY)

•  350,000 covered lives

•  All LOB (Medicare, Medicaid, Commercial, ACO)

Rates of Drug and/or alcohol screenings

–  Continuously enrolled for 12 months

–  275 days of fill of any controlled substance (75%)

–  drug screening code 80100/80101,G0434,G0431

Results : 1 year controlled drug use and UDS

•  Medicaid population = 16.8% members •  Medicaid population = 27.9% 1 year Rx

•  7.6% of all members with chronic prescriptions had a drug screen within the year

Use of ER to obtain controlled drug Rx

•  Claims data from first 6 months of 2011 •  ER claims •  Fills for controlled drugs within 2 days of ER visit •  Voluntary inpatient admissions for detoxification or

substance abuse rehabilitation

1 visit with a prescription

3 visits with a prescription

If an ER doc gives a controlled drug prescription:

•  1/58 of our commercial members they give it to use the ER three times January to July

•  1/9 of our Medicaid/FHP members they give it to use the ER three times January to July for controlled drugs.

•  Or, 1/37 of the Medicaid/FHP members in an ER right now use the ER 3 times for controlled drug from January to July

Addiction admissions who obtained rx from ER

Intermittent Schedule of Reinforcement

- 4.1 pills per rx is the average of the top 10 ER prescribers

- 20 pills or more are given in 1/15 total ER prescription

- The variability in practice pattern is high, and inversely related to numbers of prescriptions written

Plan data can drive education and policy

-Educating ER prescribers on practice patterns -Altering policies measuring quality in ERs -Educating all prescribers on need for UDS

(including ER docs) -provider systems can work with plans to get the

data needed

Plan strategies: working with providers to improve monitoring and

decrease over-prescribing

•  Information exchange •  Care Coordination •  Prior Approval •  Pharmacy management •  Innovative payment programs

Health plan tools: Information exchange

Primary Care Physician could get info if: • Pt seen in ER • Pt admitted to hospital • Pt filled Prescriptions • Pt seen by specialists • Pt had imaging

Health Plan tools: Care Coordination

•  calls between providers

•  calls to patients

•  helping support adherence

•  helping support access to ancillary services –  (often social services or behavioral health)

Health Plan tools: Prior Approval

•  Stops unnecessary re-imaging for pain complaints

•  Pharmacy management –  Can be a quality reinforcer

Health Plan tools: Pharmacy management

•  Monitors for abuse/diversion –  # of prescriptions, # of prescribers, # of pharmacies, # of pills, #

of meds in each class

•  Quantity limits (# pills, # Rxs)

•  Block payments for prescriptions –  Restrict pharmacy, prescribers, pills, facilities

•  Feedback to prescribers

Health plan tools: Innovative payment programs

- bundled payments for multidisciplinary pain programs

- buprenorphine spoke-and-wheel

- behavioral medicine and/or care coordination as part of PCMH

Best Strategies: •  Obtain objective information on your patients:

–  UDS –  where they are seen, by whom, with what treatment

•  Obtain collaboration with addictionist experts: –  ASAM –  PCSS

•  As payment reform happens, work with payers: –  Develop the programs your community needs –  Look at total cost of care ( ER, inpatient, Labs,

pharmacy, imaging, as all related to MH/SUDs)

Network for assistance

•  www.asam.org Addiction physician’s medical society

•  http://www.pcssprimarycare.org/ Provides addictionist mentors for PCPs