Pdmp coordination with_third-party_payers_final

PDMP Workshops: PDMP Coordina2on with Third-‐Party Payers

Chris Baumgartner PMP Director, Washington State Prescrip4on Drug

Monitoring Program

Bruce Wood Associate General Counsel and Director, Workers’ Compensa4on, American Insurance Associa4on

Alex Swedlow Execu4ve Vice President, Research, California Workers’

Compensa4on Ins4tute

April 2 – 4, 2013 Omni Orlando Resort at ChampionsGate

Learning Objec2ves

1.  State the basis for broad access to PDMP database, including third-‐party payers.

2.  Iden4fy specific strategies to avoid risky prescribing to help physicians avoid trouble with their Boards or the DEA.

3.  Outline approaches to data-‐sharing among states.

Disclosure Statement

Chris Baumgartner has no financial rela4onships with proprietary en44es that produce health

care goods and services.

Public Insurer Access

•  PDMP Statute: Allows PDMP data to be provided to Medicaid and Workers’ Compensa4on

•  Primary Goal: To provide for beUer pa4ent care and promote pa4ent safety.

•  Secondary Goal: To assist our public insurers in preven4ng fraud and saving state funding.

Two Types of Access

1.  Healthcare Prac44oners within the Health Care Authority (HCA -‐ Medicaid) and Department of Labor and Industries (LNI – Workers’ Compensa4on) can login with individual account access and request a pa4ent history report.

2.  Once a month each agency provides a file through secure file transfer of all their clients/pa4ents (names, DOB). Our vendor then provides matching data for each client/pa4ent in a file that is returned through secure file transfer.

LNI -‐ PDMP Bulk Transfer

•  PDMP bulk transfer uses: –  Iden4fying pre-‐exis4ng opioid use –  Iden4fying duplica4ve prescrip4ons (in process) –  Iden4fying prescribing outliers (future)

•  Bulk transfer available in May 2012

LNI Early Opioid Interven4on Pilot

•  Iden4fy claims that are 15 -‐ 45 days old AND received ≥ 1 opioid prescrip4ons within 60 days before the injury

•  Clinical review and interven4on by a nurse or pharmacist as necessary

•  BeUer coordina4on of medical care and management of claims, promote use of PMP and reduce cost and disability

LNI -‐ Early Opioid Interven4on Pilot

•  350 – 500 new claims meet this criteria each month (3-‐4% of all claims allowed)

•  Priori4za4on Criteria –  Chronic opioid use (≥ 3 prescrip4ons in previous 3 months)

–  High dose opioid (> 120mg/d MED) –  Other controlled substances (e.g. benzodiazepines, seda4ve-‐hypno4cs –  Timeloss (wage replacement)

•  Clinical review is priori4zed by the number of criteria met

Future LNI Ini4a4ves

•  Complete the Early Opioid Interven4on Pilot

•  Require L&I’s providers to access PDMP before prescribing opioids for a work-‐related injury (new guideline)

•  Iden4fy duplica4ve prescrip4ons and create a process to intervene

•  Iden4fy prescribing outliers to improve L&I’s new provider network

HCA – Pa4ent Review & Coordina4on (PRC)

•  Aimed at over-‐u4lizing clients

•  Decrease and control over-‐u4liza4on and inappropriate use of health care services

•  Minimize medically unnecessary services and addic4ve drug use

•  Client and provider educa4on and coordina4on of care •  Assist providers in managing PRC clients by providing available

resource informa4on to facilitate coordina4on of care

•  Reduce overall expenditures

PDMP Assistance to PRC to Date

•  As of May 2012 the PDMP has assisted in iden4fying 20 clients for the PRC program to date (through 5 months of using just the individual query site)

•  The minimum 4me that a client is in PRC is 2 years and they can be 3 years or 5 years.

•  These 20 clients represent 67 PRC client lock-‐in years at $6,000 per year. This amounts to over $400,000 in savings.

11

PDMP Bulk Data use by PRC •  PRC Program compliance analysis

– Of 3,800 PRC clients 1,900 are currently Fee For Service •  Of these 1,900, 1,170 clients have at least 1 PMP prescrip4on.

•  Of the 1,170 clients filling prescrip4ons –  489 Clients paid cash for 2,470 prescrip4ons. And 243 addi4onal clients are listed as paid by 04 private insurance with an addi4onal 2,059 prescrip4ons. This would be a total of 732 clients filling 4,529 total prescrip4ons

– By contrast 898 clients filled 12,240 prescrip4ons paid for by Medicaid during this same period.

12

PDMP Bulk Data use by PRC

•  Client Iden4fica4on analysis •  Allows improved algorithms with clients.

–  Iden4fied >2000 Clients in 2012 with Cash and Medicaid paid schedule prescrip4ons on the same day.

–  Iden4fied 478 clients where cash and Medicaid fills were < 10 days apart, the scripts were overlapping, for the same drug and from different prescribers.

–  Currently reviewing the top u4lizers of the 478 for PRC placement.

13

HCA -‐ Narco4c Review Program •  The Narco4c Review Program (NRP) evaluates Medicaid

clients who are receiving high doses of opioid narco4cs to verify the medical need for these excep4onal doses. It only applies to client with chronic non-‐cancer pain.

•  Each narco4c prescrip4on for these clients requires authoriza4on as long as the client is in the narco4c review program. A client’s narco4c use will be adjusted to minimize pain and maximize func4on. The lowest effec4ve dose, or zero use is determined by medical necessity and clinical considera4ons.

•  PDMP Data found that 83% of clients in the NRP had scripts that were not paid for by Medicaid.

14

Future HCA Ini4a4ves

•  HCA will be using bulk data to augment our lock-‐in PRC program.

•  HCA has already been working on threshold reports to go to managed care plans concerning clients using cash.

•  HCA will be sending threshold reports to: –  Prescribers with clients prescrip4on Informa4on

–  Pharmacies who accept cash from Medicaid clients in viola4on of their core provider agreement

15

Refining the Bulk Transfer

•  Key Areas that were fine tuned: –  Data Fields: NPI, Payment Type, etc…

–  Handling reversals, voids, duplicates –  Provide back in return file LNI pa4ent name for matching

•  Key Areas for improvement:

–  Payment Type – entered more accurately

–  NPI # -‐ require is to be reported –  Pa4ent ID – more reliable matching

•  Chris Baumgartner, PMP Director – Washington State Dept. of Health

–  Phone: 360.236.4806 –  Email: [email protected] – Website: hUp://www.doh.wa.gov/hsqa/PMP/default.htm

Program Contact

Bruce C. Wood Associate General Counsel &

Director, Workers’ Compensa4on American Insurance Associa4on

April 2 – 4, 2013 Omni Orlando Resort at ChampionsGate

PDMP Coordina2on with Third-‐Party Payers

Learning Objec2ves

•  State the basis for broad access to PDMP database, including third-‐party payers.

•  Iden4fy specific strategies to avoid risky prescribing to help physicians avoid trouble with their Boards or the DEA.

•  Outline approaches to data-‐sharing among states.


•  Bruce Wood has no financial rela4onships with proprietary en44es that produce health care goods and services.

WORKERS’ COMPENSATION ON THE FOREFRONT OF THE

EPIDEMIC

WORKERS’ COMPENSATION: AN INTRODUCTION

I Discussion/history of workers’ compensa2on

•  Evolu2on of this social insurance program over the past century = first w.c. program enacted in 1911 (Wisconsin)

•  Subs2tute for tort = quid pro quo •  Trauma2c/occupa2onal diseases •  Na2onal Commission on State Workmen’s Compensa2on Laws (1972) = watershed event/ states’ response

•  Post-‐Na2onal Commission history = benefit expansion; financial crisis (later ‘80s-‐mid-‐’90s)

II Key Program Elements

•  All medical treatment “reasonable and necessary” (w/o co-‐pays, deduc2bles, exclusions, dura2on limits) = 1st dollar coverage.

•  Indemnity benefits = commonly 2/3 of gross “average weekly wages” = Paid for:  Temporary total disability (TTD), temporary par2al disability (TPD), permanent par2al disability (PPD), permanent total disability (PTD)

•  Voca2onal rehabilita2on benefits = evalua2on and re-‐training •  Survivor/dependents’ benefits = payable for life or un2l remarriage; dependents un2l 18 or 22 if enrolled in college

III Common Areas of Dispute

• Compensability = Did the injury/disease “arise out of and in the course of employment”?

• Exclusive remedy = Was the injury encompassed within the compensa2on scheme? Did the employer intend to injure the worker?

Common Areas of Dispute – cont’d

•  PPD = Is there residual permanency; when is permanency ascertained and by what means; how is disability determined? Impairment as a proxy for disability? Lost wage-‐earning capacity? = PPD as driver of dispute, li2ga2on, and medical treatment costs = most costly element of w.c. system

• Medical treatment/RTW = Is the treatment “reasonable & necessary”? Employer/insurer is not financier of all medical treatment. Has maximum medical improvement (MMI) been reached? Is worker able to return to work? Restric2ons? Accommoda2ons?

IV The Role of Workers’ Compensa2on Medical Treatment

 Workers’ compensa2on is not a medical program. It is a disability program with a medical component = key difference with group health and informs how medical treatment is delivered and the role of a payer and its agents in administering a claim.

 Key objec2ve in workers’ compensa2on is managing disability = providing all medical treatment reasonable and necessary, of the nature and intensity required, to expedite recovery and return to work. WC medical treatment may cost more but higher cost can expedite RTW and limit indemnity exposure = coordina2ng medical treatment and indemnity.

The Role of Workers’ Compensa2on Medical Treatment – cont’d

Because workers’ compensa2on medical treatment remains first-‐dollar coverage – with no demand-‐side controls on cost and u2liza2on – it reinforces need of payers to use administra2ve tools to control cost, as well as to encourage return to work. These include:  Ability to direct medical treatment – control of physician/

networks  Treatment guidelines – na2onal = ACOEM/ODG

 Unit price controls (fee schedules) = Medicare RBRVS/DRGs   Impairment guidelines = AMA Guides to the Evalua2on of

Permanent Impairment


Delivering medical treatment, 2mely, and of the nature and intensity needed, requires an unimpeded exchange of medical informa2on with providers and evaluators.

•  No authoriza2ons/releases required in workers’ compensa2on.

•  System is intended to be less formal than civil li2ga2on, to promote quick exchange of informa2on in the employee’s interest in receiving necessary and 2mely medical treatment, in evalua2ng return-‐to-‐work restric2ons and accommoda2ons necessary, and in an employer’s understanding of poten2al health and safety risks posed by the injury.


In workers’ compensa2on, the employee is not the policyholder but a 3rd party with a legal claim for benefits against the policyholder/employer who the insurer is obligated under law and its insurance contract to defend and indemnify, paying all benefits due. For this reason, the employee, who puts his condi2on at issue, does not have the same confiden2ality expecta2ons as do claimants in a group health sekng.


The special informa2onal needs of workers’ compensa2on payers is recognized under HIPAA:

“A covered en2ty may disclose protected health informa2on as authorized by and to the extent necessary to comply with laws rela2ng to workers’ compensa2on or other similar programs, as established by law, that provide benefits for work-‐related injuries or illnesses without regard to fault.” [sec. 164.512 – Uses and disclosures for which an authoriza2on, or opportunity to agree or object is not required; 45 CFR 164.512(l)].


 Where state law, itself, mandates disclosure without authoriza2on, disclosure is permiqed under HIPAA rules and exempt from the “minimum necessary” informa2on disclosure standard. “A covered en2ty may use or disclose protected health informa2on to the extent such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law.” [164.512(a)(1)].

  A covered en2ty under HIPAA rules also may disclose informa2on to any en2ty as necessary for payment, although the covered en2ty may disclose the amount and types of informa2on necessary for payment.


In brief, HIPAA does not erect barriers to a workers’ compensa2on payer obtaining protected health informa2on, whether without an authoriza2on, or pursuant to state law requiring release. HIPAA does not preempt state privacy laws.

 State privacy laws generally do not erect barriers to obtaining medical informa2on from medical providers. Some states = explicit mandates to release informa2on to employer/insurer.

 Other states impose ex parte rules on physician communica2ons with carrier that slow evalua2on/decisions.


It is essen?al for workers’ compensa2on payors to obtain access to prescrip2on monitoring program data, to properly assess an injured worker’s use of prescrip2on medica2ons and, broadly, to provide all reasonable and necessary medical treatment and effec2vely manage disability. Without access, it is not possible for a workers’ compensa2on payer to know the full extent of prescrip2on drug use, because a worker may be obtaining prescrip2ons under other benefit systems (e.g., Medicaid, group health, Veterans) or has prescrip2ons through other providers not otherwise reported.


 Washington State’s Department of Labor & Industry has access to PMP data. The Department’s role in providing workers’ compensa2on benefits is no different from that of other private market insurers and self-‐insured employers.

  Arizona enacted legisla2on last year providing access for IMEs to that state’s PDMP database and the right to disclose that informa2on to “the employee, employer, insurance carrier and the [Industrial] commission.” [H 2155; Chp. 156, Laws of 2012; eff. 1-‐1-‐13].

OPIOID ABUSE:

THE MOST URGENT ISSUE FACING WORKERS’ COMPENSATION

OPIOID ABUSE: THE MOST URGENT ISSUE FACING WORKERS’

COMPENSATION Use of opioids, especially long-‐ac2ng medica2on, for treatment of chronic pain in workers’ compensa2on can increase chances of a “catastrophic claim ($100,000+) by almost four 2mes. Use of short-‐ac2ng opioids raises chances by almost twice. Average claim not involving opioids = $13,000.

-‐-‐ “The Effects of Opioid Use on Workers’ Compensa2on Claim Cost in the State of Michigan; Bernacki, et. al; Journal of Occupa2onal and Environmental Medicine, August 2012.


COMPENSATION   Average claim costs of workers receiving 7+ opioid

prescrip2ons for back problems without spinal cord involvement =

–  3X greater than for workers receiving 0 or 1 opioid prescrip2on

 Workers receiving mul2ple opioid prescrip2ons =

–  2.7X more likely to be off work –  4.7X as many days off work

(Swedlow et al., CWCI Special Report 2008)


COMPENSATION Prevalence of Fentanyl in California’s Workers’ Compensa2on System   More than 1 out of 5 injured workers who were prescribed

Schedule II opioids received fentanyl, and among those with non-‐surgical medical back problems (strains and sprains) who received Schedule II opioids, more than 1 out of 4 were given fentanyl.

  The top 10% of medical providers who prescribe Schedule II opioids for injured workers in California write nearly 80% of all workers’ compensa2on prescrip2ons for these drugs, which represents 87% of the morphine equivalents provided to injured workers accoun2ng for 88% of all Schedule II pharmacy payments in the CA WC system. Nearly half of Schedule II prescrip2ons = minor back injuries. [CWCI Research Bulle2n 11-‐05; April 28, 2011]


COMPENSATION AIA endorses robust PDMPs as one key element for comba2ng opioid abuse.

  Mandatory prescribing and dispensing checking of database, with data entry

  Ac2ve PDMPs pushing informa2on to prescribers and dispensers

 Broad access to PDMP database, including 3rd party payers and law enforcement

 Interstate operability


COMPENSATION FINALLY:

Comprehensive, well-‐designed prescrip2on drug monitoring programs can serve a cri2cal role in thwar2ng opioid abuse, as well as illegal drug diversion. It is essen2al for there to be broad access to PDMP data – by those with a legi2mate purpose in such data – and as essen2al for PDMP programs to ac2vely monitor their databases for suspicious ac2vity, thereby providing a cri2cal check on prescribers and dispensers and facilita2ng data-‐sharing.

Prescrip2on Drug Monitoring Program Workshop: PDMP Coordina2on with Third-‐Party Payers

Managing Pain Management in the California Workers’ Compensa2on System

Alex Swedlow California Workers’ Compensa4on Ins4tute

www.cwci.org


•  Alex Swedlow has no financial rela4onships with proprietary en44es that produce health care goods and services.

Agenda

•  Pain Management in the California Workers’ Compensation System

•  Controlled Substance Utilization Review and Evaluation System (CURES)

Pain Management in the California Workers’ Comp System

1.  Changing Role of Rx in Workers’ Compensa4on

2.  Repackaged Drugs 3.  Sole Source (Brand) v. Mul4-‐source (Generic)

4.  Opioids & Schedule-‐II Rx 5.  Compound Drugs

6.  Drug Tes4ng

Areas of CWCI Rx Research


1.  Growing use of pharmaceu4cals 2002: 5% of medical benefits 2010: 10% of medical benefits

2. Reforms in pricing and fee schedules

3. Growing influence of pain management prac4ces

4. Legisla4ve, administra4ve and payer responses

Changing Role of Rx in CA Workers’ Compensa4on


Managing Pain Management Rules and Regula4ons and Medical Management

•  Pain Mgt Guidelines Implemented July 2009 -‐ Compe4ng MTUS defini4ons and triggers -‐  Hierarchy of medical evidence -‐  Different levels of specificity

•  Limits to Workers Comp Medical Management -‐  Few supply-‐ and demand-‐side controls -‐  Liens (2012) -‐  No 3rd party payer access to PDMP


Opioid Prescrip4on & Payments in CA Workers’ Comp (2012)


Pharmaceu4cal U4liza4on & Cost Schedule-‐II Opioid Drugs1

1 CWCI 2012. Calcula4ons are on a calendar year basis

321%

345%


Report to the Industry

What is the associa4on between the use of opioids on low back pain on:

•  Average Benefit Costs -‐ Medical -‐ Indemnity

•  Loss of Produc4vity/Return To Work

Rx & Pain Management

Exhibit 50 CWCI 2008


Pain Mgt and the Use of Opioids

Data & Methods

•  166,336 California injured workers •  Medical back condi4ons without spinal cord involvement

•  A total of 854,244 opioid prescrip4ons were dispensed

•  Controls (morphine equivalents) for different types of opioids

•  Case-‐mix adjusted outcomes CWCI 2008


Opioid Prescrip4ons on Medical Back Injuries Not Involving the Spine

Medical back injuries w/ opioids typically receive 5.9 prescrip4ons per injury

Background on Pain Management

Exhibit 52 CWCI 2008


ACOEM Insights on Opioids

•  Opioid use is the most important factor impeding recovery of func4on in pa4ents referred to pain clinics

•  Opioids do not consistently and reliably relieve pain and can decrease quality of life and func4onal status

•  The use of opioids during the sub-‐acute and chronic phases of an injury, especially in the absence of an objec4vely iden4fiable pain generator, cannot be recommended.

Evidence-‐based Medicine & Compara4ve Effec4veness Research on Opioids

Genovese, Harris, Korevaar 2007


Exhibit 54

Morphine Equivalents Categories

Category

Average MEs in

Category

Range of MEs in Category

No MEs 0 0

Level 1 124 3-240

Level 2 406 241-650

Level 3 1,207 651-2100

Level 4 14,870 2,101 and up ME conversions based on American Pain Society Conversion Tables

CWCI 2008


Exhibit 55

Adverse Outcomes: Increased Costs

+203%

+196% +209%

CWCI 2008


Exhibit 56

Adverse Outcomes: Reduced Produc2vity Paid Time Off Work

+365%

CWCI 2008


Exhibit 57

Adverse Outcomes: Higher Likelihood of Lost Time and Li2ga2on

+131%

+60%

CWCI 2008


Exhibit 58

Analysis of Prescribing PaUerns Schedule II Opioids

PBM and ICIS Data: •  16,890 Claims •  9,174 Prescribing physician DEA code •  233,276 Prescrip4ons •  Script, dosage and days •  Pharmaceu4cal characteris4cs •  DOS, billed and paid amount •  ER and EE characteris4cs

CWCI March 2011

Pain Mgt and the Use of Opioids

Analysis of: 1.  Injury Characteris4cs 2.  Physician Prescribing PaUerns 3.  Injured Worker Characteris4cs


Exhibit 59

Top Injury Categories w/ Schedule II Opioids

CWCI March 2011



Diagnostic Category

Pcnt of S-II Opioid Claims

Pcnt of S-II Opioid Scrips

Pcnt of S-II Opioid Pymnts

Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2% Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1% Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5% Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4% Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8% Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7% Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8% Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6% Mental Disturbances 1.2% 1.7% 1.5% Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%

Exhibit 60 CWCI March 2011


Diagnostic Category


Pcnt of S-II Opioid Scrips

Pcnt of S-II Opioid Pymnts

Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2% Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1% Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5% Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4% Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8% Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7% Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8% Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6% Mental Disturbances 1.2% 1.7% 1.5% Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%

Top Injury Categories w/ Schedule II Opioids Analysis of Prescribing PaUerns Schedule II Opioids

Exhibit 61

Diagnostic Category


Pcnt of S-II Opioid

Scrips

Pcnt of S-II

Opioid Pymnts

Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2%

Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1% Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5% Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4% Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8% Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7% Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8% Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6% Other Mental Disturb 1.2% 1.7% 1.5% Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%

Top Injury Categories w/ Schedule II Opioids

CWCI March 2011

Outside EBM Guidelines:

•  51% of Claims

•  60% of Prescrip4ons •  62% of Payments



Exhibit 62

Cumula2ve Percentage of Schedule II Prescrip2ons (Top 10% of S-‐II Prescribing Physicians)


CWCI March 2011


Exhibit 63

Cumulative Percentage of Schedule II Payments (Top 10% of S-II Prescribing Physicians)

CWCI March 2011



Exhibit 64

Average S-‐II Opioid Prescribing Physicians per Claim (Injured Worker)

CWCI March 2011


Median: 1.5


Pain Management

Drug Tes4ng:

•  High levels of tes4ng associated with increasing opioid and S-‐II u4liza4on

•  Ra4onale for drug tes4ng: -‐ Protocols? -‐  Type of test? -‐  Timing and frequency? -‐ Medical necessity?

•  Consequences: -‐ Injured worker -‐ Physician -‐ Employer -‐ Claims administrator


Exhibit 66

Drug Testing: Calendar Year Payments ($M)

CWCI 2012


•  1939 Bureau of Narcotic Enforcement (BNE) creates PMP mandated through the Health and Safety (H&S) Code

•  September 2009, CURES program was enhanced with a web-based Prescription Drug Monitoring Program (PDMP) processing 913,874 patient activity reports.

•  CURES receives over 5 million records each month from more than 6,700 licensed pharmacies.

•  CURES is working with departmental IT to allow for the exchange of PDMP data between state PMPs.

•  Now dormant and absent a funding source, the CURES program shuts down on July 1, 2013.

CURES Background


Controlled Substance U4liza4on Review and Evalua4on System (CURES)

Claims w/ Opioid Scripts

CA Claim Count (2010)

Pcnt of Claims

1 Scripts 34,981 41% 2-‐3 Scripts 21,206 25% 3-‐7 Scripts 14,111 16% >7 Scripts 15,690 18%

Total: 85,988 100%

Building a Business Case: Estimating CURES ROI:

• Estimate number of claims by opioid use • Determine potential savings via CURES access • Adjust for CURES operating budget

Controlled Substance U4liza4on Review and Evalua4on System (CURES)


Controlled Substance U4liza4on Review and Evalua4on System

CURES: ROI for California Workers’ Compensa4on

Claims w/ Opioid Scripts

Avg Cost/ Claim (2010) Total Payments Est %

Savings Total Es4mated Savings

1 Scripts $11,200 $391,790,539 0% $ -‐

2-‐3 Scripts $14,925 $316,508,020 3% $9,495,241

3-‐7 Scripts $18,284 $257,412,625 5% $12,870,631

>7 Scripts $31,718 $497,653,698 7% $34,835,759

Total: $17,018 $1,463,364,882 5% $57,201,631

Actual savings will depend upon several factors including: •  Medical & Rx trends, Injury mix; •  Appropriate statutes, rules and regs.

CURES Opera4ng Budget (Est.): $3,700,000 ROI for CA WC: $15.5 : $1


Summary •  High rate of inappropriate opioid use; •  Limits in statutes/rules/regs make it difficult to regulate within

traditional workers’ comp controls •  Graduated use associated with adverse injured worker outcomes

•  Small number of physicians associated with high prescribing patterns

•  Rapid increase in drug testing associated to high opioid use with no national guidelines for testing

•  CURES has significant potential to increase QOC and lower cost


Pdmp coordination with_third-party_payers_final

Documents

prc clients

medicaid clients

clients narco4c use

clients lling prescrip4ons

addi4onal clients

opioid prescrip4ons

pdmp bulk data use

pdmp coordina2on