Third-Party Payer Track Rx Drugs and Urine Testing: Knowing What’s Too Much, Too Little and Just Right Presenters: • Michael Gavin, President, PRIUM • Jo-Ellen Abou Nader, CFE, CIA, CRMA, Senior Director, Drug Waste Solutions, Express Scripts, Inc. • Elaine Jeter, MD, MolDX Medical Director, Palmetto GBA Moderator: Daniel Blaney-Koen, JD, Senior Legislative Attorney, American Medical Association Advocacy Resource Center, and Member, Rx Summit National Advisory Board
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Third-Party Payer Track
Rx Drugs and Urine Testing:Knowing What’s Too Much, Too Little and Just
Drug Waste Solutions, Express Scripts, Inc.• Elaine Jeter, MD, MolDX Medical Director, Palmetto GBA
Moderator: Daniel Blaney-Koen, JD, Senior Legislative Attorney, American Medical Association Advocacy Resource Center, and Member, Rx Summit National Advisory Board
Disclosures• Michael Gavin has disclosed no relevant, real or apparent personal
or professional financial relationships with proprietary entities that produce health care goods and services.
• Jo-Ellen Abou Nader, CFE, CIA, CRMA, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
• Elaine Jeter, MD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
• Daniel Blaney-Koen, JD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
Learning Objectives
1. Describe how the PBM identifies, investigates and resolves Rx fraud, waste and abuse.
2. Compare appropriate with fraudulent and wasteful usage of UDT.
3. Advocate strategies that optimize usage of UDT.
Urine Drug Monitoring
Too Much or Too Little
Michael Gavin wishes to disclose he is the President of PRIUM, a wholly-owned subsidiary of Ameritox. He will present this content in a fair and balanced manner.
Disclosure 5
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This presentation:1. Outlines the care settings and technologies used for urine
drug monitoring2. Illustrates the clinical rationale for urine drug monitoring 3. Examines why appropriate testing does not always occur
Learning Objectives
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• Industry Context• Data and Observations• Best Practices
Agenda
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Societal BurdenMisuse and abuse of prescription drugs is hugely expensive from a financial and socioeconomic perspective
• In the United States, prescription opioid abuse costs were about $55.7 billion in 2007.1 Of this amount, 46% was attributable to workplace costs, 45% to healthcare costs, and 9% to criminal justice costs.
• Drug overdose was the leading cause of injury death in 2012. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes.2
• The drug overdose death rate has more than doubled from 1999 through 2013.3
1. Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, and Roland CL. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Medicine 2011; 12: 657-667
2. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2014) Available from URL: http://www.cdc.gov/injury/wisqars/fatal.html.
3. Centers for Disease Control and Prevention. National Vital Statistics System mortality data. (2015) Available from URL: http://www.cdc.gov/nchs/deaths.htm.
personnel1. In a recent comparison of POCT and confirmation results performed by Ameritox POCT devices produced an incorrect result over 50% of the time.2. Assays exist for some specific compounds.
Not Created EqualNot all testing technologies and settings are created equal; the quality and quantity of data differs by setting.
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Why Monitor?Urine drug monitoring informs clinical decision making by prompting new conversations between doctors and patients.
What Drug Monitoring Tells Us
• Presence of prescribed substances• Identification of non-prescribed
substances• Identification of illicits• Uncover possible misuse/abuse and
cross-reactivity risk
What Drug Monitoring Doesn’t Tell Us
• The amount of drug ingested or taken
• When last dose was taken• Source of the medication.• Proof of misuse/abuse
11Longitudinal AnalysisThe availability of information to assist with assessing likely adherence over time is of critical importance in light of chronic opioid therapy.
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MEDs1 Rx Spend2
1 2 3 4 5 6400
800
1,200
1,600 191%
Quarters Since Injury
Avg.
Qua
rter
ly M
ED p
er C
laim
2003 2004 2005 2006 2007 2008 2009 2010 2011 $150
$200
$250
$300
58%
Service Year
Dolla
rs P
aid
per M
edica
l Cla
im
Increasing Rx SpendThe need for UDM has become more critical as prescription drug spend for chronic pain (and related conditions) has skyrocketed.
1. NCCI Research Brief, 20122. NCCI Research Brief, 2013
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Observations
Illicits Found Rx Not Found Found, No Rx0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
Overall Testing Results Over Time
2006 2007 2008 2009 2010 2011 2012 2013 2014
Many samples show multiple issues; just 33.9% of samples show no abnormalities.
1. Data collected from Ameritox drug monitoring accessions.
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Observations
Illicits Rx Not Found Found, No Rx0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Overall Testing Results by Age
12-17 18-24 25-34 35-44 45-54 55-64 Above 65
Despite the declination of illicit medications with age, adherence does not follow this same trend – even beyond 65.
1. Data collected from Ameritox drug monitoring accessions.
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ObservationsThe uptick in illicit use may potentially be driven by multiples factors including payer mix, adverse selection, or a rise in use of illicits.
MediumArkansas, Illinois, Kentucky, Louisiana, Massachusetts, Montana, Nevada, New York, North Dakota, Ohio, Oklahoma, Utah, Washington, West Virginia, Wyoming
WeakColorado, Connecticut, DC, Delaware, Georgia, Indiana, Maine, New Hampshire, New Mexico, North Carolina, Pennsylvania
NoneAlaska, Arizona, Hawaii, Idaho, Iowa, Kansas, Maryland, Michigan, Minnesota, Missouri, Nebraska, New Jersey, Oregon, Rhode Island, South Carolina, South Dakota, Vermont, Virginia, Wisconsin
Utilization review is the evaluation of medical necessity, appropriateness, and reasonableness of medical treatment.
27Coordinated InterventionsManaged care tools are all essential components to ensuring compliance with medication regimens.
• Blanket UDT orders • Absent medical record documentation of tests
ordered, results of cup or IA, clinical history• Self-referral testing to maximize reimbursement• Semi-quant IA billed with specific quant codes• Cup testing, followed by IA, referral to partnered
lab arrangement with change of DOS repeat IA and definitive testing
Elizabeth Jeter
UDT Policy
• L35105 – Controlled Substances Monitoring and Drugs of Abuse Testing
• Provides covered indications and testing frequency for:– Symptomatic patients, multiple drug ingestions
and/or patients with unreliable history– Patients with substance abuse or dependence– Patients on chronic opioid therapy
“G” Code Proposal
• HCPCS – quarterly update• Gxxxx – Definitive drug testing by mass
spectroscopy, with confirmation when indicated, >40 drugs, metabolites and illicits; per encounter; includes specimen validity testing (pH, specific gravity, oxidants, creatinine)
• Asked CMS not to recognize existing 21 quant codes and 58 new codes
What Happened to Comprehensive “G” code?
• 2015 CPT drug codes – not adopted by CMS• Palmetto’s G code proposal – not adopted by
CMS• CMS cross-walked 2014 CPT codes to “G” codes• Palmetto issued Coding/Billing Guidelines• Requires short text string in SV101-7 claim field• Created CSPAN text string with # of drugs > 8• Tiered reimbursement: 8-14; 15-34; >35
Drug Waste Solutions, Express Scripts, Inc.• Elaine Jeter, MD, MolDX Medical Director, Palmetto GBA
Moderator: Daniel Blaney-Koen, JD, Senior Legislative Attorney, American Medical Association Advocacy Resource Center, and Member, Rx Summit National Advisory Board