Teaming with Clinicians in the Interven3on Process Clinical Collabora3on Achieves Be9er Outcomes Principled Strategies, Inc. Patrick J. Burns, President Lawrence Feinstein, Ph.D., Vice President, Clinical Programs Progressive Medical, Inc. Tron Emptage, R.Ph., Chief Clinical Officer Robert Hall, MD, Corporate Medical Director Presenters
Third-Party Payer: Teaming with Clinicians in the Intervention Process - Patrick Burns, Tron Emptage, Dr. Lawrence Feinstein and Dr. Robert Hall
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Teaming with Clinicians in the Interven3on Process
Clinical Collabora3on Achieves Be9er Outcomes
Principled Strategies, Inc.
Patrick J. Burns, President
Lawrence Feinstein, Ph.D., Vice President, Clinical Programs
Progressive Medical, Inc.
Tron Emptage, R.Ph., Chief Clinical Officer
Robert Hall, MD, Corporate Medical Director
Presenters
Disclosure Statements
Patrick J. Burns has no financial rela3onships with proprietary en33es that
produce health care goods and services.
Lawrence Feinstein has no financial rela3onships with proprietary en33es
that produce health care goods and services.
Tron Emptage has no financial rela3onships with proprietary en33es that
produce health care goods and services.
Robert Hall has no financial rela3onships with proprietary en33es that
produce health care goods and services.
2 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Learning Objec3ves
1. Differen3ate between threatening and collabora3ve outreach.
2. Assemble a list of words and phrases that reduce fric3on and foster partnership between payors and the physician.
3. Iden3fy tools that demonstrate effec3ve outcomes.
3 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Discussion Points
Factors that Influence Outcomes
Risk Iden3fica3on & Interven3on Tools
Lessons Learned
Clinical Collabora3on Q&A
4 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Workers’ Compensa3on vs. Group Health
Suburban Home Custom Log Cabin
The Tale of Two Doctors
6
Doctor A Doctor B
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Factors that Influence Outcomes
7
Number of Prescribers
Number of Pharmacies
Prescribing Behaviors
Medica3on Pa9erns
Body Part/ Nature of Injury
Demographics of Prescriber
Medica3on Agreement
Drug Monitoring
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Number of Prescribers
• West Virginia
• Evalua3on for doctor shopping
– Doctor shoppers: Four or more prescribers in last six months
– % of deceased pa3ents – % of living pa3ents
8
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Number of Prescribers
• West Virginia
• Evalua3on for doctor shopping
– Doctor shoppers: Four or more prescribers in last six months
– 25 % of deceased pa3ents – 3.5% of living pa3ents
9
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Number of Pharmacies
• West Virginia
• Evalua3on for pharmacy shopping
– Pharmacy shoppers: Four or more pharmacies in last six months
– % of deceased pa3ents – % of living pa3ents
10
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Number of Pharmacies
• West Virginia
• Evalua3on for pharmacy shopping
– Pharmacy shoppers: Four or more pharmacies in last six months
– 17% of deceased pa3ents – 1% of living pa3ents
• 55% of pharmacy shoppers were also doctor shoppers
11
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Number of Prescribers and Pharmacies
12
Uncoordinated Care
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Prescribing Behaviors
• Opioids prescribed early in the claim
• Days supply of opioids
• Number of fills • Morphine equivalent dose (MED)
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Medica3on Pa9erns
• Type of opioids and claim cost
• Michigan
– Final claim cost ≥ $100,000 – Short ac3ng opioids → 1.76 more likely
– Long ac3ng opioids → 3.94 more likely
14
White JA, Tao X, Talreja M, Tower J, Bernacki E. The effect of opioid use on workers' compensation claim cost in the State of Michigan. J Occup Environ Med. 2012 Aug;54(8):948-53.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Medica3on Pa9erns
• Mul3ple short-‐ac3ng and long ac3ng opioids?
• Poten3al drug-‐drug interac3ons
– West Virginia – Opioids and benzodiazepines
15
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Body Part/Nature of Injury
• Ohio
• Highest costs per claim by body part
– Lumbar spine – Shoulder – Cervical spine
• Industries with highest average costs per claim
– Transporta3on – Warehouse
– U3li3es and Construc3on
16
Dunning KK, Davis KG, Cook C, Kotowski SE, Hamrick C, Jewell G, Lockey J. Costs by industry and diagnosis among musculoskeletal claims in a state workers compensa3on system: 1999-‐2004. Am J Ind Med. 2010 Mar;53(3):276-‐84.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Demographics of Prescriber
Geographical varia3on of opioid prescribing
• Acute, work-‐related low back pain
• Decision to use opioids related to social condi3ons • Massachuse9s 5.7% vs. South Carolina 52.9%
Webster BS, Cifuentes M, Verma S, Pransky G. Geographic varia3on in opioid prescribing for acute, work-‐related, low back pain and associated factors: a mul3level analysis. Am J Ind Med. 2009 Feb;52(2):162-‐71.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Demographics of Prescriber
Geographical varia3on of opioid prescribing
• 135 million opioid prescrip3ons in 2008
• 37,000 retail pharmacies • Large varia3on in opioids prescribed
• Coun3es having the highest prescribing rates
‒ Appalachia
‒ Southern and western states
Strongest predictor of amounts prescribed
Number of available physicians…”by far”
18
McDonald DC, Carlson K, Izrael D. Geographic varia3on in opioid prescribing in the U.S. J Pain. 2012 Oct;13(10):988-‐96.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Demographics of Prescriber
19
McDonald DC, Carlson K, Izrael D. Geographic varia3on in opioid prescribing in the U.S. J Pain. 2012 Oct;13(10):988-‐96.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Medica3on Agreement
• Also know as a “pain contract”
• Recommended by
– U.S. Department of Health and Human Services – American Academy of Pain Medicine
– Veterans Health Administra3on
– American College of Occupa3onal and Environmental Medicine (ACOEM)
– Official Disability Guidelines (ODG)
20
Payne, R, E Anderson, R Arnold, L Duensing, A Gilson, C Green, C J. Haywood, S Passik, B Rich, L Robin, N Shuler, and M Christopher. "A Rose by Any Other Name: Pain Contracts/agreements." The American Journal of Bioethics : Ajob. 10.11 (2010): 5-12. ACOEM 2011; ODG 2012
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Medica3on Agreement
• Informed consent
• Promotes educa3on
• Improves compliance • Components
– Informed consent for treatment with medica3on(s)
– Acceptable and unacceptable behaviors – Consequences for failure to adhere to agreement
21
Payne, R, E Anderson, R Arnold, L Duensing, A Gilson, C Green, C J. Haywood, S Passik, B Rich, L Robin, N Shuler, and M Christopher. "A Rose by Any Other Name: Pain Contracts/agreements." The American Journal of Bioethics : Ajob. 10.11 (2010): 5-12. ACOEM 2011 ODG 2012
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Medica3on Agreement Sample
22 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Drug Monitoring
• Urine drug screen
– U.S. Department of Health and Human Services
– ACOEM – ODG
• Iden3fy possible drug misuse and abuse
23
Gilbert et al. "Importance of Urine Drug Tes3ng in the Treatment of Chronic Noncancer Pain: Implica3ons of Recent Medicare Policy Changes in Kentucky." Pain Physician 13.2 (2010): 167-‐86.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Effects on Behavior
PaCent
• “My prescrip3ons are being monitored”
• “I may be drug tested”
• “I signed an agreement”
• “I could lose my pain meds”
24
• Physician Physician
• “My prescribing habits are being monitored”
• “I could lose my license to prescribe”
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Why Some Physicians Don’t Follow Guidelines
25
KNOWLEDGE
ATTITUDES
BEHAVIORAL FACTORS
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Which prescribers not currently in the high risk group will, in six months, have a PSI Score™ equal to or greater than the cutoff value that defines “high risk”, with a 90% confidence level?
• Risk scored and rank ordered the prescriber popula3on • Iden3fied 1,200 prescribers, along with the top 3 risk factors for each
Engagement • 250 prescribers per week for four weeks • Addi3onal prescribers for two more weeks to reach goal of 1,000
ConsultaCon • 20-‐minute telephone call or office visit consulta3on with PharmD • Printed materials including instruc3ons to refer to behavioral health
Follow-‐up • Six months follow-‐up communica3on post-‐appointment • Three-‐month and six-‐month update on PSI Score™ and risk factor scores
• Risk Factor Worksheets ̶̶ Each prescriber’s top three risk factors
• Clinical Advisories specific to each prescriber’s risk factors
• Pa3ent Informa3on Report ̶̶ List of each prescriber’s pa3ents contribu3ng to his/her top three risk factor scores, and their prescrip3on informa3on
• Prescriber Resources and Recommenda3ons ̶̶ Guides; assessments; services to refer to for psych evalua3ons, rehab, consulta3on, and coordina3on of care
MoCvated / CooperaCve • Review the engagement packet materials • Explain the purpose of the program, themes, the PSI Score™, risk factors, clinical recommenda3ons, Pa3ent Informa3on Report
• Explain the program follow-‐up, score updates, and invite further discussion
Resistant / UncooperaCve • Explain the purpose of the program, themes • Focus on the resources to help the prescriber • Shorten appointment; schedule follow-‐up • Track PSI Score™ over 3me and have Regional Medical Director follow-‐up if necessary
Medica3on Reviews with addi3onal interven3on via Peer to Peer Outreach outcomes are measured separately
Medica3on Reviews Medica3on Reviews result in an average $3,500 savings per injured party
52 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Commen
tary
Chan
ge in Opioid Use Post R
eview
Success Ra
te by Med
icaC
on Class
Med
icaC
on Savings per Claim
ant
Overall success rate 62% Average decrease in opioid use 25.6% Average savings per injured party $5102 Rate of achieving contact with prescriber 79% Return on investment (ROI) 4:1
• More recep3ve when it is clearly understood that – We are NOT claiming prescriber is engaging in inappropriate behavior
– Our emphasis is on making certain the injured party receives the right medica3on at the right 3me
• Inclusion of detailed prescrip3on informa3on for the prescriber’s own pa3ents was a major contributor to prescribers’ willingness to par3cipate
• Calls to schedule appointments must occur within one week of receipt of engagement packets
• Design the Engagement Packet mailing envelope so office staff can easily iden3fy that it contains pa3ent PHI and must be delivered only to the prescriber
• Review of the themes of the program by PharmD increased comfort and collabora3on
• Most appointments were completed within 20 minutes
• Member and claim level informa3on was very useful in reconciling charts and taking ac3on as appropriate
Lesson Learned Collabora5on can drive posi5ve change
• Most prescribers – are unaware their pa3ents are engaging in aberrant behavior, such as “doctor shopping”,
drug seeking, or diversion – preferred an appointment by telephone call
– had read the engagement materials prior to the appointment
– believed that they were already implemen3ng adequate steps/precau3ons in their prac3ce
• Although most prescribers expressed concern about being “monitored” by the payor, by the end of the call, addi3onal resources and tools were iden3fied that would help improve the safe use of control substances
– Locking members into a single pharmacy
– Specific lab tests including “no threshold tes3ng” and “adultera3on panel”
– Referrals for addic3on specialists and psychological counseling services
• Many providers were not aware of these addi3onal resources