kelly clark
DESCRIPTION
Opioid Dependence: Health Plan Problems and StrategiesNational Rx Drug Abuse Summit 4-11-12TRANSCRIPT
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