tpp 5 paduda victor

Latest Research on Impact of Rx Drug Abuse on Workers

Compensa:on

Joseph Paduda, President CompPharma, LLC

Dr. Richard A. Victor, Execu:ve Director Workers’ Compensa:on Research Ins:tute

Disclosures

•  Joseph Paduda has financial rela:onships with proprietary en::es that produce health care products and services. These financial rela:onships are: consul:ng for CID, Millennium Labs, and MedRisk, Inc.

•  Richard A. Victor has disclosed no relevant, real or apparent personal or professional financial rela:onships.

Learning Objec:ves:

1.  Specify workers' comp stakeholders' current aQtudes towards opioids, the programs they have in place to address opioids, and how they are measuring success.

2.  Explain the impact of prescrip:on drugs on workers' compensa:on costs, disability, and outcomes.

3.  Compare the level of understanding of execu:ves to front-‐line staff to assess gaps in performance and policy implementa:on.

4.  Specify what types of physician dispensing of opioids exist and how common these prac:ces are used.

5.  Analyze whether a ban on physician dispensing of opioids reduces the use of opioids or merely shiYs the dispensing to pharmacies.

Latest Research on Impact of Rx Drug Abuse on Workers

Compensa:on Joseph Paduda

President CompPharma, LLC

Opioids are the most

significant problem

facing work comp today.

As a society we consume

of all the opioids prescribed in the world.

80%

pg. 2

DEA definition

“opioid” Examples include the illicit drug heroin and

pharmaceutical drugs like:

OxyContin®

Vicodin®

codeine morphine

methadone and

fentanyl

pg. 3

Routine use of opioids for the treatment of chronic nonmalignant pain conditions is not recommended.”

“

-ACOEM

pg. 4

The number of narcotics prescriptions per claim has grown 41%, from 0.56 in 2003 to 0.79 in 2011.

-NCCI

pg. 5

Respondents 400 total, 2:1 front line: executive ratio 272 completed the survey

Response rate is three times greater than any other survey we’ve conducted over 10 years.

pg. 6

Defining the Problem

pg. 7

When you hear the word “opioids,” what one or two words instantly come to mind? Addiction /

Dependence

Drug(s) / Narcotics / Drug Name

Abuse

Appropriate / Pain / Pain Killer /

Therapy

Cost

Over Prescribed / Death / Danger /

Epidemic Death

pg. 8

How concerned is senior management about opioids in workers’ compensation?

pg. 9

Why? Because these drugs drive up costs, duration – most respondents have figured this out and are starting to track the impact.

pg. 10

Opioids are perceived as having

overwhelmingly negative

consequences for payers and claimants.

What is the impact of opioids on the costs and outcomes of workers’ compensation claims?

pg. 11

Whose responsibility is it to manage opioids?

Addicts may be “responsible” but

aren’t capable, and many doctors aren’t able to

address the issue. pg. 12

How effective or ineffective have PAYERS been in addressing opioids?

pg. 13

What is causing PAYERS not to effectively address the issue of opioids?

Regulations Don’t Allow Payers to Do Enough

Tools Available Are Inadequate

Not Able to Identify Claims That Would Benefit From Intervention

Other (Please Specify)

Not a Top Priority pg. 14

How effective have REGULATORS been in addressing opioids?

pg. 15

Conclusion major problem as it directly affects

claim costs duration

risk ability to control same

As with any WC issue, payers look to regulators to enable solutions – however there are some solutions

currently in place that are delivering results despite the less than

helpful environment.

pg. 16

Solutions

pg. 17

We’re in the early stages of figuring out the problem and developing effective approaches.

pg. 18

What is the goal for the stated opioid program(s)?

What is the goal for the stated opioid program(s)?

pg. 19

What vendor(s) are you working with to address opioids?

pg. 20

Please describe what the vendor(s) is(are) doing to address opioids?

There’s a discrepancy between front-line staff and management, which indicates a disconnect with internal communication.

pg. 21

What is the vendor doing to address opioids?

pg. 22

How are you measuring the impact of the work of the vendor(s)?

pg. 23

We’re in this early stage where much of what we’re doing is based on what we think will work, but we don’t yet KNOW.

Do you believe the programs are having a positive effect?

pg. 24

What should be done?

What is being done? 80% of respondents picked best practices.

vs.

pg. 25

The ideal solution 80% identified: Peer / physician review for claims – 90 / 180 days

Drug utilization review

Random drug testing

Opioid agreement / contracts

pg. 26

Please rank the following potential solutions 1-8 in the order that you believe would be most successful in addressing the overall opioid issue starting with 1 as most successful.

pg. 27

What percentage of the claims with opioid issues do you think an opioid management program would address?

pg. 28

Takeaways

pg. 29

Consensus that opioids: Cause addiction /

dependency

Increase disability duration

Increase risk of fraud / abuse

Drive up costs

pg. 30

Opioid management

is in its infancy.

pg. 31

There is a wide

divergence between ideal

and actual opioid

management programs.

pg. 32

Treating physicians

are the crux.

pg. 33

Conclusion

pg. 34

pg. 35

•  Two public policy debates converged – Public health: “Pill mills” that dispense

controlled substances – Cost: Physician dispensing of a wide range of

Rx in workers’ compensation •  Florida legislature banned physician

dispensing of stronger opioids

Policy Context In Florida

41 © Copyright 2014 WCRI. All Rights Reserved. © Copyright 2014 WCRI. All Rights Reserved. 41

•  High levels of physician compliance with the ban •  Fewer Florida workers received stronger opioids •  Physician-dispensers switched to dispensing

other pain medications rather than continuing stronger opioids

Major Findings


Source: Impact of Banning Physician Dispensing of Opioids in Florida (Thumula, 2013)

Physician Dispensing Was Common In Florida, Higher Than Most States

0%

10%

20%

30%

40%

50%

60% M

A NY TX

AR

M N

LA

VA

N

C WI

KS

IA

SC

NJ

TN

MO PA

M

I IN

G

A CT

M D

IL

FL

CA

43

Prescriptions For 2011/12 Claims With > 7 Days Of Lost Time

Source: The Prevalence And Costs Of Physician-Dispensed Drugs (Wang, Liu, & Thumula 2013)

% Of A

ll Rx

For Physician

-‐Dispe

nsed

Rx

© Copyright 2014 WCRI. All Rights Reserved. 43

Prescriptions For 2011/12 Claims With > 7 Days Of Lost Time Source: The Prevalence And Costs Of Physician-Dispensed Drugs (Wang, Liu, & Thumula, 2013)

•  Ban on physician dispensing of schedule II, III controlled substances (effective July 1, 2011) – Few exceptions (can dispense samples, after

surgeries, clinical trials, department of corrections) – No limits on physician dispensing of other

medications •  Requires counterfeit-proof prescription pads

(effective August 29, 2011) •  Register as controlled substance prescribing

physicians (effective January 1, 2012)

HB 7095 (Florida Pill Mill Bill)


•  Early impact of reform on prescribing and dispensing practices

•  Only injuries that occurred after the law change were included in treatment group

Scope Of The Study


•  Pre-post policy implementation –  Treatment group: new injuries arising between

July-September, 2011 (Ban effective 7/1/11) – Comparison group: new injuries arising between

July-September, 2010 – Both groups had Rx filled through December of the year

of injury (3-6 months of experience) •  Data:

– 25% of Florida claims –  Indemnity and medical-only claims – Case-mix adjusted

Methods And Data


Pre-‐ And Post-‐Reform Claim Characteris:cs Were Similar

47 © Copyright 2014 WCRI. All Rights Reserved.

Pre-‐Reform Post-‐Reform

Number Of Claims 11,867 10,623

Average Age 41 41

% Female 42% 40%

% Indemnity Claims 24% 22%

Average Medical Payments $2,464 $2,521

Average # Physician Visits 3 3


Source: Impact of Banning Physician Dispensing of Opioids in Florida (Thumula, 2013)

Physician Dispensing And Use Of Pain Medica:ons Unchanged


Pre-‐Reform Post-‐Reform

Number of Rxs 22,255 19,017

% Physician-‐Dispensed Rxs 52% 52%

% All Pain Medica:ons 61% 61%


High Physician Compliance With Reform In First 3-‐6 Months Of Cases


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Pre-Reform Post-Reform

Prop

ortio

n Of

Cla

ims

With

Rx

Physician-‐Dispensed Schedule II, III Opioids


•  Of those with physician-dispensed stronger opioids after the ban: – 69% surgical cases – 21% out-of-state providers

Why Didn’t Physician-‐Dispensed Schedule II, III Opioids Drop To Zero?


Physician Dispensing Of Stronger Opioids Fell AYer The Ban

3.5%

0.5%


Prop

ortio

n Of

Cla

ims

With

Rx


Physician-‐Dispensed Opioids (II, III)


No Change In Pharmacy Dispensing Of Schedule II, III Opioids

12.0% 12.1%

3.5%

0.5%


Prop

ortio

n Of

Cla

ims

With

Rx



Pharmacy-‐Dispensed Opioids (II, III)


Physician Dispensing Of NSAIDs And Weaker Opioids Increased Post-‐Reform

9.0% 9.8%

23.8% 26.0%

3.5%

0.5%


Prop

ortio

n Of

Cla

ims

With

Rx



Physician-‐Dispensed Weaker Opioids

Physician-‐Dispensed NSAIDs


Recap: Did The Florida Ban Reduce The Overall Use Of Opioids By Injured Workers?

•  High levels of physician compliance with the ban

•  Fewer workers received stronger opioids


Ques:on Raised: Does Physician Dispensing Lead To More Opioids?

•  Physician-‐dispensers switched to other pain medica:ons in the wake of the ban — No change in pharmacy-‐dispensed schedule II, III opioids

— Increase in percentage of claims with physician-‐dispensed NSAIDs and weaker opioids

•  This raises ques:ons if physicians dispensed unnecessary opioids pre-‐ban

•  Upcoming study will examine longer-‐term impact of the ban


•  To purchase the study, Impact of Banning Physician Dispensing of Opioids in Florida, go to:

•  WWW.WCRINET.ORG

•  For comments/questions about the findings: [email protected]

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