A Healthesystems Clinical Analysis. Insidious Incrementalism of Opioid Use in Workers Compensation

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1 A Healthesystems Clinical Analysis Insidious Incrementalism of Opioid Use in Workers Compensation

2 Prescription opioid use in the United States has grown significantly over the past 20 years. In 1991, there were 40 million prescriptions written for opioids. By 2007, that number skyrocketed to 180 million. Up to 20 percent of all doctor office visits include an opioid prescription. Along with the increase in prescription volume, the issue of safety has been a significant challenge. In 2009, more than 310,000 Americans were admitted to emergency rooms due to an opioid overdose, and the amount of Oxycontin dispensed in 2009 alone was enough to give every man, woman and child in America 100 mg. Claim Age and Opioid Costs Opioid Costs by Age of Claim for Months 24 Months 36 Months 60 Months 72 Months + Approximately 75 percent of opioid drug costs are generated from claims older than five years, but typically 75 percent of all claims receiving drugs are less than five years old. Claim Count by Age of Claim for 2010 When analyzing the impact opioids have had in workers compensation, this single drug class has become one of the highest utilized of all prescription drugs, accounting for 30%-45% of many payers total annual drug spend. While the use and application of these drugs cover all claim age demographics, in most payer cases approximately 75 percent of opioid drug costs are generated from claims older than five years, but typically 75 percent of claims receiving drugs are less than five years old. Insidious Incrementalism: the incremental growth in opioid drug therapy costs and utilization as a claim ages Over a 15 year period, opioid drug costs per claim increase sharply, especially after the first five years. The major cost drivers are from: increased utilization (more prescriptions) increases in dosage amounts changes in drug mix to more potent drug agents 12 Months 24 Months 36 Months 60 Months 72 Months + 01 l

3 Drivers of Opioid Cost per Claim Drivers of Opioid Cost per Claim Cost per Claim 800% 2,700% 855% 279% 119% 289% Dura on of Service (Year) As illustrated in the Drivers of Opioid Cost per Claim graph above, when analyzing the actual drivers of opioid cost over time, the major contributors are the increases in drug mix (potency) and in dosage amounts, while utilization (i.e., the number of scripts and pills dispensed), by comparison, is relatively small. For example, when comparing the opioid cost per claim for claims in service during their first year versus year 14, the cost per claim in year 14 is 289% higher due to the impact of increased utilization, but higher dosages and the use of increasingly more potent agents (drug mix) increase the cost per claim by 855% and 2,700% respectively. It s the incremental increase in dosage and drug mix that begin manifesting during years 3 to 5 where the dramatic growth in costs per claim occurs. It s the incremental increase in dosage and drug mix that begin manifesting during years 3 to 5 where the dramatic growth in costs per claim occurs. l 02

4 Change in Drug Mix (potency) The Proportionate Costs of Opioids by Active Ingredient & Age of Claim Service Year % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 9.0% 9.0% 5.5% 3.7% 18.2% 16.4% 20.4% 1.1% 38.4% 1.7% 6.2% 6.0% 5.2% 2.0% 7.2% 64.8% 57.9% 51.5% 35.7% 4.3% 29.3% 2.8% 12.0% 32.2% 0.9% 1.2% 23.5% 29.4% 1.8% 3.8% 13.6% 11.5% 12.4% 17.7% Propoxyphene Oxymorphone Oxycodone Other Morphine Hydrocodone Fentanyl 20.0% 34.7% 45.4% Codeine 10.0% 0.0% 15.8% 1.3% 4.7% 8.1% 10.5% 5.0% 3.3% 2.7% 3 Months 12 Months 24 Months 36 Months 60 Months 10 years 15 years Several items become very apparent when analyzing the data in more detail. The shifting in drug mix begins later in the first year of opioid treatment and begins to significantly change the proportionate costs associated with these drugs. In 2007, opioid costs for claims 10 and 15 years old were heavily influenced by Fentanyl drugs (34.7% and 45.4% of total opioid costs respectively). One of the likely opioid cost contributors was the increased use of high priced, off label prescribed Fentanyl drugs like Actiq. Conversely Fentanyl represented a fairly small portion of opioid costs in the earlier stages of the claims lifecycle at only 1.3%. 03 l

5 Change in Drug Mix (potency) The Proportionate Costs of Opioids by Active Ingredient & Age of Claim Service Year % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 3.6% 2.9% 2.2% 1.7% 4.8% 6.2% 7.8% 15.9% 18.0% 28.3% 31.3% 2.0% 3.3% 3.1% 41.2% 37.6% 1.9% 6.4% 11.7% 2.8% 10.1% 3.5% 7.0% 62.5% 8.0% 61.5% 13.8% 48.2% 37.7% 29.4% 18.6% 2.1% 39.1% 7.2% 11.4% 17.4% Propoxyphene Oxymorphone Oxycodone Other Morphine Hydrocodone Fentanyl Codeine 10.0% 0.0% 21.8% 9.0% 5.7% 6.5% 7.5% 9.4% 14.0% 2.9% 3 Months 12 Months 24 Months 36 Months 60 Months 10 years 15 years These numbers significantly changed over the next few years, going into 2010, when the proportionate cost of Fentanyl drugs dropped in half to 21.8% for 15 year old claims, however, the percentage of total cost it represented for three month old claims increased by almost 800%, growing from 1.3% to 9% of total opioid costs. Much of this is the result of the growth in some newly marketed and expensive rapid release fentanyl products such as Fentora, Onsolis and Abstral each of which is much more expensive than the frequently prescribed Hydrocodone. This could also be considered therapeutically significant since in some cases this could be a shift towards more powerful drugs being used in the acute/earlier stages of a claim. l 04

6 The shifting in costs and utilization between the various opioid drug agents must be monitored very closely. While the reduction in costs and prescribing of expensive and powerful drugs such as Actiq has been a positive move, the proportional drug cost shift in 10 and 15 year old claims most notably went to other potent drugs like Oxycodone, which, on a per prescription basis, may be lower than Actiq, but tends to use high treatment doses as described in the change in dosage section of this document. In addition, the costs associated with Actiq were likely driven from a smaller group of claims, however, the usage Many of the listed drug agents comprising the higher opioid costs are also the higher Morphine Equivalent Dose (MED) drugs and therefore, the most potent. Hydromorphone (Dilaudid) are both 4 times more potent than Morphine. Therefore, the shifting in drug potency is not only more expensive, but also more powerful. Change in Dosage The changes in dosage follow a similar incremental growth pattern like the previous section on drug mix, wherein as claims age, the prescription strengths increase significantly. Therefore, the combined result is more opioids are being prescribed to more patients, and as the claims age, the opioids used are shifted to more powerful drugs with higher/stronger doses. When analyzing the proportion of Oxycodone prescriptions by strength illustrated in the following graph, the dosage changes are very clear. of the drug significantly impacted the total due to the excessively high prescription cost which could exceed $3,000. In 2010 the proportion of the costs represented by Oxycodone for claims in their 15th year of treatment increased from 23.5% to 39.1% and represented a larger group of claims being prescribed a lower cost drug compared to Actiq, yet it is still a relatively expensive and very powerful opioid drug. Many of the listed drug agents comprising the higher opioid costs are also the higher Morphine Equivalent Dose (MED) drugs and therefore, the most potent. MED is the measurement by which opioids are compared in order to determine potency. For example, oral Oxycodone is 1.5 times (50%) more potent than morphine; Oxymorphone (Opana) or 05 l

7 Change in Dosage Proportion of Oxycodone Scripts by Strength Service Year % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2.6% 2.1% 1.7% 6.6% 7.1% 7.5% 5.8% 9.4% 12.1% 1.8% 1.6% 2.5% 4.5% 2.3% 2.9% 24.6% 10.3% 9.2% 9.1% 15.0% 2.6% 5.4% 5.6% 14.7% 7.2% 28.6% 6.2% 9.7% 7.6% 6.4% 7.5% 39.2% 12.2% 42.0% 14.1% 10.4% 39.6% 15.8% 64.4% 4.4% 4.0% 26.4% 50.9% 1.6% 22.3% 31.2% 27.8% 1.6% 20.3% 0.6% 13.0% 9.9% 3 Months 12 Months 24 Months 36 Months 60 Months 10 years 15 years 80 mg 60 mg 40 mg 30 mg 20 mg 15 mg 10 mg 7.5 mg 5 mg In 2010, 87% of the prescriptions being written for claims in their first year of service were for dosage strengths less than 10 milligrams which mainly included short acting drugs such as Percocet, etc. However, claims in their 15th year had over 51% of prescriptions written for dosage strengths 20 milligrams and above which included long acting forms of drugs such as Oxycontin. Overall, the higher prescription strengths continue to significantly increase and the most dramatic changes occur for claims over three years old. Each of the metrics and examples provided illustrate a greater need for a more proactive Opioid Management Program. While the dollars and script volume for the most problematic claims tend to be in the older l 06

8 claim population, the most significant treatment pattern changes consistently occur after the third year of service. However, there are strong benefits to be gained by targeting early intervention during the first year to two years. Mainly having the ability to address claims headed in the wrong direction before the cost trajectory historically would begin, and this focused approach has delivered successful results for the Healthesystems Opioid Management Program. While payers should certainly maintain focus on older claims since they are still driving the majority of costs today, the most critical strategy of an Opioid Management Program must also be directed toward newer claims. This includes monitoring all aspects of the drug treatments and changes occurring and proactively addressing them, especially in cases with high dose opioid regimens. According to Healthesystems data, 68 percent of patients who use opioid medications for pain relief for 90 days are likely to remain on opioids 52 weeks later, further illustrating the importance of early intervention. According to Healthesystems data, 68 percent of patients who use opioid medications for pain relief for 90 days are likely to remain on opioids 52 weeks later. 07 l

9 5100 West Lemon Street Suite 311 Tampa, FL l Toll Free l Customer Service Center l Drug Information Line About Healthesystems Healthesystems is a specialty provider of innovative medical cost management solutions for the workers compensation industry. Our comprehensive products include a leading Pharmacy Benefit Management Program, expert Clinical Review Services and a revolutionary Ancillary Benefits Management solution for prospectively managing ancillary medical services. Our Verticē Claims Information Portal delivers real-time pharmacy and ancillary benefit management program information, reports and tools. This intuitive web portal allows claims professionals to access tools for quickly and efficiently processing provider transactions, running reports, retrieving relevant clinical information and many other functions. By leveraging powerful technology, clinical expertise and enhanced workflow automation tools, we provide clients with flexible programs that reduce the total cost of medical care and manage drug utilization, including the overuse of narcotics and other problematic drugs, all while increasing the quality of care for injured workers. Data referenced in this document was produced using Healthesystems proprietary pharmacy database information Healthesystems. Published 11/06/2011.

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