Protecting your employees, physicians and you.

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1 Protecting your employees, physicians and you. Opioid abuse is being talked about every day. Modern Medical has a solution - now with real outcomes.

2 Opioids are the most common drugs prescribed in workers compensation. This drug class is linked to the highest rate of prescription drug abuse. With mounting concern of the misuse and abuse of these drugs, the Centers for Disease Control and Prevention has proclaimed opioid abuse an epidemic. Chronic use of opioids can lead to higher medical costs, prolonged disability, overutilization and unintentional harm. Launched in November 2012, Opioid Defense Manager (ODM ) is a proactive, customized managed care program. ODM is designed to protect the employee, physician and the employer by reducing inappropriate drug use while maintaining the necessary balance to provide pain relief for the claimant. The case study below is an example of one of the outcomes of Opioid Defense Manager. 1 CASE STUDY: OPIOIDS WEANED Claimant injured in 2009 with a diagnosis of lumbago Initial RTW status: NO Patient returned to work within two months of ODM enrollment Result: Opioids weaned, back to work RTW = return to work Modern Medical s claimant-centered approach focuses on prevention. It starts with recognizing claimants who are at risk for prolonged disability, opioid dependence and risk of harm from opioid therapy. Modern Medical s clinical team of nurses and pharmacists will then collaborate with prescribers to ensure appropriate opioid therapy. This includes the ongoing monitoring of pain, function, adverse drug effects and risk management strategies such as urine drug screens, state prescription drug monitoring and pain agreements. Claims examiners and nurse case managers will work with Modern Medical to access realtime alerting of potentially harmful drug use patterns to more effectively manage the claimant s drug coverage. Claimants need to be involved with their care by understanding the expectations of treatment while working toward treatment goals. This is accomplished through claimant education and the pain agreements.

3 How Opioid Defense Manager Works CLAIMANT IDENTIFICATION 30 days opioids in last 60 days INJURY CLAIMANT EDUCATION FOLLOW-UP 60 day follow-up NURSE INTERVENTION Opioid Progress Report (OPR) Pain Agreements Medication History/Formulary The Core of ODM The Modern Medical Nurse Intervention is the core of the ODM program proactively monitoring claimants using opioids over time. We will review physician opioid progress reports every 60 days on an enrolled claimant, obtain pain agreements from the physician and monitor outcomes for claimants in coordination with the clinical pharmacists on staff. Other interventions may be recommended and the formulary may be modified based upon claimant progress and physician notes. When utilizing your own nurse, Modern Medical will provide alerts with letters on TruNet, Modern Medical s web portal, every 60 days. Outcomes are reported through dashboard reporting on TruNet and actions can be sent to modify the formulary or request additional services. The Technology Driving ODM TruNet Modern Medical s TruNet is a state of the art, web-based technology portal for tracking and managing all of your claims in real-time. With this tool, you will be able to review ODM claimants, set and review alerts and take actions based on information and reports. TruCase TruCase is the claims management system that Modern Medical s clinical staff uses to track outcomes for pain, function, opioid use, adverse effects, urine drug screens and pain agreements. TruRisk This prescriber intervention program works in tandem with the ODM alerts to identify and address issues with opioid and other inappropriate drug use. Modern Medical will also track multiple aspects of claimant compliance. This program is complimentary and considered a claimant safety initiative program managed by our clinical pharmacists.

4 ODM Inappropriate Drug Use Alerts Pattern of Filling Prescriptions Drug Duration Drug Dosage Concurrent Drug Use Utilization *These alerts follow the Ohio Coordinated Services Program. MED = Morphine Equivalent Dose 1. Early narcotic refill attempts 2. Using multiple physicians and pharmacies 3. Utilizing 2 or more pharmacies for prescriptions* 1. Narcotic utilization > 90 days 2. Narcotic utilization > 120 days 3. Excessive duration of use: hypnotics (beyond 90 days) 4. Excessive duration of use: muscle relaxants (beyond 90 days) 1. Daily MED > 100 mg/day 2. Daily MED > 120 mg/day 1. Concurrent use of a narcotic and sedative 2. Multiple sedative drugs 3. More than 2 narcotics and a hypnotic filled monthly* 4. More than 2 prescribers for same drug class* 5. More than 2 narcotics filled monthly with concurrent use* 1. At risk for drug-related problems (> 7 drugs) 2. More than 2 narcotics filled monthly* 3. First fill of a schedule II opioid Opioid Defense Manager Program Components Identify Risk Claimant Education Opioid Monitoring & Interventions Medication Reviews Peer Reviews Physician Reviews Urine Drug Screen Formulary Management Services Opioid Detoxification Services TruNet Alerts TruNet alerts are one of Modern Medical s clinical solutions for identifying inappropriate patterns of drug use. These alerts can trigger the following actions to be taken in the Opioid Defense Manager program. MEDICATION REVIEW SERVICES An Independent Pharmaceutical Evaluation (IPE) provides a professional opinion from a clinical pharmacist on cost effective therapy that is appropriate for the covered claim as well as to identify and recommend solutions to mitigate claimant risk. PEER REVIEW SERVICES Modern Medical is working with a peer review organization that will provide a final report and will conduct peer-to-peer contact if the current treatment requires intervention. This service can be combined with a medication review. PHYSICIAN REVIEW This service allows the current prescriber to be reimbursed for an in-depth file review. While this service is available for all alerts, we recommend that claimants with a dose above 120 mg per day of morphine equivalents receive this intervention. This will require a random urine drug screen, a pain agreement on file, a treatment plan and a state prescription drug monitoring report to be pulled. FORMULARY MANAGEMENT SERVICES Allows you to make changes to the claimant s formulary instantly. Options include: continue medications, block medications or restrict medications to a certain period of time. This action is available for opioids as well as other medications like: sedatives, hypnotics and muscle relaxants. URINE DRUG SCREEN SERVICES Modern Medical offers a comprehensive urine drug screen through Millennium Labs, that tests over 80 different drugs and metabolites including synthetic cannabinoids and bath salts. Reports are made available to you and the claimant s physician. OPIOID DETOXIFICATION SERVICES Modern Medical offers an outpatient detoxification program as an optional treatment for the claimant when recommended by the peer review physician. This outpatient detoxification program is supervised by a physician specialized in addiction medicine. Modern Medical s Clinical Services Team handles the complexities of the medication management system to cultivate positive claimant outcomes for the injured population.

5 ODM Outcomes and Case Study Synopses Modern Medical s nurse intervention is the key to the success of Opioid Defense Manager. These case studies present real outcomes directly associated with our nurse intervention and the Opioid Progress Reports. 70% of physicians are responding to Modern Medical nurse intervention 19% decrease in opioid medication costs to the employer 38% decrease in the morphine equivalent dose (MED) 46% decrease in opioid utilization 2 CASE STUDY: STARTING TO WEAN Claimant injured in 2012 with resulting joint pain of the lower leg Nucynta ER and oxycodone/apap 5-325mg were being used chronically Result: Opioids weaned in two months, formulary restricted 3 CASE STUDY: MULTIPLE PRESCRIBERS Claimant was injured over 12 months Tramadol and oxycodone were prescribed by different physicians Physician obtained information from our medication history on the OPR Result: Oxycodone no longer being prescribed OPR = Opioid Progress Report 4 CASE STUDY: DOCTOR SHOPPING (MEDICATION REVIEW) DATE DRUG QUANTITY/DAYS DOCTOR PHARMACY 6/9/12 Oxycodone 15mg 60/10 Doctor A Pharmacy 1 6/9/12 Oxycodone 5mg 60/10 Doctor A Pharmacy 1 6/25/12 Oxycodone 15mg 120/30 Doctor B Pharmacy 2 6/26/12 Tramadol 50mg 50/25 Doctor A Pharmacy 2 7/11/12 Oxycodone 5mg 120/30 Doctor B Pharmacy 1 7/20/12 OxyContin 10mg 60/30 Doctor C Pharmacy 3 7/20/12 Oxycodone 20mg 120/30 Doctor D Pharmacy 4 This chart shows only a 6 week window of the claimant s medication fill. A 48 year old claimant injured in 2005 due to amputation of four fingers Problem: Over a 4-month period, there were 4 different opioids prescribed by 6 different doctors, filled at 7 different pharmacies Claimant received over 417 extra opioid doses Result: Locked to one physician, further coverage of opioids denied 5 CASE STUDY: STARTING TO WEAN (MEDICATION REVIEW) MEDICATION DOSE INDICATION FOR USE Carisoprodol 350mg (generic for Soma ) OxyContin 40 (brand) Zolpidem 10mg (generic for Ambien ) MED = Morphine Equivalent Dose 4/day 8/day 1/day Acute muscle spasm Chronic pain; chronic pain with opiod tolerance Short-term treatment of insomnia characterized by difficulty falling asleep A 67 year old claimant injured in late 1990 s after falling on ice Reported injuries were lumbosacral sprain, disc herniation, major depression (single ep.) Problem: Opioid dose of 480 mg/day MED and chronic use of a sedative in an older claimant Result: Carisoprodol and zolpidem stopped; OxyContin weaned to 80mg/ day (over $1,500/month savings)

6 7840 Graphics Way Lewis Center, OH Fax: modernmedical.com Services: Pharmacy Benefit Management Services Home Health Services Clinical Services Durable Medical Equipment Orthotics and Prosthetics Home and Vehicle Modifications Electrotherapy Transportation and Translation Services Diagnostic Imaging Bill Review PPO Network Case Management Medicare Set-Asides

Protecting your employees, the physicians and you. Opioid abuse is being talked about every day. Modern Medical has a solution.

Protecting your employees, the physicians and you. Opioid abuse is being talked about every day. Modern Medical has a solution. TM Protecting your employees, the physicians and you. Opioid abuse is being talked about every day. Modern Medical has a solution. Goals of Opioid Defense Manager TM Opioids are the most common drugs prescribed

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