Workers Compensation and Prescription Drugs: 2016 Update

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1 NCCI s 2016 Annual Issues Symposium Workers Compensation and Prescription Drugs: 2016 Update Sean Cooper, FCAS, MAAA Director and Senior Actuary May 5, 2016

2 Why Are Prescription Drugs an Important Topic in WC? The projected prescription drug (Rx) share of total workers compensation (WC) medical costs for Accident Year 2014 is 17% Rx averages approximately 45% to 50% of annual medical costs for active claims older than 10 years Rx payments reported through NCCI s Medical Data Call were over $1 billion in 2014 Rx is among the most active subjects of legislative activity in WC In 2014, Rx price inflation was higher than overall medical price inflation 2

3 Recent WC Rx Findings Rx prices increased 11% in This is substantially higher than the 10-year average increase of 4%. Rx utilization declined by 4%. This kept the growth in Rx costs per active claim to 6% in Controlled substances prices increased 16% in 2014 while utilization was down 7%. Both physician-dispensed Rx prices and utilization increased 4% in The share of generic Rx costs increased in 2014 due to increases in prices and utilization. 3

4 NCCI s 2016 Annual Issues Symposium The Big Picture

5 Recent Activity Regarding Rx in WC Drug Formularies Choice of Pharmacy Limitations on Physician Dispensing and Repackaged Drugs Medical Conditions Resulting From WC Prescription Drugs Are Compensable Opioid Treatment Plan/Agreement and Drug Adherence Pharmacy vs. PBM (Pharmacy Benefit Manager) 5

6 The Incremental Rx Share of Total Medical Costs Increases Rapidly as Claims Age 60% Rx Share of Total Medical Costs 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 5% 7% 13% 22% 28% 32% 51% 52% 51% 50% 50% 49% 49% 47% 48% 45% 42% 39% 36% The projected Rx share of total medical costs for Accident Year 2014 is 17% Projected 2014 Accident Year Share 0% Claim Maturity in Years NCCI analysis based on Medical Data Call, for prescriptions provided in Service Years 2011 to Rx shares shown are the projected shares for Accident Year For example, we project that Rx will be 22% of medical costs paid in 2017 for injuries that occurred in Data used with permission. 6

7 Cost = Price x Utilization Cost the total dollars paid per claim Price what is paid for individual services Utilization the intensity of services provided per claim The number of units (tablets, capsules, etc.) of Rx provided per claim The mix of Rxs provided on a claim, e.g., OxyContin versus Ibuprofen 7

8 Rx Costs per Active Claim Continue to Grow $ to 2014 Cumulative Change is 25% Rx Costs per Active Claim $450 $400 $350 $300 $250 $200 $150 $100 $ % $379 +7% $406 +6% $429 $50 $ Service Year NCCI analysis based on Medical Data Call, for prescription drugs with a National Drug Code (NDC) provided in Service Years 2011 to Active Claim is a claim with at least one medical service during the service year. Data used with permission. 8

9 Rx Prices Increased 11% in 2014 Price Change Utilization Change Rx Cost Change per Active Claim 12% 10% 10% 11% % Change 8% 6% 4% 2% 0% 6% 5% 6% 1% 7% 6% -2% -4% -6% -4% Service Year NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2011 to Price changes are based on a Fisher index. Data used with permission. 9

10 Rx Utilization Components Mix of Drugs Prescribed Share of Active Claims Receiving a Prescription Prescriptions per Active Claim With at Least One Prescription 6% 5% 4% % Change 2% 0% -2% -2% 1% 1% 0% 0% 1% -1% -4% -6% % Service Year NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2011 to Data used with permission. 10

11 2014 Rx Costs per Active Claim Countrywide $429 NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Year High > $582 and Low < $202. Ranges are based on the arithmetic mean ± one standard deviation. Data used with permission. 11

12 Rx Cost Containment Pharmacy Benefit Managers Pharmacy Networks Utilization Reviews Drug Fee Schedules Prescription Drug Monitoring Programs (PDMPs) Drug Formularies and Treatment Guidelines 12

13 Closed Drug Formulary A closed formulary is a list of drugs with an associated reimbursement status For example, for ODG (adopted by TX, OK, and in 2016 TN): Status Y N Description Preauthorized for use Not allowed, or needs authorization * Both Y and N are possible depending on intended purpose On average, 24% of drug costs and 17% of prescriptions in a service year are for N drugs The intent of formularies is to use evidence-based guidelines in order to: Reduce over prescribing (opioids in particular) Maximize healing and improve return-to-work outcomes Contain drug costs The Official Disability Guidelines (ODG) Drug Formulary is a product of the Work Loss Data Institute. 13

14 Potential Rx Costs Savings From ODG Formulary NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Year The Official Disability Guidelines (ODG) Drug Formulary is a product of the Work Loss Data Institute. Data used with permission. 14

15 NCCI s 2016 Annual Issues Symposium Controlled Substances and Physician Dispensing

16 Rx Costs per Active Claim Continue to Grow All Other Rx Controlled Substances Physician Dispensing $500 Rx Costs per Active Claim $450 $400 $350 $300 $250 $200 $150 $100 $343 $40 $101 $201 +0% +5% +15% $379 $40 $107 $232 +1% +3% +10% $406 +8% $429 $41 $44 +8% $110 $119 +4% $255 $265 $50 $ Service Year NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2011 to Controlled substances are Rxs classified as Schedule 2 and 3 by the Drug Enforcement Administration, not dispensed by a physician. Physician dispensing includes controlled substances. Data used with permission. 16

17 2014 Change in Rx Costs per Active Claim (Less than 0%) Countrywide +6% NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2013 to Data used with permission. 17

18 States With a Decrease in 2014 Rx Costs per Active Claim $500 $450 All Other Rx Controlled Substances Physician Dispensing $460 $437 Rx Cost per Active Claim $400 $350 $300 $250 $200 $150 $100 $203 $3 $78 $177 $3 $67 $268 $253 $14 $8 $65 $67 $189 $178 $134 $118 $71 $68 $255 $251 $50 $122 $108 $0 OR-2013 OR-2014 AR-2013 AR-2014 FL-2013 FL-2014 NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2013 and Controlled substances are Rxs classified as Schedule 2 and 3 by the Drug Enforcement Administration, not dispensed by a physician. Physician dispensing includes controlled substances. Data used with permission. 18

19 States With an Increase in 2014 Rx Costs per Active Claim All Other Rx Controlled Substances Physician Dispensing $600 $551 $500 $474 $44 Rx Costs per Active Claim $400 $300 $200 $100 $250 $296 $217 $5 $6 $74 $84 $100 $57 $127 $145 $165 $383 $126 $57 $200 $37 $134 $304 $177 $331 $0 MA-2013 MA-2014 IL-2013 IL-2014 AZ-2013 AZ-2014 NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2013 and Controlled substances are Rxs classified as Schedule 2 and 3 by the Drug Enforcement Administration, not dispensed by a physician. Physician dispensing includes controlled substances. Data used with permission. 19

20 Controlled Substances Prices Increased 16% 20% Price Change Utilization Change Rx Cost Change per Active Claim 15% 16% % Change 10% 5% 0% 4% 2% 5% 5% 3% 8% -5% -10% -2% -7% Service Year NCCI analysis based on Medical Data Call, for controlled substances with an NDC provided in Service Years 2011 to Controlled substances are Rxs classified as Schedule 2 and 3 by the Drug Enforcement Administration, not dispensed by a physician. Price changes are based on a Fisher index. Data used with permission. 20

21 Controlled Substances Utilization Components Mix of Drugs Prescribed Share of Active Claims Receiving a Prescription Prescriptions per Active Claim Receiving at Least One Prescription 3% 2% 1% 1% 2% 2% 2% % Change 0% -1% -2% -3% -4% -5% -6% -1% -2% -3% -4% -5% Service Year NCCI analysis based on Medical Data Call, for controlled substances with an NDC provided in Service Years 2011 to Controlled substances are Rxs classified as Schedule 2 and 3 by the Drug Enforcement Administration, not dispensed by a physician. Data used with permission. 21

22 2014 Controlled Substances Share of Rx Costs Countrywide 29% NCCI analysis based on Medical Data Call, for controlled substances with an NDC provided in Service Year Controlled substances are Rxs classified as Schedule 2 and 3 by the Drug Enforcement Administration. High > 35.0% and Low < 22.5%. Ranges are based on the arithmetic mean ± one standard deviation. Data used with permission. 22

23 Physician-Dispensed Rx Utilization Increased 4% in 2014 Price Change Utilization Change Rx Cost Change per Active Claim 10% 8% 8% 6% % Change 4% 2% 0% 4% 0% 1% 0% 1% 4% 4% -2% -4% -6% -4% Service Year NCCI analysis based on Medical Data Call, for physician-dispensed prescriptions with an NDC provided in Service Years 2011 to Price changes are based on a Fisher index. Data used with permission. 23

24 Mix of Rxs Is a Major Contributor to Utilization for Physician Dispensing Utilization Components Mix of Drugs Prescribed Share of Active Claims Receiving a Prescription Prescriptions per Active Claim Receiving at Least One Prescription % Change 12% 10% 8% 6% 4% 2% 0% -2% -4% -6% -8% 10% 7% 4% 0% -3% -5% -4% -4% -7% Service Year NCCI analysis based on Medical Data Call, for physician-dispensed prescriptions with an NDC provided in Service Years 2011 to Data used with permission. 24

25 2014 Physician-Dispensed Share of Rx Costs (Medium) Countrywide 10% NCCI analysis based on Medical Data Call, for physician-dispensed prescriptions with an NDC provided in Service Year High > 16.2% and Low < 1.7%. Ranges are based on the arithmetic mean ± one standard deviation. Data used with permission. 25

26 NCCI s 2016 Annual Issues Symposium Top Drugs in Workers Compensation

27 Top Drugs by Cost Drug Name Brand Name/ Generic Therapeutic Class 2013 Cost Ranking 2014 Cost Ranking 2014 Share of Total Rx Costs OXYCONTIN Brand Name Analgesics % LYRICA Brand Name CNS Drugs % GABAPENTIN Generic CNS Drugs % OXYCODONE- ACETAMINOPHEN Generic Analgesics % CELEBREX Brand Name Antiarthritics % DULOXETINE HCL Generic Psychotherapeutic % LIDOCAINE Generic Anesthetics % MELOXICAM Generic Antiarthritics % HYDROCODONE- ACETAMINOPHEN Generic Analgesics % OXYCODONE HCL Generic Analgesics % DULOXETINE HCL is the generic formulation of Cymbalta. Cymbalta s patent expired on 12/11/2013. Cymbalta s rank changed from 3rd to 47th between 2013 and LIDOCAINE is the generic formulation of Lidoderm. Lidoderm s patent expired on 9/15/2013. Lidoderm s rank changed from 5th to 34th between 2013 and NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2013 and Data used with permission. 27

28 10 Drugs Explain More Than Half of the 2014 Change in Prices Drug Name OXYCODONE- ACETAMINOPHEN Brand Name/ Generic DEA Schedule 2013 Price Paid per Unit* 2014 Price Paid per Unit 2014 Change in Price Paid per Unit Generic 2 $1.19 $ % LYRICA Brand Name 5 $3.74 $ % OXYCODONE HCL Generic 2 $0.63 $ % CELEBREX Brand Name None $5.63 $ % OXYCONTIN Brand Name 2 $6.73 $7.27 8% DUEXIS Brand Name None $6.05 $ % BACLOFEN Generic None $0.65 $ % PERCOCET Brand Name 2 $7.15 $ % MORPHINE SULFATE ER Generic 2 $2.35 $ % IBUPROFEN Generic None $0.30 $ % NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2013 and *2013 price paid per unit based on 2014 NDC distribution. Data used with permission. 28

29 Generic Rx Utilization Increased 13% in % Price Change Utilization Change Rx Cost Change per Active Claim 20% 21% % Change 15% 10% 5% 12% 12% 8% 7% 7% 13% 0% 0% -1% -5% Service Year NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2011 to Price changes are based on a Fisher index. Data used with permission. 29

30 Brand Name Rx Utilization Decreased 18% in 2014 Price Change Utilization Change Rx Cost Change per Active Claim 20% 15% 10% 10% 9% 12% 7% 14% % Change 5% 0% -5% -10% -1% -4% -7% -15% -20% -18% Service Year NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2011 to Price changes are based on a Fisher index. Data used with permission. 30

31 Generic Shares of Rx Costs and Prescriptions Both Increased in 2014 Rx Costs Prescriptions 100% 90% 80% 76% 77% 78% 82% Generic Share of Rx 70% 60% 50% 40% 30% 44% 45% 45% 51% 20% 10% 0% Service Year NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2011 to Data used with permission. 31

32 3 Drugs Explain Most of the 2014 Change in the Generic Share of Rx Costs Drug Name 2013 Price Paid per Unit 2014 Price Paid per Unit DULOXETINE HCL $5.47 $5.70 4% 38% LIDOCAINE $6.08 $ % 27% 2014 Change in Price Paid per Unit Contribution Recent Events The brand name equivalent formulation s (Cymbalta) patent expired on 12/11/2013 The brand name equivalent formulation s (Lidoderm) patent expired on 9/15/2013 OXYCODONE- ACETAMINOPHEN $0.92 $ % 20% Price increased NCCI analysis based on Medical Data Call, for prescription drugs with an NDC provided in Service Years 2013 and Data used with permission. 32

33 Concluding Remarks Rx continue to be a significant share of WC costs, largely due to increasing prices Legislative reform and stakeholders concerted efforts to contain costs have contributed to dampened utilization of Rxs in WC Will formularies, physician-dispensing laws, and other reform efforts have the intended impact on WC experience? Choice of pharmacy and the role of PBMs and PDMPs are some of the emerging themes in the dynamic world of Rxs and WC 33

34 NCCI s 2016 Annual Issues Symposium Appendix

35 NCCI Medical Data Call The NCCI Medical Data Call (MDC) captures transaction-level detail on medical bills processed on or after July 1, 2010, including dates of service, charges, payments, procedure codes, and diagnosis codes Carriers are not required to report transactions for services provided more than 30 years after the date of the injury NCCI collects the MDC for 43 jurisdictions* *The 43 jurisdictions are AK, AL, AR, AZ, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, OR, RI, SC, SD, TN, UT, VA, VT, WI, and WV. 35

36 Data Source For this study, the Medical Data Call experience evaluated as of March 2015 was restricted to: Services provided between January 1, 2011 and December 31, 2014 States included are: AK, AL, AR, AZ, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, OR, RI, SC, SD, TN, UT, VA, VT, and WI State-specific results are based on state of jurisdiction 36