Prescription Opioid Abuse: Private Payer Perspective

Transcription

1 Prescription Opioid Abuse: Private Payer Perspective Tufts Health Care Institute s Program on Opioid Risk Management Jeffrey Sterling, Esq. Senior Investigator

2 Agenda Overall problem of prescription opioid abuse The impact on private payers What is being done

3 The Overall Problem Study: Abuse OTC drugs, prescriptions send more to Abuse of of prescription and and over-the-counter drugs drugs is is sending more more ER people people than to to cocaine emergency rooms rooms than than cocaine, according to to new new federal federal data data By Donna Leinwand, USA TODAY (2006) that that reflect reflect the the growing Abuse of prescription popularity and over-the-counter of of powerful drugs is sending painkillers more people to emergency such such rooms as as than cocaine, OxyContin, Vicodin Vicodin and and hydrocodone. The The data, data, to to be be released today today by by the (SAMHSA), show that 1.3 million people visited a hospital emergency room 2004 for illnesses involving drug the Substance Abuse abuse. Abuse and The administration and Mental Mental Health collects data Health Services from 417 hospitals Administration and 106 million total emergency room visits. (SAMHSA), One in four or 495,732 drug-related emergency room visits involved pharmaceuticals: over-the-counter or show show that that million million people people visited visited a hospital emergency room room visits. room in in for for illnesses involving drug drug abuse. abuse. The The administration "We need to see a real focus getting the message out that just because something is prescribed or over-the counter collects collects data data from from hospitals and and million million total total emergency room room prescribed by a doctor and taken exactly how the doctor prescribes can work wonders. But if it's not prescribed for visits. visits. you, if it's not taken the way it's intended, it's a recipe for disaster." One Surveys nationwide have shown a surge in prescription-drug abuse. The number of addicts seeking treatment for One in in four four or abusing or 495,732 prescription opiates, drug-related emergency while relatively small at 63,243 room in 2004, was up 62% room visits from three visits years earlier, involved pharmaceuticals: over-the-counter 2004, making it the drug or category with the highest number or prescription of new drugs. users, according to the drugs. One National Survey One in of Drug in five Use and Health. five 383,350 visits visits involved cocaine. Marijuana was was involved in in "These drugs have become very, very popular with people who abuse substances," says Joseph Troncale, medical 215,665 emergency director for room Caron room Treatment visits. visits. Centers based in Wernersville, Pa. He says up to 30% of the patients at Caron's drug- according to new federal data that reflect the growing popularity of powerful painkillers such as OxyContin, Vicodin and hydrocodone.the data, to be released today by the Substance Abuse and Mental Health Services Administration prescription drugs. One in five 383,350 visits involved cocaine. Marijuana was involved in 215,665 emergency doesn't mean it's not harmful," says SAMHSA administrator Charles Curie. "We want to recognize that medications according to data released last month by SAMHSA. About 2.4 million people abused painkillers for the first time in rehabilitation centers are being treated for prescription-drug abuse. The drugs are cheap and readily available on the street, Troncale says. "OxyContin, Percocet all these medicines are just being handed out like candy. I think there's too much availability," Troncale says. Most prescription drugs abused or sold on the street come from pharmacy robberies, pharmacist dealers or doctor dealers, says Mark Caverly, an investigator for the Drug Enforcement Administration.

4 Private Payer Impact 100 members in 90 days (4Q05) Med claims paid: $832,172 Rx claims paid: $ 20,233 Rx costs per member: $ 202 Medical costs per member: $8, members in 90 days (4Q09) Med claims paid: $1,211,130 Rx claims paid: $ 132,027 Rx costs per member: $ 1,320 Medical costs per member: $12,111

5 Impact, cont. Institutional Increases health insurance costs Direct and indirect impact on members Health Lack of medical management Financial Premium increases ID theft Particular impact on Part D beneficiaries

6 SIU Rx Initiative A comprehensive internal mechanism that proactively identifies members suspected of the inappropriate procurement of controlled drugs and institutes appropriate interventions Intervene when a member is using pharmacy and/or medical benefits inappropriately to acquire controlled medications Improve member health by encouraging the appropriate use of controlled prescription drugs Reduce cost of care by effectively reducing inappropriate utilization of health care resources

7 Case Synopsis for Medical Director Review TOTAL DEAS TOTAL Date: xx/xx/xx TOTAL AMT TOTAL PRESCRIBERS TOTAL DEAS PHARMS PAID FOR TOTAL AMT Member Name: SIU xxxxxxxxx Rx Initiative ID#: xxxxxxxxxxxxxxx Process 90 day period: xx/xx/xx xx/xx/xx TOTAL NARC FOR ALL PRESCRIBING DISPENSING NARC PAID FOR Drug Summary* PT NAME ALL CLAIMS XXXXXXX $ $ XXXXXXX $ $ XXXXXXX 20 # Days $ $ Drug Name Case Prescriptions XXXXXXX 20 identification Qty. Supply Prescribers Pharmacies $ $ $ $ XXXXXXX Close 21 coordination with PBM 18 and medical 11 $5.20 case $5.20 XXXXXXX $ $ management XXXXXXX $ $ XXXXXXX $6, $6, XXXXXXX Intervention $17.76 $ $87.84 $87.84 XXXXXXX Provider/member education 9 $ $ Total $ $ XXXXXXX Proactive steps directed 10 at 10 members 9 and $ $ XXXXXXX $64.66 $64.66 Synopsis: This member prescribers was identified based on 1Qxx pharmacy claims as having received prescriptions XXXXXXX for narcotics from 13 multiple 13 prescribers 12 and pharmacies. 12 A review of pharmacy 9 $63.71 and medical $63.71 claims from XXXXXXX _xx/xx/xx_ to _xx/xx/xx_ 9 indicates 9 that the 5 member received 5 prescriptions 9 $ for $ narcotics from XXXXXXX Road prescribers 13 and blocks 12 pharmacies. 8 The member 8had office 9 visits, $ and had $ E.R. visits. XXXXXXX [Additional case 18summary specific to member s 14 activity 14 and history] 9 $ $ XXXXXXX $55.49 $55.49 XXXXXXX $5, $5, XXXXXXX $ $ Medical necessity Working with law enforcement XXXXXXX $1, $1, XXXXXXX $1, $1,546.23

8 Results For Private Payers Drug and medical cost of care reduction Better coordination among monitoring programs Increased ID theft awareness For Members Pharmacy and medical claims reduction Improved health/effective medical management Lower health insurance costs

9 QUESTIONS???

10 Prescription Opioid Abuse; Private Payer Perspective Jeffrey Sterling, Esq. Senior Investigator Tel. 314/

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