Pdmp coordination with_third-party_payers_final

PDMP
Workshops:

PDMP
Coordina2on
with
Third-‐Party
Payers

Chris
Baumgartner

PMP
Director,
Washington
State
Prescrip4on
Drug

Monitoring
Program

Bruce
Wood

Associate
General
Counsel
and
Director,
Workers’

Compensa4on,
American
Insurance
Associa4on

Alex
Swedlow

Execu4ve
Vice
President,
Research,
California
Workers’

Compensa4on
Ins4tute

April
2
–
4,
2013

Omni
Orlando
Resort

at
ChampionsGate

Learning
Objec2ves

1.  State
the
basis
for
broad
access
to
PDMP

database,
including
third-‐party
payers.

2.  Iden4fy
speciﬁc
strategies
to
avoid
risky

prescribing
to
help
physicians
avoid
trouble

with
their
Boards
or
the
DEA.

3.  Outline
approaches
to
data-‐sharing
among

states.

Disclosure
Statement

Chris
Baumgartner
has
no
ﬁnancial
rela4onships

with
proprietary
en44es
that
produce
health

care
goods
and
services.

Public
Insurer
Access

•  PDMP
Statute:
Allows
PDMP
data
to
be

provided
to
Medicaid
and
Workers’

Compensa4on

•  Primary
Goal:
To
provide
for
beUer
pa4ent

care
and
promote
pa4ent
safety.

•  Secondary
Goal:
To
assist
our
public
insurers

in
preven4ng
fraud
and
saving
state
funding.

Two
Types
of
Access

1.  Healthcare
Prac44oners
within
the
Health
Care
Authority

(HCA
-‐
Medicaid)
and
Department
of
Labor
and
Industries

(LNI
–
Workers’
Compensa4on)
can
login
with
individual

account
access
and
request
a
pa4ent
history
report.

2.  Once
a
month
each
agency
provides
a
file
through
secure

file
transfer
of
all
their
clients/pa4ents
(names,
DOB).

Our

vendor
then
provides
matching
data
for
each
client/pa4ent

in
a
file
that
is
returned
through
secure
file
transfer.

LNI
-‐
PDMP
Bulk
Transfer

•  PDMP
bulk
transfer
uses:

–  Iden4fying
pre-‐exis4ng
opioid
use

–  Iden4fying
duplica4ve
prescrip4ons
(in
process)

–  Iden4fying
prescribing
outliers
(future)

•  Bulk
transfer
available
in
May
2012

LNI
Early
Opioid
Interven4on
Pilot

•  Iden4fy
claims
that
are
15
-‐
45
days
old
AND

received
≥ 1
opioid
prescrip4ons
within
60

days
before
the
injury

•  Clinical
review
and
interven4on
by
a
nurse
or

pharmacist
as
necessary

•  BeUer
coordina4on
of
medical
care
and

management
of
claims,
promote
use
of
PMP

and
reduce
cost
and
disability

LNI
-‐
Early
Opioid
Interven4on
Pilot

•  350
–
500
new
claims
meet
this
criteria
each

month
(3-‐4%
of
all
claims
allowed)

•  Priori4za4on
Criteria

–  Chronic
opioid
use
(≥
3
prescrip4ons
in
previous
3
months)

–  High
dose
opioid
(>
120mg/d
MED)

–  Other
controlled
substances
(e.g.
benzodiazepines,
seda4ve-‐hypno4cs

–  Timeloss
(wage
replacement)

•  Clinical
review
is
priori4zed
by
the
number
of

criteria
met

Future
LNI
Ini4a4ves

•  Complete
the
Early
Opioid
Interven4on
Pilot

•  Require
L&I’s
providers
to
access
PDMP
before

prescribing
opioids
for
a
work-‐related
injury
(new

guideline)

•  Iden4fy
duplica4ve
prescrip4ons
and
create
a

process
to
intervene

•  Iden4fy
prescribing
outliers
to
improve
L&I’s
new

provider
network

HCA
–
Pa4ent
Review
&
Coordina4on
(PRC)

•  Aimed
at
over-‐u4lizing
clients

•  Decrease
and
control
over-‐u4liza4on
and
inappropriate
use
of

health
care
services

•  Minimize
medically
unnecessary
services
and
addic4ve
drug
use

•  Client
and
provider
educa4on
and
coordina4on
of
care

•  Assist
providers
in
managing
PRC
clients
by
providing
available

resource
informa4on
to
facilitate
coordina4on
of
care

•  Reduce
overall
expenditures

PDMP
Assistance
to
PRC
to
Date

•  As
of
May
2012
the
PDMP
has
assisted
in
iden4fying

20
clients
for
the
PRC
program
to
date
(through
5

months
of
using
just
the
individual
query
site)

•  The
minimum
4me
that
a
client
is
in
PRC
is
2
years

and
they
can
be
3
years
or
5
years.

•  These
20
clients
represent
67
PRC
client
lock-‐in
years

at
$6,000
per
year.
This
amounts
to
over
$400,000
in

savings.

11

PDMP
Bulk
Data
use
by
PRC

•  PRC
Program
compliance
analysis

–  Of
3,800
PRC
clients
1,900
are
currently
Fee
For
Service

•  Of
these
1,900,
1,170
clients
have
at
least
1
PMP

prescrip4on.

•  Of
the
1,170
clients
filling
prescrip4ons

–  489
Clients
paid
cash
for
2,470
prescrip4ons.
And
243
addi4onal

clients
are
listed
as
paid
by
04
private
insurance
with
an

addi4onal
2,059
prescrip4ons.
This
would
be
a
total
of
732
clients

filling
4,529
total
prescrip4ons

–  By
contrast
898
clients
filled
12,240
prescrip4ons
paid
for
by

Medicaid
during
this
same
period.

12

PDMP
Bulk
Data
use
by
PRC

•  Client
Iden4fica4on
analysis

•  Allows
improved
algorithms
with
clients.

–  Iden4fied
>2000
Clients
in
2012
with
Cash
and
Medicaid

paid
schedule
prescrip4ons
on
the
same
day.

–  Iden4fied
478
clients
where
cash
and
Medicaid
fills
were
<

10
days
apart,
the
scripts
were
overlapping,
for
the
same

drug
and
from
different
prescribers.

–  Currently
reviewing
the
top
u4lizers
of
the
478
for
PRC

placement.

13

HCA
-‐
Narco4c
Review
Program

•  The
Narco4c
Review
Program
(NRP)
evaluates
Medicaid

clients
who
are
receiving
high
doses
of
opioid
narco4cs
to

verify
the
medical
need
for
these
excep4onal
doses.

It
only

applies
to
client
with
chronic
non-‐cancer
pain.

•  Each
narco4c
prescrip4on
for
these
clients
requires

authoriza4on
as
long
as
the
client
is
in
the
narco4c
review

program.
A
client’s
narco4c
use
will
be
adjusted
to
minimize

pain
and
maximize
func4on.

The
lowest
eﬀec4ve
dose,
or

zero
use
is
determined
by
medical
necessity
and
clinical

considera4ons.

•  PDMP
Data
found
that
83%
of
clients
in
the
NRP
had
scripts

that
were
not
paid
for
by
Medicaid.

14

Future
HCA
Ini4a4ves

•  HCA
will
be
using
bulk
data
to
augment
our
lock-‐in
PRC

program.

•  HCA
has
already
been
working
on
threshold
reports
to
go

to
managed
care
plans
concerning
clients
using
cash.

•  HCA
will
be
sending
threshold
reports
to:

–  Prescribers
with
clients
prescrip4on
Informa4on

–  Pharmacies
who
accept
cash
from
Medicaid
clients
in

viola4on
of
their
core
provider
agreement

15

Refining
the
Bulk
Transfer

•  Key
Areas
that
were
fine
tuned:

–  Data
Fields:
NPI,
Payment
Type,
etc…

–  Handling
reversals,
voids,
duplicates

–  Provide
back
in
return
file
LNI
pa4ent
name
for
matching

•  Key
Areas
for
improvement:

–  Payment
Type
–
entered
more
accurately

–  NPI
#
-‐
require
is
to
be
reported

–  Pa4ent
ID
–
more
reliable
matching

Program
Contact

•  Chris
Baumgartner,
PMP
Director

–  Washington
State
Dept.
of
Health

–  Phone:
360.236.4806

–  Email:
prescrip4onmonitoring@doh.wa.gov

–  Website:
hUp://www.doh.wa.gov/hsqa/PMP/default.htm

PDMP
Coordina2on
with
Third-‐
Party
Payers

Bruce
C.
Wood

Associate
General
Counsel
&

Director,
Workers’
Compensa4on

American
Insurance
Associa4on

April
2
–
4,
2013

Omni
Orlando
Resort

at
ChampionsGate

Learning
Objec2ves

•  State
the
basis
for
broad
access
to
PDMP

database,
including
third-‐party
payers.

•  Iden4fy
speciﬁc
strategies
to
avoid
risky

prescribing
to
help
physicians
avoid
trouble

with
their
Boards
or
the
DEA.

•  Outline
approaches
to
data-‐sharing
among

states.

Disclosure
Statement

•  Bruce
Wood
has
no
ﬁnancial
rela4onships

with
proprietary
en44es
that
produce
health

care
goods
and
services.

WORKERS’
COMPENSATION
ON

THE
FOREFRONT
OF
THE

EPIDEMIC

WORKERS’
COMPENSATION:

AN
INTRODUCTION

I

Discussion/history
of
workers’

compensa2on

•  Evolu2on
of
this
social
insurance
program
over
the

past
century
=
first
w.c.
program
enacted
in
1911

(Wisconsin)

•  Subs2tute
for
tort
=
quid
pro
quo

•  Trauma2c/occupa2onal
diseases

•  Na2onal
Commission
on
State
Workmen’s

Compensa2on
Laws
(1972)
=
watershed
event/

states’
response

•  Post-‐Na2onal
Commission
history
=
benefit

expansion;
financial
crisis
(later
‘80s-‐mid-‐’90s)

II

Key
Program
Elements

•  All
medical
treatment
“reasonable
and
necessary”
(w/o
co-‐
pays,
deduc2bles,
exclusions,
dura2on
limits)
=
1st
dollar

coverage.

•  Indemnity
benefits
=
commonly
2/3
of
gross
“average
weekly

wages”
=
Paid
for:

 Temporary
total
disability
(TTD),
temporary
par2al

disability
(TPD),
permanent
par2al
disability
(PPD),

permanent
total
disability
(PTD)

•  Voca2onal
rehabilita2on
benefits
=
evalua2on
and
re-‐training

•  Survivor/dependents’
benefits
=
payable
for
life
or
un2l

remarriage;
dependents
un2l
18
or
22
if
enrolled
in
college

III

Common
Areas
of
Dispute

• Compensability
=
Did
the
injury/disease

“arise
out
of
and
in
the
course
of

employment”?

• Exclusive
remedy
=
Was
the
injury

encompassed
within
the
compensa2on

scheme?
Did
the
employer
intend
to

injure
the
worker?

Common
Areas
of
Dispute
–
cont’d

•  PPD
=
Is
there
residual
permanency;
when
is

permanency
ascertained
and
by
what
means;
how
is

disability
determined?
Impairment
as
a
proxy
for

disability?

Lost
wage-‐earning
capacity?
=
PPD
as

driver
of
dispute,
li2ga2on,
and
medical
treatment

costs
=
most
costly
element
of
w.c.
system

•  Medical
treatment/RTW
=
Is
the
treatment

“reasonable
&
necessary”?

Employer/insurer
is
not

ﬁnancier
of
all
medical
treatment.

Has
maximum

medical
improvement
(MMI)
been
reached?

Is

worker
able
to
return
to
work?

Restric2ons?

Accommoda2ons?

IV

The
Role
of
Workers’

Compensa2on
Medical
Treatment

 Workers’
compensa2on
is
not
a
medical
program.
It

is
a
disability
program
with
a
medical
component
=

key
diﬀerence
with
group
health
and
informs
how

medical
treatment
is
delivered
and
the
role
of
a

payer
and
its
agents
in
administering
a
claim.

 Key
objec2ve
in
workers’
compensa2on
is

managing
disability
=
providing
all
medical

treatment
reasonable
and
necessary,
of
the
nature

and
intensity
required,
to
expedite
recovery
and

return
to
work.

WC
medical
treatment
may
cost

more
but
higher
cost
can
expedite
RTW
and
limit

indemnity
exposure
=
coordina2ng
medical

treatment
and
indemnity.

The
Role
of
Workers’
Compensa2on

Medical
Treatment
–
cont’d

Because
workers’
compensa2on
medical
treatment
remains
ﬁrst-‐
dollar
coverage
–
with
no
demand-‐side
controls
on
cost
and

u2liza2on
–
it
reinforces
need
of
payers
to
use
administra2ve

tools
to
control
cost,
as
well
as
to
encourage
return
to
work.

These
include:

 Ability
to
direct
medical
treatment
–
control
of
physician/
networks

 Treatment
guidelines
–
na2onal
=
ACOEM/ODG

 Unit
price
controls
(fee
schedules)
=
Medicare
RBRVS/DRGs

 Impairment
guidelines
=
AMA
Guides
to
the
Evalua2on
of

Permanent
Impairment

The
Role
of
Workers’
Compensa2on

Medical
Treatment
–
cont’d

Delivering
medical
treatment,
2mely,
and
of
the
nature
and

intensity
needed,
requires
an
unimpeded
exchange
of
medical

informa2on
with
providers
and
evaluators.

•  No
authoriza2ons/releases
required
in
workers’

compensa2on.

•  System
is
intended
to
be
less
formal
than
civil
li2ga2on,
to

promote
quick
exchange
of
informa2on
in
the
employee’s

interest
in
receiving
necessary
and
2mely
medical

treatment,
in
evalua2ng
return-‐to-‐work
restric2ons
and

accommoda2ons
necessary,
and
in
an
employer’s

understanding
of
poten2al
health
and
safety
risks
posed
by

the
injury.

The
Role
of
Workers’
Compensa2on

Medical
Treatment
–
cont’d

In
workers’
compensa2on,
the
employee
is
not
the

policyholder
but
a
3rd
party
with
a
legal
claim
for

benefits
against
the
policyholder/employer
who
the

insurer
is
obligated
under
law
and
its
insurance

contract
to
defend
and
indemnify,
paying
all

benefits
due.
For
this
reason,
the
employee,
who

puts
his
condi2on
at
issue,
does
not
have
the
same

confiden2ality
expecta2ons
as
do
claimants
in
a

group
health
sekng.

The
Role
of
Workers’
Compensa2on

Medical
Treatment
–
cont’d

The
special
informa2onal
needs
of
workers’
compensa2on

payers
is
recognized
under
HIPAA:

“A
covered
en2ty
may
disclose
protected
health

informa2on
as
authorized
by
and
to
the
extent
necessary

to
comply
with
laws
rela2ng
to
workers’
compensa2on
or

other
similar
programs,
as
established
by
law,
that

provide
beneﬁts
for
work-‐related
injuries
or
illnesses

without
regard
to
fault.”
[sec.
164.512
–
Uses
and

disclosures
for
which
an
authoriza2on,
or
opportunity
to

agree
or
object
is
not
required;
45
CFR
164.512(l)].

The
Role
of
Workers’
Compensa2on

Medical
Treatment
–
cont’d

  Where
state
law,
itself,
mandates
disclosure
without

authoriza2on,
disclosure
is
permiqed
under
HIPAA
rules
and

exempt
from
the
“minimum
necessary”
informa2on

disclosure
standard.

“A
covered
en2ty
may
use
or
disclose

protected
health
informa2on
to
the
extent
such
use
or

disclosure
is
required
by
law
and
the
use
or
disclosure

complies
with
and
is
limited
to
the
relevant
requirements
of

such
law.”
[164.512(a)(1)].

  A
covered
en2ty
under
HIPAA
rules
also
may
disclose

informa2on
to
any
en2ty
as
necessary
for
payment,

although
the
covered
en2ty
may
disclose
the
amount
and

types
of
informa2on
necessary
for
payment.

The
Role
of
Workers’
Compensa2on

Medical
Treatment
–
cont’d

In
brief,
HIPAA
does
not
erect
barriers
to
a
workers’

compensa2on
payer
obtaining
protected
health
informa2on,

whether
without
an
authoriza2on,
or
pursuant
to
state
law

requiring
release.

HIPAA
does
not
preempt
state
privacy

laws.

 State
privacy
laws
generally
do
not
erect
barriers
to

obtaining
medical
informa2on
from
medical

providers.

Some
states
=
explicit
mandates
to
release

informa2on
to
employer/insurer.

 Other
states
impose
ex
parte
rules
on
physician

communica2ons
with
carrier
that
slow
evalua2on/
decisions.

The
Role
of
Workers’
Compensa2on

Medical
Treatment
–
cont’d

It
is
essen?al
for
workers’
compensa2on
payors
to
obtain

access
to
prescrip2on
monitoring
program
data,
to
properly

assess
an
injured
worker’s
use
of
prescrip2on
medica2ons

and,
broadly,
to
provide
all
reasonable
and
necessary

medical
treatment
and
eﬀec2vely
manage
disability.

Without
access,
it
is
not
possible
for
a
workers’

compensa2on
payer
to
know
the
full
extent
of
prescrip2on

drug
use,
because
a
worker
may
be
obtaining
prescrip2ons

under
other
beneﬁt
systems
(e.g.,
Medicaid,
group
health,

Veterans)
or
has
prescrip2ons
through
other
providers
not

otherwise
reported.

The
Role
of
Workers’
Compensa2on

Medical
Treatment
–
cont’d

  Washington
State’s
Department
of
Labor
&
Industry
has

access
to
PMP
data.

The
Department’s
role
in
providing

workers’
compensa2on
benefits
is
no
different
from
that
of

other
private
market
insurers
and
self-‐insured
employers.

  Arizona
enacted
legisla2on
last
year
providing
access
for

IMEs
to
that
state’s
PDMP
database
and
the
right
to
disclose

that
informa2on
to
“the
employee,
employer,
insurance

carrier
and
the
[Industrial]
commission.”

[H
2155;
Chp.
156,

Laws
of
2012;
eff.
1-‐1-‐13].

OPIOID
ABUSE:

THE
MOST
URGENT
ISSUE
FACING

WORKERS’
COMPENSATION

OPIOID
ABUSE:

THE
MOST
URGENT
ISSUE
FACING
WORKERS’

COMPENSATION

Use
of
opioids,
especially
long-‐ac2ng
medica2on,

for
treatment
of
chronic
pain
in
workers’

compensa2on
can
increase
chances
of
a

“catastrophic
claim
($100,000+)
by
almost
four

2mes.

Use
of
short-‐ac2ng
opioids
raises
chances
by

almost
twice.

Average
claim
not
involving
opioids
=

$13,000.

-‐-‐
“ The
Eﬀects
of
Opioid
Use
on
Workers’
Compensa2on
Claim
Cost
in
the

State
of
Michigan;
Bernacki,
et.
al;
Journal
of
Occupa2onal
and

Environmental
Medicine,
August
2012.

OPIOID
ABUSE:

THE
MOST
URGENT
ISSUE
FACING
WORKERS’

COMPENSATION

 
Average
claim
costs
of
workers
receiving
7+
opioid

prescrip2ons
for
back
problems
without
spinal
cord

involvement
=

–  3X
greater
than
for
workers
receiving
0
or
1
opioid

prescrip2on

  Workers
receiving
mul2ple
opioid
prescrip2ons
=

–  2.7X
more
likely
to
be
oﬀ
work

–  4.7X
as
many
days
oﬀ
work

(Swedlow
et
al.,
CWCI
Special
Report
2008)

OPIOID
ABUSE:

THE
MOST
URGENT
ISSUE
FACING
WORKERS’

COMPENSATION

Prevalence
of
Fentanyl
in
California’s
Workers’
Compensa2on
System

  More
than
1
out
of
5
injured
workers
who
were
prescribed

Schedule
II
opioids
received
fentanyl,
and
among
those
with
non-‐
surgical
medical
back
problems
(strains
and
sprains)
who
received

Schedule
II
opioids,
more
than
1
out
of
4
were
given
fentanyl.

  The
top
10%
of
medical
providers
who
prescribe
Schedule
II

opioids
for
injured
workers
in
California
write
nearly
80%
of
all

workers’
compensa2on
prescrip2ons
for
these
drugs,
which

represents
87%
of
the
morphine
equivalents
provided
to
injured

workers
accoun2ng
for
88%
of
all
Schedule
II
pharmacy
payments

in
the
CA
WC
system.
Nearly
half
of
Schedule
II
prescrip2ons
=

minor
back
injuries.

[CWCI
Research
Bulle2n
11-‐05;
April
28,
2011]

OPIOID
ABUSE:

THE
MOST
URGENT
ISSUE
FACING
WORKERS’

COMPENSATION

AIA
endorses
robust
PDMPs
as
one
key
element
for

comba2ng
opioid
abuse.

 
Mandatory
prescribing
and
dispensing

checking
of
database,
with
data
entry

 
Ac2ve
PDMPs
pushing
informa2on
to

prescribers
and
dispensers

 Broad
access
to
PDMP
database,
including
3rd

party
payers
and
law
enforcement

 Interstate
operability

OPIOID
ABUSE:

THE
MOST
URGENT
ISSUE
FACING
WORKERS’

COMPENSATION

FINALLY:

Comprehensive,
well-‐designed
prescrip2on
drug

monitoring
programs
can
serve
a
cri2cal
role
in

thwar2ng
opioid
abuse,
as
well
as
illegal
drug

diversion.
It
is
essen2al
for
there
to
be
broad
access

to
PDMP
data
–
by
those
with
a
legi2mate
purpose

in
such
data
–
and
as
essen2al
for
PDMP
programs

to
ac2vely
monitor
their
databases
for
suspicious

ac2vity,
thereby
providing
a
cri2cal
check
on

prescribers
and
dispensers
and
facilita2ng
data-‐
sharing.

Prescrip2on
Drug
Monitoring
Program
Workshop:

PDMP
Coordina2on
with
Third-‐Party
Payers

Managing
Pain
Management

in
the
California
Workers’
Compensa2on
System

Alex
Swedlow

California
Workers’
Compensa4on
Ins4tute

www.cwci.org

Disclosure
Statement

•  Alex
Swedlow
has
no
ﬁnancial
rela4onships

with
proprietary
en44es
that
produce
health

care
goods
and
services.

Pain
Management
in
the
California
Workers’
Comp
System

Agenda

•  Pain Management in the California Workers’
Compensation System

•  Controlled Substance Utilization Review and Evaluation
System (CURES)

Pain
Management
in
the
California
Workers’
Comp
System

Areas
of
CWCI
Rx
Research

1.  Changing
Role
of
Rx
in
Workers’
Compensa4on

2.  Repackaged
Drugs

3.  Sole
Source
(Brand)
v.
Mul4-‐source
(Generic)

4.  Opioids
&
Schedule-‐II
Rx

5.  Compound
Drugs

6.  Drug
Tes4ng

Pain
Management
in
the
California
Workers’
Comp
System

Changing
Role
of
Rx
in
CA
Workers’
Compensa4on

1.  Growing
use
of
pharmaceu4cals

2002:

5%
of
medical
benefits

2010:

10%
of
medical
benefits

2.
Reforms
in
pricing
and
fee
schedules

3.
Growing
influence
of
pain
management
prac4ces

4.
Legisla4ve,
administra4ve
and
payer
responses

Pain
Management
in
the
California
Workers’
Comp
System

Managing
Pain
Management

Rules
and
Regula4ons
and
Medical
Management

•  Pain
Mgt
Guidelines
Implemented
July
2009

-‐

Compe4ng
MTUS
defini4ons
and
triggers

-‐  Hierarchy
of
medical
evidence

-‐  Different
levels
of
specificity

•  Limits
to
Workers
Comp
Medical
Management

-‐  Few
supply-‐
and
demand-‐side
controls

-‐  Liens
(2012)

-‐  No
3rd
party
payer
access
to
PDMP

Pain
Management
in
the
California
Workers’
Comp
System

Opioid
Prescrip4on
&
Payments
in
CA
Workers’
Comp
(2012)

Pain
Management
in
the
California
Workers’
Comp
System

Pharmaceu4cal
U4liza4on
&
Cost

Schedule-‐II
Opioid
Drugs1

321%

345%

1
CWCI
2012.
Calcula4ons
are
on
a
calendar
year
basis

Pain
Management
in
the
California
Workers’
Comp
System

Rx
&
Pain
Management

Report
to
the
Industry

What
is
the
associa4on
between
the
use
of

opioids
on
low
back
pain
on:

• 
Average
Beneﬁt
Costs

-‐
Medical

-‐
Indemnity

• 
Loss
of
Produc4vity/Return
To
Work

CWCI
2008

Exhibit
50

Pain
Management
in
the
California
Workers’
Comp
System

Pain
Mgt
and
the
Use
of
Opioids

Data
&
Methods

•  166,336
California
injured
workers

•  Medical
back
condi4ons
without
spinal
cord
involvement

•  A
total
of
854,244
opioid
prescrip4ons
were
dispensed

•  Controls
(morphine
equivalents)
for
diﬀerent
types
of

opioids

•  Case-‐mix
adjusted
outcomes

CWCI
2008

Pain
Management
in
the
California
Workers’
Comp
System

Background
on
Pain
Management

Opioid
Prescrip4ons
on
Medical
Back

Injuries
Not
Involving
the
Spine

Medical
back
injuries
w/
opioids
typically
receive

5.9
prescrip4ons
per
injury

CWCI
2008

Exhibit
52

Pain
Management
in
the
California
Workers’
Comp
System

Evidence-‐based
Medicine
&

Compara4ve
Eﬀec4veness
Research
on
Opioids

ACOEM
Insights
on
Opioids

•  Opioid
use
is
the
most
important
factor
impeding
recovery
of
func4on
in

pa4ents
referred
to
pain
clinics

•  Opioids
do
not
consistently
and
reliably
relieve
pain
and
can

decrease

quality
of
life
and
func4onal
status

•  The
use
of
opioids
during
the
sub-‐acute
and
chronic
phases
of
an
injury,

especially
in
the
absence
of
an
objec4vely
iden4ﬁable
pain
generator,

cannot
be
recommended.

Genovese,
Harris,
Korevaar

2007

Pain
Management
in
the
California
Workers’
Comp
System

Morphine
Equivalents
Categories

Average
Range of MEs in
MEs in
Category
Category Category

No MEs 0 0

Level 1 124 3-240

Level 2 406 241-650

Level 3 1,207 651-2100

Level 4 14,870 2,101 and up
ME
conversions
based
on
American
Pain
Society
Conversion
Tables

CWCI
2008

Exhibit
54

Pain
Management
in
the
California
Workers’
Comp
System

Adverse
Outcomes:

Increased
Costs

+203%

+196%
+209%

CWCI
2008

Exhibit
55

Pain
Management
in
the
California
Workers’
Comp
System

Adverse
Outcomes:

Reduced
Produc2vity
Paid
Time
Oﬀ
Work

+365%

CWCI
2008

Exhibit
56

Pain
Management
in
the
California
Workers’
Comp
System

Adverse
Outcomes:

Higher
Likelihood
of
Lost
Time
and
Li2ga2on

+131%

+60%

CWCI
2008
Exhibit
57

Pain
Management
in
the
California
Workers’
Comp
System

Pain
Mgt
and
the
Use
of
Opioids

Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids

Analysis
of:

1.  Injury
Characteris4cs

2.  Physician
Prescribing
PaUerns

3.  Injured
Worker
Characteris4cs

PBM
and
ICIS
Data:

•  16,890
Claims

•  9,174
Prescribing
physician
DEA
code

•  233,276
Prescrip4ons

•  Script,
dosage
and
days

CWCI
March
2011

•  Pharmaceu4cal
characteris4cs

•  DOS,
billed
and
paid
amount

•  ER
and
EE
characteris4cs

Exhibit
58

Pain
Management
in
the
California
Workers’
Comp
System

Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids

Top
Injury
Categories
w/
Schedule
II
Opioids

Pcnt of S-II Pcnt of S-II Pcnt of S-
Opioid Opioid II Opioid
Diagnostic Category Claims Scrips Pymnts

Medical Back w/o Spinal Cord Invlvmnt 35.7% 47.1% 50.2%
Spine Disorders w/ Spinal Cord or Root Invlvmnt 11.3% 15.1% 16.1%
Cranial & Peripheral Nerve Dis 5.0% 6.8% 6.5%
Degen, Infect & Metabol Joint Dis 9.3% 6.1% 5.4%
Other Injuries, Poisonings & Toxic Effects 5.5% 5.9% 6.8%
Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7%
Sprain of Shoulder, Arm, Knee or Lower Leg 6.8% 3.2% 2.8%
Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6%
Mental Disturbances 1.2% 1.7% 1.5%
Other Diagnoses of Musculoskeletal Sys 1.5% 1.4% 1.1%

CWCI
March
2011
Exhibit
59

Pain
Management
in
the
California
Workers’
Comp
System

Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids

Top
Injury
Categories
w/
Schedule
II
Opioids

Pcnt of S-II Pcnt of S-II Pcnt of S-
Opioid Opioid II Opioid

Ruptured Tendon, Tendonitis, Myositis & Bursitis 6.0% 3.6% 2.7%
Wound, FX of Shoulder, Arm, Knee or Lower Leg 6.3% 2.7% 1.6%
Mental Disturbances 1.2% 1.7% 1.5%

CWCI
March
2011
Exhibit
60

Pain
Management
in
the
California
Workers’
Comp
System

Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids

Top
Injury
Categories
w/
Schedule
II
Opioids

Pcnt of
Pcnt of S-II Pcnt of S- S-II
Opioid II Opioid Opioid

Outside
EBM
Guidelines:



• 
51%
of
Claims




Ruptured
Bursitis
Tendon, Tendonitis, Myositis &
6.0% 3.6% 2.7% • 
60%
of
Prescrip4ons


Wound, FX of Shoulder, Arm, Knee or Lower
Leg 6.3% 2.7% 1.6% • 
62%
of
Payments

Other Mental Disturb 1.2% 1.7% 1.5%


CWCI
March
2011
Exhibit
61

Pain
Management
in
the
California
Workers’
Comp
System

Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids

Cumula2ve
Percentage
of
Schedule
II
Prescrip2ons

(Top
10%
of
S-‐II
Prescribing
Physicians)

CWCI
March
2011

Exhibit
62

Pain
Management
in
the
California
Workers’
Comp
System

Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids

Cumulative Percentage of Schedule II Payments
(Top 10% of S-II Prescribing Physicians)

CWCI
March
2011

Exhibit 63

Pain
Management
in
the
California
Workers’
Comp
System

Analysis
of
Prescribing
PaUerns
Schedule
II
Opioids

Average
S-‐II
Opioid
Prescribing
Physicians

per
Claim
(Injured
Worker)

Median:
1.5

CWCI
March
2011

Exhibit
64

Pain
Management
in
the
California
Workers’
Comp
System

Pain
Management

Drug
Tes4ng:

•  High
levels
of
tes4ng
associated
with
increasing
opioid
and
S-‐
II
u4liza4on

•  Ra4onale
for
drug
tes4ng:

-‐

Protocols?

-‐ 

Type
of
test?

-‐ 

Timing
and
frequency?

-‐

Medical
necessity?

• 
Consequences:

-‐
Injured
worker

-‐
Physician

-‐
Employer

-‐
Claims
administrator

Pain
Management
in
the
California
Workers’
Comp
System

Drug Testing: Calendar Year Payments ($M)

CWCI
2012

Exhibit 66

Pain
Management
in
the
California
Workers’
Comp
System

Controlled
Substance
U4liza4on
Review
and
Evalua4on
System

(CURES)

CURES Background
•  1939 Bureau of Narcotic Enforcement (BNE) creates PMP mandated
through the Health and Safety (H&S) Code
•  September 2009, CURES program was enhanced with a web-based
Prescription Drug Monitoring Program (PDMP) processing 913,874
patient activity reports.
•  CURES receives over 5 million records each month from more than
6,700 licensed pharmacies.
•  CURES is working with departmental IT to allow for the exchange of
PDMP data between state PMPs.
•  Now dormant and absent a funding source, the CURES program
shuts down on July 1, 2013.

Pain
Management
in
the
California
Workers’
Comp
System

Controlled
Substance
U4liza4on
Review
and
Evalua4on
System

(CURES)

Building a Business Case:
Estimating CURES ROI:
•  Estimate number of claims by opioid use
•  Determine potential savings via CURES access
•  Adjust for CURES operating budget

Claims
w/
CA
Claim
Count
Pcnt
of

Opioid
Scripts (2010) Claims

1
Scripts
34,981

41%

2-‐3
Scripts 21,206

25%

3-‐7
Scripts 14,111

16%

>7
Scripts 15,690

18%
Total: 85,988 100%

Pain
Management
in
the
California
Workers’
Comp
System

Controlled
Substance
U4liza4on
Review
and
Evalua4on
System

CURES:
ROI
for
California
Workers’
Compensa4on

Claims
w/
Avg
Cost/
Claim
Total
Payments
Est
%

Total
Es4mated

(2010) Savings
Opioid
Scripts Savings

1
Scripts

$11,200

$391,790,539
0%
$
-‐

2-‐3
Scripts
$14,925

$316,508,020

3%

$9,495,241

3-‐7
Scripts
$18,284

$257,412,625

5%
$12,870,631

>7
Scripts
$31,718

$497,653,698
7%
$34,835,759

Total:
$17,018

$1,463,364,882
5%

$57,201,631

CURES
Opera4ng
Budget
(Est.):
$3,700,000

ROI
for
CA
WC:
$15.5
:
$1

Actual
savings
will
depend
upon
several
factors
including:

•  Medical
&
Rx
trends,
Injury
mix;

•  Appropriate
statutes,
rules
and
regs.

Pain
Management
in
the
California
Workers’
Comp
System

Summary
•  High rate of inappropriate opioid use;
•  Limits in statutes/rules/regs make it difficult to regulate within
traditional workers’ comp controls
•  Graduated use associated with adverse injured worker outcomes
•  Small number of physicians associated with high prescribing
patterns
•  Rapid increase in drug testing associated to high opioid use with
no national guidelines for testing
•  CURES has significant potential to increase QOC and lower cost

Pdmp coordination with_third-party_payers_final

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