Third-Party Payer: PDMPs and Third-Party Payers: Workers’ Compensation

1. Third-Party Payer Track
PDMPs and Third-Party Payers:
Workers’ Compensation
Presenters:
• Phil Walls, RPh, Chief Clinical Officer, myMatrixx
• Dan L. Hunt, DO, Corporate Medical Director, Accident Fund
Holdings, Inc.
• Joseph Paduda, MS, Principal, Health Strategy Associates
Moderator: John L. Eadie, Director, Prescription Monitoring
Program Center of Excellence, and Member, Rx Summit
National Advisory Board

2. Disclosures
• Phil Walls, RPh; Dan L. Hunt, DO; and John Eadie have
disclosed no relevant, real, or apparent personal or
professional financial relationships with proprietary entities
that produce healthcare goods and services.
• Joseph Paduda, MS – Owner: CompPharma; Consulting fees:
Healthcare solutions, Helios

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Advocate that third-party payers have access
to PDMP data as a way to interdict the opioid
epidemic.
2. Identify best practices for PDMPs when
allowing access to data.
3. Describe the implementation and impact of a
private third-party payer accessing Michigan
PDMP data.

5. PDMPs and Third-Party Payers:
Workers’ Compensation
Phil Walls, RPh
Chief Clinical Officer
myMatrixx

6. Disclosures
• Phil Walls, RPh, has disclosed no relevant, real
or apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.

7. Traditional Prescription Data Sources
In the absence of PDMPs, data came from
disparate sources:
• Medicaid and Medicare programs
• Group Healthcare Pharmacy Benefit Managers
(PBMs)
• Workers’ Compensation PBMs
This data was contained in “silo” data
warehouses and did not capture significant
sources such as cash payments

9. Limitations of PDMPs
• Inconsistencies between states
• Not “real time”
• Most states rely on a passive approach
• Access is limited to law enforcement, treating
physicians and dispensing pharmacists

10. Developing a PDMP Access
Program in Michigan
Dan L. Hunt D.O.
Corporate Medical Director
Accident Fund Holdings, Inc.

11. Disclosure Statement
• Dan L. Hunt D.O. FACOS, has disclosed no
relevant, real or apparent personal or
professional financial relationships with
proprietary entities that produce health care
goods and services

12. Learning Objectives
• Know that a commercial workers
compensation carrier having access to a state
PDMP is unusual
• Be familiar with the dual strategies Accident
Fund has developed.
• Appreciate the balance of improving the
safety of injured worker medical care with
protecting the injured workers privacy.

13. Accident Fund Holdings
• Over a 100 years old- Established
in 1912 in Michigan
• 20 Years since privatization
• Insure over 46,000 employers
nationwide
• Approximately 1 billion in annual
written premium
13

14. Michigan Automated Prescription System
• State of Michigan Public Health Code Act 368 of 1978, Section
333.7333a(b) was amended in 2012 to allow private insurance
carriers and law enforcement the ability to access the
Michigan Automated Prescription System (MAPS) to help
improve claimant safety and as a means of combating fraud.
• Michigan becomes the only state to allow a workers
compensation insurance carriers access to the state PDMP.
• Accident Fund Holdings was granted access in December of
2014
14

15. Plans for Utilization
Pharmacy Nurse Case
Managers
Individual claim focus
Provide opioid education to the
injured worker
Information sharing with the
treating provider
Investigative Services
Unit
Provider/pharmacy focused
Detect and prevent criminal
activity and fraud
Information sharing with law
enforcement
15

16. Challenges of Privacy and
Confidentiality
• Being the first insurance carrier to utilize a state PBMP carries
a high level of responsibility to protect claimant information.
• How to store report information.
• Can the information be shared and with whom.
• Can we discuss medication information that occurred prior to
the date in injury and filing of a claim.
16

17. PDMPs and Third Party Payers:
Workers’ Compensation
Joseph Paduda
President, CompPharma, LLC

18. Learning Objectives
• Advocate that third party payers have access
to PBMP data as a way to interdict the opioid
epidemic
• Identify best practices for PDMPs when
allowing access to data
• Describe the implementation and impact of a
private third party payer accessing Michigan
PDMP data

19. Disclosures
• Joseph Paduda has financial relationships with
proprietary entities that produce health care
products and services. These financial
relationships are: consulting for IROKO
Pharmaceuticals, Millennium Health, Inc., and
MedRisk, Inc.

20. What we’ll cover
• The Workers’ Compensation Primer
• Why WC is different from group health, Medicare, and Medicaid
• Workers’ comp pharmacy and drug management
M A R K E T O V E R V I E W

21. Definitions
• Not ‘Members’ - think Claimant - a worker injured or ill due to a cause arising
from or during the course of employment
• Claim - the entire injury or illness – NOT a bill for medical services
A workers comp claim is the legal term for everything associated with the occupational
injury
• Covered expense - treatment for the disabling condition and ONLY for that
condition
• Lost Time - a claim resulting in the claimant’s absence from work for a defined
period of time (usually >7 days)
• Medical Only - a claim that does not result in ‘Lost Time’
• Managed care - Group health techniques and methods from the mid-nineties e.g.
broad provider networks, bill auditing, utilization review
• Payer - an insurer, state fund, or third party administrator (TPA) that pays claims
• TPA - a firm that administers workers comp claims for an insurance company or
self-insured employer - aka claims processor

22. How workers’ comp is different from
group health
• Work Comp
– Regulated by states
– Only covers injuries/illnesses occurring
during or arising out of the course of
employment
– Return to Work is critical
– The insurer owns the claim forever…or
until the claimant is back to work or has
reached maximum medical improvement
– Mix of injuries and illnesses is different
• Musculoskeletal/orthopedic
• Trauma and some cardiovascular
– Coverage is “first dollar, every dollar”
• No copays
• No tiers
• No deductibles
– “Formularies” set by state (3) or PBM
• Group Health
– Regulated by states (fully insured) and/or
Federal government (ERISA)
– Covers all types of injuries and illnesses
– Unconcerned about Return to Work
– Covers treatment delivered during the
policy year only
– Cost sharing via deductibles, copays,
coinsurance
– Formularies dictated by payer and PBM,
can be highly restrictive
– Rebates are large and common

23. How workers’ comp is different from
group health
• Work Comp
– WC PBMs don’t handle group or
other lines (except Express Scripts Inc
(ESI))
– Injured workers can obtain a
“covered” script without a card
– Some states have strong managed
care laws, others don’t
• Networks
• Employer v. employee choice of provider
• Presumption laws
• Utilization review/evidence-based guidelines
– Provider reimbursement determined
by state regulation and/or PPO
network contract
• Approximately half of the states have a state-
set fee schedule for medical procedures,
including prescription drug
• Most Rx fee schedules are based on AWP (CA is
not)
• Group Health
– WC PBMs don’t handle work comp
(except ESI)
– Member must have a card to get a
script
– Managed care dictated by employer,
not state
– Provider reimbursement is set by
payer

24. How workers comp is different from
group health
• Work Comp
– Provider types - Occupational
Medicine, Physiatry/PM&R,
Orthopedics, Neurology,
Neurosurgery, General practice
– Relatively few physicians handle most
WC cases
• 65% of claims in CA handled by 2.2%
of physicians (<900 physicians)
(source CWCI)
– Comp docs only treat the
occupational injury, NOT the ‘whole
person’
– Comp docs often have not seen
claimant before the injury
– Constant communication with
employers about return to work
(RTW)
• Group Health
– Wide range of provider types
– Physicians treat the ‘whole person’
for all conditions and co-morbidities
– Physicians typically have an ongoing
relationship with the person
– Unconcerned with functionality and
return to work
– No contact with the employer

25. 5%
15%
29%
22%
5%
20%
4%
DME/Home Health
Drugs
Hospital/facility
Physician
Imaging
Physical Med
Diagnostics
Components of Workers Comp
Medical costs

26. Rx Cost Drivers
• Per drug costs are higher in work comp than in group
health
• Dispensing pharmacies earn more per script
• Only one state allows “direction” to network providers,
several mandate generic substitution
• Significant obstacles to altering prescribing behavior
– No economic incentives available
• Claims adjusters are ill-equipped to deal with Rx issues and
questions
• Fear of litigation drives adjusters to pay for non-
compensable drugs
– “You buy it once, you own it forever”

27. Drug types used in workers comp
35%
11%
9%
9%
8%
28%
narco analgesics
anticonvulsants
nsaids
sleletal muscle relaxant
antidepressant
other

28. Does Physician Dispensing Increase
Opioid Use?
Credit – WCRI,3/5/2015
28
Underlying data include six months of Rx utilization for FL injuries between Jan.–Jun. 2010 (pre-reform) and Jul.–Dec. 2011 (post-reform); Source: The Impact Of Physician Dispensing On Opioid Use
(2014)
© Copyright 2015 WCRI. All Rights Reserved.
3.9%
0.5%0%
2%
4%
6%
8%
10%
12%
14%
16%
Pre-Reform Post-Reform
%OfWorkersWithStrongOpioids
Physician
Dispensed
* Statistically Significant at the 0.01 level
*

29. Does Physician Dispensing Increase
Opioid Use?
Credit – WCRI,3/5/2015
7
Underlying data include six months of Rx utilization for FL injuries between Jan.–Jun. 2010 (pre-reform) and Jul.–Dec. 2011 (post-reform); Source: The Impact Of Physician Dispensing On Opioid Use
(2014)
© Copyright 2015 WCRI. All Rights Reserved.
3.9%
0.5%
12.2%
14.2%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Pre-Reform Post-Reform
%OfWorkersWithStrongOpioids
Physician
Dispensed
Pharmacy
Dispensed
*
* Statistically Significant at the 0.01 level

30. Does Physician Dispensing Increase
Opioid Use? Likely
Credit – WCRI,3/5/2015
7
3.9%
0.5%
12.2%
14.2%
12.2%
12.5%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Pre-Reform Post-Reform
%OfWorkersWithStrongOpioids
Physician
Dispensed
Pharmacy
Dispensed
Underlying data include six months of Rx utilization for FL injuries between Jan.–Jun. 2010 (pre-reform) and Jul.–Dec. 2011 (post-reform); Source: The Impact Of Physician Dispensing On Opioid Use
(2014)
© Copyright 2015 WCRI. All Rights Reserved.
* Statistically Significant at the 0.01 level
*

31. Most Received Physician-Dispensed
NSAIDs And Weaker Opioids
Credit – WCRI,3/5/2015
9.1%
10.1%
24.1%
25.8%
3.9%
0.5%
0%
5%
10%
15%
20%
25%
30%
Pre-Reform Post-Reform
%OfWorkersWithPhysician-
DispensedRx
8© Copyright 2015 WCRI. All Rights Reserved.
Underlying data include six months of Rx utilization for FL injuries between Jan.–Jun. 2010 (pre-reform) and Jul.–Dec. 2011 (post-reform); Source: The Impact Of Physician Dispensing On Opioid Use
(2014)
NSAIDs
Weaker
Opioids
Strong
Opioids
*
*
*
* Statistically Significant at the 0.01 level

32. • Drop in physician-dispensed strong opioids with no
material increase in pharmacy-dispensed strong
opioids
• Increase in workers with physician-dispensed NSAIDs
and weaker opioids
• Workers with physician-dispensed NSAIDs and
weaker opioids did not subsequently receive stronger
opioids
• 12% reduction in workers receiving stronger opioids in
the first 12 months after injury
• Physician dispensing may lead to unnecessary opioids
Underlying data includes FL injuries between Jan.–Jun. 2010 in pre-reform group and Jul.–Dec. 2011 in post-reform group; Source: The Impact Of Physician Dispensing On Opioid Use (2014)
Recap
Credit – WCRI,3/5/2015
10© Copyright 2015 WCRI. All Rights Reserved.

33. Third-Party Payer Track
PDMPs and Third-Party Payers:
Workers’ Compensation
Presenters:
• Phil Walls, RPh, Chief Clinical Officer, myMatrixx
• Dan L. Hunt, DO, Corporate Medical Director, Accident Fund
Holdings, Inc.
• Joseph Paduda, MS, Principal, Health Strategy Associates
Moderator: John L. Eadie, Director, Prescription Monitoring
Program Center of Excellence, and Member, Rx Summit
National Advisory Board