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Smart Care California: Multi-Stakeholder Strategies for Reducing Opioid Overuse
Jennifer Wong, MPH
IHA Stakeholders Meeting
September 19, 2017
© 2016 Integrated Healthcare Association. All rights reserved. 22© 2016 Integrated Healthcare Association. All rights reserved.
Why Measure Opioid Use?
1 https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm 2 Curtis S. Florence, Chao Zhou, Feijun Luo, Likang Xu. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care, 2016; 54 (10): 901 DOI: 10.1097/MLR.0000000000000625 3 Use of opioids at high dose or use of opioids and benzodiazepines increase the risk of opioid overdose deaths
ACCOUNTABILITYMeasuring opioid usage at high dosage or in combination with benzodiazepinesin the commercial VBP4P population
Enables providers and health plans to hold each other accountable.3
produces resources for patients, payers providers, health plans, and purchasers to support the reduction of the use of opioids. VBP4P Measurement compliments Smart Care CA’s efforts
$78.5B$$$$
HIGH COSTOpioid overuse in
North America is
estimated to have
an annual cost of
$78.5B2
NATIONAL EPIDEMIC
400% Increase in opioid-related deaths in last two decades
12 Californians die from drug overdose every dayand two thirds of these deaths involve opioids1
© 2017 Integrated Healthcare Association. All rights reserved..
3
Opioid Kill People
Source: Leonard J. Paulozzi, Karin A. Mack, and Christopher M. Jones,“Vital Signs: Risk for Overdose from Methadone Used for Pain Relief —United States, 1999-2010,” Morbidity and Mortality Weekly Report 61, no. 26 (July 6, 2012): 493-97, www.cdc.gov.
© 2017 Integrated Healthcare Association. All rights reserved..
4
Variation Across California:
Opioid Overdose Deaths
Source: California Opioid Overdose Surveillance Dashboard
© 2017 Integrated Healthcare Association. All rights reserved..
5
Variation Across California:
Morphine milligram equivalents (MME) by County
• Lake County: 1420 MME per resident per year
• CA average: 496 MME per resident per year • Alpine County: 83
MME per resident per year
• CA average: 496 MME per resident per year
Source: California Opioid Overdose Surveillance Dashboard
© 2017 Integrated Healthcare Association. All rights reserved..
6
Statewide Problems Require Statewide Solutions
© 2017 Integrated Healthcare Association. All rights reserved..
7
Lance Lang, MD, Covered California
• Smart Care California and the role of purchasers on reducing opioid overuse
Jean Shahdadpuri, MD, MBA, Health Net
• Health plan perspective on reducing opioid overuse
Parag Agnihotri, MD, Sharp Rees-Stealy Medical Group
• Provider perspective on reducing opioid overuse
Today’s Presenters
© 2017 Integrated Healthcare Association. All rights reserved. 8
Questions?
Smart Care California and the Role of Purchasers
IHA Stakeholders
Lance Lang, MD
September 19, 2017
▪ Public-private partnership working to promote safe, affordable
health care in California
▪ Co-chaired by the state’s largest health care purchasers:
• Department of Health Care Services (DHCS)
• Covered California
• California Public Employees' Retirement System (CalPERS)
• With participation by Pacific Business Group on Health (PBGH)
▪ Collectively, Smart Care California co-chairs purchase or manage
care for more than 16 million Californians—or 40 percent of the
state
▪ IHA convenes and coordinates the partnership
▪ CHCF provides funding and thought leadership
▪ Multi-stakeholder in the best California tradition
About Smart Care California
Smart Care California
Participants
Smart Care California:
Three Focus Areas
C-section for Low Risk
First Time Births
(Lead: Covered California)
Opioid
(Lead: DHCS)
Low Back Pain
(Lead: CalPERS)
Multi-Stakeholder Collaboration
Initial Focus: Overuse
Initial Guidelines:Choosing Wisely
Found it was not enough to define what not to do
Need multi-stakeholder alignment and focus on best practices
Variation starts
with purchasers
Multi-Lever Model for Change
Reduce Opioid
Overuse
Data/ Transparency
Purchaser Requirements
Workforce
Quality Improvement
Consumer Engagement
Public Policy
Payment
Covered California Drive for Delivery System Reform:
Key Buckets of Requirements
1. Narrow Disparities in Care
2. Integration and Coordination of Care
• Patient Centered Medical Home (PCMH)
• Accountable Care Organizations (ACOs)
3. Network Design Based on Value
• Best Current Data for Hospitals (maternity & safety)
• Not a narrow network strategy
• Rather: a QI strategy with a deadline (YE 2019)
• Comprehensive Data not yet available for physicians
3. Adopt Best Practices
• Smart Care California
Summary:
The Power of Aligning Purchaser Requirements
Providers are hungry for a consistent set of expectations and
consistent business model with revenue aligned with quality goals
• Primary Care important to but distinct from ACO
• IHA/PBGH ACO metrics
Smart Care Agenda:
• Maternity
• Establish Honor Roll sponsored by Secretary Dooley
• Define Payment Menu
• Develop Opioid and Back Pain programs
• Establish best practices
• Evaluate benefit and payment strategies for alignment
Smart Care California:
Four Core Priorities for Opioids
8
• Decrease the number of new starts —fewer prescriptions, lower doses, shorter durationsPREVENT
• Identify patients on risky regimens (high-dose opioids, or opioids and sedatives) and work with them to taper to safer doses
MANAGE
• Streamline access to buprenorphine and methadone to treat opioid addictionTREAT
• Streamline access to naloxone for overdose reversal
STOP overdose deaths
Smart Care California:
Opioid Activities to Date
9
• Online resources*
• Dashboard of
measures
• Health plan and
purchaser checklist
• Payer and provider
recommendations
(in development)
*http://www.iha.org/our-work/insights/smart-care-california/focus-area-opioids
Opioid Overutilization Management Program
1
Jean Shahdadpuri MD MBA
Senior Medical Director
Health Net
Sep 19th 2017
IHA Stakeholders Meeting
Opioid Overutilization Management Program
2
GOAL Reduce opioid overutilization and to promote appropriate opioid utilization through
coordination of care between prescribers and their patients.
Provide prescribers with strategies and resources for proper pain assessment and
treatment of their Health Net members.
Promote the safe use of opioids by sending educational flyer to members
To identify members who have a fill of an opioid on or after the fill date of a medication for
opioid dependence (exclude Medi-Cal/ CalViva, carved out)
INTERVENTIONIntervention criteria: Members must meet one or more of the following criteria over a four-
month period (current age is 20 or older) to be included:
≥ 90 morphine milligram equivalents (MME)/day
Opioid Overutilization Management Program
3
• Concurrent benzodiazepine and Soma use and ≥ 50 morphine
milligram equivalents (MME)/day
• Concurrent medications for opioid dependence and opioids with 30 or
more days of overlap (exclude Medi-Cal/ CalViva, carved out)
• Visited more than 3 physicians or pharmacies
Member opioid outreach: Educational flyer (without a letter): Do
You Take a Drug That Contains Opioids? Also known as pain
killers, opiates or narcotics
Opioid Overutilization Management Program
4
Prescriber intervention: Cover letter that explains the Opioid Utilization
Program and refers to various resources such as MHN, Be In Charge!
(Decision Power’s outreach for Medi-Cal and CalViva Health members),
and Decision Power (outreach for Commercial and Medicare members),
plus the following inserts:
✓ Patient profiles
✓ Utilize PDMP databases to confirm opioid history and concurrent prescribing
by other providers
✓ Guide to appropriate opioid prescribing with resources for opioid prescribers
✓ Optional medication contract that may be customized, signed by patient and
prescriber, and kept in patient’s chart
✓ Fax-back survey to confirm that opioid medications listed are appropriate,
medically necessary, and safe or the regimen should be adjusted.
Opioid Overutilization Management Program
5
GOAL Adhere to CMS mandates that Medicare Part D plan sponsors implement intensive
management programs to address the overuse of opioid analgesics.
COMMUNICATIONS MTM pharmacists conduct utilization reviews and receive Member Services transfers to
speak with members and their prescribers.
INTERVENTIONSIntervention criteria: Members are included in this program when they meet any of the
following:
120 mg morphine equivalent dose per day for > 90 days, and are receiving opiates from >
3 pharmacies and prescriptions from > 3 prescribers
Any member identified by CMS
Any member referred through Medicare Drug Integrity Contractors (MEDICs), case
management, MHN, or other organization
Opioid Overutilization Management Program
6
2016 RESPONSE REPORT
BDS – No further review planned: Beneficiary dis-enrolled from contract or lacks Part D eligibility due to
any reason except disenrollment due to death.
BOR – Beneficiary level POS edit not determined necessary: Beneficiary's overutilization resolved.
BXD – No further review planned: Beneficiary has exempt diagnosis.
DMN – Beneficiary level POS edit not determined necessary: Drug(s) and dose(s) are deemed medically
necessary.
INC – Review in progress.
PS1 – Beneficiary level POS edit determined necessary: No drugs allowed in the class.
PS2 – Beneficiary level POS edit determined necessary: One or more drugs in class allowed.
Opioid Overutilization Management Program
7
Count of HICN Column LabelsGrand Total
Row Labels BDS BOR DMN INC PS2
H0351 2 3 4 1 10
H0562 2 9 11
H3237 2 1 3
H3561 3 3
H5520 2 5 7
H6815 1 2 3 6
H9287 2 2
Grand Total 2 1 9 28 2 42
2016 OUTCOMES •42 cases total. We successfully closed 13 cases (30%)•9 members (21%) deemed the regimens medically necessary (DMN)•2 members required POS edits. (PS2)•28 of the cases (66%) are certain follow-ups. (INC)
Opioid – High Dosage Monitored Metric
8
Opioid – Multiple ProvidersMonitored Metric
9
Opioid – Safe Med LA collaborative
10
The Safe Med LA coalition includes County health agencies (e.g.,
Departments of Health Services, Mental Health, and Public Health), health
plans, physicians, pharmacists, substance use providers, law enforcement,
medical associations, hospitals, community clinics, prevention coalitions,
educators, and other community stakeholders. It is comprised of a lead
Steering Committee and various goal-specific Action Teams that focus on
the 6 priorities and 10 key objectives of the strategic plan.
The Safe Med LA Steering Committee will lead the coalition and
collaborative implementation of this plan through the 9 Action Teams. Action
Teams are each comprised of coalition members that will focus their
expertise on specific action items within the key objectives of the strategic
plan.
Opioid – Safe Med LA collaborative
11
Opioid – Safe Med LA collaborative
12
The Safe Med LA coalition includes County health agencies (e.g.,
Departments of Health Services, Mental Health, and Public Health), health
plans, physicians, pharmacists, substance use providers, law enforcement,
medical associations, hospitals, community clinics, prevention coalitions,
educators, and other community stakeholders. It is comprised of a lead
Steering Committee and various goal-specific Action Teams that focus on
the 6 priorities and 10 key objectives of the strategic plan.
The Safe Med LA Steering Committee will lead the coalition and
collaborative implementation of this plan through the 9 Action Teams. Action
Teams are each comprised of coalition members that will focus their
expertise on specific action items within the key objectives of the strategic
plan.
Opioid – Smart Care CA collaborative
13
Smart Care CaliforniaSmart Care California is a public-private partnership working to promote safe, affordable health care in California. The group currently focuses on three issues: C-sections, opioid overuse and low back pain. Collectively, Smart Care California participants purchase or manage care for more than 16 million Californians—or 40 percent of the state. Smart Care California is co-chaired by the state’s leading health care purchasers: DHCS, which administers Medi-Cal; Covered California, the state’s health insurance marketplace; and CalPERS. IHA convenes and coordinates the partnership with funding from CHCF.
Our learnings on promoting safe opioid prescribing practices
Parag Agnihotri MD
Medical Director for Population Health & Post Acute care
Sharp Rees-Stealy Medical Group, San Diego
How do you address this in a large multispecialty medical group with …
1.4 million visits
500+ Physicians
60+ NP/PA
2200 Clinic staff
21 Clinic locations
Internal problem
A segment of population was prescribed..
1.6 million hydrocodone at an average cost of $4M
570,000 oxycodone at average cost of $2M
Key Objectives
1. Reduce by 10% inappropriate use of Opioids Rx
2. Reduce overall Morphine Milligram Equivalent (MME)
3. Preventing overdose: increased use of Naloxone
4. Promote holistic approach for pain management
Universal Safe Opioid prescribing committee
• Pain Specialist
• Physiatrist
• Primary care
• Pharmacist
• Surgeon
• Data analyst
• Medical Director
Registry on Opioid prescribing
• Practice variation reports
• MME calculation
0
5
10
15
20
25Top 10% of Prescribers for claims where SHC MME > 90
Dr. A Dr. B Dr. C Dr. D Dr. E Dr. F Dr. G Dr. H Dr. I Dr. J Dr. K Dr. L Dr. M
Morphine Milligram Equivalent (MME)calculation
https://www.easycalculation.com/formulas/opioid-dose-formula.html
Informed Prescribing decisions
Reduce new starts
• Prescriber education
• Prescribing patterns
• Pain control agreements
• Easy Access to CURES
• Choosing wisely® material
Reducing overall MME/high dose Opioid
• Safe tapering of high dose of Opioids
• How to calculate MME?
• Access to pain specialist
• EHR embedded Opioid assessment tool
• Urine Drug screen
• Targeted outreach to high volume prescribers
• Personal experience of Physician with MBC
Safe opioid tapering handouts
Opioid assessment tool embedded in EHR
7.21
9.42
34.10
15.59
9.11
26.69
9.72
4.00
1.84
5.92
7.52
1.97
4.73
3.13
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
Site
Cla
ims
pe
r 1
00
0 f
or
MM
E >
90
Provider Region, Provider Site
Practice Variation reports for high dose Opioid prescribing Peer to Peer
shared experiences
Early access to Naloxone Retail Pharmacist able to prescribe
Sharp McDonald CenterOffering Addiction treatment
Turning the tide on opioid prescribing..
0.24%
14.04%
5.22%
11.50%
0.00
2,000.00
4,000.00
6,000.00
8,000.00
10,000.00
12,000.00
14,000.00
Fentanyl Patch Hydrocodone Oxycodone Grand Total
Opioid Type Supply Count per 1,000 HMO Patients
2015 2016
HM
O
New starts1st prescription for quantity 61-90 pills
0.37
0.28
0.142
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
61-90 pills
2015 2016 2017
24% reduction
4.68
3.03
2.16
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
MME>90
2015 2016 2017 YTD
High dose prescriptions trending downMorphine Milligram Equivalent ≥ 90 Rate Prescriptions written per 1,000
Challenges towards safe opioid prescribing
• Ongoing provider education
• Consumer participation
• Access to Medication Assisted Treatment
• ? Telehealth options for MAT
• Holistic approach to pain and available options
Lessons learned
Key Objectives
1. Reduce by 10% inappropriate use of Opioids Rx
2. Reduce overall Morphine Milligram Equivalent (MME)
3. Preventing overdose: increased use of Naloxone
• Reduce new starts by Provider and Consumer education. Consider using ‘Choosing Wisely®’ material
• Practice variation reports
• Promote CURES
• Peer to Peer experience
• Engage pharmacist
• Promote holistic approach for pain management
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