high risk controlled medication misuse and abuse · 2019-12-19 · high risk controlled medication...
TRANSCRIPT
Proprietary and Confidential
Dave Erlich, LCSW, LISACBehavioral Health ManagerMercy Care Plan & Mercy Care Advantage
August 4, 2017
High risk controlled medication misuse and abuse
Proprietary and Confidential
Mercy Care Plan 2Proprietary and Confidential
Our values
Mercy Care Plan 3Proprietary and Confidential
Objectives
• Understand the origin of controlled medication use
• Be able to identify warning sign behaviors to look out for
• Identify patients with high risk controlled medication utilization
• Have strategies to reduce member risk
Mercy Care Plan 4Proprietary and Confidential
Patient introduction to controlled medications• Acute pain or injury
• Chronic pain and pain management
• Anxiety related behavioral health conditions
Mercy Care Plan 5Proprietary and Confidential
Types of pain
Acute Pain• Surgery• Broken bones• Dental work• Burns or cuts• Labor and childbirth
Chronic Pain• Headache• Lower back pain• Cancer pain• Arthritis• Neurogenic pain• Psychogenic pain
Mercy Care Plan 6Proprietary and Confidential
Chronic pain vs. other conditions
10025.8
16.3
11.97
Number of people suffering (in millions)
Chronic painDiabetesCoronary heart diseaseCancerStroke
Mercy Care Plan 7Proprietary and Confidential
Chronic pain and depression
• 77% of chronic pain patients being treated with opiates report depression related symptoms
• 75% of people in primary care settings with depression also complain of pain related symptoms
0%50%
100%
Anti-depressants
Anti-anxietymedications
Other medication
84%
41%
17%
Patients with chronic pain being treated for
depression
Mercy Care Plan 8Proprietary and Confidential
Anxiety disorders
• General anxiety disorder
• Panic disorder
• Social anxiety disorder
Mercy Care Plan 9Proprietary and Confidential
Benzodiazepine use
• Highest long-term utilization is with older adults ages 65-80
• In all age groups, women are twice as likely as men to be prescribed benzodiazepines
• Most benzodiazepine prescriptions are written by non-psychiatrists
• Diazepam as a muscle relaxant
Mercy Care Plan 10Proprietary and Confidential
United states loves opioids
• 4.6% of the world’s population
• Use 80% of the world’s opioids
• Use 99% of the world’s hydrocodone supply
Mercy Care Plan 11Proprietary and Confidential
Opioid epidemic
• Nearly 50% of people using opioids long-term are only taking short acting opioids
• Primary care physicians are the leading prescribers of opioid prescriptions
• Almost 60% of opioid medication users were taking dangerous combinations of medications
• 27.5% of long-term opioid users were taking two or more short-acting opioids at the same time
Mercy Care Plan 12Proprietary and Confidential
Opioid epidemic
• Over 47,000 deaths resulting from opioid overdose in 2014
• Over 650,000 opioid prescriptions dispensed daily
• $55 billion in health and social costs each year
• $20 billion in emergency department and inpatient care for opioid poisonings
Mercy Care Plan 13Proprietary and Confidential
Interventions
• Prescription drug monitoring programs
• Provider outreach
• Restriction programs
Mercy Care Plan 14Proprietary and Confidential
Prescription drug monitoring programs
• Currently individually managed by each state
• 49 of 50 states currently have a PDMP
Mercy Care Plan 15Proprietary and Confidential
Provider outreach and coordination
Mercy Care Plan High Risk Opioid and Benzodiazepine Intervention Program
Members are identified based on criteria set forth by Arizona’s Medicaid program, known as Arizona Health Care Cost Containment System (AHCCCS) based on a, now closed, performance improvement project designed for all contractors
Mercy Care Plan 16Proprietary and Confidential
Provider outreach and coordination
Mercy Care Plan 17Proprietary and Confidential
Provider outreach and coordination
Notification to all opioid and/or benzodiazepine prescribers• A letter is sent to each prescriber of each
member identified in the high risk categories
• Notification of identified potential risk to the member
• Encourage coordination• Each letter lists the following:
1. Member name2. Member ID3. Member DOB4. Medication label name5. Days supply6. Fill date7. Prescriber’s name8. Prescriber’s phone number
intervention
Mercy Care Plan 18Proprietary and Confidential
Provider outreach and coordination
• Quarterly run report
• Allows for claims run out of about 3 months
• July 2016 report included data from Q1 2016 (January 2016-March 2016)
• Letters are sent out to prescribers of high risk members
Timelines
Mercy Care Plan 19Proprietary and Confidential
Provider outreach and coordination
High risk benzodiazepine and opioid members
Outcomes
Mercy Care Plan 20Proprietary and Confidential
Provider outreach and coordination
Adding a component that focuses on the members moving to a lower risk group and having their opioids or benzodiazepines reduced:
• Explore impact of reduced controlled medication
• Identify members needing additional support
next steps
Mercy Care Plan 21Proprietary and Confidential
Restriction programs
Different criteria depending on the state and/or health plan
Identify members based on particular criteria
Restrict controlled medication fills by locking the member into a particular pharmacy and/or a particular prescriber
Mercy Care Plan 22Proprietary and Confidential
Mercy Care Plan’s programReferrals via:• 10 scripts/10 prescribers/10 ED visit (aka "Poly" report)• Pain management providers - violated contract• Case managers• Pharmacies (cash customers)• State of Arizona• Emergency departments• Urgent cares• Prescribers• Other
Mercy Care Plan 23Proprietary and Confidential
Red flags we look for
• Dispensing of controlled substances from multiple providers• Use of multiple pharmacies to fill the same medications• Treatment from multiple providers for the same medical
conditions• Diagnosis of poisoning or overdose • Diagnosis of alcohol or other psychoactive substance use
disorders• Multiple ED or Urgent Care visits related to pain• Early fills of medication due to “lost” or “stolen” scripts
Mercy Care Plan 24Proprietary and Confidential
Mercy Care Plan’s programOur Process:• Confirm with provider who will be prescribing controlled substances,
PCP, BH, or pain management specialist• Request medical records• After review of the medical information
• Staff with medical director for determination to enroll in Exclusive Prescriber Program
• Restrict approved member to PCP, BH provider, pain management, or specialist
• Enroll into care management• All members will be reviewed annually or upon request of the member
and or the prescribing physician
EXCLUDE any active cancer diagnosis; if pain is associated with the malignancy
Mercy Care Plan 25Proprietary and Confidential
Exclusive prescriber program care coordination
• Identify barriers to treatment• Coordinate with the restricted prescriber• Review utilization of services and share with prescribers• Facilitate discharge planning with both medical/behavioral
health providers as requested• Educate on high risk behaviors with the aim to modify risk
factors• Screen members to identify gaps in medically necessary
services• Monitor progress and track outcomes• Evaluate for more intensive care management needs and
assign accordingly
Mercy Care Plan 26Proprietary and Confidential
Exclusive prescriber program graduation criteria
• Controlled substances obtained consistently from one medical provider and/or one behavioral health provider
• Appropriate use of ED or urgent care facilities
• Absence of poisoning and/or overdose
• No apparent psychoactive substance abuse
*NOTE: This should be sustained over a 6 month period
Mercy Care Plan 27Proprietary and Confidential
Demographics for Q1 2017
Mercy Care Plan 28Proprietary and Confidential
Average prescribers
28
Mercy Care Plan 29Proprietary and Confidential
Average prescriptions
29
Mercy Care Plan 30Proprietary and Confidential
Average emergency department visits
30
Mercy Care Plan 31Proprietary and Confidential
Average poisonings
31
Mercy Care Plan 32Proprietary and Confidential
ReferencesThe Cleveland Clinic Foundation. (2014, July 7). Acute vs. Chronic Pain. Retrieved from https://my.clevelandclinic.org/services/anesthesiology/pain-management/diseases-conditions/hic-acute-vs-chronic-pain
(2016, November 30). AAPM Facts and Figures on Pain. Retrieved from http://www.painmed.org/patientcenter/facts_on_pain.aspx
Michaelson, D. & Company, LLC. (2006, May). Voices of Chronic Pain. A national study conducted for: American Pain Foundation
Kleiber, B., Jain, S., and Trivedi, M.H. (2005, May). Depression and Pain: Implications for Symptomatic Presentation and Pharmacological Treatments. Psychiatry (Edgemont). 2(5): 12-18.
National Institute of Mental Health. (March, 2016). Anxiety Disorders. Retrieved from https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
Billioti de Gage, S. et al. (2014, September 9). Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ. 349: g5205.
Manchikanti L, Singh A. (2008, March 11). Therapeutic opioids: a ten-year perspective on the complexities and complications of escalating use, abuse, and non-medical use of opioids. Pain Physician. 11(2 Suppl): S63-S88.
Rudd, R.A. et al. (2016, January 1). Increases in Drug and Opioid Overdose Deaths – United States, 2000-2014. Morbidity and Mortality Weekly Report. 64(50); 1378-82.
Department of Health & Human Services. (June 2016). The Opioid Epidemic: By the Numbers. Retrieved from: https://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf
Mercy Care Plan 33Proprietary and Confidential
Thank you