Tpp 3 joint presentation

Teaming with Clinicians in the Interven3on Process

Clinical Collabora3on Achieves Be9er Outcomes

Principled Strategies, Inc.

Patrick J. Burns, President

Lawrence Feinstein, Ph.D., Vice President, Clinical Programs

Progressive Medical, Inc.

Tron Emptage, R.Ph., Chief Clinical Officer

Robert Hall, MD, Corporate Medical Director

Presenters

Disclosure Statements

Patrick J. Burns has no financial rela3onships with proprietary en33es that

produce health care goods and services.

Lawrence Feinstein has no financial rela3onships with proprietary en33es

that produce health care goods and services.

Tron Emptage has no financial rela3onships with proprietary en33es that


Robert Hall has no financial rela3onships with proprietary en33es that


2 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved

Learning Objec3ves

1.  Differen3ate between threatening and collabora3ve outreach.

2.  Assemble a list of words and phrases that reduce fric3on and foster partnership between payors and the physician.

3.  Iden3fy tools that demonstrate effec3ve outcomes.


Discussion Points

Factors that Influence Outcomes

Risk Iden3fica3on & Interven3on Tools

Lessons Learned

Clinical Collabora3on Q&A


Workers’ Compensa3on vs. Group Health

Suburban Home Custom Log Cabin

The Tale of Two Doctors

6

Doctor A Doctor B

Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved

Factors that Influence Outcomes

7

Number of Prescribers

Number of Pharmacies

Prescribing Behaviors

Medica3on Pa9erns

Body Part/ Nature of Injury

Demographics of Prescriber

Medica3on Agreement

Drug Monitoring



•  West Virginia

•  Evalua3on for doctor shopping

–  Doctor shoppers: Four or more prescribers in last six months

–  % of deceased pa3ents –  % of living pa3ents

8

Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.




•  Evalua3on for doctor shopping

–  Doctor shoppers: Four or more prescribers in last six months

–  25 % of deceased pa3ents –  3.5% of living pa3ents

9





•  Evalua3on for pharmacy shopping

–  Pharmacy shoppers: Four or more pharmacies in last six months

–  % of deceased pa3ents –  % of living pa3ents

10





•  Evalua3on for pharmacy shopping

–  Pharmacy shoppers: Four or more pharmacies in last six months

–  17% of deceased pa3ents –  1% of living pa3ents

•  55% of pharmacy shoppers were also doctor shoppers

11



Number of Prescribers and Pharmacies

12

Uncoordinated Care


Prescribing Behaviors

•  Opioids prescribed early in the claim

•  Days supply of opioids

•  Number of fills •  Morphine equivalent dose (MED)

–  Washington State

–  120 MED threshold

13

http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf


Medica3on Pa9erns

•  Type of opioids and claim cost

•  Michigan

–  Final claim cost ≥ $100,000 –  Short ac3ng opioids → 1.76 more likely

–  Long ac3ng opioids → 3.94 more likely

14

White JA, Tao X, Talreja M, Tower J, Bernacki E. The effect of opioid use on workers' compensation claim cost in the State of Michigan. J Occup Environ Med. 2012 Aug;54(8):948-53.


Medica3on Pa9erns

•  Mul3ple short-‐ac3ng and long ac3ng opioids?

•  Poten3al drug-‐drug interac3ons

–  West Virginia –  Opioids and benzodiazepines

15



Body Part/Nature of Injury

•  Ohio

•  Highest costs per claim by body part

–  Lumbar spine –  Shoulder –  Cervical spine

•  Industries with highest average costs per claim

–  Transporta3on –  Warehouse

–  U3li3es and Construc3on

16

Dunning KK, Davis KG, Cook C, Kotowski SE, Hamrick C, Jewell G, Lockey J. Costs by industry and diagnosis among musculoskeletal claims in a state workers compensa3on system: 1999-‐2004. Am J Ind Med. 2010 Mar;53(3):276-‐84.



Geographical varia3on of opioid prescribing

•  Acute, work-‐related low back pain

•  Decision to use opioids related to social condi3ons •  Massachuse9s 5.7% vs. South Carolina 52.9%

•  79% of state varia3on explained by 3 factors

1.  State household income inequality

2.  Number of physicians per capita

3.  Workers’ compensa3on cost containment effort score

17

Webster BS, Cifuentes M, Verma S, Pransky G. Geographic varia3on in opioid prescribing for acute, work-‐related, low back pain and associated factors: a mul3level analysis. Am J Ind Med. 2009 Feb;52(2):162-‐71.



Geographical varia3on of opioid prescribing

•  135 million opioid prescrip3ons in 2008

•  37,000 retail pharmacies •  Large varia3on in opioids prescribed

•  Coun3es having the highest prescribing rates

‒  Appalachia

‒  Southern and western states

  Strongest predictor of amounts prescribed

  Number of available physicians…”by far”

18

McDonald DC, Carlson K, Izrael D. Geographic varia3on in opioid prescribing in the U.S. J Pain. 2012 Oct;13(10):988-‐96.



19

McDonald DC, Carlson K, Izrael D. Geographic varia3on in opioid prescribing in the U.S. J Pain. 2012 Oct;13(10):988-‐96.


Medica3on Agreement

•  Also know as a “pain contract”

•  Recommended by

–  U.S. Department of Health and Human Services –  American Academy of Pain Medicine

–  Veterans Health Administra3on

–  American College of Occupa3onal and Environmental Medicine (ACOEM)

–  Official Disability Guidelines (ODG)

20

Payne, R, E Anderson, R Arnold, L Duensing, A Gilson, C Green, C J. Haywood, S Passik, B Rich, L Robin, N Shuler, and M Christopher. "A Rose by Any Other Name: Pain Contracts/agreements." The American Journal of Bioethics : Ajob. 10.11 (2010): 5-12. ACOEM 2011; ODG 2012


Medica3on Agreement

•  Informed consent

•  Promotes educa3on

•  Improves compliance •  Components

–  Informed consent for treatment with medica3on(s)

–  Acceptable and unacceptable behaviors –  Consequences for failure to adhere to agreement

21

Payne, R, E Anderson, R Arnold, L Duensing, A Gilson, C Green, C J. Haywood, S Passik, B Rich, L Robin, N Shuler, and M Christopher. "A Rose by Any Other Name: Pain Contracts/agreements." The American Journal of Bioethics : Ajob. 10.11 (2010): 5-12. ACOEM 2011 ODG 2012


Medica3on Agreement Sample


Drug Monitoring

•  Urine drug screen

–  U.S. Department of Health and Human Services

–  ACOEM –  ODG

•  Iden3fy possible drug misuse and abuse

23

Gilbert et al. "Importance of Urine Drug Tes3ng in the Treatment of Chronic Noncancer Pain: Implica3ons of Recent Medicare Policy Changes in Kentucky." Pain Physician 13.2 (2010): 167-‐86.


Effects on Behavior

PaCent

•  “My prescrip3ons are being monitored”

•  “I may be drug tested”

•  “I signed an agreement”

•  “I could lose my pain meds”

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•  Physician Physician

•  “My prescribing habits are being monitored”

•  “I could lose my license to prescribe”


Why Some Physicians Don’t Follow Guidelines

25

KNOWLEDGE

ATTITUDES

BEHAVIORAL FACTORS


RISK IDENTIFICATION & INTERVENTION TOOLS

Risk Iden3fica3on and Interven3on

27 © 2014 by Principled Strategies, Inc. All rights reserved.

Rx Data Analysis

1:1 Individualized ConsultaCon via Telephone or In person

Prescriber PSI Score™ and Scores for Top Three Risk Factors (out of 17 total factors)

#1 Early Refills #2 Excessive Use #3 Dosage and Volume of Opioids

Risk Scoring of Prescribers

Monthly CommunicaCon; Quarterly Score Updates

Prescriber Resources Toolkit

Engagement via Personalized Outreach

49 PredicCve Metrics

Pharmacy Metrics

Prescriber Metrics

PSI Score™

17 Behavioral Risk Factors

PaCent Metrics

Opioid-‐specific Metrics

Iden3fy Prescriber “Risk”

•  Concept of “risk factors” borrowed from disease management

•  At what point would you allocate resources to intervene with the following prescriber?

–  Starts most pa3ents on highest dosage

–  Frequently prescribes excess days supply –  Is located 50+ miles from many of his pa3ents –  High pa3ent volume compared to specialty peers


The PSI Score™

•  Iden3fy/Stra3fy ̶̶ Popula3on and Specialty Peers

•  Predict risky prescribers by iden3fying trends

•  Individualize the interven3on effort by iden3fying each prescriber’s top three risk behaviors

•  Monitor prescriber behavior change over 3me

•  CQI ̶̶ Measure interven3on effec3veness, and improve

•  Comply with treatment direc3ve to iden3fy prescribers and members for review of appropriateness of opioid therapy


Prescriber Risk Score Distribu3on

30

High Risk

Moderate Risk Low Risk

© 2014 by Principled Strategies, Inc. All rights reserved.

Predic3ve Risk Iden3fica3on

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Which prescribers not currently in the high risk group will, in six months, have a PSI Score™ equal to or greater than the cutoff value that defines “high risk”, with a 90% confidence level?


Prescriber Interven3on

IdenCficaCon

•  Risk scored and rank ordered the prescriber popula3on •  Iden3fied 1,200 prescribers, along with the top 3 risk factors for each

Engagement •  250 prescribers per week for four weeks •  Addi3onal prescribers for two more weeks to reach goal of 1,000

ConsultaCon •  20-‐minute telephone call or office visit consulta3on with PharmD •  Printed materials including instruc3ons to refer to behavioral health

Follow-‐up •  Six months follow-‐up communica3on post-‐appointment •  Three-‐month and six-‐month update on PSI Score™ and risk factor scores


Iden3fica3on

•  1,200 prescribers iden3fied for engagement

•  ≥ 98th %ile of the PSI Score™ distribu3on

33

High-‐risk Prescriber DistribuCon by Specialty

Family Medicine 23%

Internal Medicine 22%

Psychiatry 9%

Pain Management 7%

Surgery 7%

Physical Medicine & Rehab 7%

Anesthesiology 6%

Physician Assistant 4%

Nursing 4%

Other 12%


Iden3fica3on

Top Risk Factors Occurring most frequently among prescribers’ top three risk factors

34

PaCent-‐focused Risk Factors

Mul3ple Prescribers

Mul3ple Pharmacies

Mul3ple Family Members

Prescriber-‐focused Risk Factors

Early Refills of Similar Products

Dosage and Volume of Opioids

Opioid with benzodiazepine or carisoprodol Concomitance

Excessive Use of Controlled Substances


Engagement Packet

•  Welcome Le9er ̶̶ Personalized and Tailored

•  Risk Factor Worksheets ̶̶ Each prescriber’s top three risk factors

•  Clinical Advisories specific to each prescriber’s risk factors

•  Pa3ent Informa3on Report ̶̶ List of each prescriber’s pa3ents contribu3ng to his/her top three risk factor scores, and their prescrip3on informa3on

•  Prescriber Resources and Recommenda3ons ̶̶ Guides; assessments; services to refer to for psych evalua3ons, rehab, consulta3on, and coordina3on of care


Engagement

•  Outbound scheduling calls

–  Call prescriber’s office to schedule a 20-‐minute telephone call or office visit with a licensed PharmD

–  Confirm receipt of the engagement packet

•  Confirm the appointment 72 hours prior, by call or email


Consulta3on

•  20 to 30-‐minute 1:1 consulta3on with a PharmD trained in the program protocol –  Telephone call –  Office visit

•  In the first four minutes: Assess prescriber’s level of mo3va3on versus resistance, and adjust objec3ves, tac3cs, |and 3ming accordingly



38

Doctor A Doctor B


A Tale of Two Doctors

39

Scheduling Call

Refuse Schedule Release

Office Visit Telephone Call

MoCvated / CooperaCve •  Review the engagement packet materials •  Explain the purpose of the program, themes, the PSI Score™, risk factors, clinical recommenda3ons, Pa3ent Informa3on Report

•  Explain the program follow-‐up, score updates, and invite further discussion

Resistant / UncooperaCve •  Explain the purpose of the program, themes •  Focus on the resources to help the prescriber •  Shorten appointment; schedule follow-‐up •  Track PSI Score™ over 3me and have Regional Medical Director follow-‐up if necessary


Follow Up

•  Sa3sfac3on Survey sent within two weeks of appointment

•  Monthly Communica3ons

–  By email unless prescriber requests fax –  Links to short video vigne9es and addi3onal materials on the Web

–  Brief survey ques3ons •  Quarterly Score Updates

•  Relapse Monitoring Based on Updated Scores and Trends


Program Resources

•  Service Center

–  Staffed by four administrators and six PharmDs

–  Outbound and inbound telephone calls, email and fax; dedicated lines and auto-‐a9endant

•  CRM System

–  Tracks all outbound and inbound communica3ons

–  Collects data on all aspects of the program

–  Repository of all prescriber informa3on

–  Automated opera3onal and clinical reports


Measuring Clinical Outcomes

•  Monthly updates to the PSI Score™ and risk factor scores enable us to: –  Measure change across the prescriber popula3on and within each

specialty group –  Indirectly measure adop3on of clinical recommenda3ons

–  Iden3fy prescriber trends as they develop, permizng early-‐stage interven3on per prescriber and the popula3on

–  Have a con3nuous feedback look to evaluate program impact and improve effec3veness

•  Currently we measure

–  Risk

–  U3liza3on (pharmacy only)

–  Benefit-‐to-‐Cost (pharmacy only)

•  In the future we will measure the aforemen3oned for both pharmacy and medical


Post-‐interven3on Outcomes (12 mo)

Endpoint Model Significance P

PSI Score™ R Yes < 0.001

Mul3ple HCPs R Yes < 0.001

Mul3ple Pharmacies R Yes < 0.001

Concomitance R Yes < 0.002

Opioid Prescrip3on Claims U No

Morphine Equivalent Dose (mg) U Yes = 0.020

43

Legend: R = Risk Factor, U = U5liza5on Factor

Cost Model Significance P Savings

Opioid Rx Claims Yes = 0.041 $2,596,189

Non-‐opioid Rx Claims Yes = 0.045 $461,731

Benefit-‐to-‐Cost 4.4 : 1


CLINICAL COLLABORATION FOR BETTER OUTCOMES IN WORKERS’ COMPENSATION

Clinical Collabora3on for Be9er Outcomes

Early capture of prescripCons leads to greater control through connected programs.



Quicker access to informaCon be9er equips claims professionals and clinicians to make decisions.

46

Early capture of prescrip3ons



Quicker access to informa3on

47


MulC-‐factor risk analysis based on pharmacy behavior, the injury and overall demographics should be applied to be9er predict the path of a claim.


Analyze Risk

Predic3ve power of variables change over Cme

48

Percent of Significance (aggregated

across mul3ple variables)



Quicker access to informa3on

49


MulC-‐factor risk analysis based on pharmacy behavior, the injury and overall demographics should be applied to be9er predict the path of a claim.

There will always be claims that mature into complicated situa3ons; having the right tools to apply at the right Cme is essen3al.


•  Claims Professional Outreach •  Physician Outreach •  U3liza3on Reviews •  Interven3on Reports •  Peer-‐to-‐Peer Review

Clinical Tools and Exper3se


Commen

tary

Chan

ge in Opioid Use Post D

TM

DTM

Results

Med

icaC

on Spe

nd per Claim

ant 48 (9.3%) detected an illicit

substance

250 (48.6%) detected a Non-‐Prescribed Drug

284 (55.3%) did not detect the prescribed medica3on(s)

64% of iden3fied claimants that were tested had a result inconsistent with the prescriber therapy

Changes in UClizaCon (based on days supply)

Changes in Spend

All Medica3ons ↓ 21% ↓ 20%

All Opioids ↓ 24% ↓ 28%

All Benzodiazepines ↓ 28% ↑ 6%

360 Days Post Enrollment Compared to 90 Days Pre-‐Enrollment

Urine Drug Monitoring Drug Tes3ng and Monitoring Outcomes show significant decrease in u3liza3on

60% 61% 64%

66%

70%


Commen

tary

Chan

ge in Opioid Use Post R

eview

Success Ra

te by Med

icaC

on Class

Med

icaC

on Savings per Claim

ant

$-‐

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

$1,400.00

$1,600.00

91-‐180 days 181-‐270 days 271-‐360 days

Overall success rate 70% Average decrease in opioid use 8.4% Average savings per injured party $3,586.93 Return on investment (ROI) 8:1

Medica3on Class

Average Success Rate

Average Savings per Successful Interven3on

Muscle Relaxants 76% $ 302.78

Dermatologics 73% $ 1,794.08 Seda3ves 65% $ 1,257.18 Opioid Analgesics 57% $ 2,711.91 NSAIDs 52% $ 563.91 Gastrointes3nal 50% $ 1,014.86 An3convulsants 46% $ 1,630.16 Anxioly3cs 38% $ 244.58 Respiratory 33% $ 1,555.03 An3depressants 31% $ 316.17

Medica3on Reviews with addi3onal interven3on via Peer to Peer Outreach outcomes are measured separately

Medica3on Reviews Medica3on Reviews result in an average $3,500 savings per injured party


Commen

tary

Chan

ge in Opioid Use Post R

eview

Success Ra

te by Med

icaC

on Class

Med

icaC

on Savings per Claim

ant

Overall success rate 62% Average decrease in opioid use 25.6% Average savings per injured party $5102 Rate of achieving contact with prescriber 79% Return on investment (ROI) 4:1

Medica3on Class

Average Success Rate

Average Savings per Successful Interven3on

An3-‐migraine agents 82% $ 6,662.66

NSAIDs 77% $ 524.23 Laxa3ves 69% $ 131.67 Muscle Relaxants 65% $ 422.69 Dermatologics 63% $ 1,587.41 Opioid Analgesics 62% $ 2,995.51 An3convulsants 61% $ 1,077.05 An3depressants 60% $ 723.16 Seda3ves 57% $ 884.56 Anxioly3cs 50% $ 1,290.77 $-‐

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

$1,400.00

91-‐180 days 181-‐270 days 271-‐360 days

Peer Outreach Combining Medica3on Reviews with Peer Outreach results in an overall 4:1 ROI



54

Doctor A Doctor B

Both trea3ng doctors ul3mately made medica3on changes based on recommenda3ons from the reviewing physician. Doctor B was willing to partly compromise.


LESSONS LEARNED

Lesson Learned Carefully cra<ed outreach fosters engagement

•  More recep3ve when it is clearly understood that –  We are NOT claiming prescriber is engaging in inappropriate behavior

–  Our emphasis is on making certain the injured party receives the right medica3on at the right 3me

•  Inclusion of detailed prescrip3on informa3on for the prescriber’s own pa3ents was a major contributor to prescribers’ willingness to par3cipate

•  Calls to schedule appointments must occur within one week of receipt of engagement packets

•  Design the Engagement Packet mailing envelope so office staff can easily iden3fy that it contains pa3ent PHI and must be delivered only to the prescriber

•  Review of the themes of the program by PharmD increased comfort and collabora3on

•  Most appointments were completed within 20 minutes

•  Member and claim level informa3on was very useful in reconciling charts and taking ac3on as appropriate


Lesson Learned Collabora5on can drive posi5ve change

•  Most prescribers –  are unaware their pa3ents are engaging in aberrant behavior, such as “doctor shopping”,

drug seeking, or diversion –  preferred an appointment by telephone call

–  had read the engagement materials prior to the appointment

–  believed that they were already implemen3ng adequate steps/precau3ons in their prac3ce

•  Although most prescribers expressed concern about being “monitored” by the payor, by the end of the call, addi3onal resources and tools were iden3fied that would help improve the safe use of control substances

–  Locking members into a single pharmacy

–  Specific lab tests including “no threshold tes3ng” and “adultera3on panel”

–  Referrals for addic3on specialists and psychological counseling services

•  Many providers were not aware of these addi3onal resources


Lesson Learned Addi5onal Challenges of Pain Management Clinics

•  Members are sent back to the PCP for ‘follow-‐up’, refills on controlled substances, and long-‐term pain management

•  PCPs expressed a low comfort level with managing chronic pain pa3ents but felt they were ‘le� with no choice’


Thank you!

Ques3ons?

Contact Us

Lawrence Feinstein, Ph.D.

Office: (760) 230-‐6326

Email: [email protected]

Patrick J. Burns

Office: (760) 230-‐6323

Email: [email protected]

60

Contact Us

Tron Emptage, R.Ph., Chief Clinical Officer

Tron.Emptage@progressive-‐medical.com

Robert Hall, MD, Medical Director

Robert.Hall@progressive-‐medical.com

61

Date post:	07-May-2015
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Tpp 3 joint presentation

Health & Medicine