A Paradigm Shift of Payer Strategy National Rx Drug Abuse Summit 4-11-12

1. A Paradigm Shift of Payer
Strategy
April 10-12, 2012
Walt Disney World Swan Resort

2. Learning Objectives:
1. Analyze the scope of the payers’ role in the
prescription drug abuse problem.
2. Identify specific best practice methodologies
that can be implemented by payers to
reduce fraud, waste and abuse through
member and prescriber interventions/
education and support
3. Describe the “drug seeker” profile and how it
has changed.

3. Disclosure Statement
• All presenters for this session, Dr.
Kathryn Mueller, Dr. Brian K. Solow and
Dr. Beverly Franklin-Thompson have
disclosed no relevant, real or apparent
personal or professional financial
relationships.

4. A Paradigm Shift of
Payer Strategy
Beverly Franklin-Thompson, PharmD
Director, Regional Pharmacy
BlueCross BlueShield Tennessee

5. The Issues
• Tennessee is one of the top three states for per
capita prescription drug use – about 18 Rx’s per
person each year
• According to the Tennessee Controlled Substance
Database, 275,496,939 hydrocodone tablets were
dispensed in 2010
• Admissions to drug abuse treatment programs
increased seven-fold between 2000 and 2010.
• In 2010, more people died in Tennessee from drug
overdoses than from auto accidents, homicide or
suicide.
Sources: Kingsport Times-News and Knoxville News Sentinel
Nashville Tennessean, Novartis Pharmacy Benefit Report 2011

6. U.S. Annual Opioid Sales
($ billions)
$8.1 $8.4
9
$6.8 $6.8 $7.4
8
$5.8
7
6
5
4
3
2
1
0
2006 2007 2008 2009 2010 2011
Source: IMS Data

7. Distribution of Prescription Pain Killers
8.5-12.6
7.3-8.4
6.0-7.2
3.7-5.9
in Kg/10,000 people
Drug Enforcement Administration, 2010

8. Healthcare Costs
• Annual medical costs for opioid abuser are
$14,054 higher than the non-abuser with
private insurance:
– 4X more likely to visit ER
– 11X more likely to visit outpatient mental health
– 12X more likely to have an inpatient
hospitalization
• $72.5 Billion=Estimated direct health care
costs related to nonmedical use of
prescription painkillers
(McAdam‐Marx et al., 2010; White et al., 2005)

9. Managed Care Tools
• Review/monitor prescription
claims
• Prescriber notification
• Patient outreach/case
management
• Quantity limits for certain drugs
• Limiting refills
• ID check/DOB Matching
• Assign patients to single
pharmacy

10. The Next Level
Advanced Safety and Monitoring Program
• Multidisciplinary team reviews, identifies and
addresses excessive medication use in high-
risk patients
• Promotes member safety and reduces
avoidable prescription and medical costs

11. The Next Level
• Academic Detailing
Pharmacist visits prescribers who write high numbers
of controlled substances prescriptions to discuss
rationale and alternatives
• Prescriber Toolkit
Educational information and questionnaires helps
prescriber manage patients with chronic pain
• Clinical Risk/Credentialing
Identifies and investigates practitioners for quality of
care concerns if there is evidence or possibility to
harm a member.

12. Prescriber Tools
• Health Care Plan’s Expectations
• Treatment Guidelines
• Opioid Dosing Calculators
• Pain Management Contracts
• Urine Drug Screens
• Questionnaires-Addiction Risk
Assessment, Pain and Function

14. H&P Pain Pill Count
Assess Progress
Screen
Monitor
Lab Function UDS
Risk AE’s Misuse
Depression