Overview of New DSHS Drug and Alcohol Programs, PRR Program, and ER Initiative

1
Overview of New DSHS Drug and Alcohol Programs,
PRR Program, and ER Initiative What Physicians,
Hospitals Communities Need to Know

• Presenters
• Jeff Thompson, MD
• Phyllis Coolen, RN, MN
• Dan Dowler, MSW (MPH)
• David Mancuso, Ph.D.
• DSHS Health and Recovery Services Administration
• and
• Research and Data Analysis Division
• July 6, 2006

2
Objectives

• Understand the issues facing Medicaid related to
  narcotics and integration of services
• Review the work to date
• Understand the tools available
• Discuss additional opportunities to partner

3
Overview

• DSHS has responded to SA/AD issues with a family
  of tools and integration
• Narcotic review and Prior Authorization
• PRR/Lock in
• Referral to DASA Screening and Treatment
• Coordination with Mental Health and other
  agencies
• Informing the Provider Community (ER Work Group,
  IBM, Academic Detailing)
• Next Steps

Key DSHS Research Findings

• Some Medicaid clients receive excessive narcotics
• Emergency Room (ER) cycling is strongly
  correlated with narcotics
• Clients with diagnoses (headaches, abdominal
  pain, LBP) should not be receiving chronic
  narcotics in the ER
• Medical and DASA need to coordinate activities

4
Quantifying the problem
Number of prescriptions Number of clients Number of narcotics claims Amount paid Number of prescribers Number of pharmacies
10 or more 320 16,274 900,762 2,002 638

Number of ER clients Number of ER claims Amount paid
202 6,629 3,095,455
ER
5
Frequent ER Visitors Have High Rates of AOD
Disorders and Mental Illness
6
(No Transcript)
7
(No Transcript)
8
Opiate Treatment Savings
Pain Rx Among Frequent ER Users Narcotic
Analgesic Prescriptions Per Client Per Year
Average Number of Pain Prescriptions is Highest
Among Those Most Frequently Visiting the ER
INCLUDES persons who are Medicaid-only aged,
blind, disabled, presumptively disabled, or
General Assistance-Unemployable in Fiscal Year
2002. SOURCE Medicaid Integration Project
database. TOTAL CLIENTS (FY 2002) 130,274.
9
Opiate Prescribing Patterns
Example 1 Expected Prescribing Pattern
SOURCE DSHS Research and Data Analysis
Division, 2005.
10
Opiate Prescribing Patterns
Example 2 ER Cycling Plus Overlapping
Prescriptions
Number of Medical Providers Identified
SOURCE DSHS Research and Data Analysis
Division, 2005.
11
Average Prescribed Days of Narcotic Analgesics
Per Year, by Diagnosis Group
Average Number of Days Supplied Narcotic
Analgesics in Calendar Year 2001
0 25 50 75 100 125 150 175
Connective Tissue Respiratory Cancer Headaches Dis
eases of Spine Leukemia Pulmonary
Circulation Poison/Medicinal/Biologic Immune
Disorders Peripheral Arthritis Tobacco Abuse
Disorder HIV/AIDS Drug Abuse/Dependence/Psychosis
Gastrointestinal Cancer Hepatitis Inflammatory
Bowel Bleeding Disorders Fractures Breast
Cancer Chronic Obstructive Pulmonary
Disorder Sprains/Strains Superficial
Injuries Alcohol Abuse/ Dependence/Psychosis Poiso
n/Non-Medicinal
n 707 n 756 n 2,479 n 16,601 n 261 n
428 n 1,214 n 762 n 9,955 n 3,568 n
766 n 2,699 n 650 n 2,184 n 4,980 n
1,014 n 4,603 n 784 n 9,579 n 10,673 n
7,365 n 2,854 n 554
INCLUDES persons who are Medicaid-only aged,
blind, disabled, presumptively disabled, or
General Assistance-Unemployable in Fiscal Year
2002. SOURCE Medicaid Integration Project
database. TOTAL CLIENTS (FY 2002) 130,274.
Statewide Average 49
SOURCE DSHS Research and Data Analysis
Division, 2005.
12
DSHS Response

• Developed intervention focused on the Top 320
  Medicaid clients using extreme amounts of
  narcotic analgesics
• Filled 10 or more narcotic prescriptions in a
  single month or
• Filled 7 or more narcotic prescriptions for 6
  consecutive months
• Excluded from the intervention clients with
  Cancer, HIV/AIDS, or in hospice. We subsequently
  modified exclusion list to add Nursing Home
  clients.
• This identification approach sought to isolate
  significant clients along with prescribing
  providers and pharmacists who are filling Rxs.
• Provide for a fourfold intervention approach.

13
High-risk Vulnerable Population

• Clients receiving more than 10 narcotic scripts
  per month
• From multiple prescribers
• Using multiple ER visits

HIGH RISK OPPORTUNITY
Education/ Communication
Restrictions Utilization Management

• Intensified Benefit Management
• Share Rx history with prescriber
• Let provider know about the ER visits and other
  Rxg

• Prior Authorization
• Review claims
• Determine medical necessity

Case Management Restriction
Case Management Intervention

• Patient Review and Restriction
• One primary care physician
• One pharmacy

• DASA
• Referral
• Signed releases
• Shared outcomes

14

• The Top 320 Intervention

• Key components of the intervention
• Education/ Communication
• Letter to provider community introducing project.
• Outlining identification criteria
• Describing how this would influence medical
  practice
• Explaining WAC 388-530-1250 (Prior Authorization
  Policy)
• Explaining WAC 388-501-0135 (Patient Review and
  Restriction)
• Additional Resource information and links.
• Client Letter
• Indicating deaths from Narcotics growing concern,
  new program and MD reviewing last 12 months of
  history and in MD would work with client
• Pharmacy Broadcast FAX
• Enlist support of Pharmacy community to work
  together.
• Intensified Benefits Management
• Client Profile and consultation with MD and
  Pharmacies represented

15

• Key components of the intervention (contd)
• Restrictions/Utilization Management
• Prior Authorization (PA)
• Claims submitted for PA client are subject to
  pre-payment review, medical justification, etc.
  before payment
• Of the original 320 identified and immediately
  placed on PA, currently 205 remain (5/2006)
• If medically justified PA on client is removed,
  otherwise remains in place.
• Case Management Restriction
• Patient Review and Restriction (PRR)
• 75 new clients were placed on PRR
• Phyllis and Trang will detail this program
  further.
• Case Management Intervention
• 52 clients were identified in the Long Term Care
  program area with gt case management.
• 4th Qtr 2005 and 1st Qtr of 2006 clients has
  added 44 more clients.
• 27 patients on the 320 list have entered DASA
  treatment since July 1, 2005.
• All twenty-seven patients are receiving publicly
  funded treatment
• This is the first treatment admission for
  fourteen of the twenty-seven patients
• In May 2006, twenty-five of the twenty-seven were
  still in treatment.

16
Patient Review and Restriction Program (PRR)

• PRR is a health and safety program for both
  fee-for-service and managed care clients needing
  help in the appropriate use of medical services
• Authority
• Federal Regulations
• 42 CFR 431.54 Allows states to restrict/lock-in
  recipients to designated providers when recipient
  utilized services at a frequency or amount that
  is not medically necessary
• 42 CFR 456.3 Requires Medicaid agency to
  implement a statewide surveillance and
  utilization control program
• 42 CFR 455.16 Imposition of sanctions for
  instances of abuse identified by the agency
• State Regulation
• WA Administrative Code (WAC) 388-501-0135

17
Goals of PRR Program

• To improve medical coordination of care for
  clients with a history of inappropriate
  utilization of services
• To reduce expenditures on unnecessary and
  inappropriate services

PRR WAC Criteria (WAC 388-501-0135)

• Two or more of the following apply in a 90-day
  period
• Saw 4 or more physicians
• Prescriptions filled at 4 or more pharmacies
• Received 10 or more prescriptions
• Had prescriptions written by 4 or more
  prescribers
• Received similar services from 2 or more
  providers in the same day
• OR
• Any one of the following applies
• Made 2 or more ER visits in a 90-day period
• Medical history indicating at-risk utilization
  patterns
• Repeated and documented efforts to seek medically
  unnecessary services and counseled at least once
  by health care provider or managed care
  representative about appropriate use of health
  care services

18
Referral Sources for Identifying Potential
Clients

• Referrals
• By HRSA staff, providers, pharmacies, and other
  state agencies
• Received by phone, fax, e-mail, or letter
• Caseload of terminated providers
• Utilization Reports
• Intermittently reports are generated on top users
  of services, such as high emergency room users,
  high narcotic users

19
Provider Assignment

• Client is assigned to a PCP, Pharmacy, and/or
  Hospital for non-emergent care
• Provider is reasonably accessible to client
• Provider is chosen by client or HRSA
• Staff work closely with health care providers to
  find a provider willing to coordinate the PRR
  clients care
• Assignment letter is sent to client, provider,
  and local Community Service Office (CSO)
• Client is restricted for 24 months, then reviewed
  and extended if appropriate

20
Services Not Affected

• The following services are not affected by PRR
• Dental - Emergency Services
• Hospital in-Patient - Renal Dialysis
• Home Health Care - Hospice Services
• Medical Equipment - Transportation Services
• Long Term Care - Vision
• Hearing Aids - Family Planning
• Womens Health
• Clients may be responsible for payment of
  services
• Not referred by the PRR PCP
• Obtained from non-PRR providers

21
PRR Referrals

• PRR Referral Line
• [phone] Calls are returned within 24 hours
• PRR Website
• http//maa.dshs.wa.gov/PRR

22
Impact of the Top 320 intervention on narcotic
prescribing patterns and medical service use

• Clear reduction in volume of narcotic analgesics
  supplied to Top 320
• Less evidence of an impact on use of other
  outcomes
• Overall Medical Assistance expenditures
• ER visits
• Use of chemical dependency treatment services
• Analyses use a comparison group to control for
  regression to the mean

23
Top 320 vs. Comparison Group Narcotic
Analgesic Scripts Filled Per Member Per
Month Based on MMIS claims paid through 3/31/2006
PRELIMINARY
Prescriptions Per Member Per Month
POST-INTERVENTION PERIOD
Top 320
Comparison Group
SOURCE DSHS Research and Data Analysis
Division, 2006.
24
Top 320 vs. Comparison Group Narcotic
Analgesic Days Supplied Per Member Per
Month Based on MMIS claims paid through 3/31/2006
PRELIMINARY
Days Supplied Per Member Per Month
POST-INTERVENTION PERIOD
Top 320
Comparison Group
SOURCE DSHS Research and Data Analysis
Division, 2006.
25
Top 320 vs. Comparison Group Outpatient ER
Visits Per 1,000 Members Per Month Based on
MMIS claims paid through 3/31/2006
PRELIMINARY
OP ER Visits Per 1,000 Members Per Month
POST-INTERVENTION PERIOD
Top 320
Comparison Group
SOURCE DSHS Research and Data Analysis
Division, 2006.
26
Conclusion

• Take home messages
• Integration inside DSHS
• Education of the provider population
• Use data to identify and target opportunity
• Inform clients/providers of risk and resources.
• Make sure resources are known-tool-kit and
  coordination
• Collaborate outside traditional program lines
• Collaborate and work with medical and screening
  and treatment resources in the community.

27
Next Steps

• NEXT STEPS/COMING SOON
• Using Evidence Based Medicine
• Developing a tool kit for providers
• Sharing Rx Records on poly-prescribers and
  poly-pharmacy
• Sharing diagnosis with the community (HIPPA and
  Title 42 compliant)
• Working with the community to establish an
  Evidence Based Maximal narcotic dose (120 mg of
  morphine equivalent/day
• http//www.globalrph.com/index.htm
• QUESTIONS