2015 Third-Party Payer Track

Legislative and Medication Trends Impacting Third-Party Payers
Tuesday, April 7, 2015, 12:30 pm – 1:45 pm
 Moderator Landers_Michelle-smMichelle C. Landers, JD
Executive Vice President and General Counsel, Kentucky Employers’ Mutual Insurance, and Member, Rx Summit National Advisory Board
 Presenters Allen_Brian_smBrian Allen
Vice President of Government Affairs, Helios
Emptage_Tron-smTron Emptage, RPh
Chief Clinical Officer, Helios
 Session Description This session will alert Third-Party payers to legislative and medication trends impacting the industry, based on reviews of issues currently impacting workers’ compensation. To begin, participants will learn about current and pending legislation and various special interest influences that impact the development of laws and rules affecting the workers’ compensation system. Presenters will discuss what the various legislative and regulatory changes mean for the industry and how industry stakeholders can affect political change to their advantage. Next, presenters will draw from pharmacy benefit management and industry data to examine medication costs and utilization trends, such as compounded medications, chronic pain management and opioids. Participants will gain understanding that will help ensure optimal outcomes clinically and financially.
 Learning Objectives 1. Identify legislative and regulatory issues relevant to Third-Party payers.
2. Explain strategies for Third-Party payers to influence legislative and regulatory outcomes.
3. Outline medication cost and utilization trends relevant to Third-Party payers so that the injured worker receives the right medication at the right time in a cost-effective manner.
PDMPs and Third-Party Payers: Workers’ Compensation
Tuesday, April 7, 2015, 2:00 pm – 3:15 pm
 Moderator Eadie_John-smJohn L. Eadie
Director, Prescription Drug Monitoring Program Center of Excellence and Member, Rx Summit National Advisory Board
 Presenters Hunt_Dan-smDr. Dan L. Hunt, DO
Corporate Medical Director, Accident Fund Holdings, Inc.
Paduda_Joe-smJoseph Paduda, MS
Principal, Health Strategy Associates
Walls_Phil-smPhillip Walls, RPh
Chief Clinical Officer, myMatrixx
 Session Description Prescription drug monitoring program (PDMP) data has informed and improved responses to the Rx drug abuse epidemic by those stakeholders that have access to the data. This session will explore the value and feasibility of sharing PDMP data with third-party payers.

Presenters will explain how knowing the full Rx history of an enrolled patient would help TPPs provide safe, effective care and control costs. They will outline data sharing policies and procedures, including best practices for PDMPs. The discussion will include the perspective of a workers compensation pharmacy benefits manager and clinical pharmacist. Participants will hear observations from a workers compensation carrier on its experience with accessing PDMP data in Michigan, which is the only state permitting private third-party payer firms to access PDMP data, so far.

 Learning Objectives 1. Advocate that third-party payers have access to PDMP data as a way to interdict the opioid epidemic.
2. Identify best practices for PDMPs when allowing access to data.
3. Describe the implementation and impact of a private third-party payer accessing Michigan PDMP data.
Rx Drugs and Urine Testing: Knowing What’s Too Much, Too Little and Just Right
Tuesday, April 7, 2015, 3:30 pm – 4:45 pm
 Moderator Daniel Blaney-Koen-smDaniel Blaney-Koen, JD
Senior Legislative Attorney, American Medical Association Advocacy Resource Center, and Member, Rx Summit National Advisory Board
 Presenters Abou_Nader_Jo-Ellen_smJo-Ellen Abou Nader CFE, CIA, CRMA
Senior Director, Drug Waste Solutions, Express Scripts
Gavin_Michael-smMichael Gavin
President, PRIUM
Jeter_Elaine-smDr. Elaine Jeter, MD
MolDx Medical Director, Palmetto GBA
 Session Description Many stakeholder groups share responsibility for ensuring patients get quality and safe health care services without the waste, abuse or outright fraudulent spending of health care dollars. This session will explore how pharmacy benefit managers (PBM) monitor the medications obtained by patients and how urine drug testing (UDT) tracks appropriate use of those drugs.

From Express Scripts, participants will gain the PBM perspective on Rx drug fraud, waste and abuse. The presenter will share observations on drug seeking and explain how a PBM works in collaboration with plans/clients on patient safety and reducing healthcare waste. Actual case studies from the company will demonstrate how incidents are identified, investigated and resolved.

Presenters will explain the clinical rationale for UDT and examine why appropriate testing does not always occur, including financial incentives for over-testing. Discussion will include the risks of under-testing for patients and physicians alike. Participants will learn how to minimize costly UDT fraud and abuse while maximizing its usage as a critical objective measure of actual drug use or misuse.

 Learning Objectives 1. Describe how the PBM identifies, investigates and resolves Rx fraud, waste and abuse.
2. Compare appropriate with fraudulent and wasteful usage of UDT.
3. Advocate strategies that optimize usage of UDT.
Financial Toll of Rx Addiction
Wednesday, April 8, 2015, 11:15 am – 12:30 pm
 Moderator Baldwin_Grant-smGrant T. Baldwin, PhD, MPH
Director, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, and Member, Rx Summit National Advisory Board
 Presenters Fisher_Dr_Stephen-smDr. Stephen N. Fisher, MD, PhD
Medical Advisor to the CEO, Chesapeake Employers’ Insurance Company
Skinner_Asheley-smAsheley Cockrell Skinner, PhD
Associate Professor, Injury Prevention Research Center, The University of North Carolina at Chapel Hill
Zhou_Chao-smChao Zhou, PhD
Economist, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention
 Session Description Increased third-party payer payments may expand access to opioids, as well as the related problems. This session will review trends in opioid payments and two third-party payer efforts to identify and manage high-risk claims.

Participants will learn recent trends in opioid use, based on Medical Expenditure Panel Survey data. By reviewing estimated expenditures on Rx opioids and the proportion financed by households, government and business, the presentation will show that private payers and public insurance have paid a much larger share in recent years. The largest increases occurred in Medicare and Medicaid, which accounted for 33 percent of opioid spending in 2011.

From Maryland’s largest workers’ compensation insurer, participants will gain insights into the demographics and characteristics of Rx drug dependency among injured workers and the factors leading to over-prescribing and RX drug dependence. The presenter will share the company’s strategies for identifying and managing high-risk claims, as well as the obstacles to affecting such claims.

In the North Carolina Medicaid Program, PDMP data and a narcotic lock-in program are being used to reduce the misuse of opioids within a population of high-risk patients. The presentation will describe the lock-in program, patient attempts to circumvent it and its impact on the amount of opioids paid for by Medicaid. There also will be discussion of using PDMPs to their maximum capacity.

 Learning Objectives 1. Identify national trends in opioid use and expenditures.
2. Outline strategies to identify and manage high-risk claims within the workers’ compensation population.
3. Describe the North Carolina Medicaid Lock-In Program.
Workers’ Compensation: Examining Policy Issues and What Works
Wednesday, April 8, 2015, 3:00 pm – 4:15 pm
 Moderator Landers_Michelle-smMichelle C. Landers, JD
Executive Vice President and General Counsel, Kentucky Employers’ Mutual Insurance, and Member, Rx Summit National Advisory Board
 Presenters Hanna_John-smJohnnie L. Hanna, RPh, MBA
Pharmacy Program Director, Ohio Bureau of Workers’ Compensation
Paduda_Joe-smJoseph Paduda, MS
Principal, Health Strategy Associates
White_Jeff-smJeffrey Austin White, MS
Director of Medical Management Practices and Strategy, Accident Fund Holdings, Inc.
 Session Description Nearly 80 percent of injured workers receive at least one prescription for opioids, according to the Workers’ Compensation Research Institute. Narcotics account for 25 percent of drug costs, according to the National Council on Compensation Insurance. Workers’ compensation managers are working to limit exposure to potentially addictive Rx drugs and mitigate costs. This session will highlight the challenges presented by physician-dispensing of opioids and the successes from Ohio’s recent changes to its workers’ compensation pharmacy management program.

In many states, physicians are dispensing opioids in their offices instead of sending workers’ compensation patients to pharmacies to pick up their prescriptions. This practice bypasses key safeguards and may incent doctors to prescribe opioids, with studies showing that when physicians dispense opioids, the duration of care is longer, patients are out of work longer, outcomes are poorer and overall claims costs are higher. Presenters will cover the latest research, probe possible contributing factors and suggest potential solutions to the problem.

Participants will learn about the creation, operation and outcomes of the Ohio Bureau of Workers’ Compensation (BWC) pharmacy program. When compared with FY2011, in FY2014, which was the first full year of impact of the formulary, there was a 29 percent reduction in opioid prescriptions, a 74 percent reduction in muscle relaxant prescriptions and an 80 percent reduction in the use of anti-ulcer agents. The presentation will conclude with points about opiate mortality among Ohio’s injured workers as well as the significance of drug regimens in mortality.

 Learning Objectives 1. Identify negative consequences of physicians dispensing opioids in their offices.
2. Advocate solutions to the problem of physicians dispensing opioids in their offices.
3. Describe the Ohio BWC pharmacy program.
4. Evaluate the outcomes of the BWC pharmacy program during its five years of operation.
Proactive Identification and Intervention Approaches
Wednesday, April 8, 2015, 4:30 pm – 5:15 pm
 Moderator Massey_J_Kevin Massey-smJ. Kevin Massey, MS
Program Administrator, Division of Public Health, Delaware Department of Health and Social Services, and Board Member, Rx Summit National Advisory Board
 Presenters Anderson_Joseph_smJoseph Anderson, MBA
Director of Analytics, Helios
Emptage_Tron-smTron Emptage, RPh
Chief Clinical Officer, Helios
Henderson_Rochelle-smRochelle Henderson, PhD
Senior Director of Research, Express Scripts, Inc.
 Session Description To improve patient outcomes and prevent overspending, third-party payers seek to identify high-risk claims and chronic opioid users. This session will identify strategies for early identification and intervention.

With predictive analytics and statistical models, the 10 percent of workers’ compensation claims that make up 90 percent of long-term pharmacy cost can be identified accurately, allowing for necessary intervention efforts. Presenters will explain the role of statistical models in data analysis, offer tips in how to expend clinical intervention resources on the right claims at the right time, and offer guidance on how claims professionals and physicians can effectively collaborate to help injured workers recover.

In workers’ compensation, the use of long-acting opioids medications can lead to costs exceeding $100,000. Presenters will explain how third-party payers can proactively curb abuse and misuse by identifying characteristics associated with chronic opioid use in a newly injured worker population. Robust results from this approach can help in more accurately identifying opportunities to monitor opioid prescribing practices and investigate utilization.

 Learning Objectives 1. Explain the role of predictive analytics and statistical models to identify high-risk claims.
2. Describe strategies for intervening in high-risk claims to help injured workers and control costs.
3. Identify characteristics associated with chronic opioid use in a newly injured worker population.
4. Outline proactive strategies for curbing opioid abuse and misuse by chronic users.