Third-Party Payer Track

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To learn more about individual breakout sessions click on the title name (updated 3-25-16):

Tuesday
Ensuring Access to Quality Treatment
Workers’ Compensation: Dangerous Prescribing Practices and At-Risk Patients
Advances in Treating Chronic Pain and Addiction
 
Wednesday
Using Workers’ Compensation Formularies to Reduce Rx Opioids
Turning Off the Faucet from Above: Health Plan Involvement in Safe Prescribing
Managing Morphine Equivalent Dose and Red Flagging Red Flags

Overview
Third-party payers are grappling with the rising usage and costs of Rx drugs. In workers’ compensation insurance, for example, the average number of narcotics prescriptions per claim grew from 0.56 in 2003 to 0.79 in 2011, according to the National Council on Compensation Insurance. That trend translated into higher costs of narcotics prescriptions per workers’ compensation claim, with a rise from $39 in 2003 to $59 in 2011. Third-party payers are working to mitigate those costs and to limit exposure to potentially addictive Rx drugs to avoid unwanted outcomes, lengthened disability and additional medical concerns for patients. Topics in the Third-Party Payer Track will include ensuring access to quality treatment for substance use disorders, identifying and helping at-risk patients, promoting safe prescribing practices, and reviewing state responses, such as establishing workers’ compensation formularies and Medicaid lock-in programs.
Ensuring Access to Quality Treatment
Tuesday, March 29, 2016 | 4:15 pm to 5:30 pm
CE certified AMA | ACPE | ANCC | AAFP
Presenters Melissa Williams, MPH
Coordinator of State Government Relations, National Patient Advocate Foundation
 
Stacey L. Worthy, JD
Director of Public Policy, Alliance for the Adoption of Innovations in Medicine
Moderator Daniel Blaney-Koen
Senior Legislative Attorney, American Medical Association Advocacy Resource Center, and Member, Rx & Heroin Summit National Advisory Board
Session Description Less than one in five of the 22.5 million people in America who need treatment for alcohol or illicit drug use actually receive it, according to the 2014 National Survey on Drug Use and Health. The need to close this “treatment gap” has intensified due to the public health threats posed by recent outbreaks of Hepatitis C and HIV infections, which were associated with injection drug use. This session will discuss barriers that impede access to quality treatment for substance use disorders, especially in light of federal and state laws, such as the Patient Protection and Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (the Parity Act).

Presenters will provide information and guidance to help third-party payers fully comply with patient protection laws and improve access to quality addiction treatment. They will identify common third-party payer practices that impede access to addiction treatment and are limited by federal and state laws, such as prior authorization, step therapy and adverse tiering. The presentation will provide an overview of the Federal Parity Act, the ACA and state parity laws; identify recent enforcement actions; review recently proposed policies; identify trends in state legislation; and recommend policies to improve access to treatment and reduce likelihood of an enforcement action.

Learning Objectives 1. Identify common barriers to addiction treatment.
2. Explain federal and state patient protection and parity laws that are intended to improve access to quality treatment for substance abuse disorders.
3. Outline strategies to improve access to quality treatment for substance abuse disorders.
4. Provide accurate and appropriate counsel as part of the treatment team.
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Workers’ Compensation: Dangerous Prescribing Practices and At-Risk Patients
Tuesday, March 29, 2016 | 5:45 pm to 7:00 pm
CE certified AMA | ACPE | ANCC | AAFP
Presenters Teresa Bartlett, MD
Senior Vice President of Medical Quality, Sedgwick
 
Stephen N. Fisher, MD, PhD
Director of Health Services and Medical Advisor to the CEO, Chesapeake Employers’ Insurance Company
 
Paul Peak, PharmD
Director, Clinical Pharmacy, Sedgwick
Moderator Christopher M. Jones, PharmD, MPH
Director, Division of Science Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and Member, Rx & Heroin Summit National Advisory Board
Session Description From their unique vantage point, workers’ compensation insurance providers can spot behaviors that contribute to Rx drug misuse and abuse. This session will address two areas of concern: dangerous prescribing practices and at-risk patients. Tips for identifying and responding to these issues will be given by a global provider of claims-management services and Maryland’s largest provider of workers’ compensation insurance.

Representatives of Sedgwick Claims Management Services, Inc., will address dangerous prescribing practices. The company’s pharmacy program — which teams expert physicians, pharmacists, nurses and claims examiners — often discovers a great number of physicians practicing beyond guidelines for best practices, such as Morphine Equivalent Dose. By consistently emphasizing the importance of best practices in opioid prescribing, the program has demonstrated a positive impact on the health and safety of injured workers. Presenters will describe the troubling prescribing patterns identified through the program, as well as success stories resulting from its multidisciplinary approach and clinical intervention.

A representative of Chesapeake Employers’ Insurance Company will discuss “outside-the-box” management of Rx drug use. The presenter will explain how the company identifies at-risk patients early and then manages those claims with a team of healthcare, legal and adjustor professionals using a multi-faceted approach. The company also reviews older claims that involve chronic opiate use and intervenes if help seems to be needed. Topics will include the increasing importance of referrals for cognitive behavioral therapy and the aspects of Rx drug issues that differentiate workers’ compensation patients from group health patients.

Learning Objectives 1. Identify dangerous prescribing practices observed in management of workers’ compensation insurance claims.
2. Describe strategies that have proven successful in resolving dangerous prescribing practices.
3. Outline approaches to identify and manage high-risk claims within the workers’ compensation population.
4. Provide accurate and appropriate counsel as part of the treatment team.
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Advances in Treating Chronic Pain and Addiction
Tuesday, March 29, 2016 | 7:15 pm to 8:30 pm
CE certified AMA | ANCC | APA | AAFP
Presenters David R. Gastfriend, MD
Scientific Advisor, Treatment Research Institute
 
Michael Gavin, MBA
President, PRIUM
 
Jennifer Saddy
Director of Workers’ Compensation, American Airlines
Moderator Michael C. Barnes, JD
Executive Director, Center for Lawful Access and Abuse Deterrence, and Member, Rx & Heroin Summit National Advisory Board
Session Description With Rx opioid use, abuse and costs at staggeringly high levels, stakeholders are stepping up to mitigate the epidemic. For third-party payers, this session will examine two new approaches to prevent and respond to Rx drug abuse in patients: (1) managing the mental and behavioral dynamics of chronic pain, and (2) implementing a new standard of addiction treatment assessment and managed care.

Clinicians and payers are starting to recognize how psychosocial factors affect chronic pain. (One theory is that early adverse experiences and early-onset mental disorders contribute to a chronic imbalance in hormonal and neurotransmitter mediators.) Presenters will show how to address psychosocial issues while mitigating the potential for a psychiatric claim. They will outline mental and behavioral issues and their influences on chronic pain, explore payers’ responsibilities for addressing psychosocial pain issues, and provide practical strategies for managing chronic pain and claims involving chronic pain. Topics will include non-pharmaceutical treatment of chronic pain, direction of care, stakeholder involvement and using physical medicine billing codes for cognitive behavioral therapy.

The American Society of Addiction Medicine (ASAM) first published the ASAM Criteria in 1991, providing decision rules to determine the optimal care for addiction treatment. In July 2015, the U.S. Centers for Medicare and Medicaid Services notified all state Medicaid directors that these criteria must be implemented in an independent third party clinical review, under a new waiver system. This presentation will explain how the new ASAM Criteria Decision Engine, CONTINUUM™, will serve this role, improve intake clinicians’ performance, standardize placement, reform managed care and establish the first national addiction treatment patient data registry. State policymakers need to understand the basis and process for implementing this new standard, and providers need to understand how it will aid their efforts to provide the best care, with the least restrictiveness and the most efficient use of resources.

Learning Objectives 1. Outline mental and behavioral issues and their influence on chronic pain.
2. Identify strategies to address psychosocial pain issues when managing chronic pain and claims involving chronic pain.
3. Explain the basis and impacts of the new federal requirements for state Medicaid directors to implement the ASAM Criteria.
4. Describe a tool for implementing the new ASAM Criteria requirement.
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Panel Discussion: Using Workers’ Compensation Formularies to Reduce Rx Opioids
Wednesday, March 30, 2016 | 11:15 am to 12:30 pm
CE certified AMA | ACPE | ANCC | AAFP
Panelists Joseph Paduda, MS
Principal, Health Strategy Associates
 
Mark Pew
Senior Vice President, PRIUM
Moderator Michelle C. Landers, JD
Executive Vice President & General Counsel, Kentucky Employers’ Mutual Insurance, and Member, Rx & Heroin Summit National Advisory Board
Session Description Drug formularies are poised to become the leading tools in managing pharmacy usage in workers’ compensation. Drug formularies in Texas and Ohio have documented their ability to reduce the number of prescriptions for opioids and other risky, inappropriate drugs. In this panel discussion, two industry experts will explain formularies and offer guidance to optimize their success, based on lessons learned in states such as Texas, Ohio, Oklahoma and Washington. They will identify the elements of effective formularies, as well as best practices for designing and implementing formularies. Their topics will include: patient safety and access, utilization review, two-phased implementation, dispute resolution, building consensus among stakeholders, metrics for measuring success and ongoing maintenance of the drug list.
Learning Objectives 1. Explain how workers’ compensation formularies reduce opioid prescriptions.
2. Describe the operations and outcomes of formularies in such states as Texas, Ohio, Oklahoma and Washington.
3. Identify best practices for designing and implementing a workers’ compensation formulary.
4. Provide accurate and appropriate counsel as part of the treatment team.
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Turning Off the Faucet from Above: Health Plan Involvement in Safe Prescribing
Wednesday, March 30, 2016 | 2:00 pm to 3:15 pm
CE certified AMA | ACPE | ANCC | AAFP
Presenters Daniel Calac, MD, FAAP
Chief Medical Officer, Indian Health Council, Inc.
 
Roneet Lev, MD
Director of Operations, Scripps Mercy Hospital Emergency Department, and Chair, San Diego County (CA) Rx Drug Abuse Medical Task Force
 
Margaret Mendes, PharmD
Program Director, Academic Detailing Service, VA Desert Pacific Healthcare Network
 
George Scolari
Behavioral Health Program Manager, Community Health Group
Moderator Mark D. Birdwhistell, MPA
Vice President for Administration and External Affairs, University of Kentucky HealthCare
Session Description Drug overdose deaths are the leading cause of injury death in the United States, ahead of deaths from motor vehicle accidents and firearms, according to the U.S. Drug Enforcement Agency’s 2015 National Drug Threat Assessment. In 2013, the most recent year for which data is available, 46,471 people in the U.S. died from a drug overdose, and more than half of those were caused by Rx painkillers and heroin. This session will address the role of third-party payers in reducing Rx drug overdoses.

The San Diego Death Diaries of 2013 — which were prescription drug monitoring program (PDMP) reports of unintentional deaths from prescriptions — revealed that 713 physicians prescribed over 4,000 medications to 186 people. Physician education and feedback can continue one doctor at a time, but why are health plans paying for medications that end up killing people? The faucet can be shut off from above. The San Diego Prescription Drug Abuse Task Force had made efforts to engage health plans in safe prescribing efforts. The presenters will describe those efforts and results, and they will share initiates by the Veterans Affairs Administration, Indian Health Council and San Diego Managed Care plans.

Learning Objectives 1. Describe strategies to engage health plans in safe prescribing efforts.
2. Identify some red flag medications and combinations that are key to safe prescribing.
3. Outline some health plan policies that can be used for safe prescribing.
4. Provide accurate and appropriate counsel as part of the treatment team.
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Managing Morphine Equivalent Dose and Red-Flagging Red Flags
Wednesday, March 30, 2016 | 3:30 pm to 4:45 pm
CE certified AMA | ACPE | ANCC | AAFP
Presenters Brigette Nelson, PharmD, MS, BCNP
Senior Vice President, Workers’ Compensation Clinical Management, Express Scripts
 
Andrew Roberts, PharmD, PhD
Assistant Professor of Pharmacy Sciences, Creighton University School of Pharmacy and Health Professions
 
Asheley Cockrell Skinner, PhD
Associate Professor, Duke Clinical Research Institute
 
Michael B. Stack
Principal, Amaxx Risk Solutions
Moderator Karen L. Kelly
District Director, Congressman Harold “Hal” Rogers (KY-5th District), Member, Rx & Heroin Summit National Advisory Board, and Member, Operation UNITE Board of Directors
Session Description This session will illustrate the complexities of crafting strategies to reign in Rx drug use, misuse and abuse. One presentation will describe an effective use of pharmacy benefit management, and the other will raise red flags about relying on red flags when screening claims data.

To begin, two industry experts will address how to ensure the safety of Morphine Equivalent Dose (MED). They will show that half of injured workers using narcotics in 2014 took a combination of Rx drugs for their work-related injury that carried potentially serious safety risks. Among patients taking one of these potentially dangerous combinations, 42 percent were prescribed the medications by two or more physicians and 19.1 percent filled their prescriptions at two or more pharmacies. Not only does concurrent use of narcotics with other drugs pose serious safety concerns; it can also lead to unsustainable costs for payers. This presentation will provide an in-depth explanation of MED and the importance of understanding dosage for both individual and cumulative MED. Proactive pharmacy solutions — as part of a comprehensive workers’ compensation program — are critical to ensure safe utilization for injured workers and effectively contain costs. The presenters will unveil results from payers who implemented solutions to effectively manage their pharmacy benefit, including a 12 percent decrease in injured workers using narcotics and a 30 percent decrease of prescriptions over 120 MED.

Then, two researchers will address the pitfalls of using simple screens in claims data to flag high-risk opioid use. Identifying patients for policy intervention who are at risk of preventable opioid overdose often relies on dichotomous flags of high-risk opioid use. For example, many Medicaid controlled substance lock-in programs typically enroll patients exceeding a pre-determined number of opioid prescriptions, opioid prescribers or opioid-dispensing pharmacies used in a given time period. We will share findings from a recent investigation that call into question the appropriateness of simple opioid use threshold screens in administrative claims data to identify patients at risk for substance use and overdose outcomes. Drawing on administrative claims data from North Carolina Medicaid, we will show how even the best performing dichotomous flags of high-risk opioid use failed to effectively distinguish between patients that experience unintended overdose events from those that do not. We provide recommendations for alternative claims-based screening methods to more precisely target necessary interventions to patients at highest risk of preventable overdose. They also will highlight results of their research into the unintended costs and overall effectiveness of Medicaid lock-in programs.

Learning Objectives 1. Explain Morphine Equivalent Dose (MED) and the importance of understanding dosage for both individual and cumulative MED.
2. Describe pharmacy benefit management solutions that decreased the number of injured workers using narcotics and of prescriptions over 120 MED.
3. Evaluate the effectiveness of dichotomous flags of high-risk opioid use to distinguish between patients that experience unintended overdose events and those that do not.
4. Identify alternative claims-based screening methods to more precisely target necessary interventions to patients at highest risk of preventable overdose.
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The content and scheduled time of these breakout sessions are subject to change.