1 pharmaceutical descriptive analysis texas department of insurance, workers’ compensation...

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Pharmaceutical Descriptive Analysis

Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group

July 2007

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Overview

• Data and Methods• Distribution of System Costs• Utilization and Costs by Prescription Year:

– Injury Year– Injury Type– Therapeutic Classification Group– Therapeutic Classification Sub-Class

• Payment Denial Patterns• Generic Substitution Patterns• Summary of Key Results• Next Step

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Data and Methods Data sources:

DWC 837 Medical data Medi-Span Master Drug Database (Classification Groups) ECS 2000-2004 Medical/Hospital Bills (To identify Injury Types)

Data Parameters: Injury Years 1991 – 2006Prescription Years 2005 and 2006Prescriptions for 90 Days or less (99.8% of all data)Dropped prescriptions with denials for Duplicate,

Entitlement, and Compensability issues

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Data and Methods, Continued Measures:

Prescriptions: Number of Billing LinesUnits = Number of DaysPaymentsCharges Injured Employees (Defined by number of unique

SSN/Injury Date) Injury Types (Standard ICD9 classifications used by REG)

Data Issues: Injury Types unidentifiable for 30% of prescription billsThe number of Drug Days varied widely

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System Measures

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Payments in the Texas Workers’ Compensation System

Prescription Years 2005 - 2006

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note 1: Percent of Total Payments may not add up to 100% because of rounding. Note 2: The California Workers’ Compensation Institute (CWCI) estimates that in 2005 California’s Pharmacy cost was 7 percent of that state’s medical costs.

Medical Type

Prescription Year2005

Prescription Year2006

TotalPayments

Percent ofTotal

Payments1

TotalPayments

Percent ofTotal

Payments1

Professional $626,309,000 62% $535,603,000 57%

Hospital $250,938,000 25% $275,923,000 29%

Pharmacy $132,973,000 13%2 $131,647,000 14% 2

Dental $580,000 <1% $1,049,000 <1%

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Percent of Medical Paymentsin the Texas Workers’ Compensation System

by Medical Type, Prescription Years 2005-2006

62%

57%

25%

29%

13% 14%

<1% <1%

0%

10%

20%

30%

40%

50%

60%

70%

Pe

rce

nt

of

Me

dic

al

Co

st

Professional Hospital Pharmacy Dental

Medical Type

2005

2006

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note 1: Percent of Total Payments may not add up to 100% because of rounding.

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Payment to Charge RatioTexas Workers’ Compensation System


42%39%

29% 28%

73% 72%

55%

60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pa

y t

o C

ha

rge

Ra

tio

Professional Hospital Pharmacy Dental

Medical Type

2005

2006

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.

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Injured Employees Receiving Prescriptions in the Texas Workers’ Compensation System


171,330

171,146(50%)

176,127

168,225(49%)

0%

20%

40%

60%

80%

100%

2005 2006

Injured Employees Without Prescriptions Injured Employees With Prescriptions


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Pharmaceuticals in The Texas Workers’ Compensation System

Utilization and Costs

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Distribution of Pharmaceutical Utilization and Payments by Injury Year

Prescription Year 2006

Injury Years

Numberand (%) of

InjuredEmployees

Number and (%) of

Prescriptions

Number and (%) of Drug Days

Total and (%) ofPayments

1991 - 2000 21,094(13%)

545,591(33%)

12,749,849(40%)

$61,061,807(46%)

2001- 2004 25,666(15%)

457,480(28%)

9,770,829(31%)

$38,651,958(29%)

2005 23,766(14%)

252,673(15%)

4,288,462(14%)

$14,898,811(11%)

2006 97,699(58%)

392,822(24%)

4,759,971(15%)

$17,034,883(13%)

Total 168,225 1,648,566 31,565,111 $131,647,459

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note 1: Percent of Total Payments may not add up to 100% because of rounding.

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Pharmaceutical Utilization and Paymentsby Injury Year


13%

33%

40%

46%

15%

28%31% 29%

14%15%14%

11%

58%

24%

15%13%

0%

10%

20%

30%

40%

50%

60%

Pe

rce

nt

1991 - 2000 2001 - 2004 2005 2006

Injury Years

% of Injured Employees % of Prescriptions % of Drug Days % of Payments


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Average Pharmaceutical Utilization and Payments Per Injured Employee

by Injury Year, Prescription Year 2006

Injury Years

Number ofInjured

Employees

AverageNumber of

PrescriptionsPer InjuredEmployee

AverageNumber of Drug Days Per InjuredEmployee

AveragePayment

Per InjuredEmployee

1991 - 2000 21,094 25.8 604 $2,895

2001- 2004 25,666 17.8 381 $1,506

2005 23,766 10.6 180 $627

2006 97,699 4.0 49 $174


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Pharmaceutical Utilization and Paymentsby Injury Year


604

$2,895

381

$1,506

180

$627

49 $174

0

500

1,000

1,500

2,000

2,500

3,000

Da

ys

/Do

llars

1991 - 2000 2001 - 2004 2005 2006

Injury Years

Average Number of Drug Days Per Injured Employee Average Payment Per Injured Employee


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Distribution of Pharmaceutical Utilization and Payments by Injury Type, Prescription Year 2006

Injury TypeNumber

and (%) 1ofInjured

Employees

Number and (%) 1 of

Prescriptions

Number and (%) 1 of Drug Days

Total and (%) 1 ofPayments

Low Back S.T. 27,020 (16%) 293,250 (18%) 5,560,347 (18%) $21,506,129 (16%)

Shoulder 10,989 (7%) 85,193 (5%) 1,370,246 (4%) $4,851,641 (4%)

Hand-Wrist S.F. 9,645 (6%) 28,596 (2%) 352,444 (1%) $1,489,780 (1%)

Neck 8,263 (5%) 104,803 (6%) 1,995,353 (6%) $7,601,174 (6%)

Low-Back N.C. 6,287 (4%) 116,067 (7%) 2,327,423 (7%) $9,202,987 (7%)

Hand-Wrist S.T. 6,166 (4%) 31,914 (2%) 493,668 (1%) $1,748,383 (1%)

Knee 5,321 (3%) 37,710 (2%) 576,614 (2%) $2,024,647 (2%)

Ankle-Foot S.T. 4,777 (3%) 22,859 (1%) 347,788 (1%) $1,292,345 (1%)

Multiple S.T. 2,651 (2%) 20,144 (1%) 362,711 (1%) $1,248,457 (1%)

Hand-Wrist N.C. 1,725 (1%) 16,191 (1%) 312,917 (1%) $1,186,166 (1%)

Other 61,993 (36%) 436,474 (27%) 7,526,788 (24%) $29,626,946 (23%)

Unknown 2 23,388 (13%) 455,365 (28%) 10,342,812 (33%) $49,868,801 (37%)

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note 1: Percents may not add up to 100% because of rounding. Note 2: More than 30% of injured employees with unknown injury types were injured between 1991 and 1995

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Pharmaceutical Utilization and Paymentsby Injury Type


16%18% 18%

16%

4%2%

1%1%

5%6% 6% 6%

58%

60%

33%

37%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Pe

rce

nt

Low Back S.T. Hand Wrist S.T. Neck Unknown *

Injury Types

% of Injured Employees % of Prescriptions % of Drug Days % of Payments

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007. Note *: More than 30% of injured employees with unknown injury types were injured between 1991 and 1995

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Distribution of Pharmaceutical Utilization and Payments Per Injured Employee

by Injury Type, Prescription Year 2006

Injury TypeNumber of

InjuredEmployees

Average Number ofPrescriptions

Per InjuredEmployee

Average Number of Drug Days Per InjuredEmployee

AveragePayment

Per InjuredEmployee

Low Back S.T. 27,020 47 888 $3,433

Shoulder 10,989 8 126 $445

Hand-Wrist S.F. 9,645 3 37 $155

Neck 8,263 13 243 $924

Low-Back N.C. 6,287 4 87 $343

Hand-Wrist S.T. 6,166 19 287 $1,018

Knee 5,321 7 109 $383

Ankle-Foot S.T. 4,777 5 73 $272

Multiple S.T. 2,651 8 137 $472

Hand-Wrist N.C. 1,725 3 51 $194

Other 61,993 7 123 $486

Unknown 1 23,388 20 448 $2,158

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007. Note 1: More than 30% of injured employees with unknown injury types were injured between 1991 and 1995

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Pharmaceutical Utilization and Paymentsby Selected Injury TypesPrescription Year 2006

888

$3,433

287

$1,018

243

$924

448

$2,158

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Day

s/D

olla

rs

Low Back Soft Tissue Hand Wrist SoftTissue

Neck Unknown *

Injury Type

Average Number of Drug Days Average Payment

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007. Note *: More than 30% of injured employees with unknown injury types were injured between 1991 and 1995

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Pharmaceutical Utilization and Payments by Therapeutic Classification Group


TherapeuticClassification

Group *

Numberof Injured

Employees

Number and (%) of

Prescriptions

Number and (%) of Drug Days


ANALGESICS - OPIOID 102,628 522,521 (32%) 8,648,112 (27%) $43,046,837 (33%)

ANALGESICS – ANTI-INFLAMMATORY

91,634 257,092 (16%) 5,242,347(17%) $18,637,705 (14%)

MUSCULOSKELETALTHERAPY

59,233 225,173 (14%) 4,653,704 (15%) $17,141,168 (13%)

ANTIDEPRESSANTS 18,129 99,189 (6%) 2,697,351 (9%) $9,164,644 (7%)

ANTICONVULSANTS 16,378 96,298 (5%) 2,568,263 (8%) $14,362,712 (11%)

HYPNOTICS 12,672 64,116 (4%) 1,635,314 (5%) $6,315,282 (5%)

ANTIANXIETY AGENTS 9,173 40.668 (2%) 947,215 (3%) $2,030,153 (1%)

OTHER GROUPS 67,222 343,509 (21%) 5,176,805 (16%) $20,948,958 (16%)

Total 377,069 ** 1,648,566 31,569,111 $131,647,461

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note*: The 7 selected groups are the most frequently utilized groups (79% of all prescriptions) in the Texas WC system. The Other Groups are the remaining 82 less frequently utilized groups (21% of all prescriptions). Note**: Total number of Injured Employees include duplicates since each employee could receive prescriptions from multiple therapeutic classification groups.

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Cumulative Distribution of Pharmaceutical Prescriptions by Therapeutic Classification Group

Prescription Year 2006Therapeutic

ClassificationGroup

Number ofPrescriptions

CumulativePercentage ofPrescriptions


CumulativePercentage of

Payments

ANALGESICS -OPIOID

522,521 (32%) 32% $43,046,837 (33%) 33%

ANALGESICS – ANTI- IFLAMMATORY

257,092 (16%) 48% $18,637,705 (14%) 47%

MUSCULOSKELETALTHERAPY

225,173 (14%) 62% $17,141,168 (13%) 60%

ANTIDEPRESSANTS 99,189 (6%) 68% $9,164,644 (7%) 67%

ANTICONVULSANTS 96,298 (5%) 73% $14,362,712 (11%) 78%

HYPNOTICS 64,116 (4%) 77% $6,315,282 (5%) 82%

ANTIANXIETYAGENTS

40.668 (2%) 79% $2,030,153 (2%) 84%

OTHER GROUPS * 343,509 (21%) 100% $20,948,958 (16%) 100%

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note*: Texas WC prescriptions in 2006 were for 6,001 unique Drug Names from 626 Subclasses. The Subclasses fall into 89 distinct Therapeutic Classification Groups as defined by the Medi-Span classification system

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Most Frequently Dispensed Prescriptions by Therapeutic Classification Subclass*


Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note*: These 40 subclasses represent all the subclasses found in the 7 most frequently utilized Therapeutic Classification Groups

Therapeutic Classification Subclass*


Number of Drug Days

Number of Injured

Employees

Total Payments

1. Hydrocodone Combinations 309,990 4,797,088 70,786 $12,547,298

2. Central Muscle Relaxants 224,188 4,633,852 60,103 $16,920,573

3. Nonsteroidal Anti-inflammatory Agents 199,744 3,815,133 80,491 $11,407,594

4. Opioid Agonists 114,270 2,502,033 26,185 $25,394,160

5. Anticonvulsants - Misc. 82,994 2,218,229 16,750 $13,511,221

6. Non-Benzodiazepine - GABA-Receptor Modu

55,309 1,409,857 11,182 $5,974,277

7. Cyclooxygenase 2 (COX-2) Inhibitors 52,443 1,305,935 18,229 $6,652,473

8. Propoxyphene Combinations 51,626 668,065 20,939 $1,720,978

9. Benzodiazepines 37,127 876,531 7,989 $1,803,903

10. Selective Serotonin Reuptake Inhibitors

33,774 915,145 6,620 $3,439,146

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Most Frequently Dispensed Prescriptions, Continued by Therapeutic Classification Subclass*





Number of Drug Days

Number of Injured

Employees

Total Payments

11. Tramadol Combinations 27,151 379,244 12,017 $1,872,588

12. Tricyclic Agents 25,549 688,708 5,886 $751,348

13. Serotonin-Norepinephrine Reuptake Inhib

23,240 640,601 4,646 $3,629,052

14. Anticonvulsants - Benzodiazepines

10,589 275,389 2,156 $483,467

15. Codeine Combinations 8,425 111,870 3,592 $282,020

16. Modified Cyclics 7,833 209,737 1,823 $288,114

17. Benzodiazepine Hypnotics 7,444 189,424 1,911 $236,589

18. Antidepressants - Misc 6,906 191,272 1,406 $879,031

19. Opioid Combinations 5,973 113,197 2,062 $724,693

20. Nonsteroidal Anti- inflammatory Agent Co

4,854 120,319 1,715 $550,776

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Number of Drug Days

Number of Injured

Employees

Total Payments

21. Opioid Partial Agonists 3,874 59,989 1,089 $428,992

22. Antianxiety Agents - Misc. 3,541 70,684 1,445 $226,250

23. Alpha-2 Receptor Antagonists (Tetracycl

1,883 51,768 376 $176,472

24. Selective Melatonin Receptor Agonists

1,237 32,280 539 $102,486

25. GABA Modulators 1,166 31,715 234 $209,783

26. Hydantoins 792 22,072 161 $32,360

27. Valproic Acid 755 20,827 138 $125,464

28. Pentazocine Combinations 584 8,475 179 $34,705

29. Muscle Relaxant Combinations 580 11,245 243 $55,054

30. Dihydrocodeine Combinations***

491 6,663 219 $37,424

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Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note*: The first 40 subclasses represent all the subclasses found in the 7 most frequently utilized Therapeutic Classification Groups

TherapeuticClassification Subclass*


Number of Drug Days

Number ofInjured

Employees

TotalPayments

31. Viscosupplements 276 4,665 215 $149,879

32. Meperidine Combinations 137 1,488 49 $3,980

33. Direct Muscle Relaxants 129 3,942 23 $15,662

34. Barbiturate Hypnotics 77 2,552 15 $815

35. Non-Barbiturate Hypnotics 42 1,133 14 $1,072

36. Pyrimidine Synthesis Inhibitors

40 669 14 $12,613

37. Soluble Tumor Necrosis Factor Receptor

11 291 1 $14,248

38. Antihistamine Hypnotic Combinations

7 68 3 $43

39. Monoamine Oxidase Inhibitors (MAOIs)

4 120 3 $1,481

40. Succinimides 2 31 1 $416

Subtotal (40 Subclasses) 1,305,057 (79%) 26,392,306 (84%) 361,449 $110,698,503 (84%)

OTHER (586 Subclasses) 343,509 (21%) 5,176,805 (16%) 68,412 $20,948,959 (16%)

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Five Most Frequently Utilized Drug Subclasses *Total Number of Prescriptions


Hydrocodone Combinations:

309K

Central Muscle Relaxants: 224K

Nonsteroidal Anti- Inflammatory Agents:

200K

Anticonvulsants: 83K

Opioid Agonists: 114K

0 50,000 100,000 150,000 200,000 250,000 300,000 350,000

Number of Prescriptions

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007. Note*: These 5 subclasses represent 56 percent of all the drugs dispensed in the Texas workers compensation system

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Prescription Denials

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Most Frequently Denied Prescriptions by Therapeutic Classification Groups


Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007. Note*: Total number of injured employees include duplicates since each employee could receive prescriptions from multiple therapeutic classification groups.

TherapeuticClassification Group

Number ofDenied

Prescriptions

Number ofInjured

EmployeesW/Denied

Prescriptions *

Total DeniedCharges

OTHER GROUPS 71,219 (42%) 13,020 $23,732,524

ANALGESICS – OPIOID 34,020 (20%) 14,062 $3,038,485

ANALGESICS - ANTI-INFLAMMATORY 22,729 (13%) 11,515 $1,988,809

MUSCULOSKELETAL THERAPY AGENTS 18,020 (11%) 8,267 $1,781,442

ANTIDEPRESSANTS 9,183 (5%) 3,506 $1,051,773

ANTICONVULSANTS 6,618 (4%) 2,889 $1,170,175

HYPNOTICS 5,123 (3%) 2,285 $602,530

ANTIANXIETY AGENTS 3,610 (2%) 1,630 $250,892

Total 170,522 57,174* $33,616,630

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Approved and Denied Prescriptionsby Therapeutic Classification Groups


21%

42%

32%

20%

16%

13%14%

11%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

OTHER GROUPS ANALGESICS – OPIOID ANALGESICS - ANTI-INFLAMMATORY

MUSCULOSKELETALTHERAPY AGENTS

% of Approved Prescriptions % of Denied Prescriptions


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Five Most Frequently Denied Drug Subclasses Prescription Year 2006

Other Subclasses *

71K

Hydrocodone Combinations: 20K

Nonsteroidal Anti- Inflammatory Agents:

18K

Opioid Agonists: 6K

Central Muscle Relaxants: 17K

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000

Number of Prescriptions

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007. Note*: The Other Subclasses group represents 586 subclasses system

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Percent of Denied Prescriptionsby Denial Codes


40%

23%

20%

8%

5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Unnecessary Fee Not Timely Filed NegotiatedContract

Unbundling

% of Denied Prescriptions


31

Percent of Denied Prescriptionsby Injury Types


26%24%

19%

7% 7%

0%

5%

10%

15%

20%

25%

30%

Other Unknown Low Back SoftTissue

Low BackNerve

Compression

Neck

% of Denied Prescriptions


32


Generic Substitution

33

Generic Substitution Rate Where Generics were available *


28%

72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Brand Name Generic

Brand Name Generic

Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, 2007.Note* : Approximately 85,000 prescriptions (5 percent) did not have generics available

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Generics and Brand Name Frequencies by Therapeutic Classification Groups



Number Total Average Number Total AverageTherapeutic Groups of Prescriptions Payments Payment of Prescriptions Payments Payment*ANALGESICS - OPIOID* 494,875 $27,629,212 $56 50,846 $15,389,614 $303*MUSCULOSKELETAL THERAPY AGENTS*

194,805 $10,996,991 $56 41,988 $6,132,912 $146

*ANALGESICS - ANTI-INFLAMMATORY*

186,024 $8,246,712 $44 86,214 $10,376,793 $120

*HYPNOTICS* 7,387 $176,472 $24 59,875 $6,135,427 $102*ANTICONVULSANTS* 54,934 $7,099,768 $129 45,530 $7,256,920 $159*ANTIDEPRESSANTS* 52,899 $2,622,095 $50 52,223 $6,539,631 $125*ANTIANXIETY AGENTS* 40,282 $1,650,071 $41 2,492 $379,661 $152

Generic Brand name

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Generic Substitution RatesTherapeutic Classification Groups


OTHER GROUPS, 55%

ANTIDEPRESSANTS, 50%

HYPNOTICS, 11%

Antianxiety Agents: 94%

Analgesics -Opioid: 91%

Muscular-Skeletal Therapeutic Agents: 82%

ANTICONVULSANTS: 55%

ANALGESICSAnti-Inflammatory 68%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Percentage of Prescriptions


36

Summary• Pharmaceutical costs comprise 14 percent of all

workers’ compensation costs in Texas• Seventy two percent of all pharmaceutical charges are

paid (compared to 60 percent for dental, 39 percent for professional, and 29 percent for hospital bills)

• Approximately 48 percent of all injured workers receiving medical services in 2006 also received prescribed drugs for their injuries

• Injuries sustained between the years 1991 and 2000 (13%) account for a disproportionate share of pharmaceutical costs in 2006(46%)

• Among the identifiable injury types, Low Back soft tissue injuries account for the highest number of prescriptions

37

Summary, Continued• A total of 7 of the 89 Therapeutic Classification Groups

(40 of the 626 Subclasses) account for 79 percent of all the prescriptions filled in 2006

• Approximately 10% of prescriptions and 28% of charges are denied

• Approximately 11% of Hypnotics prescriptions are substituted to the generic alternative

1 pharmaceutical descriptive analysis texas department of insurance, workers’ compensation...

Documents

injury types data parameters

injury years

overview data

methods data sources

medical type prescription

reg data issues

step slide

injury types unidentifiable