tpp 3 joint presentation
DESCRIPTION
Third-Party Payer: Teaming with Clinicians in the Intervention Process - Patrick Burns, Tron Emptage, Dr. Lawrence Feinstein and Dr. Robert HallTRANSCRIPT
Teaming with Clinicians in the Interven3on Process
Clinical Collabora3on Achieves Be9er Outcomes
Principled Strategies, Inc.
Patrick J. Burns, President
Lawrence Feinstein, Ph.D., Vice President, Clinical Programs
Progressive Medical, Inc.
Tron Emptage, R.Ph., Chief Clinical Officer
Robert Hall, MD, Corporate Medical Director
Presenters
Disclosure Statements
Patrick J. Burns has no financial rela3onships with proprietary en33es that
produce health care goods and services.
Lawrence Feinstein has no financial rela3onships with proprietary en33es
that produce health care goods and services.
Tron Emptage has no financial rela3onships with proprietary en33es that
produce health care goods and services.
Robert Hall has no financial rela3onships with proprietary en33es that
produce health care goods and services.
2 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Learning Objec3ves
1. Differen3ate between threatening and collabora3ve outreach.
2. Assemble a list of words and phrases that reduce fric3on and foster partnership between payors and the physician.
3. Iden3fy tools that demonstrate effec3ve outcomes.
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Discussion Points
Factors that Influence Outcomes
Risk Iden3fica3on & Interven3on Tools
Lessons Learned
Clinical Collabora3on Q&A
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Workers’ Compensa3on vs. Group Health
Suburban Home Custom Log Cabin
The Tale of Two Doctors
6
Doctor A Doctor B
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Factors that Influence Outcomes
7
Number of Prescribers
Number of Pharmacies
Prescribing Behaviors
Medica3on Pa9erns
Body Part/ Nature of Injury
Demographics of Prescriber
Medica3on Agreement
Drug Monitoring
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Number of Prescribers
• West Virginia
• Evalua3on for doctor shopping
– Doctor shoppers: Four or more prescribers in last six months
– % of deceased pa3ents – % of living pa3ents
8
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
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Number of Prescribers
• West Virginia
• Evalua3on for doctor shopping
– Doctor shoppers: Four or more prescribers in last six months
– 25 % of deceased pa3ents – 3.5% of living pa3ents
9
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Number of Pharmacies
• West Virginia
• Evalua3on for pharmacy shopping
– Pharmacy shoppers: Four or more pharmacies in last six months
– % of deceased pa3ents – % of living pa3ents
10
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Number of Pharmacies
• West Virginia
• Evalua3on for pharmacy shopping
– Pharmacy shoppers: Four or more pharmacies in last six months
– 17% of deceased pa3ents – 1% of living pa3ents
• 55% of pharmacy shoppers were also doctor shoppers
11
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
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Number of Prescribers and Pharmacies
12
Uncoordinated Care
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Prescribing Behaviors
• Opioids prescribed early in the claim
• Days supply of opioids
• Number of fills • Morphine equivalent dose (MED)
– Washington State
– 120 MED threshold
13
http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf
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Medica3on Pa9erns
• Type of opioids and claim cost
• Michigan
– Final claim cost ≥ $100,000 – Short ac3ng opioids → 1.76 more likely
– Long ac3ng opioids → 3.94 more likely
14
White JA, Tao X, Talreja M, Tower J, Bernacki E. The effect of opioid use on workers' compensation claim cost in the State of Michigan. J Occup Environ Med. 2012 Aug;54(8):948-53.
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Medica3on Pa9erns
• Mul3ple short-‐ac3ng and long ac3ng opioids?
• Poten3al drug-‐drug interac3ons
– West Virginia – Opioids and benzodiazepines
15
Peirce GL, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 2012 Jun;50(6):494-500.
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Body Part/Nature of Injury
• Ohio
• Highest costs per claim by body part
– Lumbar spine – Shoulder – Cervical spine
• Industries with highest average costs per claim
– Transporta3on – Warehouse
– U3li3es and Construc3on
16
Dunning KK, Davis KG, Cook C, Kotowski SE, Hamrick C, Jewell G, Lockey J. Costs by industry and diagnosis among musculoskeletal claims in a state workers compensa3on system: 1999-‐2004. Am J Ind Med. 2010 Mar;53(3):276-‐84.
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Demographics of Prescriber
Geographical varia3on of opioid prescribing
• Acute, work-‐related low back pain
• Decision to use opioids related to social condi3ons • Massachuse9s 5.7% vs. South Carolina 52.9%
• 79% of state varia3on explained by 3 factors
1. State household income inequality
2. Number of physicians per capita
3. Workers’ compensa3on cost containment effort score
17
Webster BS, Cifuentes M, Verma S, Pransky G. Geographic varia3on in opioid prescribing for acute, work-‐related, low back pain and associated factors: a mul3level analysis. Am J Ind Med. 2009 Feb;52(2):162-‐71.
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Demographics of Prescriber
Geographical varia3on of opioid prescribing
• 135 million opioid prescrip3ons in 2008
• 37,000 retail pharmacies • Large varia3on in opioids prescribed
• Coun3es having the highest prescribing rates
‒ Appalachia
‒ Southern and western states
Strongest predictor of amounts prescribed
Number of available physicians…”by far”
18
McDonald DC, Carlson K, Izrael D. Geographic varia3on in opioid prescribing in the U.S. J Pain. 2012 Oct;13(10):988-‐96.
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Demographics of Prescriber
19
McDonald DC, Carlson K, Izrael D. Geographic varia3on in opioid prescribing in the U.S. J Pain. 2012 Oct;13(10):988-‐96.
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Medica3on Agreement
• Also know as a “pain contract”
• Recommended by
– U.S. Department of Health and Human Services – American Academy of Pain Medicine
– Veterans Health Administra3on
– American College of Occupa3onal and Environmental Medicine (ACOEM)
– Official Disability Guidelines (ODG)
20
Payne, R, E Anderson, R Arnold, L Duensing, A Gilson, C Green, C J. Haywood, S Passik, B Rich, L Robin, N Shuler, and M Christopher. "A Rose by Any Other Name: Pain Contracts/agreements." The American Journal of Bioethics : Ajob. 10.11 (2010): 5-12. ACOEM 2011; ODG 2012
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Medica3on Agreement
• Informed consent
• Promotes educa3on
• Improves compliance • Components
– Informed consent for treatment with medica3on(s)
– Acceptable and unacceptable behaviors – Consequences for failure to adhere to agreement
21
Payne, R, E Anderson, R Arnold, L Duensing, A Gilson, C Green, C J. Haywood, S Passik, B Rich, L Robin, N Shuler, and M Christopher. "A Rose by Any Other Name: Pain Contracts/agreements." The American Journal of Bioethics : Ajob. 10.11 (2010): 5-12. ACOEM 2011 ODG 2012
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Medica3on Agreement Sample
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Drug Monitoring
• Urine drug screen
– U.S. Department of Health and Human Services
– ACOEM – ODG
• Iden3fy possible drug misuse and abuse
23
Gilbert et al. "Importance of Urine Drug Tes3ng in the Treatment of Chronic Noncancer Pain: Implica3ons of Recent Medicare Policy Changes in Kentucky." Pain Physician 13.2 (2010): 167-‐86.
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Effects on Behavior
PaCent
• “My prescrip3ons are being monitored”
• “I may be drug tested”
• “I signed an agreement”
• “I could lose my pain meds”
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• Physician Physician
• “My prescribing habits are being monitored”
• “I could lose my license to prescribe”
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Why Some Physicians Don’t Follow Guidelines
25
KNOWLEDGE
ATTITUDES
BEHAVIORAL FACTORS
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RISK IDENTIFICATION & INTERVENTION TOOLS
Risk Iden3fica3on and Interven3on
27 © 2014 by Principled Strategies, Inc. All rights reserved.
Rx Data Analysis
1:1 Individualized ConsultaCon via Telephone or In person
Prescriber PSI Score™ and Scores for Top Three Risk Factors (out of 17 total factors)
#1 Early Refills #2 Excessive Use #3 Dosage and Volume of Opioids
Risk Scoring of Prescribers
Monthly CommunicaCon; Quarterly Score Updates
Prescriber Resources Toolkit
Engagement via Personalized Outreach
49 PredicCve Metrics
Pharmacy Metrics
Prescriber Metrics
PSI Score™
17 Behavioral Risk Factors
PaCent Metrics
Opioid-‐specific Metrics
Iden3fy Prescriber “Risk”
• Concept of “risk factors” borrowed from disease management
• At what point would you allocate resources to intervene with the following prescriber?
– Starts most pa3ents on highest dosage
– Frequently prescribes excess days supply – Is located 50+ miles from many of his pa3ents – High pa3ent volume compared to specialty peers
28 © 2014 by Principled Strategies, Inc. All rights reserved.
The PSI Score™
• Iden3fy/Stra3fy ̶̶ Popula3on and Specialty Peers
• Predict risky prescribers by iden3fying trends
• Individualize the interven3on effort by iden3fying each prescriber’s top three risk behaviors
• Monitor prescriber behavior change over 3me
• CQI ̶̶ Measure interven3on effec3veness, and improve
• Comply with treatment direc3ve to iden3fy prescribers and members for review of appropriateness of opioid therapy
29 © 2014 by Principled Strategies, Inc. All rights reserved.
Prescriber Risk Score Distribu3on
30
High Risk
Moderate Risk Low Risk
© 2014 by Principled Strategies, Inc. All rights reserved.
Predic3ve Risk Iden3fica3on
31
Which prescribers not currently in the high risk group will, in six months, have a PSI Score™ equal to or greater than the cutoff value that defines “high risk”, with a 90% confidence level?
© 2014 by Principled Strategies, Inc. All rights reserved.
Prescriber Interven3on
IdenCficaCon
• Risk scored and rank ordered the prescriber popula3on • Iden3fied 1,200 prescribers, along with the top 3 risk factors for each
Engagement • 250 prescribers per week for four weeks • Addi3onal prescribers for two more weeks to reach goal of 1,000
ConsultaCon • 20-‐minute telephone call or office visit consulta3on with PharmD • Printed materials including instruc3ons to refer to behavioral health
Follow-‐up • Six months follow-‐up communica3on post-‐appointment • Three-‐month and six-‐month update on PSI Score™ and risk factor scores
32 © 2014 by Principled Strategies, Inc. All rights reserved.
Iden3fica3on
• 1,200 prescribers iden3fied for engagement
• ≥ 98th %ile of the PSI Score™ distribu3on
33
High-‐risk Prescriber DistribuCon by Specialty
Family Medicine 23%
Internal Medicine 22%
Psychiatry 9%
Pain Management 7%
Surgery 7%
Physical Medicine & Rehab 7%
Anesthesiology 6%
Physician Assistant 4%
Nursing 4%
Other 12%
© 2014 by Principled Strategies, Inc. All rights reserved.
Iden3fica3on
Top Risk Factors Occurring most frequently among prescribers’ top three risk factors
34
PaCent-‐focused Risk Factors
Mul3ple Prescribers
Mul3ple Pharmacies
Mul3ple Family Members
Prescriber-‐focused Risk Factors
Early Refills of Similar Products
Dosage and Volume of Opioids
Opioid with benzodiazepine or carisoprodol Concomitance
Excessive Use of Controlled Substances
© 2014 by Principled Strategies, Inc. All rights reserved.
Engagement Packet
• Welcome Le9er ̶̶ Personalized and Tailored
• Risk Factor Worksheets ̶̶ Each prescriber’s top three risk factors
• Clinical Advisories specific to each prescriber’s risk factors
• Pa3ent Informa3on Report ̶̶ List of each prescriber’s pa3ents contribu3ng to his/her top three risk factor scores, and their prescrip3on informa3on
• Prescriber Resources and Recommenda3ons ̶̶ Guides; assessments; services to refer to for psych evalua3ons, rehab, consulta3on, and coordina3on of care
35 © 2014 by Principled Strategies, Inc. All rights reserved.
Engagement
• Outbound scheduling calls
– Call prescriber’s office to schedule a 20-‐minute telephone call or office visit with a licensed PharmD
– Confirm receipt of the engagement packet
• Confirm the appointment 72 hours prior, by call or email
36 © 2014 by Principled Strategies, Inc. All rights reserved.
Consulta3on
• 20 to 30-‐minute 1:1 consulta3on with a PharmD trained in the program protocol – Telephone call – Office visit
• In the first four minutes: Assess prescriber’s level of mo3va3on versus resistance, and adjust objec3ves, tac3cs, |and 3ming accordingly
37 © 2014 by Principled Strategies, Inc. All rights reserved.
The Tale of Two Doctors
38
Doctor A Doctor B
© 2014 by Principled Strategies, Inc. All rights reserved.
A Tale of Two Doctors
39
Scheduling Call
Refuse Schedule Release
Office Visit Telephone Call
MoCvated / CooperaCve • Review the engagement packet materials • Explain the purpose of the program, themes, the PSI Score™, risk factors, clinical recommenda3ons, Pa3ent Informa3on Report
• Explain the program follow-‐up, score updates, and invite further discussion
Resistant / UncooperaCve • Explain the purpose of the program, themes • Focus on the resources to help the prescriber • Shorten appointment; schedule follow-‐up • Track PSI Score™ over 3me and have Regional Medical Director follow-‐up if necessary
© 2014 by Principled Strategies, Inc. All rights reserved.
Follow Up
• Sa3sfac3on Survey sent within two weeks of appointment
• Monthly Communica3ons
– By email unless prescriber requests fax – Links to short video vigne9es and addi3onal materials on the Web
– Brief survey ques3ons • Quarterly Score Updates
• Relapse Monitoring Based on Updated Scores and Trends
40 © 2014 by Principled Strategies, Inc. All rights reserved.
Program Resources
• Service Center
– Staffed by four administrators and six PharmDs
– Outbound and inbound telephone calls, email and fax; dedicated lines and auto-‐a9endant
• CRM System
– Tracks all outbound and inbound communica3ons
– Collects data on all aspects of the program
– Repository of all prescriber informa3on
– Automated opera3onal and clinical reports
41 © 2014 by Principled Strategies, Inc. All rights reserved.
Measuring Clinical Outcomes
• Monthly updates to the PSI Score™ and risk factor scores enable us to: – Measure change across the prescriber popula3on and within each
specialty group – Indirectly measure adop3on of clinical recommenda3ons
– Iden3fy prescriber trends as they develop, permizng early-‐stage interven3on per prescriber and the popula3on
– Have a con3nuous feedback look to evaluate program impact and improve effec3veness
• Currently we measure
– Risk
– U3liza3on (pharmacy only)
– Benefit-‐to-‐Cost (pharmacy only)
• In the future we will measure the aforemen3oned for both pharmacy and medical
42 © 2014 by Principled Strategies, Inc. All rights reserved.
Post-‐interven3on Outcomes (12 mo)
Endpoint Model Significance P
PSI Score™ R Yes < 0.001
Mul3ple HCPs R Yes < 0.001
Mul3ple Pharmacies R Yes < 0.001
Concomitance R Yes < 0.002
Opioid Prescrip3on Claims U No
Morphine Equivalent Dose (mg) U Yes = 0.020
43
Legend: R = Risk Factor, U = U5liza5on Factor
Cost Model Significance P Savings
Opioid Rx Claims Yes = 0.041 $2,596,189
Non-‐opioid Rx Claims Yes = 0.045 $461,731
Benefit-‐to-‐Cost 4.4 : 1
© 2014 by Principled Strategies, Inc. All rights reserved.
CLINICAL COLLABORATION FOR BETTER OUTCOMES IN WORKERS’ COMPENSATION
Clinical Collabora3on for Be9er Outcomes
Early capture of prescripCons leads to greater control through connected programs.
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Clinical Collabora3on for Be9er Outcomes
Quicker access to informaCon be9er equips claims professionals and clinicians to make decisions.
46
Early capture of prescrip3ons
Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Clinical Collabora3on for Be9er Outcomes
Quicker access to informa3on
47
Early capture of prescrip3ons
MulC-‐factor risk analysis based on pharmacy behavior, the injury and overall demographics should be applied to be9er predict the path of a claim.
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Analyze Risk
Predic3ve power of variables change over Cme
48
Percent of Significance (aggregated
across mul3ple variables)
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Clinical Collabora3on for Be9er Outcomes
Quicker access to informa3on
49
Early capture of prescrip3ons
MulC-‐factor risk analysis based on pharmacy behavior, the injury and overall demographics should be applied to be9er predict the path of a claim.
There will always be claims that mature into complicated situa3ons; having the right tools to apply at the right Cme is essen3al.
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• Claims Professional Outreach • Physician Outreach • U3liza3on Reviews • Interven3on Reports • Peer-‐to-‐Peer Review
Clinical Tools and Exper3se
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Commen
tary
Chan
ge in Opioid Use Post D
TM
DTM
Results
Med
icaC
on Spe
nd per Claim
ant 48 (9.3%) detected an illicit
substance
250 (48.6%) detected a Non-‐Prescribed Drug
284 (55.3%) did not detect the prescribed medica3on(s)
64% of iden3fied claimants that were tested had a result inconsistent with the prescriber therapy
Changes in UClizaCon (based on days supply)
Changes in Spend
All Medica3ons ↓ 21% ↓ 20%
All Opioids ↓ 24% ↓ 28%
All Benzodiazepines ↓ 28% ↑ 6%
360 Days Post Enrollment Compared to 90 Days Pre-‐Enrollment
Urine Drug Monitoring Drug Tes3ng and Monitoring Outcomes show significant decrease in u3liza3on
60% 61% 64%
66%
70%
51 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Commen
tary
Chan
ge in Opioid Use Post R
eview
Success Ra
te by Med
icaC
on Class
Med
icaC
on Savings per Claim
ant
$-‐
$200.00
$400.00
$600.00
$800.00
$1,000.00
$1,200.00
$1,400.00
$1,600.00
91-‐180 days 181-‐270 days 271-‐360 days
Overall success rate 70% Average decrease in opioid use 8.4% Average savings per injured party $3,586.93 Return on investment (ROI) 8:1
Medica3on Class
Average Success Rate
Average Savings per Successful Interven3on
Muscle Relaxants 76% $ 302.78
Dermatologics 73% $ 1,794.08 Seda3ves 65% $ 1,257.18 Opioid Analgesics 57% $ 2,711.91 NSAIDs 52% $ 563.91 Gastrointes3nal 50% $ 1,014.86 An3convulsants 46% $ 1,630.16 Anxioly3cs 38% $ 244.58 Respiratory 33% $ 1,555.03 An3depressants 31% $ 316.17
Medica3on Reviews with addi3onal interven3on via Peer to Peer Outreach outcomes are measured separately
Medica3on Reviews Medica3on Reviews result in an average $3,500 savings per injured party
52 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
Commen
tary
Chan
ge in Opioid Use Post R
eview
Success Ra
te by Med
icaC
on Class
Med
icaC
on Savings per Claim
ant
Overall success rate 62% Average decrease in opioid use 25.6% Average savings per injured party $5102 Rate of achieving contact with prescriber 79% Return on investment (ROI) 4:1
Medica3on Class
Average Success Rate
Average Savings per Successful Interven3on
An3-‐migraine agents 82% $ 6,662.66
NSAIDs 77% $ 524.23 Laxa3ves 69% $ 131.67 Muscle Relaxants 65% $ 422.69 Dermatologics 63% $ 1,587.41 Opioid Analgesics 62% $ 2,995.51 An3convulsants 61% $ 1,077.05 An3depressants 60% $ 723.16 Seda3ves 57% $ 884.56 Anxioly3cs 50% $ 1,290.77 $-‐
$200.00
$400.00
$600.00
$800.00
$1,000.00
$1,200.00
$1,400.00
91-‐180 days 181-‐270 days 271-‐360 days
Peer Outreach Combining Medica3on Reviews with Peer Outreach results in an overall 4:1 ROI
53 Progressive Medical, Inc. -‐ Copyright 2014 -‐ All Rights Reserved
The Tale of Two Doctors
54
Doctor A Doctor B
Both trea3ng doctors ul3mately made medica3on changes based on recommenda3ons from the reviewing physician. Doctor B was willing to partly compromise.
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LESSONS LEARNED
Lesson Learned Carefully cra<ed outreach fosters engagement
• More recep3ve when it is clearly understood that – We are NOT claiming prescriber is engaging in inappropriate behavior
– Our emphasis is on making certain the injured party receives the right medica3on at the right 3me
• Inclusion of detailed prescrip3on informa3on for the prescriber’s own pa3ents was a major contributor to prescribers’ willingness to par3cipate
• Calls to schedule appointments must occur within one week of receipt of engagement packets
• Design the Engagement Packet mailing envelope so office staff can easily iden3fy that it contains pa3ent PHI and must be delivered only to the prescriber
• Review of the themes of the program by PharmD increased comfort and collabora3on
• Most appointments were completed within 20 minutes
• Member and claim level informa3on was very useful in reconciling charts and taking ac3on as appropriate
56 © 2014 by Principled Strategies, Inc. All rights reserved.
Lesson Learned Collabora5on can drive posi5ve change
• Most prescribers – are unaware their pa3ents are engaging in aberrant behavior, such as “doctor shopping”,
drug seeking, or diversion – preferred an appointment by telephone call
– had read the engagement materials prior to the appointment
– believed that they were already implemen3ng adequate steps/precau3ons in their prac3ce
• Although most prescribers expressed concern about being “monitored” by the payor, by the end of the call, addi3onal resources and tools were iden3fied that would help improve the safe use of control substances
– Locking members into a single pharmacy
– Specific lab tests including “no threshold tes3ng” and “adultera3on panel”
– Referrals for addic3on specialists and psychological counseling services
• Many providers were not aware of these addi3onal resources
57 © 2014 by Principled Strategies, Inc. All rights reserved.
Lesson Learned Addi5onal Challenges of Pain Management Clinics
• Members are sent back to the PCP for ‘follow-‐up’, refills on controlled substances, and long-‐term pain management
• PCPs expressed a low comfort level with managing chronic pain pa3ents but felt they were ‘le� with no choice’
58 © 2014 by Principled Strategies, Inc. All rights reserved.
Thank you!
Ques3ons?
Contact Us
Lawrence Feinstein, Ph.D.
Office: (760) 230-‐6326
Email: [email protected]
Patrick J. Burns
Office: (760) 230-‐6323
Email: [email protected]
60
Contact Us
Tron Emptage, R.Ph., Chief Clinical Officer
Tron.Emptage@progressive-‐medical.com
Robert Hall, MD, Medical Director
Robert.Hall@progressive-‐medical.com
61