th annual iha stakeholders · dmn –beneficiary level pos edit not determined necessary: drug(s)...

September 19, 2017

Hilton Los Angeles Airport

16th Annual IHA Stakeholders Meeting – Session 2A

Thank you to our Content Partner:

Smart Care California: Multi-Stakeholder Strategies for Reducing Opioid OveruseJennifer Wong, MPH

IHA Stakeholders Meeting

September 19, 2017

© 2016 Integrated Healthcare Association. All rights reserved. 3

3© 2016 Integrated Healthcare Association. All rights reserved.

Why Measure Opioid Use?

1 https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm 2 Curtis S. Florence, Chao Zhou, Feijun Luo, Likang Xu. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care, 2016; 54 (10): 901 DOI: 10.1097/MLR.0000000000000625 3 Use of opioids at high dose or use of opioids and benzodiazepines increase the risk of opioid overdose deaths

ACCOUNTABILITYMeasuring opioid usage at high dosage or in combination with benzodiazepinesin the commercial VBP4P population Enables providers and health plans to hold each other accountable.3

produces resources for patients, payers providers, health plans, and purchasers to support the reduction of the use of opioids. VBP4P Measurement compliments Smart Care CA’s efforts

$78.5B$$$$

HIGH COSTOpioid overuse in North America is estimated to have an annual cost of

$78.5B2

NATIONAL EPIDEMIC

400% Increase in opioid-related deaths in last two decades

12 Californians die from drug overdose every dayand two thirds of these deaths involve opioids1

© 2017 Integrated Healthcare Association. All rights reserved..

4

Opioids Kill People

Source: Leonard J. Paulozzi, Karin A. Mack, and Christopher M. Jones,“Vital Signs: Risk for Overdose from Methadone Used for Pain Relief —United States, 1999-2010,” Morbidity and Mortality Weekly Report 61, no. 26 (July 6, 2012): 493-97, www.cdc.gov.


5

Variation Across California: Opioid Overdose Deaths

Source: California Opioid Overdose Surveillance Dashboard

Counties with Highest Opioid Overdose Death Rates:1. Inyo2. Humboldt3. Siskiyou


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Variation Across California:Morphine milligram equivalents (MME) by County

• Lake County: 1420 MME per resident per year

• CA average: 496 MME per resident per year • Alpine County: 83

MME per resident per year

• CA average: 496 MME per resident per year

Source: California Opioid Overdose Surveillance Dashboard


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Statewide Problems Require Statewide Solutions


8

Lance Lang, MD, Covered California

• Smart Care California and the role of purchasers on reducing opioid overuse

Jean Shahdadpuri, MD, MBA, Health Net

• Health plan perspective on reducing opioid overuse

Parag Agnihotri, MD, Sharp Rees-Stealy Medical Group

• Provider perspective on reducing opioid overuse

Today’s Presenters

Smart Care California and the Role of Purchasers

IHA Stakeholders

Lance Lang, MD

September 19, 2017

▪ Public-private partnership working to promote safe,

affordable health care in California

▪ Co-chaired by the state’s largest health care purchasers:

• Department of Health Care Services (DHCS)

• Covered California

• California Public Employees' Retirement System (CalPERS)

• With participation by Pacific Business Group on Health (PBGH)

▪ Collectively, Smart Care California co-chairs purchase or

manage care for more than 16 million Californians—or 40

percent of the state

▪ IHA convenes and coordinates the partnership

▪ CHCF provides funding and thought leadership

▪ Multi-stakeholder in the best California tradition

About Smart Care California

Smart Care California

Participants

Smart Care California:

Three Focus Areas

C-section for Low Risk

First Time Births

(Lead: Covered California)

Opioid

(Lead: DHCS)

Low Back Pain

(Lead: CalPERS)

Multi-Stakeholder Collaboration

Initial Focus: Overuse

Initial Guidelines:Choosing Wisely

Found it was not enough to define what not to do

Need multi-stakeholder alignment and focus on best practices

Variation starts

with purchasers

Multi-Lever Model for Change

Reduce Opioid

Overuse

Data/ Transparency

Purchaser Requirements

Workforce

Quality Improvement

Consumer Engagement

Public Policy

Payment

Covered California Drive for Delivery System Reform:

Key Buckets of Requirements

1. Narrow Disparities in Care

2. Integration and Coordination of Care

• Patient Centered Medical Home (PCMH)

• Accountable Care Organizations (ACOs)

3. Network Design Based on Value

• Best Current Data for Hospitals (maternity & safety)

• Not a narrow network strategy

• Rather: a QI strategy with a deadline (YE 2019)

• Comprehensive Data not yet available for physicians

3. Adopt Best Practices

• Smart Care California

Summary:

The Power of Aligning Purchaser Requirements

Providers are hungry for a consistent set of expectations and

consistent business model with revenue aligned with quality goals

• Primary Care important to but distinct from ACO

• IHA/PBGH ACO metrics

Smart Care Agenda:

• Maternity

• Establish Honor Roll sponsored by Secretary Dooley

• Define Payment Menu

• Develop Opioid and Back Pain programs

• Establish best practices

• Evaluate benefit and payment strategies for alignment


Four Core Priorities for Opioids

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• Decrease the number of new starts —fewer prescriptions, lower doses, shorter durationsPREVENT

• Identify patients on risky regimens (high-dose opioids, or opioids and sedatives) and work with them to taper to safer doses

MANAGE

• Streamline access to buprenorphine and methadone to treat opioid addictionTREAT

• Streamline access to naloxone for overdose reversal

STOP overdose deaths


Opioid Activities to Date

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• Online resources*

• Dashboard of

measures

• Health plan and

purchaser checklist

• Payer and provider

recommendations

(in development)

*http://www.iha.org/our-work/insights/smart-care-california/focus-area-opioids

http://www.iha.org/our-work/insights/smart-care-california/focus-area-opioids

Opioid Overutilization Management Program

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Jean Shahdadpuri MD MBA

Senior Medical Director

Health Net

Sep 19th 2017

IHA Stakeholders Meeting

Centene Corp – Health Net

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Jean Shahdadpuri MD MBA

Senior Medical Director

Sep 19th 2017

Present in 28 states

2 international markets

12.2 million managed care members

#66 FORTUNE 100 (2017)

# 244 FORTUNE’S “GLOBAL 500 LIST” (2017)

31,500 employees

2017 expected revenues $46.4-$47.2B

$10.0 billion in cash and investments

Centene will acquire New York's Fidelis Care for $3.75 billion

The deal will help Centene expand in New York.

Centene expects the deal to close in the first quarter of 2018, and boost its

earnings in the first year of the transaction.

Centene Corp – Health Net

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Medicaid Plan

with 19%

market share

#1

Market share

statewide

11% $14B

Revenue - 45%

in Commercial

and Medicare

3M

Members


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GOAL

Reduce opioid overutilization and to promote appropriate opioid utilization through

coordination of care between prescribers and their patients.

Provide prescribers with strategies and resources for proper pain assessment and

treatment of their Health Net members.

Promote the safe use of opioids by sending educational flyer to members

To identify members who have a fill of an opioid on or after the fill date of a medication for

opioid dependence (exclude Medi-Cal/ CalViva, carved out)

INTERVENTION

Intervention criteria: Members must meet one or more of the following criteria over a four-

month period (current age is 20 or older) to be included:

≥ 90 morphine milligram equivalents (MME)/day


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• Concurrent benzodiazepine and Soma use and ≥ 50 morphine milligram

equivalents (MME)/day

• Concurrent medications for opioid dependence and opioids with 30 or more

days of overlap (exclude Medi-Cal/ CalViva, carved out)

• Visited more than 3 physicians or pharmacies

Member opioid outreach: Educational flyer (without a letter): Do You Take

a Drug That Contains Opioids? Also known as pain killers, opiates or

narcotics


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Prescriber intervention: Cover letter that explains the Opioid Utilization

Program and refers to various resources such as MHN, Be In Charge!

(Decision Power’s outreach for Medi-Cal and CalViva Health members), and

Decision Power (outreach for Commercial and Medicare members), plus the

following inserts:

✓ Patient profiles

✓ Utilize PDMP databases to confirm opioid history and concurrent prescribing

by other providers

✓ Guide to appropriate opioid prescribing with resources for opioid prescribers

✓ Optional medication contract that may be customized, signed by patient and

prescriber, and kept in patient’s chart

✓ Fax-back survey to confirm that opioid medications listed are appropriate,

medically necessary, and safe or the regimen should be adjusted.


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GOAL

Adhere to CMS mandates that Medicare Part D plan sponsors implement intensive

management programs to address the overuse of opioid analgesics.

COMMUNICATIONS

MTM pharmacists conduct utilization reviews and receive Member Services transfers to

speak with members and their prescribers.

INTERVENTIONS

Intervention criteria: Members are included in this program when they meet any of the

following:

120 mg morphine equivalent dose per day for > 90 days, and are receiving opiates from >

3 pharmacies and prescriptions from > 3 prescribers

Any member identified by CMS

Any member referred through Medicare Drug Integrity Contractors (MEDICs), case

management, MHN, or other organization


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2016 RESPONSE REPORT

BDS – No further review planned: Beneficiary dis-enrolled from contract or lacks Part D eligibility due to

any reason except disenrollment due to death.

BOR – Beneficiary level POS edit not determined necessary: Beneficiary's overutilization resolved.

BXD – No further review planned: Beneficiary has exempt diagnosis.

DMN – Beneficiary level POS edit not determined necessary: Drug(s) and dose(s) are deemed medically

necessary.

INC – Review in progress.

PS1 – Beneficiary level POS edit determined necessary: No drugs allowed in the class.

PS2 – Beneficiary level POS edit determined necessary: One or more drugs in class allowed.


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Count of HICN Column LabelsGrand Total

Row Labels BDS BOR DMN INC PS2

H0351 2 3 4 1 10

H0562 2 9 11

H3237 2 1 3

H3561 3 3

H5520 2 5 7

H6815 1 2 3 6

H9287 2 2

Grand Total 2 1 9 28 2 42

2016 OUTCOMES •42 cases total. We successfully closed 13 cases (30%)•9 members (21%) deemed the regimens medically necessary (DMN)•2 members required POS edits. (PS2)•28 of the cases (66%) are certain follow-ups. (INC)

Opioid – High Dosage Monitored Metric

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Opioid – Multiple ProvidersMonitored Metric

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Opioid – Safe Med LA collaborative

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The Safe Med LA coalition includes County health agencies (e.g., Departments of

Health Services, Mental Health, and Public Health), health plans, physicians,

pharmacists, substance use providers, law enforcement, medical associations,

hospitals, community clinics, prevention coalitions, educators, and other community

stakeholders. It is comprised of a lead Steering Committee and various goal-specific

Action Teams that focus on the 6 priorities and 10 key objectives of the strategic plan.

The Safe Med LA Steering Committee will lead the coalition and collaborative

implementation of this plan through the 9 Action Teams. Action Teams are each

comprised of coalition members that will focus their expertise on specific action items

within the key objectives of the strategic plan.


31


32

The Safe Med LA coalition includes County health agencies (e.g., Departments of

Health Services, Mental Health, and Public Health), health plans, physicians,

pharmacists, substance use providers, law enforcement, medical associations,

hospitals, community clinics, prevention coalitions, educators, and other community

stakeholders. It is comprised of a lead Steering Committee and various goal-specific

Action Teams that focus on the 6 priorities and 10 key objectives of the strategic plan.

The Safe Med LA Steering Committee will lead the coalition and collaborative

implementation of this plan through the 9 Action Teams. Action Teams are each

comprised of coalition members that will focus their expertise on specific action items

within the key objectives of the strategic plan.

Opioid – Smart Care CA collaborative

33

Smart Care CaliforniaSmart Care California is a public-private partnership working to promote safe, affordable health care in California. The group currently focuses on three issues: C-sections, opioid overuse and low back pain. Collectively, Smart Care California participants purchase or manage care for more than 16 million Californians—or 40 percent of the state. Smart Care California is co-chaired by the state’s leading health care purchasers: DHCS, which administers Medi-Cal; Covered California, the state’s health insurance marketplace; and CalPERS. IHA convenes and coordinates the partnership with funding from CHCF.

http://www.iha.org/our-work/insights/smart-care-california/focus-area-c-sections

http://www.iha.org/our-work/insights/smart-care-california/focus-area-opioids

http://www.iha.org/our-work/insights/smart-care-california/focus-area-low-back-pain

Our learnings on promoting safe opioid prescribing practices

Parag Agnihotri MD

Medical Director for Population Health & Post Acute care

Sharp Rees-Stealy Medical Group, San Diego

How do you address this in a large multispecialty medical group with …

1.4 million visits

500+ Physicians

60+ NP/PA

2200 Clinic staff

21 Clinic locations

Internal problem

A segment of population was prescribed..

1.6 million hydrocodone at an average cost of $4M

570,000 oxycodone at average cost of $2M

Key Objectives

1. Reduce by 10% inappropriate use of Opioids Rx

2. Reduce overall Morphine Milligram Equivalent (MME)

3. Preventing overdose: increased use of Naloxone

4. Promote holistic approach for pain management

https://youtu.be/ay5_HgZLDoE

https://youtu.be/ay5_HgZLDoE

Universal Safe Opioid prescribing committee

• Pain Specialist

• Physiatrist

• Primary care

• Pharmacist

• Surgeon

• Data analyst

• Medical Director

Registry on Opioid prescribing

• Practice variation reports

• MME calculation

0

5

10

15

20

25

Top 10% of Prescribers for claims where SHC MME > 90

Dr. A Dr. B Dr. C Dr. D Dr. E Dr. F Dr. G Dr. H Dr. I Dr. J Dr. K Dr. L Dr. M

Morphine Milligram Equivalent (MME)calculation

https://www.easycalculation.com/formulas/opioid-dose-formula.html

Informed Prescribing decisions

Reduce new starts• Prescriber education

• Prescribing patterns

• Pain control agreements

• Easy Access to CURES

• Choosing wisely® material

Reducing overall MME/high dose Opioid

• Safe tapering of high dose of Opioids

• How to calculate MME?

• Access to pain specialist

• EHR embedded Opioid assessment tool

• Urine Drug screen

• Targeted outreach to high volume prescribers

• Personal experience of Physician with MBC

Safe opioid tapering handouts

Opioid assessment tool embedded in EHR

7.21

9.42

34.10

15.59

9.11

26.69

9.72

4.00

1.84

5.92

7.52

1.97

4.73

3.13

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

Site

Cla

ims

pe

r 1

00

0 f

or

MM

E >

90

Provider Region, Provider Site

Practice Variation reports for high dose Opioid prescribing Peer to Peer

shared experiences

Early access to Naloxone Retail Pharmacist able to prescribe

Sharp McDonald CenterOffering Addiction treatment

Turning the tide on opioid prescribing..

0.24%

14.04%

5.22%

11.50%

0.00

2,000.00

4,000.00

6,000.00

8,000.00

10,000.00

12,000.00

14,000.00

Fentanyl Patch Hydrocodone Oxycodone Grand Total

Opioid Type Supply Count per 1,000 HMO Patients

2015 2016

HM

O P

atie

nts

New starts1st prescription for quantity 61-90 pills

0.37

0.28

0.142

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

61-90 pills

2015 2016 2017

24% reduction

4.68

3.03

2.16

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

MME>90

2015 2016 2017 YTD

High dose prescriptions trending downMorphine Milligram Equivalent ≥ 90 Rate Prescriptions written per 1,000

Challenges towards safe opioid prescribing

• Ongoing provider education

• Consumer participation

• Access to Medication Assisted Treatment

• ? Telehealth options for MAT

• Holistic approach to pain and available options

Lessons learned

Key Objectives

1. Reduce by 10% inappropriate use of Opioids Rx

2. Reduce overall Morphine Milligram Equivalent (MME)

3. Preventing overdose: increased use of Naloxone

• Reduce new starts by Provider and Consumer education. Consider using ‘Choosing Wisely®’ material

• Practice variation reports

• Promote CURES

• Peer to Peer experience

• Engage pharmacist

• Promote holistic approach for pain management

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