Third-Party Track: A Tale of Two Companies, National Rx Drug Abuse Summit, April 2-4, 2013, Presentation by Jim Andrews, Dave Smith, Michael Gavin and Ron Mazariegos

1. A
Tale
of
2
Companies
Jim
Andrews
Senior
Vice
President,
Pharmacy
Services,
Healthcare
Solu=ons
Dave
Smith
Divisional
Vice
President,
Risk
Management,
Family
Dollar
Stores
Michael
Gavin
Chief
Strategy
Officer,
PRIUM
Ron
Mazariegos
Claim
Execu=ve,
Arrowpoint
Capital
1

2. Learning
Objec>ves
1. Highlight
opioid
management
methods
available
to
employers
2. Learn
how
and
when
to
leverage
clinical
tools
and
medical
and
legal
strategies
to
curtail
abuse
of
prescrip=on
drugs
3. Describe
the
importance
of
collabora=on
between
workers’
compensa=on
payers
and
pharmacy
benefit
managers
2

3. Disclosure
Statement
• Jim
Andrews
has
no
financial
rela=onships
with
proprietary
en==es
that
produce
health
care
goods
and
services.
• Dave
Smith
has
no
financial
rela=onships
with
proprietary
en==es
that
produce
health
care
goods
and
services.
• Michael
Gavin
has
no
financial
rela=onships
with
proprietary
en==es
that
produce
health
care
goods
and
services.
• Ron
Mazariegos
has
no
financial
rela=onships
with
proprietary
en==es
that
produce
health
care
goods
and
services.
3

4. Third
Party
Payer
Track:
A
Tale
of
Two
Companies
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate
Dave
Smith
Jim
Andrews,
R.Ph.
Family
Dollar
Stores,
Inc.
Healthcare
Solu=ons
Divisional
VP
of
Risk
Management
EVP
of
Pharmacy
Services

5. Disclosure
Statement
Jim
Andrews,
EVP
of
Pharmacy
Services
with
Healthcare
Solu<ons,
and
Dave
Smith,
Divisional
VP
of
Risk
Management
with
Family
Dollar,
have
no
financial
rela<onships
with
proprietary
en<<es
that
produce
health
care
goods
and
services.
5

6. Topics
of
Discussion
• Introduc=ons
and
corporate
overviews
• The
na=onal
challenge:
opioid
abuse
epidemic
• Three
steps
to
fight
drug
abuse
• How
Family
Dollar
is
mee=ng
the
challenge
– Three
phases
of
program
development
– Program
results
– CPRx™
-­‐
Medicare
Set-­‐Aside
(MSA)
case
studies
• The
future
of
pharmacy
benefit
management
6
6

7. Family
Dollar
Stores,
Inc.
Corporate
Overview
CharloMe,
NC
based
stores
offering
quality
merchandise
at
everyday
low
prices,
in
easy-­‐to-­‐shop
neighborhood
loca>ons
• 54
year
anniversary
• Fortune
300
company
• 7,700+
stores
– “Small
Box”
– One
new
store
every
17
hours
– 1
to
3
team
members
staff
the
stores
– 1
billion
customers
per
year
• 11
distribu=on
centers
• 45
states
• 55,000
team
members
• Annual
sales
in
excess
of
$10
billion
7

8. Healthcare
Solu>ons
Corporate
Overview
Healthcare
Solu>ons,
the
parent
company
of
Healthcare
Solu>ons,
ScripNet
&
Procura
Management,
is
a
health
services
company
delivering
technology-­‐based
solu>ons
to
the
workers’
compensa>on
&
auto
casualty
markets.
Pharmacy
Benefit
Management
(PBM)
Program
Stringent
cost
and
u/liza/on
management
controls
produce
maximum
program
savings,
efficient
claims
handling
&
op/mal
clinical
outcomes.
Prospec>ve
Concurrent
Retrospec>ve
• Network
Management
• Customized
• Rx360™
Formularies
– Paper
Bill
Management
• Outreach/Enrollment
– Physician
Dispensing
– 850+
employees
Services
• POS
Administra>on
– Compound
&
Re-­‐
– First
Fills
&
Dynamic
Packaged
Drugs
– 750+
valued
customers
– Generic
Enforcement
Enrollment
– ProDUR
Rx™
/
Clinical
– Non-­‐Retail
Network
– URAC
accredited
– Card
Administra=on
Edi=ng
Billing
with
Persistent
– SSAE
16
compliant
– Prior
Authoriza=on
Outreach
Management
• Clinical
Rx™
– 30%
revenue
growth
year
over
year
– Conversion
to
Home
– Academic
Detailing
Delivery
– Therapeu=c
– End-­‐to-­‐end
WC
solu=ons
Subs=tu=ons
• Regulatory
&
– Narco=cs
Management
Compliance
Oversight
– Drug
Urinalysis
Tes=ng
– Physician
Reviews
8
8

9. 9
9

10. Iden/fy:
Substance
Abuse
is
an
Epidemic
• 8.7%
of
the
American
popula=on
used
an
illicit
drug
or
prescrip=on
drug
non-­‐medically
in
the
past
Non-­‐medical
use
=
month1
use
without
a
prescrip/on
of
the
individual's
own
or
• 2.4%
of
the
American
popula=on
used
prescrip=on
simply
for
the
experience
or
drugs
non-­‐medically
in
the
past
month1
feeling
the
drugs
caused
– Pain
relievers:
4.5
million
– Tranquilizers:
1.8
million
– S=mulants:
970,000
– Seda=ves:
231,000
• In
2010,
there
were
more
deaths
related
to
drug
overdoses
than
motor
vehicle
crashed
for
the
first
=me2
• Among
the
prescrip=on
drug
deaths,
opioids
are
involved
in
close
to
75%3
Sources:
1
Source:
Substance
Abuse
and
Mental
Health
Services
Administra=on,
Results
from
the
2011
Na<onal
Survey
on
Drug
Use
and
Health:
Summary
of
Na<onal
Findings,
NSDUH
Series
H-­‐44,
HHS
Publica=on
No.
(SMA)
12-­‐4713.
Rockville,
MD:
Substance
Abuse
and
Mental
Health
Services
Administra=on,
2012.
2NCHS
Data
Brief,
December,
2011.
Updated
with
2009
and
2010
mortality
data.
3CDC,
Na=onal
Center
for
Health
Sta=s=cs,
Na=onal
Vital
Sta=s=cs
System.
10
10

11. Iden/fy:
Substance
Abuse
among
the
Employed
• 75%
of
all
adult
illicit
drug
users
• 38%
to
50%
of
all
workers’
compensa=on
are
employed
claims
are
related
to
substance
abuse
in
the
workplace
• When
compared
to
non-­‐substance
abusers,
substance-­‐abusing
employees
are
more
likely
to
be
involved
in
a
workplace
accident
• Substance
abusers
file
three
to
five
=mes
as
many
workers’
compensa=on
claims
• Opioid
abusers
generate,
on
average,
annual
direct
health
care
costs
8.7
=mes
higher
than
nonabusers2
Preven/ve
Measures:
Pre-­‐employment
and
employment
drug
tes=ng
Sources:
Why
You
Should
Care
About
Having
A
Drug-­‐Free
Workplace
Fact
Sheet.
Drug-­‐Free
Workplace
Kit.
U.S.
Department
of
Health
and
Human
Services,
Substance
Abuse
and
Mental
Health
Services
Administra=on.
'Working
Partners',
Na=onal
Conference
Proceedings
Report:
sponsored
by
U.S.
Dept.
of
Labor,
the
SBA,
and
the
Office
of
Na=onal
Drug
Control
Policy.
Substance
Abuse
and
Mental
Health
Services
Administra=on,
Center
for
Behavioral
Health
Sta<s<cs
and
Quality,
Na<onal
Survey
on
Drug
Use
and
Health,
2007
–
2010
2White
AG,
Birnbaum,
HG,
Mareva
MN,
et
al.
Direct
costs
of
opioid
abuse
in
an
insured
popula=on
in
the
United
States.
J
ManagCare
Pharm
2005;11(6):469-­‐479.
11

12. Iden/fy:
Aberrant
Behavior
linked
to
Abuse/Diversion
Source
of
Prescrip>on
Pain
Relievers
Source
When
Obtained
by
Used
Non-­‐medically
Friend
or
Rela>ve
From
Friend
or
Rela=ve
for
3.1%
.2%
.2%
Free
.3%
.3%
.2%
1.3%
1.9%
1.9%
From
One
Doctor
.2%
2%
5.5%
4.2%
5.7%
3.9%
Bought
from
Friend
or
Rela=ve
4.8%
Took
from
Friend
or
Rela=ve
without
Asking
Bought
from
Drug
Dealer
or
Other
Stranger
16.6%
Some
Other
Way
54.2%
From
More
Than
One
Doctor
18.1%
81.6%
Bought
on
the
Internet
Wrote
Fake
Prescrip=on
Diversion
from
only
one
doctor
Stole
From
Doctor's
Office,
Clinic,
Hospital,
or
Pharmacy
Source:
Substance
Abuse
and
Mental
Health
Services
Administra=on,
Results
from
the
2011
Na<onal
Survey
on
Drug
Use
and
Health:
Summary
of
Na<onal
Findings,
NSDUH
Series
H-­‐44,
HHS
Publica=on
No.
(SMA)
12-­‐4713.
Rockville,
MD:
Substance
Abuse
and
Mental
Health
Services
Administra=on,
2012.
12

13. Iden/fy:
Heavily
Abused
Medica>ons
In
2011
there
were
483,000
new
non-­‐
medical
users
of
OxyCon>n4
Top
Abused
2009
WC
Rank
2010
WC
Rank
by
Controlled
Substance
Medica>ons1
by
Cost2
U>liza>on3
Oxycodone
1
5
CII
Alprazolam
Not
in
top
50
33
CIV
Hydrocodone
3
1
CIII
Methadone
Not
in
top
50
53
CII
Clonazepam
Not
in
top
50
38
CIV
Lorazepam
Not
in
top
50
58
CIV
Carisoprodol
18
15
CIV
Morphine
38
29
CII
Zolpidem
21
17
CIV
Diazepam
Not
in
top
50
22
CIV
Fentanyl
13
28
CII
1:
2008:
Na=onal
Es=mates
of
Drug-­‐Related
Emergency
Department
visits,
Office
of
Applied
Studies,
Substance
Abuse
and
Mental
Health
Services
Administra=on,
2011
2:
Lipton
B,
Laws
C,
and
Li
L.
Workers
Compensa=on
Prescrip=on
Drug
Study:
2011
Update.
NCCI.
August
2011
3:
Healthcare
Solu=ons
Data
4:
Substance
Abuse
and
Mental
Health
Services
Administra=on,
Results
from
the
2011
Na<onal
Survey
on
Drug
Use
and
Health:
Summary
of
Na<onal
Findings,
13
NSDUH
Series
H-­‐44,
HHS
Publica=on
No.
(SMA)
12-­‐4713.
Rockville,
MD:
Substance
Abuse
and
Mental
Health
Services
Administra=on,
2012
13

14. Iden/fy:
Drug
Mix
Differences
in
Claim
Age
Developing
Claims
Mature
Claims
14
2012
Healthcare
Solu=ons
Drug
Trends
Report
14

15. Iden/fy:
High
Opioid
U>liza>on
96 mg/person in 1997
698 mg/person in 2007
Enough for every American to take
5mg Vicodin every 4 hrs for 3 weeks
The share of claims
receiving narcotics
within one year after
injury has increased
National Vital Statistics System, multiple cause of death data set and Drug Enforcement Administration ARCOS System
Report of the International Narcotics Control Board for 2005. United Nations, NY. 2006
Laws C,. Narcotics in Workers Compensation Drug Study: 2012 Update. NCCI. May 2012
15

16. Communicate:
Predic>ve
Markers
in
Opioid
Therapy
↑
Disability
dura/on
Opioid
use
in
first
15
↑
Medical
costs
days
↑
Risk
of
surgery
(3
fold)
↑
Late
opioid
use
(6
fold)
↑
Costs
↑
Lost
/me
from
work
When
2
or
more
↑
Dura/on
of
paid
temporary
disability
prescrip>ons
for
↑
Indemnity
opioids
present
↑
AQorney
involvement
↑
Open
claim
Opioids
with
over
100
↑
Accidental
overdose
morphine
equivalents
↑
Morbidity
and
mortality
(8.9
fold)
per
day
Source:
Swedlow
A,
Gardner
LB,
Ireland
J,
Genovese,
E.
Pain
Management
and
the
Use
of
Opioids
in
the
Treatment
of
Back
Condi=ons
in
the
California
Workers’
Compensa=on
System.
CWCI
June
2008
Webster
BS,
Verma
SK,
Gatchel
RJ.
Rela=onship
Between
Early
Opioid
Prescribing
for
Acute
Occupa=onal
Low
Back
Pain
and
Disability
Dura=on,
Medical
costs,
Subsequent
Surgery
and
Late
Opioid
Use.
Spine.
2007.
32
(19)
2127-­‐2132.
Bohnert
AS,
Valenstein
M,
Blair
M,
et
al.
Associa=on
Between
Opioid
Prescribing
Paterns
and
Opioid
Overdose-­‐Related
Deaths.
JAMA.
2011
305:1315-­‐1321
16
16

17. Communicate:
Early
and
High
Dose
Opioid
Use
Changes
in
Narco>c
Potency
in
Daily
Morphine
Equivalents
as
a
Claim
Ages
Source:
Laws
C.
Narco=cs
in
Workers
Compensa=on.
NCCI.
May
2012
2012
Healthcare
Solu=ons
Trends
Report
17

18. Coordinate:
Best
Prac>ces
in
Opioid
Therapy
Pa>ent
Selec>on
Ini>al
Pa>ent
Alterna>ves
to
Assessment
Opioid
Therapy
Trial
of
Opioid
Therapy
Conversion
to
Long-­‐Ac>ng
Opioid
Pa>ent
Reassessment
Exit
Strategy
Opioid
Rota>on
Con>nued
Opioid
Therapy
18
18

19. Coordinate:
Physician
Interven>on
• CPRx™
program
uses
licensed,
prac=cing
physicians
to
review
injured
workers’
medical
and
prescrip=on
histories
Drug
Decisions
• Physicians
examine:
Wean
– Appropriateness
of
regimen
to
diagnosis
12%
– Long-­‐term
pharmacological
effects
16%
37%
Approved
– Poten=al
drug
interac=ons
Confirmed
DC
– Denial
or
approval
of
current
regimen
11%
Discon=nue
– Pa=ent
compliance
24%
Unrelated
– Relatedness
of
regimen
to
claim
• Automated
reports
provide
recommenda=ons
for
CPRx
based
on
weighted
red
flag
triggers
• Follow-­‐up
by
telephonic
nurse
support
helps
to
ensure
compliance
with
the
agreed
upon
changes
to
the
injured
worker’s
medica=on
therapy
plan
19

20. Mee<ng
the
Challenge:
Family
Dollar’s
Pharmacy
Benefit
Management
Program
20
20

21. Casualty
Claims
Profile
Annually
• 8,400
workers’
compensa=on
(WC)
incidents
– 1,400
pending
• 10,800
general
liability
incidents
– 1,250
pending
Most
expensive
claim
in
the
past
10
years
• 2003
WC
claim:
$3.2
million
– $2
million
in
pharmacy
Annual
loss
pick
• ~$80
million
21

22. Mee>ng
the
Challenge:
Three
phase
program
to
fight
WC
drug
abuse
Phase
III
Phase
II
CPI
Phase
I
Proac>ve/Opportuni>es
Refinement/MSAs
Best
Prac>ces
Program
Design
2008
-­‐
2011
Assessment
2007
22
22

23. Phase
One:
WC
Medical
Assessment
Family
Dollar
2007
Expert
Partners
• Total
WC
medical
spend
was
51%
of
total
claim
• Prescrip=on
cost
was
21%
of
total
WC
medical
spend
Benchmarking
Measurement
• Industry
benchmark
• PBM
reports
• Ourselves
Goals
23
23

24. Phase
Two:
Pharmacy
management
program
design
Phase
I
Phase
III
• Healthcare
Solu=ons
2008
• GL
MSAs
• Sedgwick
2009
• California
custom
MPN
• Low
hanging
fruit
• Health
and
wellness
• Health
insurance
Phase
II
• Legacy
claims
Phase
III
• Pharmacy
nurse
Proac>ve
Phase
II
• Formulary
management
Refinement/MSAs
management/
opportuni>es
(tradi=onal
and
non-­‐ Phase
I
CPI
subscriber)
Best
prac>ces
• Ac=ve
prescrip=on
review
• MSAs/forensics
Program
Design
2008
-­‐
2011
Assessment
2007
24
24

25. Family
Dollar
CPRx™
Results
Physician
interven>on
program
CPRx
Program
Summary
Number
of
CPRs
Completed
18
Total
Number
of
Drugs
Reviewed
112
Drugs
Not
Recommended
by
Reviewer
82%
of
drugs
Discussion
Rate
69%
of
drugs
Trea=ng
Physician
and
Reviewer
in
Agreement
60%
of
drugs
CPRs
with
Agreement
to
make
a
change
50%
of
CPRs
Actual
ROI
To-­‐Date
$4.31
:
$1
25
25

26. CPRx
Case
Study
#
1
Injured
team
member
• 46
year
old
female
with
November
29,
2008
DOI
• Low
back
injury
with
previously
failed
fusion
surgery
and
failed
injec=on
trials
• Prescrip=on
drug
cost
to
date:
$16,159
• Prescrip=on
drug
therapy:
– Cyclobenzaprine
-­‐
muscle
relaxant
– Endocet
-­‐
opioid
/
pain
medica=on
– Fentanyl
(generic
Duragesic
Patch)
–
opioid
/
pain
medica=on
– Meloxicam
–
NSAID
– Tramadol
–
opioid
/
pain
medica=on
Resolu>on:
All
medica>ons
discon>nued.
Tramadol
is
the
only
drug
filled
in
the
previous
6
months
and
was
last
filled
in
November
2012
26
26

27. CPRx
Case
Study
#
2
Injured
team
member
• 41
year
old
male
with
May
11,
2010
DOI
• Pa=ent
was
lixing
several
cases
when
he
strained
the
lex
side
of
his
lower
back
• Prescrip=on
drug
cost
to
date:
$23,115
• Prescrip=on
drug
therapy:
– Gabapen=n
–
an=convulsant
/
neuropathic
pain
– Kadian
–
opioid
/
pain
medica=on
– Norco
–
opioid
/
pain
medica=on
– Relistor
–
cons=pa=on
medica=on
– Cymbalta
–
An=depressant
/
neuropathic
pain
– Neuropathic
cream
–
topical
analgesic
Resolu>on:
Gabapen>n,
Relistor
and
Cymbalta
have
been
discon>nued.
Kadian
has
been
switched
to
the
generic,
morphine
sulfate
and
reduced
in
quan>ty
since
December,
2012
27
27

28. Family
Dollar’s
Success
• Total
WC
medical
spend
was
51%
of
total
• Total
WC
medical
spend
is
37.8%
of
total
claim
claim
expense
(25%
reduc=on
from
• Prescrip=on
cost
was
21%
of
total
WC
2007)
medical
spend
• Prescrip=on
costs
are
11.7%
of
total
WC
• Family
Dollar’s
goal:
reduce
pharmacy
claim
expense
(48%
reduc=on
from
2007)
spend
to
14%
• Family
Dollar’s
current
goal
is
to
reduce
pharmacy
spend
to
9%
• Medicare
Set-­‐Aside
savings
of
$2,808,616
• Pharmacy
costs
are
19.5%
• Average
medical
expense
is
60%
of
the
total
WC
claim
cost
28
28

29. Mee/ng
the
Challenge:
Where
Is
Family
Dollar
in
the
Three
Stage
Process?
Phase
III
Phase
II
CPI
Phase
I
Proac>ve/Opportuni>es
Refinement/MSAs
Best
Prac>ces
2013
Program
Design
2008
-­‐
2011
Assessment
2007
29

30. Phase
Three:
Con>nual
Process
Improvement
(CPI)
Explora>on
of
opportuni>es
Review
• Maintain
sen=nel
effect
on
u=liza=on
and
cost
trending
• Monitor
jurisdic=onal
regula=on
• Iden=fy
opportuni=es
–
Legacy
claims
Modify
Monitor
– Jurisdic=onal
MPN
expansion
– Corporate
culture
– Health
insurance
– Educa=on
and
training
30
30

31. Family
Dollar’s
Con>nuing
Opportuni>es
Open
WC
claims
1,397
2013
trended
WC
Medical
Total
incurred
pharmacy
Profile
losses
expense:
2-­‐28-­‐2013
$125
Million
$4.3
Million
2013
trended
medical
expense:
$48
Million
31
31

32. The
Future
of
Pharmacy
Management
Transac>onal
Services
Analy>cal
Services
Strategic
Services
• Card
administra=on
• Program
benchmarking
• Customized
strategy
development
• POS
processing
• Quality
measurement
• Regulatory/compliance
oversight
• Home
delivery
• Ad
hoc
repor=ng
• Program/product
development
Impact
on
Program
Effec>veness
• Paper
bill
processing
• Formulary
management
• Outcomes
measurement
• Call
center
support
• Clinical
management
• Payment
and
billing
• Transac=onal
audi=ng
• Network
administra=on
• State
repor=ng
• Provider
communica=ons
Impact
on
Expenditures
Transac>onal
Services
Analy>c
Services
Strategic
Services
32
32

33. Thank
You
Dave
Smith
Family
Dollar
Divisional
VP
of
Risk
Management
DSmith2@FAMILYDOLLAR.com
Jim
Andrews,
R.Ph.
Healthcare
Solu=ons
EVP
of
Pharmacy
Services
Jim.andrews@healthcaresolu=ons.com
33

34. Arrowpoint
Capital
• 150-­‐year-­‐old
organiza=on
• Acquired
US
opera=on
of
Royal
&
SunAlliance
USA
in
2007
• Experience
in
run-­‐off
insurance
business
• “Redefining
success”
by
developing
and
execu=ng
comprehensive
solu=ons
to
manage
claims
and
sa=sfy
policyholder
obliga=ons.

35. Claim
Resolu>on
Assessment
Ac>ons
Results
• Inventory
of
121,000
claims,
• Iden>fied,
capitalized
on
rapid
• Reduced
inventory
by
92%
to
including:
resolu>on
opportuni>es
<12,000
maMers
• >35,000
workers
comp
cases
• Streamlined
and
centralized
physical
handled
by
403
adjusters
• Centralized
claim
management
office
loca>ons
to
1
• >10,000
cases
in
li=ga=on
• Enhanced
data
tracking
and
repor>ng
• Developed
a
standardized
claim
handled
by
10
offices
through
the
Data
Hut
transfer
and
integra>on
process
• Staff
located
in
29
offices
• Ensured
‘best
prac>ce’
claims
from
underperforming
TPAs
and
handling
with
full-­‐service
capabili>es,
disposals
• Bi-­‐furcated,
mul>-­‐layered
management
structure
with
liMle
cross-­‐func>onal
interac>on
• Transi=oned
4,000
claims
to
governance
and
control
• Implemented
li>ga>on
management
direct
handling
• Several
high-­‐cost
specialized
strategy
• Converted
>15,000
legal
files
from
internal
units
• Cost
controls
through
>me-­‐and-­‐expense
to
flat
fee
reduc=on
in
law
firms
• Improved
data
sharing,
analysis,
• Lack
of
comprehensive
data-­‐ • Re-­‐engineered
legal
bill
review,
profiling
and
segmenta>on
sharing
capabili>es,
tools
process
–
flat
fees
• Leveraged
a
mul>-­‐disciplinary
• >3000
external
lawyers
handling
• Specialized
technology
approach
to
handling
complex
claims
with
hourly
billing
• Introduced
new
TPA
management
maMers
• >80
TPAs
with
services
cos>ng
func>on
• Retained
key
staff
and
cri>cal
$10m
annually
• Outsourced
specialized
func>ons
knowledge
• Limited
interac>on
with
Actuarial,
• Medical
case
management
Reinsurance,
other
func>ons
• Inves=ga=on
services
• Subroga=on
and
recovery

36. Claim
Resolu>on
Strategy
Key
Drivers
• Medical
Management
• Claim
Inves=ga=on
• Legal
Strategy
• Setlement
Ini=a=ves
• Li=ga=on
Management
• Data
Management

37. Medical
Management
=
Data
Management
Iden=fica=on
and
segmenta=on
of
high
value,
high
exposure
claims:
• Age
of
claimant
• Occupa=on
• Type
of
injury
• Current
medical
treatment
• Current
Rx
regimen
• Future
recommended
medical
treatment
(i.e.,
spinal
injec=ons,
physical
therapy,
surgery)
• Unrelated
co-­‐morbidi=es
and
condi=ons
• Medical
provider
discipline
• Setlement
Opportunity
– Indemnity
– Medical
– Both
– MSA
or
not

38. Medical
Management
-­‐
Tools
PRIUM
• U=liza=on
Reviews
• Comprehensive
Clinical
Assessments
• Medical
Director
Reviews
PMSI
–
Pharmacy
Benefit
Management
Vendor
• Peer-­‐to-­‐Peer
Reviews
• Durable
Medical
Equipment
• Drug
Monitoring
Program
G4S
–
Inves>ga>ons
MHayes
–
Cer>fied
Case
Management
Crowe
Paradis
–
Medicare
Vendor
• Medicare
Set-­‐Asides
• Condi=onal
Liens
Atlas
–
Structured
SeMlement
Vendor

39. Medical
Management
-­‐
Adjuster
Ensure
ongoing
communica>on
with
the
aMending
physician
regarding
the
medical
treatment
being
rendered
to
the
injured
worker
(where
permiMed):
• Clearly
defined
and
updated
treatment
plan?
• Drug
Monitoring
–
Urinary
analysis,
pill
counts,
patch
counts
• Narco=c
Agreement
in
place?
• Conference
calls
with
the
trea=ng
provider,
face-­‐to-­‐face
scheduled
mee=ngs
with
the
provider
and/or
the
IME
physician.
• Understand
the
applicable
state
guidelines
and
evidence-­‐based
medicine
(i.e.,
ODG,
ACOEM).
• Outreach
leters
to
the
provider
–
referencing
guidelines
• Con=nuous
medical
educa=on
–
Lunch
&
Learns,
Summits,
etc.

40. Medical
Management
–
State
Specific
CA
-­‐
Establishment
of
Specifically
Designed
Medical
Provider
Network
(MPN)
and
Pharmacy
Benefit
Network
(PBN)
• EK
Health
–
Medical
Provider
Network
• PMSI
–
Pharmacy
Benefit
Manager
TX
-­‐
ODG
N-­‐Drug
Project
• PRIUM
₋ No=fica=on
to
the
injured
worker
and
prescribing
physician
of
the
Closed
Formulary
changes
to
take
place
on
September
1,
2013.
₋ Conference
calls
with
the
prescribing
physician
with
Claims
on
conference
call.
₋ Follow
up
writen
agreements
to
wean
and
change
treatment
plans.
DE
-­‐
Ensuring
Prescrip>ons
are
Filled
In-­‐Network
• Boone
vs.
SYAB
Services,
2012
Del.
Super.
LEXIS
407
–
The
Delaware
Superior
Court
held
that
the
Delaware
Industrial
Accident
Board
had
the
authority
to
require
a
claimant
to
use
an
employer’s
preferred
prescrip>on
plan
rather
than
receive
medica>ons
via
physician
dispensing.
• Leters
to
providers,
claimants
and
counsel
advising
them
will
not
pay
for
out-­‐of-­‐network
Rx.
PA
–
UR
of
Highly
Addic>ve
Narco>cs
on
Chronic
Opioid
Claimants
• Bedford
Somerset
MHMR
v.
Workers'
Comp.
Appeal
Bd.
(Turner),
51
A.3d
267;
2012
Pa.
Commw.
LEXIS
261
(2012):
The
Appellate
Court
reversed
the
full
Board’s
decision
and
reinstated
the
the
WCJ
decision
which
determined
the
highly
addic=ve
nature
of
the
Fentanyl
lozenges
as
evidenced
by
Claimant's
increased
use
of
the
medica=on
and
rendered
it
unreasonable
and
unnecessary
where
an
alterna>ve
treatment
plan
could
be
implemented.

41. Claim
Inves>ga>on
• SONAR
(Specialized
Online
Networking
Advanced
Research)/Social
Media
• Claim
Index
Bureau
every
6
months
• Surveillance
(when
appropriate)
• Criminal
Background
• DMV
• Dunn
&
Bradstreet
• State
Records
• Area
Canvas
• Alive
and
Well
(leter
vs.
in
person)
• Con=nuance
of
Disability
(in
person)

42. Claim
Inves>ga>on
in
Ac>on
• Claimant
residing
in
Florida
travels
to
Long
Island,
NY
once
a
year
to
see
his
doctor
and
get
prescrip=ons
filled.
• Doctor
writes
three-­‐month
refills
of
Oxycon=n
and
Vicodin
and
fills
via
phone
call
from
claimant
to
front
desk.
• No
visit,
no
examina=on.
No
evidence
of
drug
monitoring
(urinary
analysis,
pill
counts,
narco=c
agreement)
being
performed.
• When
asked
why
drug
monitoring
tools
not
being
used,
doctor
becomes
extremely
defensive.
• SONAR
inves=ga=on
ini=ated
(medical
record
review
and
Peer-­‐to-­‐
Peer).
• CCA
–
medical
records
indicate
claimant
unable
to
func=on.
• BUT
.
.
.

43. Claim
Inves>ga>on
• SONAR
Inves=ga=on
yields
claimant’s
Facebook
photos

44. SeMlement
Ini>a>ves
• Over
300
New
York
claims
reviewed
and
targeted
for
resolu=on.
• Setlement
counsel
retained
to
perform
claim
data
analysis,
provide
claim
file
review
and
assessment,
and
handle
all
logis=cal/back-­‐office
aspects.
• Conferences
scheduled
at
various
Workers’
Compensa=on
Boards
throughout
New
York
–
Manhatan,
Long
Island,
Peekskill,
and
Syracuse.
It
Takes
a
Village.
.
.
On-­‐site
team
• Defense
counsel
( jurisdic=onal
knowledge)
• Setlement
counsel
• MSA
service
provider
• Structured
setlement
vendor
• Claims
Management
Feed
them
and
they
will
come!

45. SeMlement
Ini>a>ves
• Adver=se
–
Differen=ate
• Adver=sed
on
the
NY
Injured
Workers’
Bar
website
as
well
as
the
various
Boards.
• 134 invitations
Don’t
just
 *61 RSVP’s
 2 no-show
send
leter!
• 6 settled before
Call,
Fax,
initiative began
Email
• 3 were not settled

46. Medical/Legal
Summit
• Three
summits
held
to
date.
• Approximately
120
insurance,
legal,
and
medical
professionals
and
consultants
from
around
the
country
gathered
for
Arrowpoint
Capital’s
2012
Medical/
Legal
Summit
in
mid-­‐June
2012.
• More
than
30
defense
counsel
from
23
law
firms
atended
from
states
as
far
away
as
California,
Wisconsin,
and
New
Hampshire.
• Presenters
included
Arrowpoint’s
WC
claims
management
team,
along
with
delegates
from
some
of
its
WC
claims
service
provider
partners,
and
na=onally
recognized
expert
Dr.
Andrew
Kolodny.

47. Medical/Legal
Summit
Topics
• Medical
treatment
and
alterna=ve
therapies
for
trea=ng
chronic
pain,
coordina=on
of
care,
figh=ng
fraud
inside
the
pill
mill,
monitoring
long-­‐term
opioid
use,
Medicare
and
secondary
payer
rules
and
regula=ons,
and
Key
States
• Medical
treatment
updates
• “Ask
a
Doctor”/
“Ask
a
Pharmacist”/
“Ask
a
DME
Specialist”
/
“Ask
a
Registered
Nurse”
sessions
• Actual
case
studies
presented
by
each
team
on
the
Summit’s
last
day

48. Selec>on
of
Counsel
• Defense
Counsel
vs.
Setlement
Counsel
• Develop
Resolu=on
Strategies
• Stay
informed!
Review
recent
case
law
and
statute
updates.
• In
NY,
use
the
law
to
your
favor,
e.g.,
Labor
Market
Atachment,
Medical
Treatment
Guidelines,
RFA,
C8.1.
• Conduct
discovery!
Deposing
the
atending
physicians,
claimants
and
other
witnesses
can
yield
useful
informa=on.
• Appor=onment/subroga=on/third-­‐party
ac=ons
• Consult
ODG
and
ACOEM
Guidelines
• Conduct
IME’s,
UR’s

49. PRIUM
• Established
in
1987
primarily
as
a
u>liza>on
review
organiza>on
– Perform
UR
na=onwide
and
this
remains
a
core
competency
– Experience
in
u=liza=on
review
allows
for
a
unique
perspec=ve
on
both
medical
and
legal
avenues
– Work
primarily
within
the
Workers
Compensa=on
space,
but
also
do
liability
• Recogni>on
and
shiy
towards
pharmaceu>cal
therapy
– Recognized
overprescribing
in
the
early
2000’s
– Developed
a
product
line
of
reviews
to
help
combat
the
issue
– Focus
on
physician
led
interven=on
with
peer-­‐to-­‐peer
reach
out

50.  Culture
of
over-­‐treatment
 Reimbursement
methodology
favors
treatment
over
preven=on
 Interven=onal
procedures
(vs.
cogni=ve
medicine)
drive
economics
 Influence
of
big
pharma
 Total
sales
of
Oxycon=n
in
1996:
$45
million
 Total
sales
of
Oxycon=n
in
2009:
$3
billion
 Lack
of
predictability
in
claims
management
 Who
can
handle
90
days
of
hydrocodone
without
issues?
 Who
will
end
up
dependent
on
the
medica=on?
 Co-­‐morbidi>es
 Growing
in
number
and
complexity
 Each
one
gets
its
own
drug!

51.  Statutes:
Laws
passed
by
legislators
and
signed
by
governors
 Regula>ons:
Rules
developed
by
regulatory
agencies
 Case
Law:
Judicial
decisions
resul=ng
from
challenges
to
either
statutes
or
rules/regula=ons
or
from
the
dispute
resolu=on
process

52.  Ex
Parte
Communica>on
 Medical
Treatment
Guidelines
 U>liza>on
Review
/
IME
 Directed
Care
 Physician
Dispensing
 Prescrip>on
Drug
Monitoring
Programs
(PDMPs)

53.  “Prohibited”:
Mississippi,
Illinois,
New
Mexico,
Colorado,
Connec>cut,
South
Dakota
 Restricted:
Nevada,
New
Hampshire,
Alaska,
Minnesota,
North
Carolina,
South
Carolina
 All
other
jurisdic>ons:
No
restric>ons
on
interac>ng
with
trea>ng
physicians

54.  Evidence-­‐Based,
Na>onally
Recognized
(e.g.,
ODG,
ACOEM)
 Texas
 Nevada
 Oklahoma
 California
 New
Mexico
 Utah
 Hawaii
 North
Dakota
 Vermont
 Kansas
 Ohio
 Wyoming
 Missouri
 Consensus-­‐Based,
Locally
Developed:
 Arkansas
 Maryland
 New
York
 Colorado
 Maine
 Oregon
 Connec=cut
 Massachusets
 Rhode
Island
 Delaware
 Minnesota
 Washington
 Louisiana
 Arizona,
Tennessee:
Under
Virginia
Montana
 West
considera<on

55.  Statutorily
Required
and/or
Recognized:
22
states
with
17
of
those
statutes
lending
some
real
authority
for
the
payer
 Medica>on-­‐specific:
Texas,
Tennessee,
Washington,
West
Virginia,
Ohio

56.  Case
Study:
Texas
 Statute:
HB
7
passed
in
2005
 Rules:
Texas
Administra>ve
Code
Title
28,
Part
2,
Chapter
134,
Subchapter
F,
Rule
134.500
Ini<al
results:
60%+
drop
in
Open
Formulary
for
DOI
N
drug
scripts
prior
to
9/1/11
Two
year
remedia<on
9/1/11
period
for
legacy
9/1/13
Open
Formulary
claims
Closed
Formulary
for
for
all
DOI
all
DOI
Closed
Formulary
for
DOI
a^er
to
9/1/11

57.  Considera>ons:
 Claim
life
cycle
 Networks
 Panel-­‐driven
 Regulatory
order
of
opera=ons
 Fundamental
Goal
 Don’t
overlook
an
opportunity
to
remove
an
injured
worker
from
the
care
of
a
physician
that
is
failing
to
provide
evidence-­‐based
care

58.  Prohibited:
 Allowed:
 Silent:
 Massachusets
 Arizona
 Connec=cut
 New
York
 California
 Indiana
 Texas
 Georgia
 Illinois
 Illinois
 Maryland
 Restricted:
 Michigan
 Arkansas
Recommenda<on:
 North
Carolina
 Florida
Focus
on
pricing,
not
 Pennsylvania
prac<ce
 Louisiana
 South
Carolina
 Maryland
 Tennessee
 Minnesota
 Virginia
 New
Jersey
 Wisconsin
Source:
WCRI
Study,
July
2012

59.  Status:
 43
states
have
programs
up
and
running
 6
addi=onal
states
have
programs
authorized,
but
not
yet
func=onal
 No
Program:
 Missouri
 Mandatory
Use
of
PDMP
by
Physician/Prescriber:
 Kentucky
 Massachusets
(first
script
for
schedule
II
or
III
drug
only)

60. Statute/Rule
Op>mal
for
Limi>ng
Rx
Drug
Your
State?
Overu>liza>on
Ex
Parte
Allowed,
no
restric=ons
?
Communica=on
Medical
Treatment
Na=onally
recognized
guidelines
?
Guidelines
mandated
U=liza=on
Review
Mandatory
UR
?
Direc=on
of
Care
Allowed
?
Physician
Dispensing
Restricted
pricing
?
PDMP
Program
in
place;
?
Mandatory
search
prior
to
Rx

61.  Physician
Engagement:
Do
not
assume
the
trea=ng
physician
is
the
enemy...
un=l
the
trea=ng
physician
is
the
enemy.
 Follow
up,
follow
up,
follow
up:
Engagement
is
not
a
“one
=me”
event...
treatment
changes
are
difficult
and
must
be
monitored.
 Leverage
technology:
PBMs
can
help
to
closely
monitor
and
customize
medica=on
regimens...
use
the
technology
available!
 Have
a
Plan
B:
Collegial
engagement
doesn’t
always
work...
know
what
your
op=ons
are
if
voluntary
engagement
fails.