Overview of New DSHS Drug and Alcohol Programs, PRR Program, and ER Initiative– What Physicians, Hospitals & Commun

1. Overview of New DSHS Drug and Alcohol Programs, PRR Program, and ER Initiative– What Physicians, Hospitals & Communities Need to Know Presenters Jeff Thompson, MD Phyllis Coolen, RN, MN Dan Dowler, MSW (MPH) David Mancuso, Ph.D. DSHS Health and Recovery Services Administration and Research and Data Analysis Division July 6, 2006

2. Objectives • Understand the issues facing Medicaid related to narcotics and integration of services • Review the work to date • Understand the tools available • Discuss additional opportunities to partner

3. Overview DSHS has responded to SA/AD issues with a family of tools and integration: Narcotic review and Prior Authorization PRR/Lock in Referral to DASA Screening and Treatment Coordination with Mental Health and other agencies Informing the Provider Community (ER Work Group, IBM, Academic Detailing) Next Steps Key DSHS Research Findings • Some Medicaid clients receive excessive narcotics • Emergency Room (ER) “cycling” is strongly correlated with narcotics • Clients with diagnoses (headaches, abdominal pain, LBP) should not be receiving chronic narcotics in the ER • Medical and DASA need to coordinate activities

4. Quantifying the problem ER

5. 100% 11% Clients With No Identified AOD or Mental Illness Disorder 23% 89% 69% Mental Illness Only AOD Disorder Only Had AOD disorder or mental illness or both 10% 56% • Co-Occurring Diagnoses • BOTH • AOD Disorder AND • Mental Illness Disorder 23% 4% 4% n = 81,980 n = 19,393 n = 10,765 n = 11,474 n = 4,526 n = 1,607 n = 331 n = 198 Number of Visits to the ER, FY 2002 Frequent ER Visitors Have High Rates of AOD Disorders and Mental Illness

6. Patient Review and Restriction Program DSHS July 6, 2006

7. Patient Review and Restriction Program DSHS

8. Opiate Treatment Savings Average Number of Narcotic Analgesic Prescriptions Per Client in FY 2002 Percent Who Received Prescriptions for Pain Among clients in FY 2002 that had. . . NO Emergency Visit ONE Visit 31+ Visits Yes 27% No 49% Yes 51% No 73% Yes 99% n = 81,980 n = 19,393 n = 10,765 n = 11,474 n = 4,526 n = 1,607 n = 331 n = 198 Number of Visits to the ER, FY 2002 Pain Rx Among Frequent ER Users Narcotic Analgesic Prescriptions Per Client Per Year Average Number of Pain Prescriptions is Highest Among Those Most Frequently Visiting the ER INCLUDES persons who are Medicaid-only aged, blind, disabled, presumptively disabled, or General Assistance-Unemployable in Fiscal Year 2002. SOURCE = Medicaid Integration Project database. TOTAL CLIENTS (FY 2002) = 130,274.

9. 10 In September, Rex switchesto a different medical provider 8 In month two, Rex fills a prescription for a 30-day supply of a long-acting narcotic analgesic In October, Rex concurrently receives long-acting and short-acting narcotic analgesics, both from the same provider 6 Over the next few months, Rex’s receives a 30-day refill about once a month, all prescribed by the same medical provider Number of Medical Providers Identified 4 One to three day supplies of a short-acting narcotic analgesic are supplied intermittently throughout the year (circled)  2  0 JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC  = Provider Number = Short-acting =Long-acting Opiate Prescribing Patterns Example 1: Expected Prescribing Pattern SOURCE = DSHS Research and Data Analysis Division, 2005.

10. 10  Rex obtains prescriptions for short-acting narcotic analgesics from nine different providers in the first four months of the year  8  By the end of the year, Rex has managed to obtain three concurrent prescriptions for short-acting narcotic analgesics from at least two different medical providers  6   4   2  0 JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC  = Short-acting =Long-acting = Provider Number Opiate Prescribing Patterns Example 2: ER Cycling Plus Overlapping Prescriptions Number of Medical Providers Identified SOURCE = DSHS Research and Data Analysis Division, 2005.

11. Average Prescribed Days of Narcotic Analgesics Per Year, by Diagnosis Group Relationship with drug-seeking behavior: More likely Less likely Average Number of Days Supplied Narcotic Analgesics in Calendar Year 2001 0 25 50 75 100 125 150 175 Connective Tissue Respiratory Cancer Headaches Diseases of Spine Leukemia Pulmonary Circulation Poison/Medicinal/Biologic Immune Disorders Peripheral Arthritis Tobacco Abuse Disorder HIV/AIDS Drug Abuse/Dependence/Psychosis Gastrointestinal Cancer Hepatitis Inflammatory Bowel Bleeding Disorders Fractures Breast Cancer Chronic Obstructive Pulmonary Disorder Sprains/Strains Superficial Injuries Alcohol Abuse/ Dependence/Psychosis Poison/Non-Medicinal n = 707 n = 756 n = 2,479 n = 16,601 n = 261 n = 428 n = 1,214 n = 762 n = 9,955 n = 3,568 n = 766 n = 2,699 n = 650 n = 2,184 n = 4,980 n = 1,014 n = 4,603 n = 784 n = 9,579 n = 10,673 n = 7,365 n = 2,854 n = 554 INCLUDES persons who are Medicaid-only aged, blind, disabled, presumptively disabled, or General Assistance-Unemployable in Fiscal Year 2002. SOURCE = Medicaid Integration Project database. TOTAL CLIENTS (FY 2002) = 130,274. Statewide Average = 49 SOURCE = DSHS Research and Data Analysis Division, 2005.

12. DSHS Response Developed intervention focused on the “Top 320” Medicaid clients using extreme amounts of narcotic analgesics: Filled 10 or more narcotic prescriptions in a single month or Filled 7 or more narcotic prescriptions for 6 consecutive months Excluded from the intervention clients with Cancer, HIV/AIDS, or in hospice. We subsequently modified exclusion list to add Nursing Home clients. This identification approach sought to isolate significant clients along with prescribing providers and pharmacists who are filling Rx’s. Provide for a fourfold intervention approach.

13. High-risk Vulnerable Population • Clients receiving more than 10 narcotic scripts per month • From multiple prescribers • Using multiple ER visits HIGH RISK OPPORTUNITY Education/ Communication Restrictions Utilization Management • Intensified Benefit Management • Share Rx history with prescriber • Let provider know about the ER visits and other Rx’g • Prior Authorization • Review claims • Determine medical necessity Case Management Restriction Case Management Intervention • Patient Review and Restriction • One primary care physician • One pharmacy • DASA • Referral • Signed releases • Shared outcomes

14. Key components of the intervention • Education/ Communication • Letter to provider community introducing project. • Outlining identification criteria • Describing how this would influence medical practice • Explaining WAC 388-530-1250 (Prior Authorization Policy) • Explaining WAC 388-501-0135 (Patient Review and Restriction) • Additional Resource information and links. • Client Letter • Indicating deaths from Narcotics growing concern, new program and MD reviewing last 12 months of history and in MD would work with client • Pharmacy Broadcast FAX • Enlist support of Pharmacy community to work together. • Intensified Benefits Management • Client Profile and consultation with MD and Pharmacies represented The “Top 320” Intervention

15. Key components of the intervention (cont’d) • Restrictions/Utilization Management • Prior Authorization (PA) • Claims submitted for PA client are subject to pre-payment review, medical justification, etc. before payment • Of the original 320 identified and immediately placed on PA, currently 205 remain (5/2006) • If medically justified PA on client is removed, otherwise remains in place. • Case Management Restriction • Patient Review and Restriction (PRR) • 75 new clients were placed on PRR • Phyllis and Trang will detail this program further. • Case Management Intervention • 52 clients were identified in the Long Term Care program area with > case management. • 4th Qtr 2005 and 1st Qtr of 2006 clients has added 44 more clients. • 27 patients on the 320 list have entered DASA treatment since July 1, 2005. • All twenty-seven patients are receiving publicly funded treatment • This is the first treatment admission for fourteen of the twenty-seven patients • In May 2006, twenty-five of the twenty-seven were still in treatment.

16. Patient Review and Restriction Program (PRR) PRR is a health and safety program for both fee-for-service and managed care clients needing help in the appropriate use of medical services Authority: Federal Regulations: 42 CFR 431.54: Allows states to restrict/lock-in recipients to designated providers when recipient utilized services at a frequency or amount that is not medically necessary 42 CFR 456.3: Requires Medicaid agency to implement a statewide surveillance and utilization control program 42 CFR 455.16: Imposition of sanctions for instances of abuse identified by the agency State Regulation: WA Administrative Code (WAC) 388-501-0135

17. Goals of PRR Program To improve medical coordination of care for clients with a history of inappropriate utilization of services To reduce expenditures on unnecessary and inappropriate services PRR WAC Criteria (WAC 388-501-0135) • Two or more of the following apply in a 90-day period: • Saw 4 or more physicians • Prescriptions filled at 4 or more pharmacies • Received 10 or more prescriptions • Had prescriptions written by 4 or more prescribers • Received similar services from 2 or more providers in the same day OR • Any one of the following applies: • Made 2 or more ER visits in a 90-day period • Medical history indicating at-risk utilization patterns • Repeated and documented efforts to seek medically unnecessary services and counseled at least once by health care provider or managed care representative about appropriate use of health care services

18. Referral Sources for Identifying Potential Clients Referrals By HRSA staff, providers, pharmacies, and other state agencies Received by phone, fax, e-mail, or letter Caseload of terminated providers Utilization Reports Intermittently reports are generated on top users of services, such as high emergency room users, high narcotic users

19. Provider Assignment Client is assigned to a PCP, Pharmacy, and/or Hospital for non-emergent care Provider is reasonably accessible to client Provider is chosen by client or HRSA Staff work closely with health care providers to find a provider willing to coordinate the PRR client’s care Assignment letter is sent to client, provider, and local Community Service Office (CSO) Client is restricted for 24 months, then reviewed and extended if appropriate

20. Services Not Affected The following services are not affected by PRR: Dental −Emergency Services Hospital in-Patient −Renal Dialysis Home Health Care −Hospice Services Medical Equipment −Transportation Services Long Term Care −Vision Hearing Aids −Family Planning Women’s Health Clients may be responsible for payment of services: Not referred by the PRR PCP Obtained from non-PRR providers

21. PRR Referrals PRR Referral Line (360) 725-1780 Calls are returned within 24 hours PRR Website http://maa.dshs.wa.gov/PRR

22. Impact of the “Top 320” intervention on narcotic prescribing patterns and medical service use Clear reduction in volume of narcotic analgesics supplied to “Top 320” Less evidence of an impact on use of other outcomes Overall Medical Assistance expenditures ER visits Use of chemical dependency treatment services Analyses use a comparison group to control for “regression to the mean”

23. First data point post-intervention “Top 320” vs. Comparison Group: Narcotic Analgesic Scripts Filled Per Member Per Month Based on MMIS claims paid through 3/31/2006 PRELIMINARY Prescriptions Per Member Per Month POST-INTERVENTION PERIOD Top 320 Comparison Group SOURCE = DSHS Research and Data Analysis Division, 2006.

24. First data point post-intervention “Top 320” vs. Comparison Group: Narcotic Analgesic Days Supplied Per Member Per Month Based on MMIS claims paid through 3/31/2006 PRELIMINARY Days Supplied Per Member Per Month POST-INTERVENTION PERIOD Top 320 Comparison Group SOURCE = DSHS Research and Data Analysis Division, 2006.

25. First data point post-intervention “Top 320” vs. Comparison Group: Outpatient ER Visits Per 1,000 Members Per Month Based on MMIS claims paid through 3/31/2006 PRELIMINARY OP ER Visits Per 1,000 Members Per Month POST-INTERVENTION PERIOD Top 320 Comparison Group SOURCE = DSHS Research and Data Analysis Division, 2006.

26. Conclusion Take home messages Integration inside DSHS Education of the provider population Use data to identify and target opportunity Inform clients/providers of risk and resources. Make sure resources are known-”tool-kit” and coordination Collaborate outside traditional program lines Collaborate and work with medical and screening and treatment resources in the community.

27. Next Steps NEXT STEPS/COMING SOON Using Evidence Based Medicine Developing a tool kit for providers Sharing Rx Records on poly-prescribers and poly-pharmacy Sharing diagnosis with the community (HIPPA and Title 42 compliant) Working with the community to establish an Evidence Based Maximal narcotic dose (120 mg of morphine equivalent/day http://www.globalrph.com/index.htm QUESTIONS