Enhancing Patient Safety and Controlling Cost:

informedRx^® Controlled Drug Program

Problem Identification

Visits to hospital emergency departments involving nonmedical use of prescription narcotic pain relievers more than doubled between 2004 and 2008, according to a study by the Substance Abuse and Mental Health Services Administration and the U.S. Centers for Disease Control and Prevention (CDC).  This trend reflects in part, a dramatic increase in the rate at which these drugs are prescribed in the U.S., according to a CDC statement.[i]

Patients receiving multiple narcotic prescriptions from multiple providers is an all-too-common occurrence.  Use of multiple narcotics can have an adverse impact on both members and payers:

• Compromised patient safety;
• Risk of addiction and diminished quality of life;
• Risk of on-the-job injuries and
• Waste of precious health plan financial resources.

In addition, providers rely on their patients for historical and current treatment information; they have no standardized mechanism for visibility into their patients’ complete drug profile.  Often, providers are not aware when patients are “doctor shopping”.

Objective of the informedRx® Controlled Drug Program

informedRx considers patient safety and well-being a central focus of our programs.  The Controlled Drug Program:

Promotes patient safety by identifying and addressing situations such as overlapping prescriptions from multiple prescribers, potential “doctor shopping” and other abuses;

• Promotes patient safety by identifying and addressing situations such as overlapping prescriptions from multiple prescribers, potential “doctor shopping” and other abuses;
• Enhances quality of life by addressing usage behavior that suggests risk for addiction;
• Decreases risk for on-the-job injuries due to misuse of narcotics;
• Achieves and reports savings by managing utilization of controlled medications; 
• Identifies cases for more intensive intervention, such as limiting the number of narcotic prescribers or instituting prior authorization for all narcotics and
• Enhances overall plan savings via reductions in medical services used by patients to obtain prescriptions, including physician visits or emergency room treatment.

Target Audience

All payer types, including workers’ compensation, can benefit, as this program helps to reduce risk, enhance safety and decrease waste/abuse.

Solution and Implementation Plan/Methodology

A patient is identified for review based on the following edits: 

• The number of controlled substances;
• The number of prescribers;
• The number of pharmacies and
• A defined period of time.

 Standard informedRx criteria include: 

• 5 or more claims for narcotic drug claims (and)
• 1 or more pharmacies for controlled drugs (and)
• 2 or more prescribers for controlled drugs
• Assessment period is a calendar month

Our flexible technology allows our clients to customize these criteria, based on their history and/or unique goals.

Once a member is identified using these criteria, informedRx performs a pharmacist review of the prescription claim and intervention history to determine if member intervention is indicated.  In some cases, members may have justifiable reasons for receiving prescriptions from multiple prescribers, such as specialist care or multiple physicians within the same medical group.  In addition, the presence of drugs, such as antineoplastics, antiemetics, hematopoietic factors and HIV treatment, indicates that the member is likely on a comprehensive pain management program.  This targeted approach is more impactful with physicians as we eliminate excessive system-generated mailings that lack clinical oversight and cause unnecessary physician disruption.

Process – How it Works

We find at-risk plan members and provide the physician with actionable information to enable informed decision-making regarding the member’s treatment plan.

 On a monthly basis informedRx: 

• Analyzes prescription data for narcotics to identify members receiving multiple prescriptions and using multiple prescribers.
• Excludes members with claims that indicate a serious clinical diagnosis, such as cancer or AIDS, which can have a significant pain management component.
• Performs a pharmacist review of the prescription claim and intervention history for the identified members to determine if prescriber intervention is indicated. 
• Sends a member intervention packet to enable the prescriber to act in the best interest of the patient. Prescriber intervention mailings include a:

-        Letter that explains the potential concern

-        Member-specific medication profile

-        Prescriber response form to capture the prescriber’s decision related to patient intervention

• Uses the response form to capture the prescriber’s decision to maintain the current drug therapy, discontinue the drug(s) in question, pursue a taper of the drug or contact the other prescribers.
• Evaluates appropriate next steps, based on prescriber feedback and the patient situation.  Interventions can include limiting the number of prescribers writing controlled prescriptions, limiting the number of retail pharmacies for patient use or requiring prior authorization for all narcotic medications.

Program Results

Savings

Insights Drive Actions that Drive Results informedRx® Controlled Drug Program

$105.16 average savings per case

58% fewer narcotic prescriptions written

57% fewer prescribers wrote narcotic prescriptions

76% of prescribers rated our intervention as useful and 81% rated our medication profile as useful.

Book of Business results 5/1/2009 through 6/30/10

Because informedRx provides a 120 day profile including medication history, prescribing physicians and dispensing pharmacies, the physician has clear visibility into the patient’s current situation and their history.  Physicians report the intervention as useful, as they do not currently have a standardized mechanism for obtaining this information.

An Award-Winning Client Partnership

informedRx® as a partner with our client, EMPLOYERS Occupational Health, was awarded the Gold Best Practices in Health Care Consumer Empowerment and Protection Award.  This program is a unique model, in that informedRx and EMPLOYERS share intervention responsibilities.

EMPLOYERS is a specialty provider of workers’ compensation insurance.  Many injured employees face the challenge of having injuries that require coordination of care among several providers.  Treatment by multiple providers increases the risk of overlapping or interacting medications.  informedRx implemented the Controlled Drug Program to identify patients who are receiving multiple narcotic prescriptions.  This information is reviewed by informedRx and shared with the physician, who is then better equipped to intervene in the injured employee’s medication regimen. EMPLOYERS’ nurse case managers work collaboratively with the providers.  informedRx promotes appropriate medication use and safety through drug utilization review, prior authorization, quantity limitations and other claims processing system edits to limit the number of prescribers and pharmacies used to fill narcotics.

Future Enhancements

Future enhancements include incorporation of dosages into criteria used to identify members for intervention and potential expansion into other classes of drugs, such as muscle relaxers or migraine medications.  In addition, the criteria will be integrated with integrailRx™, informedRx’s risk prediction tool.

 

 

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[i] CDC Morbidity and Mortality Weekly Report, V.59, No.23, available at http://www.cdc.gov, accessed October 19, 2010.