Impact of a Managed Controlled-Opioid Prescription Monitoring Program on Care Coordination
Published Online: September 19, 2012
Arsenio M. Gonzalez III, PharmD, RPh; and Andrew Kolbasovsky, PsyD, MBA
The overwhelming majority of global opioid prescription medications are consumed by residents of the United States.1 A direct correlation exists between the increase in prescription opioid utilization over the last decade and the growing prevalence of opioid misuse.2 Coordinating efforts to improve management of pain, the most common chief complaint encountered by physicians, has been acknowledged as a national priority due to the considerable increase in prescription opioid misuse.3,4
Uncoordinated pain management leads to poor health outcomes for patients5 and increases societal cost burden.6 Opioid-related admissions to substance abuse treatment centers increased by 400% between 1996 and 2006.7,8 Emergency department visits associated with opioid use increased by over 100% between 2004 and 2008.9 Recent measures taken by the legal and medical communities are a clear response to these dramatic upward trends.6,10,11
Approximately 35 US states, in addition to several local health organizations, have implemented Prescription Monitoring Programs (PMPs).12 Many state PMPs collect controlled substance prescription claims data from dispensing pharmacies, usually on a monthly basis, and make that information available to prescribers to facilitate informed treatment decisions.13-17 These prescribers are alerted when prescription claims for a given member meet predetermined inclusion criteria, usually based on prescription claim patterns associated with doctor and/ or pharmacy shopping. These patterns can be indicators of potential misuse of prescription medication.
A standardized methodology for identifying opioid misuse based on prescription claims information has yet to be established.18 The Massachusetts PMP defines questionable controlled substance dispensing as 5 or more prescribers and pharmacies during a 12-month time frame.19 The Upper Peninsula Health Plan (UPHP), a Michigan Medicaid health maintenance organization (HMO), intervenes when members have received 3 or more prescriptions from 2 or more prescribers over a 6-month period.20 PMPs typically disseminate prescription claims information to controlled substance prescribers, as part of the intervention, via mail or a secure website. Pharmacy claims data provided to prescribers may include information related to the dispensed controlled substances, the prescribers, the member, and the dispensing pharmacies. Challenges exist with each type of notification. When information is mailed, it is difficult to determine whether the prescriber received the communication and whether the information was integrated into clinical practice. When information is available via a secure website, prescribers must access the site, an added step which often does not occur. A New York–based managed care organization (NYMCO) developed a Managed Controlled-Opioid Prescription Monitoring Program to identify and address uncoordinated treatment of pain with opioid analgesic medications. The clinical pharmacy department used its internal database to analyze adjudicated schedule II-IV opioid prescription claims quarterly between the 2008 fourth quarter and the 2010 first quarter. Approximately 980,000 members were covered under the included NYMCO line of business during this time frame and a total of 79,754 members obtained at least 1 opioid prescription using the pharmacy benefit. Members who obtained controlled opioid medications from 3 or more prescribers and 3 or more pharmacies within a 3-month time period were identified through this database. Prescription claims data was the driving force behind this initiative which integrated the skills of clinical pharmacy, behavioral health, and medical management specialists at the NYMCO to deliver comprehensive information/service resources to facilitate care coordination when a member received opioid prescriptions from multiple prescribers. The NYMCO hypothesized that use of these resources would streamline pain management and enhance care coordination and medication safety for identified members by reducing the number of prescriptions filled, the number of opioid-dispensing pharmacies, and the number of opioid prescribers utilized by the member.
Eligibility for Randomization
Eligible NYMCO members were identified using adjudicated pharmacy claims data. Members had 1 of the following types of insurance coverage: commercial (HM), Medicare Advantage Part D Plan (MR), or Medicare Part D Prescription Drug Plan (MP). HM and MR policies included both medical and pharmacy coverage with the health plan. MP policies included only pharmacy benefits. Members with MP policies typically had medical benefits, but these benefits were managed by another health plan.
On a quarterly basis between first quarter 2009 and first quarter 2010, members filling controlled opioid medications prescribed by 3 or more prescribers and filled at 3 or more pharmacies in a 3-month period were identified. A quarterly average of 195 members met the aforementioned criteria. First Databank therapeutic class codes (GC3) were used internally to identify prescription claims for opioid pain medicine (H3A and H3U). Reports were executed 1 week after the end of each quarter.
Upon identification, members were randomly assigned to either the intervention group (IG) or the comparison group (CG). Members identified in multiple quarterly reports remained in the group they were initially assigned to. All members included in the 12-month outcomes analysis maintained pharmacy insurance coverage throughout the study period. Prescribers who wrote opioid prescriptions for these identified members included healthcare practitioners, contracted with the NYMCO, given authorization by the Drug Enforcement Agency to prescribe controlled substances (ie, physicians, physician assistants, nurse practitioners, dentists, etc).
Members in both the IG and CG had access to the NYMCO’s pharmacy services, including member services, the ability to fill prescriptions at a vast array of network pharmacies, access to all medications covered under the member’s pharmacy benefits, drug utilization evaluation, and safety alerts for a given prescription relayed as a result of processed claims submitted to the NYMCO by the dispensing pharmacy. Prescriptions paid for in full by the patient were not transmitted to the NYMCO for reimbursement processing and could not be accounted for because these claims were not available within the database used for this analysis.
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