Many states are trying to get prescription drug abuse under control by reviewing the possibility of a formulary, tightening their formulary regulations, if they have one, or supplementing the formulary with other requirements, such as a PDMP which tracks a patient’s drugs use. Many states are not only requiring providers to upload prescribing data to the PDMP, but also state that any physician dispensing drugs check the PDMP before prescribing. While this creates an additional step for the physician or physician’s office, it can help ensure patient safety. Another interesting and effective measure several states have adopted is the “first fill” script limit, usually a 7-day limit for opioids.
So how is the data currently captured as it relates to prescription drugs? And how are adjusters and treating physicians in particular, using data analytics?.
Adjuster – most carriers use some type of Pharmacy Benefit Management (PBM) program. The PBM tracks the prescription as it passes through the PBM for dispensing. However, if those are the only segments of data utilized, it may give a false report of the data as many times drugs are not processed through the PBM. This means that not only must the adjuster compile the claim related data from the PBM, but they must also track the data through the utilization review (UR) or actual billing data.
Why is it important for the adjuster to monitor the PBM, UR and billing data? Overall, it is the adjuster’s responsibility to handle the injured workers’ claim appropriately. This means the adjuster must help the injured worker obtain necessary medical treatment, avoid unnecessary or harmful treatment, and if possible help that worker to get back to work, while at the same time trying to keep costs under control.
Physician – Physicians utilize data based on medical records (either theirs or those of a prior treating physician or specialist). But are they using PDMPs when available? And are they using MED (Morphine Equivalent Dose) like those found in the CDC opioid prescribing guideline?
Data has shown that patients prescribed longer doses of opioids early have a higher chance of addiction. For example, a report by pharmacist Bradley Martin and colleagues from the University of Arkansas show that about 13.5 percent of patients receiving opioids for the first time for eight days or fewer were still taking opioids a year later. That number shot up to 30 percent for those patients who received a first time prescription of 31 days or more.
On a related note, it would be helpful to adjusters and treating physicians to have an agreement with all neighboring states to collaborate on patient drug use. This is because patients often cross the border into neighboring states to see an out-of-state physician to get more opioids or benzodiazepines, like Valium and Xanax. My suggestion is that after one state implements an electronic PDMP, that state asks neighboring states for a data exchange agreement. That way, a doctor can check for possible doctor shopping if an out-of-state patient presents seeking drugs.
While ‘data analytics’ sounds like a boring topic to many, the information gleaned from it can provide powerful opportunities to raise red flags by adjusters and treating physicians. At UR Nation, we believe that as things become even more electronic and computer controlled, more data will be available. For example, we can see injured workers doing more and more home based physical therapy while wearing devices that capture data. This will be data that can, if used correctly, make a difference to injured workers and help them get the medical care they need, and if possible, back to work.