A Prescription for Mitigating MSA Settlement Costs

1. www.prium.com A Prescription for Mitigating MSA Settlement Costs

2. Your Speaker • Mark Pew, Senior Vice President • PRIUM (www.prium.net) • Medical Intervention on Clinically Complex Claims • Mr. Pew brings over 30 years of expertise in the property and casualty and healthcare industries, strategic planning, and technology to his presentations. He has worked with PRIUM in a variety of roles since 1989 including IT, operations, product and service development, and executive management. Other experience includes CoreSpeed, MedicaView International, ChoicePoint and Equifax. • Mr. Pew has been following the prescription drug issue since 2003 and created PRIUM’s Medical Intervention Program. He is a member of the medical issues committee of International Association of Industrial Accident Boards and Commissions (IAIABC). • Current responsibilities at PRIUM include educational outreach, product development and marketing.

3. MSA Basics

4. MSA 101The Problem • CMS and WCMSA • Used for lump-sum settlements with future medical costs • Protect Medicare’s financial interest • Protect the claimant’s Medicare coverage • They want the proposal at MMI • Biggest issues … • No defined appeal process • Response can be unpredictable and inconsistent • Pharmacy costs can be as much as 70% of a WCMSA proposal

5. MSA 101Enormous Costs • Medication costs over a 30-year expectancy:

6. MSA 101The Drug Problem • The logic … • If the treating physician said it … • Or the payer paid for it … • Within the past 2 years … • It’s the treatment * the rated life expectancy • The AHA … now … OMG moment • Settlement

7. MSA 101Some Reasons • AWP pricing is required • Nobody pays AWP • No generic substitutions for brand-name drugs • DAW doesn’t matter if the brand-name drug was dispensed • Only the treating physician’s opinion / actions matter • Even if they just mention it • Reluctance to accept “projected” prescription drug reductions or tapering • Only “actual” reductions matter • Generalized calculations often based on unrealistic assumptions about future medical care • The same dosage/frequency forever? Really?

8. Treatment Red Flags

9. Treatment Red FlagsPolypharmacy • Variety of definitions: • Concurrent use of multiple drugs, with some researchers discriminating between minor (two drugs) and major (more than four drugs) • The use of more drugs than are clinically indicated • Too many inappropriate drugs • Two or more medications to treat the same condition • Two or more drugs of the same clinical class • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000563/ • Risk Factors • Treatment of side effects • Multiple prescribers, uncoordinated care • Co-morbidities that complicate care • Patient non-adherence • The Enemy of Function … And Cost

10. Treatment Red FlagsPolypharmacy PAIN Opioid fentanyl? • Insomnia • Lethargy • Atrophy • Depression • Sexual dysfunction • Constipation • Addiction zolpidem modafinil carisoprodol duloxetine sildenafil stool softener buprenorphine All of this makes the pain harder to identify and treat

11. Treatment Red FlagsInappropriate Patterns • Treatment Red Flags • Opioid dosage exceeding 120mg MED per day • ACOEM’s new guidelines say 50mg MED/day • Acetaminophen dosage exceeding 4000mg per day • NSAID dosage exceeding 3200mg per day • Opioids used for more than 2 contiguous months after surgery • Muscle relaxants used for more than 2 contiguous months • NSAIDs used for more than 6 contiguous months • Benzodiazepines used for more than 4 contiguous weeks • No exit strategy by the prescriber

12. Treatment Red FlagsInappropriate Patterns • Topical analgesics • Anti-narcoleptic drugs (Provigil, Nuvigil) • Hormonal supplements • Spinal Cord Stimulator / Intrathecal Pump and topical / oral analgesics • Drug regimen that has automatic refills • More than one prescribing physician involved in the overall drug regimen • No opioid treatment agreement • No urine drug monitoring • No liver / kidney toxicity tests where applicable • Prescriber not utilizing the state’s PDMP

13. Treatment Red FlagsDeveloping a Strategy • Opinions are not enough • Standard of Care is not enough • MMI < > Polypharmacy • With no appeal process, it needs to be your “best offer” • Incorporate services and procedures that create that “best offer”

14. The Package of Evidence

15. Optimizing a MSAPackage of Evidence • Assess the clinical appropriateness of ongoing treatment • If clinically questionable, STOP THE MSA PROCESS

16. Optimizing a MSAPackage of Evidence • Assess the clinical appropriateness of ongoing treatment • If clinically questionable, STOP THE MSA PROCESS • Intervene collegially with treating physician(s) • EV1: Proves the treating physician agrees with changes

17. Optimizing a MSAIntervention • Creating an Epiphany • Must be collegial • Don’t start with Utilization Review or IME • Sometimes a prescriber will only respond to a peer • PM&R specialty that focuses on function • Diligent • 3 calls over 3 days does not constitute reasonable effort • Recommendations should be from Evidence Based Medicine • Even if the jurisdiction doesn’t mandate it • Get the agreement in writing • For CMS, the decision needs to come from the treating physician

18. Optimizing a MSAPackage of Evidence • Assess the clinical appropriateness of ongoing treatment • If clinically questionable, STOP THE MSA PROCESS • Intervene collegially with treating physician(s) • EV1: Proves the treating physician agrees with changes • Have a plan ready for a non-cooperative physician and/or patient • Options are jurisdictionally driven

19. Optimizing a MSAPackage of Evidence • Assess the clinical appropriateness of ongoing treatment • If clinically questionable, STOP THE MSA PROCESS • Intervene collegially with treating physician(s) • EV1: Proves the treating physician agrees with changes • Have a plan ready for a non-cooperative physician and/or patient • Options are jurisdictionally driven • Initiate consistent oversight with treating physician(s) to implement changes • EV2: You weren’t just lucky

20. Optimizing a MSAIntervention • Accountability • Must be consistent • The treating physician should be expecting the call • Must include accountability • Not just checking … Verifying • Must provide flexibility • If Plan A isn’t working, help determine a Plan B • Must connect the dots • Ensure all stakeholders know the plan and concur

21. Optimizing a MSAIntervention • Tapering Basics • Motivation of the patient • Identify how patient will manage pain with less/no dosage • Recovery lifestyle • Coping skills • Function • Competence of the provider • Can the treating physician facilitate the weaning? • In-patient / out-patient? • Is the goal reduction in dosage or removal of drugs?

22. Optimizing a MSAPackage of Evidence • Utilize the PBM (and bill review) to create a customized formulary • EV3: Enforce the changes

23. Optimizing a MSAIntervention • Customization • Create a customized formulary per patient • As drugs/dosages change, edit the formulary • Determine Prior Auth or Block • How will exceptions be handled? • Edits + Transactions = Strategy • Active engagement tells a good story to CMS

24. In Summary … Collegial, evidence-based Leverage PBM system, customize the formulary Consistent, coordinated, team-based follow up on changes

25. Optimizing a MSAPackage of Evidence • Utilize the PBM (and bill review) to create a customized formulary • EV3: Enforce the changes • Create a story to show the strategic effort to remove inappropriate drugs • Reviewing physician’s assessment • Treating physician’s agreement • Ongoing interaction with treating physician during tapering • Transactional record from PBM shows dosage reduced / drugs removed • This is compelling to CMS

26. Optimizing a MSAPackage of Evidence • Utilize the PBM (and bill review) to create a customized formulary • EV3: Enforce the changes • Create a story to show the strategic effort to remove inappropriate drugs • Reviewing physician’s assessment • Treating physician’s agreement • Ongoing interaction with treating physician during tapering • Transactional record from PBM shows dosage reduced / drugs removed • This is compelling to CMS • RESTART THE MSA PROCESS

27. Optimizing a MSAIn Summary • Your first calculation may not be your best offer • Identify triggers for when to delay the WCMSA proposal • Create a compelling case to CMS that history does not predict future • And document everything … • This all requires patience

28. Mark Pew Senior Vice President (678) 735-7309 Office mpew@prium.net LinkedIn: markpew Twitter: @RxProfessor Our Evidence Based blog www.priumevidencebased.com