A Prescription for Mitigating MSA Settlement Costs

Your Speaker Mark Pew, Senior Vice President PRIUM ( 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.

MSA Basics

MSA 101 The 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

MSA 101 Enormous Costs Medication costs over a 30-year expectancy: DrugPurposeDosageTotal Cost AbilifyDepression, schizophrenia 10mg$251,521 DuragesicFentanyl (opioid) patch for pain 100mcg$173,052 ButransBuprenorphine (opioid) patch for pain 20mcg$165,984 ImitrexMigraine treatment20mg$164,628 OxyContinOxycodone (opioid) for pain 80mg$147,606

MSA 101 The 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

MSA 101 Some 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?

Treatment Red Flags

Treatment Red Flags Polypharmacy 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 Risk Factors Treatment of side effects Multiple prescribers, uncoordinated care Co-morbidities that complicate care Patient non-adherence The Enemy of Function … And Cost

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

Treatment Red Flags Inappropriate 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

Treatment Red Flags Inappropriate 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

Treatment Red Flags Developing 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”

The Package of Evidence

Optimizing a MSA Package of Evidence 1.Assess the clinical appropriateness of ongoing treatment If clinically questionable, STOP THE MSA PROCESS

Optimizing a MSA Package of Evidence 1.Assess the clinical appropriateness of ongoing treatment If clinically questionable, STOP THE MSA PROCESS 2.Intervene collegially with treating physician(s) EV1: Proves the treating physician agrees with changes

Optimizing a MSA Intervention 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

Optimizing a MSA Package of Evidence 1.Assess the clinical appropriateness of ongoing treatment If clinically questionable, STOP THE MSA PROCESS 2.Intervene collegially with treating physician(s) EV1: Proves the treating physician agrees with changes 3.Have a plan ready for a non-cooperative physician and/or patient Options are jurisdictionally driven

Optimizing a MSA Package of Evidence 1.Assess the clinical appropriateness of ongoing treatment If clinically questionable, STOP THE MSA PROCESS 2.Intervene collegially with treating physician(s) EV1: Proves the treating physician agrees with changes 3.Have a plan ready for a non-cooperative physician and/or patient Options are jurisdictionally driven 4.Initiate consistent oversight with treating physician(s) to implement changes EV2: You weren’t just lucky

Optimizing a MSA Intervention 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

Optimizing a MSA Intervention Tapering Basics 1.Motivation of the patient Identify how patient will manage pain with less/no dosage Recovery lifestyle Coping skills Function 2.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?

Optimizing a MSA Package of Evidence 5.Utilize the PBM (and bill review) to create a customized formulary EV3: Enforce the changes

Optimizing a MSA Intervention 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

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

Optimizing a MSA Package of Evidence 5.Utilize the PBM (and bill review) to create a customized formulary EV3: Enforce the changes 6.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

Optimizing a MSA Package of Evidence 5.Utilize the PBM (and bill review) to create a customized formulary EV3: Enforce the changes 6.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 7.RESTART THE MSA PROCESS

Optimizing a MSA In 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

Mark Pew Senior Vice President (678) Office LinkedIn: markpew Our Evidence Based blog