Pharmacy Management

Leveraging PDMPs in the Opioid Battle

Prescription monitoring programs are a prime tool in the fight against opioid abuse. Unfortunately there are barriers to access.
By: | February 24, 2017 • 4 min read

Many of those in the industry may have read the recent musings of Judge Langham, the Deputy Chief Judge of Compensation Claims for The Florida Division of Administrative Hearings regarding the drug abuse crisis we have in our industry and the deaths resulting from that crisis.

He notes, “The bottom line is that drugs are directly killing people, lots of people. The 2015 total of 55,403 deaths from drugs comes out to an overdose death about every 9.5 minutes all day long.” Shocking!

We, in our industry, have certainly put a lot of focus on the opioid epidemic in workers compensation but as Judge Langham points out, it’s not just opioids we need to worry about. As he notes, the use of pharmaceuticals is staggering — there are deadly combinations of multiple drugs as well as drugs and alcohol that are killing our injured workers and sometimes their family members as well.

The pharmacy benefit management programs we all utilize are doing a good job of controlling workers’ comp pharmacy costs and identifying inappropriate or unapproved medications and high MED (Morphine Equivalent Dose) levels insofar as they know.

Our stove-piped insurance programs keep these PBMs in the dark about all the drugs a particular injured worker might be taking, i.e. the right hand and the left hand not knowing what the other hand is doing.

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What can we do about this; you ask? That is where the PDMPs come in.

PDMPs, or prescription drug monitoring programs, collect, monitor, and analyze electronically transmitted prescribing and dispensing data submitted by pharmacies and dispensing practitioners, no matter the insurance coverage.

The data is used to support states’ efforts to educate, research, enforce and prevent abuse and diversion. PDMPs are managed by the individual states. Forty-nine states, the District of Columbia and one U.S. territory (Guam) currently have a PDMP that is operational (meaning collecting data from dispensers and reporting information from the database to authorized users).

The PDMP provides nationwide information about prescriptions that are being filled: their strengths, dosages and quantities; the prescribing physicians; the pharmacies that are filling them; and when they are being filled.

Bottom line, your PBM does not have the whole picture concerning an injured worker’s pharmaceuticals.

Per state law, PDMPs monitor controlled substances as defined by Federal and State Controlled Substances Laws. Some PDMPs also monitor additional drugs of concern. You can find out which drugs are monitored by a specific state by going to this website: www.pdmpassist.org.

Recent studies have shown that when states require mandatory reporting, it cuts down on abuse and leads to improved outcomes.

For example, in 2015, there were 439 total drug deaths in New Hampshire, of which 397 were caused by opiates/opioids. If nothing had changed, the state was on a path to hit 500 opioid related deaths in 2016. On June 7, 2016, Governor Hassan signed House Bill 1423, which mandates the use of the prescription drug monitoring program when initially prescribing an opioid and at least twice a year thereafter.

Their 2016 annual report showed that the PDMP is beginning to have positive effects on their opioid epidemic. Prescriptions for schedule II drugs, such as opioids, went down by almost 13% and the number of patients that were flagged for potential doctor shopping (using 5 or more doctors or pharmacies for prescriptions) decreased from 9/month to 3/month.

So you are probably thinking that this is just what we need, a way to look across insurance programs to identify inappropriate drug dispensing/usage and individual injured workers who may be at serious risk.

State law determines access to PDMP information. Most states only allow physicians and dispensing pharmacists to obtain PDMP reports on patients under their care. This allows the treating physicians and dispensing pharmacists an opportunity to intervene with the physician and the injured worker prior to dispensing a controlled substance if the PDMP suggests this might not be safe or in the injured worker’s best interest.

States may also provide PDMP information to other authorized groups such as law enforcement or licensing or regulatory boards but not to pharmacy benefit managers who are third party participants and not considered part of the injured workers treatment team.

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Bottom line, your PBM does not have the whole picture concerning an injured worker’s pharmaceuticals.

What do you need to do?

Take a look around, as there are new players in this PBM market who are taking this problem we have with controlled substances seriously and adding experienced dispensing pharmacists with access to this tool to their program on cases that appear to be at risk.

But keep this in mind as well. Knowing about all the injured worker’s prescribed controlled substances before dispensing is one thing. Providing clinical interventions once you know and before the controlled substance is dispensed is the real key to better outcomes.

Maddy Bowling is a principal in Maddy Bowling Consulting, Inc., a WC consulting firm. Bowling has 35 years of broad-based executive management experience within operating, corporate and consulting environments. She can be reached at [email protected]

Risk Report: Entertainment

On With the Show

Entertainment companies are attractive and vulnerable targets for cyber criminals.
By: | December 14, 2017 • 7 min read

Recent hacks on the likes of Sony, HBO and Netflix highlight the vulnerability entertainment companies have to cyber attack. The threat can take many forms, from the destruction or early release of stolen content to the sabotage of broadcast, production or streaming feeds.

Brian Taliaferro, entertainment and hospitality specialist, JLT Specialty USA

“Cyber attacks are becoming the biggest emerging threat for entertainment companies, bringing risk to reputations, bottom lines and the product itself,” said Brian Taliaferro, entertainment and hospitality specialist, JLT Specialty USA.

For most entertainment firms, intellectual property (IP) is the crown jewel that must be protected at all costs, though risk profiles vary by sub-sector. Maintaining an uninterrupted service may be the biggest single concern for live broadcasters and online streaming providers, for example.

In the case of Sony, North Korea was allegedly behind the leak of stolen private information in 2014 in response to a film casting leader Kim Jong Un in what it considered an unfavorable light.

This year, Netflix and HBO both faced pre-broadcast leaks of popular TV series, and Netflix last year also had its systems interrupted by a hack.

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Online video game platforms are also ripe for attack, with Steam admitting that 77,000 of its gamer accounts are hacked every month.

The list goes on and will only get more extensive over time.

Regardless of the platform, any cyber attack that prevents companies from producing or distributing content as planned can have huge financial implications, particularly when it comes to major releases and marquee content, which can make or break a financial year.

“People and culture are the biggest challenges but also the keys to success.” — David Legassick, head of life science, technology and cyber, CNA Hardy

The bottom line, said David Legassick, head of life science, technology and cyber, CNA Hardy, is that these firms have a combination of both assets and business models that are inherently open to attack.

“Vulnerabilities exist at every point in the supply chain because it’s all tech-dependent,” he said, adding that projects often run on public schedules, allowing criminals to time their attacks to maximize impact.

“The combination of IP, revenue and reputation risk make entertainment a hot sector for cyber criminals.”

Touch Point Vulnerabilities

Film, TV, literary and music projects invariably involve numerous collaborators and third-party vendors at every stage, from development to distribution. This creates multiple touchpoints through which hackers could gain access to materials or systems.

According to Kyle Bryant, regional cyber manager, Europe, for Chubb, there is nothing unique about the type of attack media companies suffer — usually non-targeted ransomware attacks with a demand built in.

“However, once inside, the hackers often have a goldmine to exploit,” he said.

He added targeted attacks can be more damaging, however. Some sophisticated types of ransomware attack, for example, are tailored to detect certain file types to extract or destroy.

“NotPetya was designed to be non-recoverable. For a media company, it could be critical if intellectual property is destroyed.”

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As entertainment companies have large consumer bases, they are also attractive targets for ideological attackers wishing to spread messages by hijacking websites and other media, he added.

They also have vast quantities of personal information on cast and crew, including celebrities, which may also have monetary value for hackers.

“It is essential to identify the most critical information assets and then put a value on them. After that, it is all about putting protection in place that matches the level of concern,” Bryant advised.

As with any cyber risk, humans are almost always the biggest point of vulnerability, so training staff to identify risks such as suspicious messages and phishing scams, as well as security and crisis response protocols, is essential. Sources also agree it is vital for entertainment companies to give responsibility for cyber security to a C-suite executive.

“People and culture are the biggest challenges but also the keys to success,” said Legassick.

“Managing the cyber threat is not a job that can just be left to the IT team. It must come from the top and pervade every aspect of how a company works.”

David Legassick, head of life science, technology and cyber, CNA Hardy

Joe DePaul, head of cyber, North America, Willis Towers Watson, suggested entertainment companies adopt a “holistic, integrated approach to cyber risk management,” which includes clearly defining processes and conducting background checks on the cyber security of any third party that touches the IP.

This includes establishing that the third parties understand the importance of the media they are handling and have appropriate physical and non-physical security at least equal to the IP owner in place. These requirements should also be written into contracts with vendors, he added.

“The touchpoints in creating content used to be much more open and collaborative, but following the events of the last few years, entertainment firms have rapidly introduced cyber and physical security to create a more secure environment,” said Ryan Griffin, cyber specialist, JLT Specialty USA.

“These companies are dealing with all the issues large data aggregators have dealt with for years. Some use secure third-party vendors, while others build their own infrastructure. Those who do business securely and avoid leaks can gain an advantage over their competitors.”

Quantification Elusive

If IP is leaked or destroyed, there is little that can be done to reverse the damage. Insurance can cushion the financial blow, though full recovery is very difficult to achieve in the entertainment space, as quantifying the financial impact is so speculative.

As Bill Boeck, insurance and claims counsel, Lockton, pointed out, there are only “a handful of underwriters in the world that would even consider writing this risk,” and sources agreed that even entertainment firms themselves struggle to put a monetary value on this type of exposure.

“The actual value of the IP taken isn’t generally going to be covered unless you have negotiated a bespoke policy,” said Boeck.

“If you’re in season five of a series with a track record and associated income stream, that is much easier, but putting a value on a new script, series or novel is difficult.”

Companies for whom live feeds or streaming are the primary source of revenue may find it easier to recoup losses. Determining the cost of a hack of that sort of service is a more easily quantifiable business interruption loss based on minutes, hours, ad dollars and subscription fees.

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Brokers and insurers agree that while the cyber insurance market has not to date developed specific entertainment products, underwriters are open for negotiation when it comes to covering IP. The ball is therefore in the insured’s court to bring the most accurate projections to the table.

“Clients can get out of the insurance market what they bring to the equation. If you identify your concerns and what you want to get from insurance, the market will respond,” said Bryant.And according to Griffin, entertainment companies are working with their brokers to improve forecasts for the impact of interruptions and IP hacks and to proactively agree to terms with underwriters in advance.

However, Legassick noted that many entertainment firms still add cyber extensions to their standard property policies to cover non-physical damage business interruption, and many may not have the extent of coverage they need.

Crisis Response

Having a well-planned and practiced crisis response plan is critical to minimizing financial and reputational costs. This should involve the input of experienced, specialist third parties, as well as numerous internal departments.

Ryan Griffin, cyber specialist, JLT Specialty USA

“The more business operation leaders can get involved the better,” said Griffin.

Given the entertainment industry’s highly public nature, “it is critically important that the victim of a hack brings in a PR firm to communicate statements both outside and within the organization,” said Boeck, while DePaul added that given that most cyber attacks are not detected for 200-plus days, bringing in a forensic investigator to determine what happened is also essential.

Indeed, said Griffin, knowing who perpetrated the attack could help bring the event to a swifter and cheaper conclusion.

“Is it a nation state upset about the way it’s been portrayed or criminals after a quick buck? Understanding your enemy’s motivation is important in mitigating the damage.”

Some hackers, he noted, have in the past lived up to their word and released encryption keys to unlock stolen data if ransoms are paid. Inevitably, entertainment firms won’t always get so lucky.

Given the potentially catastrophic stakes, it is little surprise these firms are now waking up to the need for robust crisis plans and Fort Knox-level security for valuable projects going forward. &

Antony Ireland is a London-based financial journalist. He can be reached at [email protected]