Pharmacy Cost Control

State Drug Monitoring Programs Not Fully Utilized

With access to PDMP data, pharmacy benefit managers could be an important ally in the fight against opioid addiction.
By: | May 2, 2017 • 4 min read

Among the most powerful tools in America’s fight against opioid abuse are state-run Prescription Drug Monitoring Programs (PDMPs). In 49 out of 50 states, PDMPs mandate reporting of the prescription and dispensation of opioids and other controlled medications by physicians and pharmacists, who are then able to consult that data.

G. Caleb Alexander, MD, FACP, oo-director, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health

Unfortunately, PDMP data is largely inaccessible to Pharmacy Benefit Managers (PBMs), who should be well-positioned to detect, prevent, and intervene in high-risk opioid prescription situations.

This centralized, comprehensive data can be enormously valuable in detecting patterns that could indicate actual or potential addiction issues, including polypharmacy (multiple opioid prescriptions); multiple prescribers or payers; excessive dosages and dangerous interactions.

Having multiple prescriptions or failing to take a prescribed mediation may be an innocent mistake. But those instances can also indicate efforts to game the system, such as “doctor shopping.” Either way, detecting high-risk patterns and responding quickly is essential to patient outcomes and to reducing excess drug costs and addiction treatment costs.

A 2015 study released by Johns Hopkins University’s Bloomberg School of Public Health, “The Prescription Opioid Epidemic: An Evidence-Based Approach,” advocates granting PBMs access to PDMP data — with proper patient privacy protections —citing PBM’s prescription claims surveillance, prescriber intervention programs, and claims review software algorithms.

Describing the proven effectiveness of prescriber letters from PBMs, as well as prior authorization, precertification, and maximum quantity limits per prescription, the report says, “These programs could be enhanced if the PBM has complete controlled substance claims history, including cash claims, through access to states’ PDMPs.”

“PBMs are uniquely able to help shape patient care in many ways that no other stakeholder has the capacity to do,” said G. Caleb Alexander, MD, FACP, Co-Director, Center for Drug Safety and Effectiveness at Johns Hopkins Bloomberg School of Public Health, the report’s co-editor.

“PBMs are uniquely able to help shape patient care in many ways that no other stakeholder has the capacity to do.” — G. Caleb Alexander, MD, FACP, Co-Director, Center for Drug Safety and Effectiveness at Johns Hopkins Bloomberg School of Public Health

“Our health care system is incredibly fragmented,” said Alexander. “[PDMPs] allow for comprehensive collection and organization of the totality of a patient’s controlled substance use … [enabling PBMs] to better design and deploy and evaluate a variety of different mechanisms or interventions.”

PBMs could also aggregate data across state lines, revealing patterns not apparent from individual state PDMP data. PBMs are not only equipped to monitor such data in real time, they are financially incentivized to do so.

“Our role is to ensure the safe use of medication and that they are being used effectively and cost-effectively,” said Patrick Gleason, Pharm.D, a signatory of the Johns Hopkins report and Senior Director of Health Outcomes at Prime Therapeutics, a PBM owned by 14 not-for-profit Blue Cross and Blue Shield health plans, subsidiaries or affiliates.

“If the unsafe use of medication is leading to health care costs and harm for our members, we want to do everything we can to ensure that doesn’t happen. … First and foremost it’s about safety, and unsafe use of medications leads to higher cost.”

Debate Over Access

Some have voiced concerns about PBM access to PDMP data, even among those who advocate for it. In addition to patient privacy concerns, there are questions about PBM financial incentives, which Alexander calls, “horribly opaque.”

Patrick Gleason, senior director of health outcomes, Prime Therapeutics

In lieu of access to PDMP data, some PBMs have established structural relationships with dispensing pharmacists.

“We partnered with a workers’ comp dedicated pharmacy for those high-risk patients … where there’s a lot of opioid exposure,” explained Mike Cirillo, Managing Director at Specialty Solutions Rx, a PBM specializing in workers’ comp.

“We actually route the patient into that pharmacy, [who then does] the PDMP look up. They can do an outreach to the patient and to the physician to talk about medications.”

According to Cirillo, “three to five percent of the opioid prescriptions that come in get a polypharmacy hit on the PDMP.”

Prime Therapeutics is pursuing a similar strategy.

“We have a validated, controlled substance scoring system and we’re developing a process to send the individuals that are scoring the highest to Walgreens, to have Walgreens’ pharmacists look those people up in the PDMP and provide more consultative services at the point of care,” said Gleason, emphasizing that the PBM itself will not be looking into the PDMP.

While there is currently no concerted effort to gain PBM access to PDMP data, according to Corey Davis, Deputy Director, Southeastern Region Network for Public Health Law, there are some encouraging trends among PDMPs.

“It’s becoming more standardized, so states are kind of all moving in the same direction of collecting more data, more drug schedules, and requiring that the data be uploaded more often.” &

Jon McGoran is a novelist and magazine editor based outside of Philadelphia. He can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Risk Management

The Profession

Pinnacle Entertainment’s VP of enterprise risk management says he’s inspired by Disney’s approach to risk management.
By: | November 1, 2017 • 4 min read

R&I: What was your first job?

Bus boy at a fine dining restaurant.

R&I: How did you come to work in this industry?

I sent a résumé to Harrah’s Entertainment on a whim. It took over 30 hours of interviewing to get that job, but it was well worth it.

R&I: If the world has a modern hero, who is it and why?

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The Chinese citizen (never positively identified) who stood in front of a column of tanks in Tiananmen Square on June 5, 1989. That kind of courage is undeniable, and that image is unforgettable. I hope we can all be that passionate about something at least once in our lives.

R&I: What emerging commercial risk most concerns you?

Cyber risk, but more narrowly, cyber-extortion. I think state sponsored bad actors are getting more and more sophisticated, and the risk is that they find a way to control entire systems.

R&I: What is the riskiest activity you ever engaged in?

Training and breaking horses. When I was in high school, I worked on a lot of farms. I did everything from building fences to putting up hay. It was during this time that I found I had a knack for horses. They would tolerate me getting real close, so it was natural I started working more and more with them.

Eventually, I was putting a saddle on a few and before I knew it I was in that saddle riding a horse that had never been ridden before.

I admit I had some nervous moments, but I was never thrown off. It taught me that developing genuine trust early is very important and is needed by all involved. Nothing of any real value happens without it.

R&I: What about this work do you find the most fulfilling or rewarding?

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Setting very aggressive goals and then meeting and exceeding those goals with a team. Sharing team victories is the ultimate reward.

R&I: What is the most unusual/interesting place you have ever visited?

Disney World. The sheer size of the place is awe inspiring. And everything works like a finely tuned clock.

There is a reason that hospitality companies send their people there to be trained on guest service. Disney World does it better than anyone else.

As a hospitality executive, I always learn something new whenever I am there.

James Cunningham, vice president, enterprise risk management, Pinnacle Entertainment, Inc.

The risks that Disney World faces are very similar to mine — on a much larger scale. They are complex and across the board. From liability for the millions of people they host as their guests each year, to the physical location of the park, to their vendor partnerships; their approach to risk management has been and continues to be innovative and a model that I learn from and I think there are lessons there for everybody.

R&I: What is the risk management community doing right?

We are doing a much better job of getting involved in a meaningful way in our daily operations and demonstrating genuine value to our organizations.

R&I: What could the risk management community be doing a better job of?

Educating and promoting the career with young people.

R&I: What have you accomplished that you are proudest of?

Being able to tell the Pinnacle story. It’s a great one and it wasn’t being told. I believe that the insurance markets now understand who we are and what we stand for.

R&I: Who is your mentor and why?

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John Matthews, who is now retired, formerly with Aon and Caesar’s Palace. John is an exceptional leader who demonstrated the value of putting a top-shelf team together and then letting them do their best work. I model my management style after him.

R&I: What is your favorite book or movie?

I read mostly biographies and autobiographies. I like to read how successful people became successful by overcoming their own obstacles. Jay Leno, Jack Welch, Bill Harrah, etc. I also enjoyed the book and movie “Money Ball.”

R&I: What is your favorite drink?

Ice water when it’s hot, coffee when it’s cold, and an adult beverage when it’s called for.

R&I: What does your family think you do?

In my family, I’m the “Safety Geek.”

R&I:  What’s your favorite restaurant?

Vegas is a world-class restaurant town. No matter what you are hungry for, you can find it here. I have a few favorites that are my “go-to’s,” depending on the mood and who I am with.

If you’re in town, you should try to have at least one meal off the strip. For that, I would suggest you get reservations (you’ll need them) at Herbs and Rye. It’s a great little restaurant that is always lively. The food is tremendous, and the service is always on point. They make hand-crafted cocktails that are amazing.

My favorite Mexican restaurant is Lindo Michoacan. There are three in town, and I prefer the one in Henderson as it has the best view of the valley. For seafood, you can never go wrong with Joe’s in Caesar’s Palace.




Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]