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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

The risk manager for Boyd Gaming Corp. says curiosity keeps him engaged, and continual education will be the key to managing emerging risks.
By: | May 1, 2018 • 4 min read

R&I: What was your first job?

I was trained as an accountant, worked in public accounting and became a CPA. Being comfortable with numbers is helpful in my current role, and obviously, the language of business is financial statements, so it helps.

R&I: How did you come to work in risk management?

Working in finance in the corporate environment included the review of budgets and the analysis of business expenses. I quickly found the area of benefits and insurance — and how “accepting risk” impacted those expenses — to be fascinating. I asked a lot of questions. Be careful what you ask for — I soon found myself responsible for those insurance areas and haven’t looked back!

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

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I have found the risk management community to be a close-knit group, whether that’s industry professionals, risk managers with other companies or support organizations like RIMS and other regional groups. The expertise of the carriers and specialty vendors to develop new products and programs, along with the appropriate education, will continue to be of key importance to companies going forward.

R&I: What’s been the biggest change in the risk management and insurance industry since you’ve been in it?

As I’m sure many in the insurance field would agree, Hurricanes Katrina and Rita in 2005 changed our world and our industry. It was a particularly intense time and certainly a baptism by fire for people like me who were relatively new to the industry. This event clearly accelerated the switch to the acceptance of more risk, which impacted mitigation strategies and programs.

Bob Berglund, vice president, benefits and insurance, Boyd Gaming Corp.

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

The fast-paced threat that cyber security represents today. Our company, like so many companies, is reliant upon computers, software and IT expertise in our everyday existence. This new risk has forged an even stronger relationship between risk management and our IT department as we work together to address this growing threat.

Additionally, the shooting event in Las Vegas in 2017 will have an enduring impact on firms that host large gatherings and arena-style events all over the world, and our company is no exception.

R&I: What insurance carrier do you have the highest opinion of?

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With the various types of insurance programs we employ, I have been fortunate to work with most of the large national and international carriers — all of whom employ talented people with a vast array of resources.

R&I:  How much business do you do direct versus going through a broker?

We use brokers for many of our professional coverages, such as property, casualty, D&O and cyber. We are self-insured under our health plans, with close to 25,000 members. We tend to manage those programs internally and utilize direct relationships with carriers and specialty vendors to tailor a plan that works best for team members.

R&I: Who is your mentor and why?

I have been fortunate to have worked alongside some smart and insightful people during my career. A key piece of advice, said in many different ways, has served me well. Simply stated: “Seek to understand before being understood.”

What this has meant to me is try everything you can to learn about something, new or old. After you have gained this knowledge, you can begin to access and maybe suggest changes or adjustments. Being curious has always been a personal enjoyment for me in business, and I have found people are more than willing to lend a hand, offer information and advice — you just need to ask. Building those alliances and foundations of knowledge on a subject matter makes tackling the future more exciting and fruitful.

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

Our benefit health plan is much more than handing out an insurance card at the beginning of the year. We encourage our team members and their families to learn about their personal health, get engaged in a variety of health and wellness programs and try to live life in the healthiest possible way. The result of that is literally hundreds of testimonials from our members every year on how they have lost weight, changed their lifestyle and gotten off medications. It is extremely rewarding and is a testament to [our] close-knit corporate culture.

R&I: What’s the best restaurant you’ve ever eaten at?

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Some will remember the volcano eruption in Iceland in spring of 2010. I was just finishing a week of meetings in London with Lloyd’s syndicates related to our property insurance placement when the airspace in England and most of northern Europe was shut down — no airplanes in or out! Flights were ultimately canceled for the following five days. Therefore, with a few other stranded visitors like myself, we experimented and tried out new restaurants every day until we could leave. It was a very interesting time!

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

I am originally from Canada, and I played ice hockey from the time I was four years old up until quite recently. Too many surgeries sadly forced my recent retirement.

R&I: What do your friends and family think you do?

That’s a funny one … I am a CPA working in the casino industry, doing insurance and risk management, so neighbors and acquaintances think I either do tax returns or they think I’m a blackjack dealer at the casino!




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