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 Report: Marine

Crewless Ships Raise Questions

Is a remote operator legally a master? New technology confounds old terms.
By: | March 5, 2018 • 6 min read

For many developers, the accelerating development of remote-controlled and autonomous ships represents what could be the dawn of a new era. For underwriters and brokers, however, such vessels could represent the end of thousands of years of maritime law and risk management.

Rod Johnson, director of marine risk management, RSA Global Risk

While crewless vessels have yet to breach commercial service, there are active testing programs. Most brokers and underwriters expect small-scale commercial operations to be feasible in a few years, but that outlook only considers technical feasibility. How such operations will be insured remains unclear.

“I have been giving this a great deal of thought, this sits on my desk every day,” said Rod Johnson, director of marine risk management, RSA Global Risk, a major UK underwriter. Johnson sits on the loss-prevention committee of the International Union of Maritime Insurers.

“The agreed uncertainty that underpins marine insurance is falling away, but we are pretending that it isn’t. The contractual framework is being made less relevant all the time.”

Defining Autonomous Vessels

Two types of crewless vessels are being contemplated. First up is a drone with no one on board but actively controlled by a human at a remote command post on land or even on another vessel.

While some debate whether the controllers of drone aircrafts are pilots or operators, the very real question yet to be addressed is if a vessel controller is legally a “master” under maritime law.


The other type of crewless vessel would be completely autonomous, with the onboard systems making decisions about navigation, weather and operations.

Advocates tout the benefits of larger cargo capacity without crew spaces, including radically different hull designs without decks people can walk on. Doubters note a crew can fix things at sea while a ship cannot.

Rolls-Royce is one of the major proponents and designers. The company tested a remote-controlled tug in Copenhagen in June 2017.

“We think the initial early adopters will be vessels operating on fixed routes within coastal waters under the jurisdiction of flag states,” the company said.

“We expect to see the first autonomous vessel in commercial operation by the end of the decade. Further out, around 2025, we expect autonomous vessels to operate further from shore — perhaps coastal cargo ships. For ocean-going vessels to be autonomous, it will require a change in international regulations, so this will take longer.”

Once autonomous ships are a reality, “the entire current legal framework for maritime law and insurance is done,” said Johnson. “The master has not been replaced; he is just gone. Commodity ships (bulk carriers) would be most amenable to that technology. I’m not overly bothered by fully automated ships, but I am extremely bothered by heavily automated ones.”

He cited two risks specifically: hacking and fire.

“We expect to see the first autonomous vessel in commercial operation by the end of the decade. Further out, around 2025, we expect autonomous vessels to operate further from shore — perhaps coastal cargo ships. For ocean-going vessels to be autonomous, it will require a change in international regulations, so this will take longer.” — Rolls-Royce Holdings study

Andrew Kinsey, senior marine risk consultant, Allianz Global Corporate & Specialty, asked an even more existential question: “From an insurance standpoint, are we even still talking about a vessel as it is under law? Starting with the legal framework, the duty of a flag state is ‘manning of ships.’ What about the duty to render assistance? There cannot be insurance coverage of an illegal contract.”

Several sources noted that the technological development of crewless ships, while impressive, seems to be a solution in search of a problem. There is no known need in the market; no shippers, operators, owners or mariners advocate that crewless ships will solve their problems.

Kinsey takes umbrage at the suggestion that promotional material on crewless vessels cherry picks his company’s data, which found 75 percent to 90 percent of marine losses are caused by human error.


“Removing the humans from the vessels does not eliminate the human error. It just moves the human error from the helm to the coder. The reports on development by the companies with a vested interest [in crewless vessels] tend to read a lot like advertisements. The pressure for this is not coming from the end users.”

To be sure, Kinsey is a proponent of automation and technology when applied prudently, believing automation can make strides in areas of the supply chains. Much of the talk about automation is trying to bury the serious shortage of qualified crews. It also overshadows the very real potential for blockchain technology to overhaul the backend of marine insurance.

As a marine surveyor, Kinsey said he can go down to the wharf, inspect cranes, vessels and securements, and supervise loading and unloading — but he can’t inspect computer code or cyber security.

New Times, New Risks

In all fairness, insurance language has changed since the 17th century, especially as technology races ahead in the 21st.

“If you read any hull form, it’s practically Shakespearean,” said Stephen J. Harris, senior vice president of marine protection UK, Marsh. “The language is no longer fit for purpose. Our concern specifically to this topic is that the antiquated language talks about crew being on board. If they are not on board, do they still legally count as crew?”

Harris further questioned, “Under hull insurance, and provided that the ship owner has acted diligently, cover is extended to negligence of the master or crew. Does that still apply if the captain is not on board but sitting at a desk in an office?”

Andrew Kinsey, senior marine risk consultant, Allianz Global Corporate & Specialty

Several sources noted that a few international organizations, notably the Comite Maritime International and the International Maritime Organization, “have been very active in asking the legal profession around the world about their thoughts. The interpretations vary greatly. The legal complications of crewless vessels are actually more complicated than the technology.”

For example, if the operational, insurance and regulatory entities in two countries agree on the voyage of a crewless vessel across the ocean, a mishap or storm could drive the vessel into port or on shore of a third country that does not recognize those agreements.

“What worries insurers is legal uncertainty,” said Harris.

“If an operator did everything fine but a system went down, then most likely the designer would be responsible. But even if a designer explicitly accepted responsibility, what matters would be the flag state’s law in international waters and the local state’s law in territorial waters.


“We see the way ahead for this technology as local and short-sea operations. The law has to catch up with the technology, and it is showing no signs of doing so.”

Thomas M. Boudreau, head of specialty insurance, The Hartford, suggested that remote ferry operations could be the most appropriate use: “They travel fixed routes, all within one country’s waters.”

There could also be environmental and operational benefits from using battery power rather than conventional fuels.

“In terms of underwriting, the burden would shift to the manufacturer and designer of the operating systems,” Boudreau added.

It may just be, he suggested, that crewless ships are merely replacing old risks with new ones. Crews can deal with small repairs, fires or leaks at sea, but small conditions such as those can go unchecked and endanger the whole ship and cargo.

“The cyber risk is also concerning. The vessel may be safe from physical piracy, but what about hacking?” &

Gregory DL Morris is an independent business journalist based in New York with 25 years’ experience in industry, energy, finance and transportation. He can be reached at [email protected]