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Ensuring Safe and Appropriate Prescription Painkiller Use: UPMC Health Plan | Pittsburgh, Pennsylvania35528252552065The Alliance of Community Health Plans (ACHP) is a national leadership organization bringing together innovative health plans and provider groups that are among America’s best at delivering affordable, high-quality coverage and care. The community based and regional health plans and provider organizations from across the country that make up ACHP’s membership provide coverage and care for approximately 16 million Americans. These 22 organizations focus on improving the health of the communities they serve and are on the leading edge of innovations in affordability and the quality of care, including patient care coordination, patient-centered medical homes, accountable health care delivery and use of information technology. To learn more about ACHP, visit us at .00The Alliance of Community Health Plans (ACHP) is a national leadership organization bringing together innovative health plans and provider groups that are among America’s best at delivering affordable, high-quality coverage and care. The community based and regional health plans and provider organizations from across the country that make up ACHP’s membership provide coverage and care for approximately 16 million Americans. These 22 organizations focus on improving the health of the communities they serve and are on the leading edge of innovations in affordability and the quality of care, including patient care coordination, patient-centered medical homes, accountable health care delivery and use of information technology. To learn more about ACHP, visit us at .IntroductionAs part of an integrated health care delivery system, UPMC Health Plan (UPMCHP),owned by the University of Pittsburgh Medical Center, partners with the medical center and a community network of more than 80 hospitals and 7,600 physicians to serve residents in a 29-county region of western Pennsylvania. Approximately 30 percent of UPMCHP members are seen by affiliated physicians; the remainder are aligned with contracted network providers. UPMCHP’s opioid misuse initiatives address both the management of chronic pain and the monitoring of fraud and abuse, with a focus on supporting primary care physicians. Initially, UPMCHP addressed the opioid issue through the aggressive but traditional approaches of formulary management, retrospective analysis of claims, clinical programs and ranking of physicians on quality measures. For example, UPMCHP was one of the first plans to mandate that Actiq be prescribed only by oncologists, and instituted a prior authorization process for the drug that required a cancer diagnosis. When the plan removed OxyContin from its medication formulary, 13 percent of members who had been using the drug not only stopped taking it, but also did not switch to another opioid, suggesting medication diversion, fraud or medically unnecessary use of the narcotic.In the past few years, however, UPMCHP realized that it needed a more focused approach to opioid management. In 2010, the plan convened a workgroup of addiction specialists, pain specialists, psychiatrists, pharmacists and primary care physicians to solicit feedback on the best ways to support providers at the plan level. A number of initiatives were instituted at UPMCHP, based largely on feedback from the workgroup. At their core is a provider toolkit developed by a multidisciplinary group of providers, which includes resources for physicians on appropriate opioid prescribing.InitiativesPatient identificationAs part of its pain management program, the health plan created an algorithm to identify patients who exhibit warning signs of addiction, improperly managed pain, opioid abuse or fraud (such as doctor shopping). Criteria for identification include the use of more than three separate opioids in a three-month period, or having three or more prescribers and more than eight filled opioid prescriptions in a quarter. The program attempts to distinguish between patients who need assistance managing pain (for example, after a serious accident) and those who are suspected of engaging in fraud and abuse. The latter category of patients is sent to the Fraud, Waste and Abuse Department.Approximately 400 to 600 patients are identified for follow-up every quarter. Provider outreach36957003343275UPMC’s provider toolkit includes information about appropriate narcotic prescribing and pain management, patient assessments and screening tools for early identification of misuse and other resources to assist physicians with delivering evidence-based care.00UPMC’s provider toolkit includes information about appropriate narcotic prescribing and pain management, patient assessments and screening tools for early identification of misuse and other resources to assist physicians with delivering evidence-based care.If abnormal use patterns persist six months after identification of patients, UPMCHP sends prescribing physicians a list of these patients’ names along with their prescription drug history. Providers can request help in referring any of these patients to specialists or can ask for pharmacist assistance in determining appropriate dosing or possible drug interactions. Care management nurses are also available to patients and providers to manage psychosocial issues, assist with scheduling appointments and conduct patient outreach.In addition to coordinating care between providers and facilitating referrals to pain and addiction specialists, UPMCHP has been working with Community Care Behavioral Health, part of the UPMC Insurance Services Division company, to develop workflows on referring patients to behavioral health services. Provider toolkitAlong with the patient list, UPMC sends providers a comprehensive toolkit — developed based on workgroup feedback — on best practices in pain management. The toolkit includes information about appropriate narcotic prescribing; patient assessments and screening tools for early identification of misuse; strategies for acute and chronic pain management; forms to assist with documentation, including patient pain agreements formulary and drug information; and charts that help providers compare doses of different analgesics (painkillers). The toolkit recommends non-pharmacological treatment for pain whenever possible, including initiatives to address underlying physical, emotional, social and vocational issues that may be exacerbating or causing the pain. This toolkit comes with a CD from which providers can copy and reproduce the information. UPMC has received very positive feedback from providers on this toolkit, which has won multiple awards, including the Gold Award in the 2011 Aster Awards competition, an “elite competition recognizing the nation’s most talented marketing professionals and excellence in health care marketing” sponsored by Marketing Healthcare Today magazine. The toolkit was also a Gold Award Winner at MarCom, an international competition sponsored by the Association of Marketing and Communication Professionals. Tackling fraud and abuseUPMCHP’s Fraud, Waste and Abuse program identifies patients who may be diverting narcotics and other medications. An algorithm identifies the total number of prescriptions, pharmacies and physicians each patient uses to obtain opioids; files for members with total scores above a certain cut-off point are sent to pharmacists to review on a case-by-case basis. The pharmacists use their clinical judgment to determine whether the individual cases require follow-up; for example, patients with an oncology diagnosis may be excluded from further review. These patients’ files would instead be sent to their primary care physicians as part of the pain management program described above.OutcomesUtilization42005252600325In its first year, UPMC Health Plan’s Pain Management Program led to a 13 percent decrease in utilization of opioid claims for the targeted members.00In its first year, UPMC Health Plan’s Pain Management Program led to a 13 percent decrease in utilization of opioid claims for the targeted members.In its first year, UPMCHP’s Pain Management Program led to a 13 percent decrease in utilization of opioid claims for the targeted members in an analysis of claims before and after the initiative began. In addition, cost trends for the identified members have been essentially flat for both overall pharmacy costs as well as the opioid category. Provider engagementUPMCHP has experienced a 28 percent fax-back response rate, signaling positive provider engagement. Of those responding, approximately 20 percent requested assistance from a UPMCHP care manager or pharmacist; the remainder expressed appreciation for the information but did not desire additional help. Among those physicians who requested help, UPMCHP provided assistance in four key domains: care coordination assistance (35 percent), pain specialist referrals (32 percent), member outreach assistance (23 percent) and management of abuse issues (30 percent).-190506286500A copy of the full ACHP brief on ensuring safe and appropriate prescription painkiller use, supplementary profiles on member plan initiatives, a one-page fact sheet and other resources are available online at or by emailing innovations@.00A copy of the full ACHP brief on ensuring safe and appropriate prescription painkiller use, supplementary profiles on member plan initiatives, a one-page fact sheet and other resources are available online at or by emailing innovations@.Based on initial findings, UPMCHP will continue this program and further evaluate its effectiveness. All program components, including the targeting algorithm, outreach protocols, stakeholder satisfaction and toolkit clinical content are monitored and reviewed for potential modification and/or enhancement. ................
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