Reprinted from DRUG BENEFIT NEWS, biweekly news, proven cost management strategies and unique data for health plans, PBMs, pharma companies and employers.
By Lauren Flynn Kelly, Editor
March 15, 2013 Volume 14 Issue 5
Through its in-house PBM unit, Aetna Pharmacy Management, Aetna Inc. has taken what Pharmacy Director Yrena Friedmann, Pharm.D., described as both a compassionate and diligent approach to managing prescription drug misuse, waste and abuse, with specific controls and case review around opioid dependence. As a result of its mail campaign to promote the use of Suboxone (buprenorphine HCl and naloxone HCl dihydrate), which has just gone generic and is indicated for opioid addiction (see box, p. 6), the insurer has seen a 16% jump in adherence, Friedmann said in a recent conference presentation.
Deaths related to drug overdose, including those involving prescription drugs, have steadily risen over the last 11 years, reports the CDC. Opioid analgesics (e.g., oxycodone, hydrocodone, methadone) were involved in about three out of every four pharmaceutical overdose deaths documented in 2010, or 16,651, up from 15,597 in 2009 and 4,030 deaths in 1999, according to a research letter published in the Feb. 20 issue of the Journal of the American Medical Association.
Moreover, opioid abusers have an average of eight times the health care costs compared with non-abusers, thanks to frequent physician visits, hospital stays and other outpatient costs such as emergency room visits, pointed out Friedmann, who spoke at the 2013 Pharmacy Benefit Management Institute Drug Benefit Conference, held Feb. 18-20 in Las Vegas. “In other words, treating opioid use, while it is labor intensive, can have a positive impact on total health care costs in the long run,” she suggested. “Also, this shows that we can’t rely on pharmacy costs alone to identify patients in need of help from prescription drug abuse.”
Aetna Tackles Rx Abuse With DUR
As part of a multilevel initiative aimed at tackling abuse, Aetna in January 2011 crafted a case review program that encourages the use of Suboxone with certain precertification requirements followed by a high-touch outreach component. The insurer covers Suboxone only when there is a diagnosis of opioid dependence, and requires a commitment from the member to be enrolled in a counseling program. Of Aetna’s decision to place the coverage restriction on Suboxone, Friedmann explained, “We found quite a few cases where the physicians were prescribing it for pain.” Despite the drug containing the narcotic buprenorphine, Suboxone is FDA-approved only for opioid dependence.
Following the precertification, Aetna performs a retrospective drug utilization review (DUR) with a system called Rx Check where Aetna monitors patients who have been diagnosed with opioid dependence but are not compliant with their treatment plan and are still receiving opioids, usually from other doctors, not the physician with whom they arranged a treatment plan. Aetna sends a letter to the physician and also has a specially trained pharmacist call the physician to describe the continued opioid use and encourage the provider to not discharge the member from practice and instead to work with the member privately. “We don’t want the member to run away. We want the member to continue to work with the Suboxone prescriber and get the help they need,” she said.
“After we have done everything we can to try to engage the members and the physicians to work together on a reasonable treatment plan, sometimes there is a time to limit access for patients who don’t respond to our support,” acknowledged Friedmann. Aetna employs a pharmacy case review committee to look at the really complex cases and make determinations as to when and how to deny coverage (e.g., locking the member into one physician, placing a quantity limit on a drug). In the case of Suboxone patients who are continuing to fill opioid claims, those patients are sent a denial letter with a two-week grace period letting them know their options, behavioral health resources and their appeal rights. “We don’t want to shut anybody off abruptly; we just don’t think that would be the right thing to do,” she asserted. After two weeks, the insurer blocks all opioid claims for that patient.
Friedmann added that Aetna has just updated its DocFind database to identify physicians in the network who are certified to prescribe Suboxone. (Under the Drug Addiction Treatment Act of 2000, physicians must meet certain qualifying requirements to be able to prescribe Suboxone in the treatment of opioid dependence.) That way, if a nurse working in its integrated case management program determines that a patient is ready for addiction services, he or she can recommend a physician in the network who can provide that type of service for the patient, she explained.
As of November 2011, 49.3% of patients who were approved for Suboxone continued to get opioids even though they received a letter from Aetna letting them know the insurer’s expectations to be opioid abstinent. However, for those whose physicians were engaged in the retrospective outreach, only 2.3% persisted in concurrent Suboxone/opioid use. In January 2010, when Aetna first introduced a mailing program, DUR and certain safety edits on opioids, about 42,000 opioid prescriptions were being processed a month. By January 2011, when the Suboxone mailing and case review program began, monthly opioid prescriptions totaled about 39,000, and dropped to 36,000 a year later for an overall two-year reduction of 15%. Preliminary analysis also shows Suboxone adherence rates have improved by 16%.
“With diligence, we’ve been able to fight the good fight against opioid misuse, waste and abuse, so it’s good to know that our labor is not in vain,” concluded Friedmann. “I was really pleased to see this since the trend in general in our culture is that opioid use is increasing.” The Suboxone program is available only to fully insured clients at this time.
http://aishealth.com/archive/ndbn031513-01
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