Your pharmacy benefits managermay produce beautiful reports and retain troops of competent staff, but it probably is not watching your group's narcotic painkillers. Most PBMs do not utilize warning systems to flag high use or potential abuse of narcotics. Armed with a calculator and standard PBM reports, though, you can spot major problems and get something done about them.
Your first step is to find the PBM report that addresses "indication" - the illness or condition that the drug is treating. Then, identify the indication of pain. The report likely will note "Rxs," which is the number of prescriptions filled, and may also have "patients." Calculate the number of patients receiving pain medications as a percentage of your whole covered group.
For example, a group with 1,500 people (including spouses and children) could have 400 people receiving pain medications. With 400 people, the group has a little over 25% receiving drugs for pain; this doesn't raise a red flag for widespread use of pain meds. However, if half the group was using drugs for pain, you could assume that something is awry.
You also can calculate the number of pain prescriptions per patient. Using the same example, say the 400 patients had 1,300 prescriptions during a 12-month period. That averages 3.25 per patient. Since these medications only should be used for short-term pain - such as after a surgery or for end-of-life care - the average seems high. Thus, it's likely there are some patients on long-term painkillers.
Suppose you spot a problem. What's next? As an employer, you cannot get the specific data on who is using which medication and how much. However, you can request that your PBM send a report to your disease management vendor that shows every member who has been using narcotics for more than 30 days. Your DM vendor's nursing staff can reach out to these members and their physicians. (If chronic pain isn't already on your list for disease management, it's definitely time to add it - especially if you suspect narcotic abuse.) Your PBM may be willing to notify the physicians whose patients show an overuse of narcotics; a simple letter may be enough to change prescribing patterns.
Addiction to painkillers is a nationwide problem. A recent New England Journal of Medicine story stated that 60% of opioids that are abused by patients are obtained directly or indirectly from a physician's prescription. Physicians may even be aware that the patient is addicted, but cannot get the patient into addiction treatment. Therefore, the prescriptions continue to get written.
It's amazing what a benefit manager can do with a simple calculator and a good eye. You might be saving someone's life.
Linda K. Riddell is a principal at Health Economy, LLC. She can be contacted at LRiddell@HealthEconomy.net.
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