AMCP: How to reduce use, cost related to controlled substances

Telephonic intervention for members with high controlled-substance utilization appears to result in substantial decreases in utilization and cost, according Prime Therapeutics. The PBM presented its study results at the Academy of Managed Care Pharmacy’s 26th Annual Meeting & Expo in Tampa, Fla. Savings totaled $220 per member over a three-month period with health plan-directed, pharmacist-prescriber interventions.

Because prescription drug abuse is seen as an epidemic, Prime began monitoring controlled substance users through its pharmacist consultant program. It found decreases in controlled substances scores, claims and unique prescribers and pharmacies per user over a three-month period.

The study reviewed Medicare Part D administrative pharmacy claims from more than 1 million members to identify those who potentially were overusing controlled substances and identified members based on an internally defined controlled substances score of greater than 120, for at least one day, and a daily morphine equivalent dose of more than 120 mg, during December 2012 through March 2013.

The controlled substance score has been published and demonstrated a retrospective drug utilization letter was effective in decreasing controlled substance use and costs.

Prime attempted to contact the members’ physicians up to four times to determine if therapy was appropriate or if changes were warranted. If the physician did not respond, therapy was considered inappropriate and changes were made.

Example of changes in therapy were:

1) approving only certain medications going forward;

2) blocking all access to controlled substances; or

3) quantity limits on certain controlled substances.

Of the 158 members who met the intervention criteria, researchers found about half (77) had doctor directed changes and one had no response. After implementing the controlled substances therapy changes, Prime analyzed the controlled substances claims for these 78 members.

The study found the average controlled substances score declined 40%; controlled substances claims decreased 33% (from 18 to 12); and opioid claims decreased 40% (from 12.9 to 7.8). The number of unique pharmacies decreased for both controlled substances (down 29% from 3.1 to 2.2) and opioids (down 36% from 2.8 to 1.8); as did the number of unique prescribers.

Over three months, there was a controlled substances claims savings of $17,160–an average of $220 per member.

“On a quarterly basis, the new Medicare Part D Overutilization Monitoring System [OMS] identifies beneficiaries with potential opioid over utilization issues and refers them to plan sponsors for investigation,” said Pat Gleason, PharmD, BCPS, FCCP, director of health outcomes for Prime. “Plan sponsors are expected to respond within 30 days as to what they are doing to ensure the members' are safely using opioids”

Gleason says findings demonstrate a pharmacist call to prescribers on behalf of the plan sponsor resulted in 49% of prescribers taking action and the other 51% of prescribers validated controlled substances therapy was appropriate.