Improved Retrospective DUR Programming

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Improved Retrospective Drug Utilization Review for
Potential Opioid Overutilizers — Results from the Pilot
CMS 2012
Medicare Advantage &
Prescription Drug Plan
Fall Enrollment, Marketing,
and Compliance Conference
Image of spilled med capsules
Cynthia G. Tudor, Ph.D., Director
Medicare Drug Benefit and C&D
Data Group
September 5, 2012
Session Overview
• Background
• Improved Retrospective DUR Programming
and Case Management
• Morphine Equivalent Dose (MED) Analysis
• Pilot Panel
• Questions
• Epidemic: Responding to America’s Prescription Drug
Abuse Crisis, April 20111
• Opioid overdose is now the second leading cause of
unintentional death in the United States, second only to
motor vehicle crashes2
• People who abuse opioids have direct health care costs
more than eight times those of nonabusers3
• GAO Report, Sept. 6, 2011,“Medicare Part D, Instances of
Questionable Access to Prescription Drugs”4
ND, McLellan TA. Curtailing Diversion and Abuse of Opioid Analgesics Without Jeopardizing Pain Treatment. JAMA
3Unintentional drug poisoning in the United States [July 2010]. National Center for Injury Prevention and Control. Centers for Disease
Control and Prevention.
4GAO-11-699. (Washington, D.C.: Sept. 6, 2011).
Improved Retrospective DUR
Programming & Case Management
• For 2013, “Level Three” controls to apply to
opioids (P&T Committee involvement)
• Part D sponsors should look for apparent
duplicative opioid drug use over sustained
periods of time and/or across multiple opioid
drug products in high doses
• Focus on high dosage, sustained opioid use,
and multiple providers
Improved Retrospective DUR
Programming & Case Management
• Clinical staff should communicate with prescribers and
beneficiaries to ascertain medical necessity
• Give prescribers information about the existence of
multiple prescribers and the beneficiary’s total opioid
• Results of case management to confirm: 1) current level;
2) lower level; or 3) no opioids. No status quo if prescribers
non-responsive and MEDIC referrals as appropriate
• Provide 30-day advance written notice to beneficiary and
opioid prescriber(s) of pending POS edits with the right to
contest. No lock-in to specific prescribers or pharmacies
Morphine Equivalent Dose (MED)
• MED is useful tool to assess and manage risks
associated with use of opioids5,6
• CMS MED Analyses in Part D (2011 PDE)
– Methodology
Identify exclusion criteria (cancer, hospice)
Develop MED conversion table for oral opioid analgesics
Calculate cumulative, daily MED for each beneficiary
Assess use of greater than 120 mg MED for at least 90
consecutive days
• Add criteria for multiple prescribers and pharmacies
KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff
M. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152(2):85-92.
6Washington State Agency Medical Directors’ Group, Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid
to improve care and safety with opioid therapy, 2010 Update. Available at
Morphine Equivalent Dose (MED)
• CMS MED Analyses in Part D (2011 PDE)
– Results, excluding cancer and hospice care
• 8.8 million (28%) opioid analgesic utilizers in Part D
• 1.8 million (5.6%) exceeded 120 mg MED for at least
one day
• 225,000 (0.71%) exceeded 120 mg MED for at least 90
consecutive days
• 22,222 (0.07%) also used more than 3 prescribers and
more than 3 pharmacies during the 90-day period
Pilot Panel for “Level Three”
• Participants: CVS/Caremark, Humana,
• Discussion
– Targeting criteria/beneficiaries selected
– Due Diligence
– Outreach to prescribers and beneficiaries
– Outcomes and follow-up
– Lessons learned
Any additional questions about the Part D overutilization policy
should be directed to [email protected] using the
Subject Line “Overutilization.”

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