Opioid Use + Multiple Prescribers
It may come as a surprise, but injured workers receiving multiple prescriptions from multiple prescribers is not all that uncommon. Naturally, this is a dangerous situation with serious potential for things to go wrong for both payer and patient.
While these cases may be thought of as extreme and even rare, injured workers using opioids and seeing multiple prescribers is a relatively frequent phenomenon. For example, during several recent new client implementations converting payers to our pharmacy program, Healthesystems identified situations where more than 25% of claimants who were receiving prescriptions on more than one occasion, and were prescribed opioid medications, also saw three or more prescribers during the same period.
When multiple prescribers are involved there is a much greater probability for patient confusion and misadventure, including drug interactions, therapeutic duplication, additive adverse side effects, and possible abuse, misuse or diversion. Not only does this practice place claimants at risk for medication-related issues, their monthly prescription costs were 24% higher when compared to claimants who saw a single provider.
To analyze this risk-laden scenario further, Healthesystems reviewed the prior PBM programs’ historical data to further study cases in which claimants:
- Received prescriptions from three or more prescribers,
- Received prescriptions from three or more pharmacies
- Concurrently received multiple opioids
Opioid spend alone for these claimants averaged nearly $5,000 annually. When compared to all claims with opioid use, these claims averaged (see Chart below):
Payers and their PBM partners must continually develop and improve fraud, waste and abuse programs that target claims with identified risks. For example, the Healthesystems VigilantRx clinical program proactively identifies patients with multiple prescribers, high-dose opioid prescriptions, high pharmacy costs and inappropriate medications, as these risks occur. This allows payers to address the situation immediately and mitigate the risk quickly. Consistent communication by clinical experts with the prescribers — discussing the importance of patients having a lead prescriber and a single pharmacy or pharmacy system (e.g., a national drug chain) – is critical.
Communication between prescribers also is essential for ensuring patient safety and optimal clinical outcomes in regards to recovery and return-to-work. In every case where multiple prescribers must be involved, and especially when opioids are prescribed, it is important to establish a lead prescriber. This provider should coordinate not only the care plan but also the drug therapy, including discussing the patient’s choice of pharmacy to prevent possible miscommunication and overlap in therapy.
The need to identify claimants upon initiation of opioids, especially those seeing multiple prescribers, is clear. This specific type of case and any potential issues should be discussed with both the injured worker and prescribers, and tightly managed through the rehabilitation process. Finally, claims professionals must be empowered to ask physicians to coordinate care with other prescribers and document the expectations and outcomes of opioid use and medication therapy.
This potential for abuse in these cases can be detected fairly easily with the right tools, but any solution lies in a tightly integrated communications effort among the PBM, payer, prescriber and patient.