Dennis Jay

www.InsuranceFraud.org

The Financial Impact to Payers

April 10-12, 2012 Walt Disney World Swan Resort

Learning Objectives: 1. Identify the primary causes for increased health care costs as it relates to opioid abuse. 2. Outline simple steps that employers can implement within their work place to reduce their risks, lower their costs and improve productivity.

3. Explain why employers should be concerned about prescription drug abuse even if they are not currently dealing with an abuse-related issue in their workplace.

Disclosure Statement

•  All presenters for this session, Michael Gavin and Dennis Jay, have disclosed no relevant, real or apparent personal or professional financial relationships.

4 www.InsuranceFraud.org

Prescription Drug Diversion

•  Increased cost to workers comp insurers and health plans lead to a comprehensive study in 2007.

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•  Abuse, theft, illegal sale, illicit use of insurer-paid prescription narcotics, mostly painkillers or opioids.

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Perfect storm of abuse

• Development of new painkillers

• Pain management as a discipline

• a via insurance systems

• Addiction

• High profits



•  Report estimated that cost to public and private health systems as high as $27 billion annually.

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•  Has the problem lessened in recent years?


Strategies

• Know who’s prescribing — pain specialist vs. general practitioner

• Form pain management workgroups with medical director and SIU.

• Question off-label prescriptions on first instance. Don’t wait.

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Strategies • Prescriptions with no logical relationship to the injury.

• Monitor patterns as far as early refills and pill quantity.

• Multiple prescribers and/or pharmacies.

• Look for claimants who may be selling drugs to offset loss of income.

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Strategies • Develop investigative protocols

• Require claimant to use only one pharmacy

• Better datamining - ID problem docs and pharmacies

• Compare prescription with medical claim data.

• Better training - NADDI

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Strategies • Prescription monitoring • Pharmacy photo ID

• Better training of docs • Better credentialing of specialists

• Restrict pharma influence on docs • More investigations & prosecutions by DAs and state fraud bureaus

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The Good News


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The Not-So-Good News


The Final Solution • Development of an effective painkiller that is not addictive.

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Health & Medicine

Dennis Jay