Monday, January 14, 2013

Payer Access to Prescription Drug Information

CWCI has published a research piece suggesting that 3rd party payer access to the CURES database (Controlled Substance Utilization Review and Evaluation System) - California's Prescription Drug Monitoring program - could create material cost savings for the California work comp system.

California is on the verge of pulling the plug on CURES.  Despite significant evidence from across the nation that Prescription Drug Monitoring Programs (PDMPs) are critical to fighting the inappropriate utilization of opioids, California has yet to commit to the $3.7 million in annual funding necessary to keep the system online.  If funding doesn't materialize before this summer, the database will go offline in July. 

So why should a state with a massive budget deficit throw $3.7 million at a database?  Perhaps because it would save 15X that number if the database was accessible and usable by 3rd party payers.  The analysis from CWCI is characterized as conservative, but still suggests potential savings (ranging from 3% to 7%, depending on the complexity of the claim) of nearly $60 million simply through the elimination of fraud and abuse by 3rd party payers having access to critical data not currently available to them.

Before the chorus of "privacy concerns" erupts, keep in mind that CWCI is merely suggesting that payers be granted access to data regarding services and therapies for which they are most likely already paying.  The aggregation of the data by prescriber and by pharmacy offers insight into inappropriate and/or unsafe activities such doctor shopping, pharmacy shopping, drug-drug interactions, etc. and can serve as a powerful tool that an individual payer can use to help manage care more effectively. 

Pain management guidelines don't appear to be working (that's a post for another time) and the study found that 41% of work comp claims end up with at least one opioid script, with >20% of injured workers receiving at least 7 opioid scripts over a 24 month period.

That's a lot of drugs.  And a $3.7 million database with a potential for a $60 million return sounds like a good investment to me.

On Twitter @PRIUM1


  1. Michael:

    Thanks for the coverage of the CWCI analysis. One correction to your summary of the study's findings regarding the prevalence of opioids in California workers' comp. Using the opioid claim distribution derived from a sample of 417,508 AY 2007-2009 claims from the Industry Claims Information (ICIS) database (based on payment records), the authors estimated that out of approximately 500,000 California work injury claims from AY 2011, 115,447 (23.1%) had opioids dispensed within 2 years of the injury date. Of those 115,447 claims in which opioids were dispensed, 41.1% involved a single opioid prescription; 24.7% involved 2-3 scripts; 13.6% involved 4-7 scripts; and 20.6% involved more than 7 scripts.

    Best Regards, Bob Young, CWCI Communications Director


  2. Michael:

    The suggestion to allow third party payers access to a PDMP is not without precedent. Last year we successfully inserted an amendment into the iSTOP legislation in New York that allowed for PBMs and other agents of the payers to access the database. The iSTOP program is still under development but we are optomistic that we will be able to use that information to better manage potential abuse and diversion situations and help bring costs down for payers.

    Brian Allen - Govt Affairs
    Progressive Medical