Drug management programs that require at-risk individuals to use designated pharmacies or physicians for opioid prescriptions can protect patients from using harmful amounts of opioids while ensuring they still receive appropriate amounts of pain medication, according to the lead author of a new report on the programs.
Through these patient review and restriction (PRR) programs, insurers assign patients who are at risk for drug abuse to pre-designated pharmacies and prescribers to obtain these drugs. Designated medical providers can then better coordinate patient care and prevent inappropriate access to medications that are susceptible to abuse.
“Our indicators suggest these programs are protecting patients, saving lives and reducing overall healthcare costs,” said Jennifer Welch, MPH, an officer at The Pew Charitable Trusts, who led a review of state Medicaid drug management programs. She spoke about her findings at the recent Rx Drug Abuse & Heroin Summit.
PRR programs are used by most state Medicaid programs and some private insurance and pharmacy management companies. Only California, South Dakota and Puerto Rico do not operate Medicaid PRR programs. Some programs have been in operation since the early 1970s, but some are as new as 2016.
In 2014, the number of beneficiaries enrolled in Medicaid PRR programs varied substantially among states, from as few as 19 in Oregon to over 5,700 in New York. Welch’s review found many differences in how state programs operate. Pew Trusts is hoping to convene leaders of several state programs and come up with best practices for these programs.
Several states have data indicating PRR programs can reduce opioid use. Tennessee’s program enrolled 96 patients in 2010 and saw a 51 percent decrease in pharmacies visited, a 33 percent decrease in prescribers visited and a 46 percent decrease in the number of paid prescriptions.
Minnesota saved an estimated $1.2 million in one year of the program, based on a projected enrollment of 245 patients. Oklahoma has decreases in narcotics claims, emergency department visits, the number of pharmacies visited and the number of prescribers seen.
Currently Medicare does not use PRR programs. Welch said The Pew Charitable Trusts is urging Congress to pass legislation allowing use of these programs in Medicare.
In most PRR programs, potential patients are identified through set criteria, such as the number of pharmacies and prescribers they have visited, and the number of filled prescriptions they have received. Programs use a clinical review process to determine if enrollment is appropriate for the patient. They may call the patient’s doctors for further information. Patients whose pain is difficult to manage, including those in hospice, long-term care or nursing facilities, typically are excluded from enrollment.
After patients are placed in a program, they are given a chance to appeal. Welch said her study found 72 percent of programs said no beneficiaries appealed their placement.
Patients typically are enrolled for one to three years, and then another review is conducted to see if further enrollment is necessary.
The report found 22 PRR programs do not have access to their state’s prescription drug monitoring programs—state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients. Prescription drug monitoring programs allow insurers to identify cash payments. This is important because if a provider or pharmacy does not submit a claim for reimbursement, the Medicaid department cannot identify the prescription. “Without access to the database, Medicaid can’t monitor patients’ cash payments for prescriptions,” Welch noted. “Patients can circumvent the system.”