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April 27, 2017

Insights with Impact: Different, but not just to be different

Being different is only better when it makes a difference.


Prime’s research team is a market differentiator. We know. That phrase gets thrown around a lot. But what makes us different isn’t just that we mine medical and pharmacy data. It’s the results.

We’re not trying to be different for attention. It’s what we need to do to do this right — looking beyond current measures with a different idea, question, objective or method.

Idea: create a member-specific controlled substance (CS) score, then lower that score

More than half of drug overdose deaths involve prescription drugs, with the vast majority being opioids. To fight back against this epidemic, health plans have looked at:

  • The volume of controlled substance claims
  • The number of unique pharmacies and prescribers
  • The rate of utilization of CS

But what would happen if we looked at all three at the same time? Our research team looked at all three, and weighted them on a continuum. This ranked members by risk and cost in a way that had never been done before. They assigned a CS score that helped Prime prioritize interventions. Additional research demonstrated that for every one point increase in CS score there was an annual increase in costs:

  • $1,488 more in total cost of care
  • $235 more in CS costs
  • 0.9 percent more hospitalizations
  • 1.5 percent more ER visits

Prime’s CS score gave plan sponsors a powerful new way to identify members at risk for CS misuse and abuse.

The study identified members with a CS score above a certain level. Their prescribers were then sent a letter through Prime’s GuidedHealth program. The intervention was shown to reduce CS use and provide a net claims savings of $0.06 PMPM across 1 million commercial lives compared to a concurrent control group.

Idea: Look, then look again.

Concurrent use of benzodiazepine and opioid medications can result in death. In 2016, the Centers for Disease Control guidelines strongly recommended clinicians should avoid prescribing both to the same patient. The U.S. Food and Drug Administration (FDA) issued enhanced warnings and safety information. The Centers for Medicaid and Medicare Services (CMS) expressed concern — one analysis found concurrent use in 24 percent of Medicare Part D opioid users.

Simply put — we all know it’s a problem. An expensive and dangerous one.

Using Pharmacy Quality Alliance (PQA) measure

Combination opioid and benzodiazepine use for 30 or more cumulative days was found at a rate of nine per 1,000 or 0.9 percent of the entire commercially insured population.  An alarming one of every six opioid users, with no evidence of cancer, had concurrent opioid and benzodiazepine use for 30 or more cumulative days in 2015.

Idea: Is that all there is? We saw more.

We understood the problem. But we wanted a different way to identify members at potential risk. Prime expanded the study parameters and found additional members at the margins that may also be at risk. Our study found the rate of concurrent use increased dramatically when methods of identification were modified. These modifications included requiring fewer claims and fewer overlapping days. 

Three additional ways to look beyond the current measure

Advanced knowledge around concurrent opioid and benzodiazepine use can help plan sponsors take steps to improve member safety. Plan sponsors need to understand their own member data to determine their tailored intervention thresholds.

When you know where and how concurrent drug use is occurring, then programs like Prime’s GuidedHealth® can be used to help prevent it from happening again.

Prime’s research team searches to find the questions others have not yet asked or answered. Prime is committed to producing evidence-based analyses to help improve health outcomes and reduce costs.

From mountains of medical and pharmacy claims data comes what matters most — insight. This is what separates Prime from the pack. This is what fine-tunes our products. This is evidence-based analysis that supports our company’s purpose and our clients’ performance.

Follow our Insights with Impact series in Prime’s newsroom, or contact us for more information.