Prime showcases its controlled substance work at national conference

The 2019 Rx Drug Abuse & Heroin Summit held this past April in Orlando, Fla., featured the high-profile keynote speakers of President Donald Trump and First Lady Melania Trump. Over 3,000 representatives from a variety of industries were in attendance to discuss what’s working in prevention and treatment of controlled substance misuse and abuse.

At this year’s event, Prime was honored to present “Capitalizing on Integrated Medical, Pharmacy Data: Working Upstream and Downstream to Identify Misuse, Abuse” by Pat Gleason, assistant vice president, health outcomes and Jo-Ellen Abou Nader, vice president of fraud, waste, and abuse and supply chain optimization.

Dr. Gleason kicked off his break-out session before an audience of over 100 providers, government program officials, and payers. Gleason discussed what Prime is doing to help curb misuse and abuse of controlled substances by highlighting its programs and offerings available to health plan clients. He also covered what others in the pharmacy benefits management industry are doing. “Pharmacy benefit managers play a critical role in helping to ensure members who need controlled substances, have appropriate access to them, the proper education on when and how to take them, and also how to dispose of them,” said Gleason.

Prime has been leading this work for over a decade. Prime is now working upstream on this issue using artificial intelligence through predictive modeling to identify potential high-dose opioid utilizers. Predictive modeling includes four steps:

• Predict: Identify members’ probability of high-dose opioid use
• Screen: Review and remove members who meet criteria for legitimate use (e.g. cancer patients managing chronic pain)
• Score: Calculate members’ Controlled Substance Score (a number based on volume of controlled substance claims, number of unique pharmacies and prescribers, and utilization rate of controlled substances – the higher the score, the higher likelihood of misuse and abuse of controlled substances)
• Rank: Prioritize members to receive intervention

To develop models that better predict which members could be at an increased probability to receive high dose opioids, Prime researched the Medicare population. It found that using two different predictive models – 1) for new opioid users, and 2) for prior opioid users – achieved more accurate results than if the same model were used. “Finding that different models were needed for different members was an important outcome,” said Gleason. “The more accurately we can target potential misusers and abusers, the better we will be at managing this epidemic. Prime has seen an 84 percent reduction in opioid outliers – those who are at the highest risk of misuse and abuse – in the past six years, so we have reason to believe our research and programming are working.”

The claims data feeding Prime’s clinical work, also contributes to identifying fraud, waste and abuse within controlled substances. Prime uses its integrated pharmacy and medical data to research pharmacy, prescriber, and member fraud, waste, and abuse cases.

“Pharmacy fraud schemes trends have evolved over the past 10 years,” said Abou Nader. “We’ve seen ‘phantom pharmacies’ inappropriate compounding and most recently, inappropriate use of telemedicine and lack of patient/physician relationship cases. Our team works hard on behalf of health plan clients to stay abreast of the changes in the industry to best manage fraud, waste and abuse.”

Software systems are becoming more sophisticated to keep up the changes as well. Prime now has artificial intelligence and visual link analysis capabilities that show connections between providers, members and pharmacies, so risky behavior can be easily flagged. Prime’s best in class fraud, waste and abuse approach is able to ultimately deliver actionable outcomes through collaboration with health plans, government agencies and industry partners. This work has amounted to a savings to health plan clients of $279 million in the last year.

At the event, Abou Nader shared several case studies. They included:

• Members who were drug-seeking by seeing multiple prescribers and filling prescriptions at multiple pharmacies,
• Pharmacies inappropriately submitting a high volume of claims for the same drug and creating prior authorizations using fraudulent information, and
• Prescribers who submitted claims to pharmacies from members located in different states or who had never seen the prescriber.

More about these cases: Integrated medical and pharmacy data helps identify opioid FWA

By using industry leading artificial intelligence coupled with Prime’s integrated medical and pharmacy data to tackle controlled substance misuse and abuse, Prime is working both upstream and downstream to reduce the harms of opioid epidemic for its health plan clients and their members.