Articles on Pharmacy Benefit Management

Featured HBD Story February 5, 2008

PBMs, Health Plans Are Working with States to Stem the Alarming Increase in Abuse of Prescription Drugs

Reprinted from DRUG BENEFIT NEWS, biweekly news, data and business strategies for health plans, PBMs and pharmaceutical companies.

Aiming to stem an alarming increase in the abuse of prescription drugs, more and more states are tracking prescribing data on certain drugs, such as painkillers, tranquilizers and stimulants. Health plans and PBMs contacted by DBN say they are working with states to help combat the diversion of prescription drugs, while taking steps of their own to intervene when unusual prescribing patterns are identified. One PBM says state Rx tracking efforts could, in turn, help the industry.

South Carolina on Jan. 1 became the latest state to start collecting prescribing data on medications known as “controlled substances.” Roughly 35 other states have similar monitoring programs that target Rx drug abuse, a problem that federal officials say is more widespread than illegal drug usage.

Under the South Carolina law, pharmacies and dispensing practitioners in the state are now required to collect specific prescribing information, including certain drug and dosage types, as well as physician and patient identifiers. The data must be reported to the state’s Department of Health and Environmental Control between Feb. 1 and 15, and each month thereafter, says Clair Boatwright, a DHEC spokeswoman. Steps will be taken to protect the privacy of the public, using physical security measures as well as cyber-security measures, she tells DBN.

“DHEC’s charge…is to investigate and make appropriate arrests when there is sufficient evidence that a person is diverting prescription drugs,” Boatwright says. The goal is to detect diversion trends “much sooner” so that officials can act on that information quickly, she adds.

Medco Health Solutions, Inc., for one, says it’s prepared to electronically report information on controlled substances directly to South Carolina. The state tool, in turn, could help the PBM, says Medco spokeswoman Jennifer Luddy. “Such a tracking tool could be useful for Medco to validate suspected inappropriate physician prescribing habits, fraudulent activities, and suspected misuse of these medications by patients with drug-seeking behaviors,” she says in an interview.

Nationally, the problem of Rx diversion appears to be growing. In late November 2007, the U.S. Drug Enforcement Administration (DEA) said in a news release that more than 6 million Americans are abusing prescription drugs. “That is more than the number of Americans abusing cocaine, heroin, hallucinogens, and inhalants combined,” DEA added.

Prescription drug abuse “became a crisis practically overnight,” the agency said. “In just five years, from 2000 to 2005, the number of Americans abusing prescription drugs rose more than two-thirds, from 3.8 million abusers to 6.4 million.” Opioid painkillers now cause more drug overdose deaths than cocaine and heroin combined, DEA said.

As such, health plans and PBMs are required by some states to not only provide data on controlled substances, but also to monitor unusual drug prescribing and take appropriate interventions when necessary. California is one such state.

“By law, [Kaiser Permanente] must transmit weekly all the information to the California Department of Justice about each prescription filled for three of the four classes for controlled substances,” says Steven W. Gray, Pharm.D., J.D., California pharmacy regulatory compliance and professional affairs leader at Kaiser Permanente.

Kaiser also has policies and procedures in place to help prevent abuse of drugs, Gray tells DBN. “For example, we have computer functions that alert the pharmacist to duplicate therapies, refills that are requested too soon, etc.,” he says. “Though these are not always indicative of an attempt to abuse drugs, they can be helpful.”

Drug diversion and abuse is dangerous to patients and detrimental to other members of the public, Gray stresses. “It can also be very wasteful of limited health care funds and thereby reduce the accessibility to affordable high-quality care.”

Regence Responds to ‘Red Flags’

The Regence Group, which operates Blue Cross and Blue Shield plans in the Northwest, also must adhere to state laws in this area.

“In our Washington plan, we are mandated to have initiatives that look at trends as they relate to pain management,” says Lynn Nishida, director of pharmacy services at Regence BlueCross BlueShield of Oregon. “It’s poly-pharmacy overall, but a subset of that is the pain medications, narcotics — taking a look at members who got medications from multiple prescribers, multiple pharmacies and multiple prescription drugs.”

The state leaves it up to the health plan to provide an intervention, Nishida says in an interview. “Some have done prescriber alerting; some actually have implemented tighter controls by restricting pharmacies [and] prescribers,” she says.

One red flag that gets Regence’s attention is when two or more doctors prescribe similar types of medications to the same patient, Nishida says. “Just alerting the physicians is intervention in and of itself. The doctors may not be aware that other doctors may be prescribing for the same patient.”

Medco pharmacists also conduct drug-utilization reviews on patients’ medication history and therapy. “The pharmacists review high doses prescribed and duplicate therapies from the same or multiple prescribers for the same patient,” Luddy says. “In the event an investigation is needed, Medco can review the prescribing habits of the physician for prescriptions.”

A DEA official says that health plans and PBMs can help in the agency’s effort to combat illegal diversion. “We work with health insurers nationwide,” Mark Caverly, chief of the liaison and policy section in the DEA’s Office of Diversion Control, tells DBN. “I can think of specific instances where we received tips from different insurers as to particular prescribing or dispensing patterns. That is something that we welcome and look forward to cooperating.”

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