Update on Medicaid
John M. Coster, Ph.D., R.Ph.
Director, Division of Pharmacy
Medicaid National Meeting on Prescription Drug Abuse and Overdose
February 1, 2016
Presidential Memorandum:
Issued October 2015
Goals
• Reduce prescription opioid and heroin deaths
• Promote appropriate and effective pain medication prescribing
• Improve access to treatment
Actions
• Train federal prescribers
• Identify barriers to accessing MAT in federal health programs
• Review the use of methadone as a preferred or first-line pain
reliever
Secretary’s Initiative on Opioid Abuse:
Launched March 2015
Priority Areas
Opioid prescribing
practices
Expanded use and
distribution of
naloxone
Expansion of
medication-assisted
treatment
Two Primary Goals:
Decrease opioid overdoses and overdose mortality
Decrease prevalence of opioid use disorder
CMCS Initiatives on Opioid Use
Disorder
July 2014
Informational
Bulletin on
MAT issued
April 2015
Parity rule
proposed
October 2014
Medicaid Innovation
Accelerator Program
initiative on SUD
launched
Upcoming efforts to
support Secretary’s
Initiative and President’s
Memorandum
July 2015
Section 1115
demonstration
opportunity for SUD
announced
Why Focus on Prescription
Opioids
US prescription opioid deaths quadrupled between
1999 - 2013
CDC identified addiction to
prescription opioids as the
strongest risk factor
for heroin addiction
Medicaid enrollees are prescribed prescription
opioids at twice the rate of non-Medicaid
patients
Medicaid enrollees are at higher risk of
prescription opioid overdose than
non-Medicaid patients
One state found that Medicaid
enrollees made up 45% of all
prescription overdose deaths
between 2004-2007
Why Focus on Methadone for
Pain?
Methadone accounts for a disproportionate share
of opioid pain medication overdoses and deaths
Between 2002 – 2008,
methadone represented less
than 5% of analgesic
prescriptions
Methadone also represented 30% of
opioid-related deaths during that same
period
In one state, the overdose rate of
Medicaid enrollees was 10 times
higher for methadone than other
prescription opioids
Overdoses involving methadone were
twice as fatal compared to other
prescription opioids
State Medicaid Director Letter
• Released July 2015
• Encourages states to transform their system for
individuals with an SUD
• Encourages states to use an 1115 for this
transformation
• Interested in gathering information that will be
helpful for the field
• Sets forth 13 expectations for states
• Approved California in August 2015
• 8 states have expressed interest in this 1115
opportunity
7
1115 Demonstration Areas of
Focus
•
•
•
•
•
•
•
Better Benefit Design
Integration
Parity
Measures and Data
Program Integrity Efforts
Strategies to Address Opioid Abuse
Technical Assistance to States
8
IAP SUD Areas of Focus
• Major Areas of Focus for this IAP:
•
•
•
•
•
•
•
•
•
Increasing SUD Provider Capacity
Integration of Primary Care and SUD Services
Incorporating SUD into Managed Care Contracts
Using Data for Further State Goals
Performance Metrics
Benefit Design
Pay-For-Performance
MAT strategies
Recovery and supportive housing
IAP SUD Platforms
• High Intensity Learning Collaborative
– 7 participating states: Washington, Texas, Louisiana,
Michigan, Minnesota, Kentucky, Pennsylvania
– 1:1 TA to support SUD program innovations
• Targeted Learning Opportunities
– 10 webinars completed, 4 scheduled
– 47 states engaged to date
Medicaid Pharmacy Program Drug Use
Management Strategies
•
•
•
•
•
•
Preferred Drug List placement
Preferred drug criteria
Step therapy
Prior authorization
Quantity limits
Provider education and prescribing guidelines
Medicaid Pharmacy Program Drug Use
Management Strategies
• Drug Utilization Review
• Patient Review and Restriction Programs
• Prescription Drug Monitoring Program
– Mandated prescriber use shows reductions in
controlled substance prescribing and multiple provider
episodes (75% in NY)
Quality: DUR Background
• Section 1927(g) requires that States shall
provide for a drug use review program (pro
DUR, retro DUR, educational interventions) to
ensure that:
– Drugs are appropriate;
– Medically necessary;
– Not likely to result in adverse medical results;
We appreciate that all states responded in time to our
survey!
13
Status of Prescription Drug Monitoring
Program (PDMP)
100%
% of 50 States Completing Survey
90%
80%
72%
70%
60%
54%
50%
40%
30%
20%
14%
10%
0%
Query the state's PDMP database
Require prescribers to access the
PDMP patient history
Barriers that hinder the agency from
fully accessing the PDMP
Source: State Comparison/Summary Report FFY 2013
14
POS Edits Limiting Quantity of Opioid
100%
90%
84%
82%
% of 50 States Completing Survey
80%
70%
60%
50%
40%
30%
20%
10%
0%
Short-acting opioids
Long-acting opioids
Source: State Comparison/Summary Report FFY 2013
15
Psychotropic Drugs/Stimulants
100%
% of 50 States Completing Survey
90%
82%
82%
80%
74%
70%
60%
50%
40%
30%
20%
10%
0%
Manage/monitor appropriate use of
psychotropic drugs in children
Monitor all children, not just those
children in foster care
Restrictions/special program to
monitor/manage or control the use
of stimulants
Source: State Comparison/Summary Report FFY 2013
16
Child and Adult Voluntary Core Set:
In Different Stages of Maturity
• Child Core Set: CMS has spent the past five years (20102014) working with states to understand the 24 Child Core Set
measures and to refine the reporting guidance
– Immunizations, HPV vaccine, ADHD medication follow up,
MTM for asthmatics
• Adult Core Set: New program. 2013 was first year of
reporting. As with any new reporting program, the early years
focused on working with states to understand the Core Set
measures, refine the reporting guidance, and improving data
quality.
– Vaccinations, smoking cessation, antidepressant MTM,
antipsychotic medication adherence, annual monitoring for patients
on persistence medications, hemoglobin A1c control, diabetes
control, HIV viral load suppression
• Increased Use of Pharmacy MTM and Quality Measures
17
Medicaid Strategies for
Expanded Use of Naloxone
Formulations: Vial-and-syringe, nasal spray, auto-injectable
Preferred Drug List placement
Reviewing benefit design for barriers to access
(e.g. prior authorization)
Co-prescribing and at-risk prescribing
State Strategies for
Expanded Use of Naloxone
Making naloxone available without a prescription or third-party
prescribing
Overdose response training for professionals and laypersons
Good Samaritan laws
Community-based naloxone education and distribution programs
reduce opioid overdose deaths
MAT Coverage: A Snapshot
MAT is evidence-based treatment for a chronic disease
FDA-approved medications for opioid dependence
• Buprenorphine
• Methadone
• Naltrexone
Prior Authorization
• 48 states have prior authorization for buprenorphine
• Prior authorization for antipsychotics leads to higher rates of
hospitalization and higher total Medicaid expenditures
Very low utilization of extended-release injectable naltrexone
Expanding Coverage to MAT
• Review limitations for barriers to access
• Medical, psychological and rehabilitative
services in conjunction with medication
management
• Data analytics on:
– Penetration rates (diagnosed and receiving SUD
treatment, including MAT)
– Network adequacy and MAT provider availability
– Inactive authorized prescribers
– Concurrent behavioral therapies delivery rates
Questions
?