In an era when healthcare payers are demanding more value for the money they spend on health services and pharmaceuticals, managed care organizations increasingly have focused on meeting nationally accepted quality measures that are used to judge their performance and, in turn, that MCOs use to hold providers accountable for their healthcare and prescribing decisions. The national attention to the misuse and abuse of opioid analgesics makes the chronic pain market ripe for examination in the context of quality improvement programs, such as the Medicare star rating program (which rewards high-performing Medicare Advantage plans with increased reimbursement) and the Healthcare Effectiveness Data and Information Set (HEDIS). This access & reimbursement content examines the effect of quality measures—as well as recent opioid advisories by the Centers for Disease Control and Federal Drug Administration—on MCO reimbursement policies for opioids and brand prescribing by primary care physicians and pain specialists. Although the focus is on opioid analgesics, other chronic pain drugs are also included in the examination.

Table of contents

  • Chronic Pain - Access & Reimbursement - Special Topic: Impact Of HEDIS And Medicare Star Quality Measures On Prescribing Of Pain Drugs (US)

Author(s): William J. Melville Jr; Chris Lewis

Mr. Melville is Managed Market Insights expert on health insurance exchanges and Medicare. He provides state and market-level analysis in Colorado, Nevada, New Mexico and other states. He has been quoted in the Wall Street Journal, Bloomberg News, Connecticut Mirror, USA Today, Pittsburg Post-Gazette, the Tennessean, and numerous industry publications including Inside Health Policy and RevCycle Intelligence. Melville joined DRG in May 2007.

Mr. Melville was previously a commentary editor, associate editor and reporter for Suburban News Publications, a chain of 22 weekly papers in Columbus, Ohio from 1999 to 2007. He graduated from Mercyhurst College in 1999 with a bachelor’s degree in English, minor in political science and was winner of the President’s Award for Excellence for the Humanities Division.

Chris Lewis serves as primary research manager, U.S. Access and Reimbursement, with responsibility for coordination, content review and content generation of the market access and reimbursement insights at DRG. Content is based on online surveys of managed care organizations and physicians and expert analysis of reimbursement and prescribing patterns of key therapies treating various disease states.

Lewis was an analyst/senior analyst for the group’s HealthLeaders-InterStudy subsidiary for eight years, specializing in the managed care and pharmacy benefit management industries. Throughout her tenure, she has produced the Health Plan Analysis reports for California, New York, New Jersey, Connecticut, and Pennsylvania and authored DRG’s series of pharmacy benefit manager profiles. She has also conducted numerous webinars for the group. She is a seasoned journalist with a B.A. in communications from California State University, Sacramento.


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