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)
    • Actionable Recommendations to Optimize Market Access
      • Successes and Stumbles
        • Successes Among Chronic Pain Therapies in the United States
        • Stumbles Among Chronic Pain Therapies in the United States
        • United States: Reimbursement Successes and Stumbles
          • U.S. Reimbursement Successes and Stumbles
      • Key Stakeholders in the Road to Market Access
        • United States: Stakeholder Dynamics in the Road to Reimbursement
      • Key Market Access Roadblocks
        • Reimbursement Dynamics
          • United States: Commercial Managed Care Organizations
            • Lessons Learned and Key Takeaways
            • Drivers of Reimbursement by MCOs for Opioid Analgesics
            • Key Findings
            • Restrictions Used in Commercial Plans
            • Key Restriction: Prior Authorization
            • Impact of Prior Authorization
            • Key Findings
            • MCO Medicare Star Ratings for Measures Related to Chronic Pain Drugs
        • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
          • Patient Share in Key Payer Channel
            • Key Findings
            • Commercial Patient Share for Chronic Pain Drug Classes
            • Commercial Patient Share for Opioid Analgesics
            • Commercial Patient Share for Dual-Acting Opioid Analgesics
            • Commercial Patient Share for Opioid Plus Acetaminophen/NSAID Combinations
            • Key Findings
            • Factors That Most Strongly Influence Prescribing of a Chronic Pain Drug: PCPs
            • Factors That Most Strongly Influence Prescribing of a Chronic Pain Drug: Pain Specialists
          • Prescriber Preference
            • Prescriber Preferences for Opioid Analgesics
            • PCPs' Preferences for Opioid Analgesics Absent Market Access Issues
            • Pain Specialists' Preferences for Opioid Analgesics Absent Market Access Issues
            • PCPs' Preferences for Dual-Acting Opioid Analgesics Absent Market Access Issues
            • Pain Specialists' Preferences for Dual-Acting Opioid Analgesics Absent Market Access Issues
            • PCPs' Preferences for Opioid Analgesic Combinations Absent Market Access Issues
            • Pain Specialists' Preferences for Opioid Analgesic Combinations Absent Market Access Issues
            • Most-Prescribed Agents: Opioid Analgesics
            • Most-Prescribed Agents: Dual-Acting Opioid Analgesics
            • Most-Prescribed Agents: Opioid Analgesic Combinations
          • Impact of Payer Policy on Prescribing
            • Level of Restrictiveness on Opioids Encountered by PCPs
            • Level of Restrictiveness on Opioids Encountered by Pain Specialists
            • Most Burdensome Restrictions Encountered by PCPs
            • Most Burdensome Restrictions Encountered by Pain Specialists
            • Key Findings
            • U.S. Reimbursement Successes and Stumbles
        • Market Access Landscape for Emerging Therapies
          • Likely Impact of Emerging Therapy
            • Likely Impact of Emerging Opioid Analgesic Therapies
            • PCPs' Predicted Patient Shares for Opioids in 2018 Depending on Tiering of Emerging Therapies
            • Pain Specialists' Predicted Patient Shares for Opioids in 2018 Depending on Tiering of Emerging Therapies
            • Predicted Patient Shares for Tanezumab Based on Formulary Tiering
          • Potential Placement of Emerging Therapy at Various Prices
            • MCOs' Potential Reimbursement of Emerging Chronic Pain Therapies
            • Potential Placement of CEP-33237 at Various Price Points
            • Potential Placement of ALO-02 at Various Price Points
            • Potential Placement of Tanezumab at Various Price Points
          • Prescriber and MCO Opinion on Remaining Unmet Need
            • Key Findings
            • Physician Advice on Pharma R&D Spending for Chronic Pain Therapies
            • MCO Advice on Pharma R&D Spending for Chronic Pain Therapies
        • Methodology
          • Abbreviations
          • Primary Market Research Methodology - Physicians
            • Specialty of Surveyed Physicians
            • Prescribing of Opioid Analgesics to at Least Ten Patients per Year
            • Clinical Setting of Pain Specialists
            • Post-Residency Practice Experience
            • Average Number of Patients Treated per Month for Chronic Pain
            • Practice Setting of Surveyed Physicians
            • Distribution of Medical Practice by Region
            • Distribution of Medical Practice by State
            • Insurance Coverage for Chronic Pain Patients
            • Drug Classes Prescribed to Chronic Pain Patients
            • Drugs Prescribed to Chronic Pain Patients
          • Primary Market Research Methodology - MCOs
            • Distribution of MCO Respondents by Job Title
            • Distribution of MCOs by Region
            • Distribution of MCOs by State
            • Operations of MCOs: National, Regional, or Single State
            • Types of Health Plans Offered by MCOs
            • Distribution of MCOs by Number of Covered Lives
            • Average Number of Lives Managed by Surveyed MCOs
            • Commercial Tier Structure
        • Appendix
          • Physician Survey
            • Level of Restrictiveness on Non-Opioid Therapies Encountered by PCPs
            • Level of Restrictiveness on Non-Opioid Therapies Encountered by Pain Specialists
            • Most Burdensome Restrictions on Non-Opioid Analgesics Encountered by PCPs
            • Most Burdensome Restrictions on Non-Opioid Analgesics Encountered by Pain Specialists
            • PCPs' Expected Impacts of Healthcare Cost-Containment Measures on Prescribing
            • Pain Specialists' Expected Impacts of Healthcare Cost-Containment Measures on Prescribing
            • Prescribing Impacts from CDC Guidelines on Opioid Use: PCPs
            • Prescribing Impacts from CDC Guidelines on Opioid Use: Pain Specialists
            • Prescribing Impacts from CDC Guidelines on Immediate Release Opioid Use
            • Agreement Level With CDC Guidelines on Opioid Dosing: PCPs
            • Agreement Level With CDC Guidelines on Opioid Dosing: Pain Specialists
            • Physician Reaction to CDC Guidelines Regarding Naloxone Use
            • Impact of CDC Guidelines Regarding Naloxone Use on Prescribing of Targiniq ER
            • Likelihood of Using a State Prescription Drug Monitoring Program: PCPs
            • Likelihood of Using a State Prescription Drug Monitoring Program: Pain Specialists
            • Predicted Impact of Drug Monitoring on Prescribing of Opioid Analgesics
            • Prescribing Impact Reported By Physicians Currently Using a Drug Monitoring Program
            • Involvement in Quality Programs for Medicare Advantage: PCPs
            • Involvement in Quality Programs for Medicare Advantage: Pain Specialists
            • Impacts from Pain Assessments: PCPs
            • Impacts from Pain Assessments: Pain Specialists
            • Impacts from Medication Reviews: PCPs
            • Impacts from Medication Reviews: Pain Specialists
            • Opioids That Have Seen Decreased Prescribing Due To Pain Assessments or Medication Reviews
            • Dual-Acting Opioids That Have Seen Increases in Prescribing Due to Pain Assessments or Medication Reviews
            • Performance Measurement for Preventing Avoidable Hospital Use
            • Frequency of Performance Reports
            • Impact of Hospital Use Measures on Prescribing of Opioids
            • Use of Opioids Upon Patient Transition from Hospital to Home
            • Extent of Physician Knowledge of Medication Reconciliation Reviews
            • Source of Medication Reconciliation Reviews by Physician Practice Setting
            • Physicians Reporting Changes to Drugs as a Result of Medication Reviews
            • Results of Medication Reconciliation Reviews
            • Physician Actions Taken as a Result of Uncovering Medication Discrepancies
            • Percentage of Hospital-Based Physicians Aware of Hospital Measure on Pain Control
            • Impacts on Prescribing from Hospital Measure on Pain Control: Pain Specialists
            • Impacts on Prescribing from Hospital Measure on Pain Control: PCPs
            • Impact of Pain Control Measure on Physician Compensation
            • Expected Impact of Future CMS Measures Tracking Medicare Plans on Opioid Overuse
            • Impact of Regulatory Repercussions on Opioid Prescribing
            • Chronic Pain Drugs That Have Experienced Reduced Prescribing Due to Regulatory Repercussions
            • Percentage of Physicians Likely to Prescribe Opioids with Abuse Deterrent Properties
            • Physician Comfort Level with Extended-Release, Long-Acting Opioids With Crush-Resistant Features
            • Reaction to FDA Draft Guidance Regarding Generic Versions of Opioids with Abuse-Deterrent Properties
            • Physician Opinion on Whether Generic Opioids Without Abuse-Deterrent Properties Should be Removed from Market
            • Physician Expectation of Prescribing Tanezumab
          • MCO Survey
            • Average Number of Voting Members on MCO P&T Committees
            • Timing of Formulary Reviews for New Product Entries in Chronic Pain Market
            • Degree of Influence of P&T Committee Members
            • Items Needed for Formulary Review of Pain Drugs
            • Preferred Comparator for an Emerging Opioid Analgesic
            • Current Formulary Tiering for Non-Opioid Chronic Pain Drugs
            • Future Formulary Tiering of Non-Opioid Pain Drugs
            • Tier Status of Opioid Analgesics
            • Most Common Coinsurance for Opioid Analgesics
            • Most Common Copay for Opioid Analgesics
            • Utilization Management Controls Used in Commercial Plans for Opioid Analgesics
            • Quantity Limits for Opioid Analgesics
            • Duration Limits for Opioid Analgesics
            • Effect of Medicare Star Measure Regarding Members' Ease in Getting Needed Pain Drugs on UM Restrictions
            • Effect of Medicare Star Measure Regarding Members' Ease in Getting Needed Pain Drugs on Tier Coverage
            • Effect of Medicare Star Measures Regarding Pain Screenings and Medication Reviews on Opioid Prescriptions
            • Contribution of Opioid Misuse/Abuse to Unplanned Hospital Readmissions
            • MCOs' Response to Unplanned Readmissions Due to Opioid Misuse/Abuse
            • MCO Reaction to Concerns Over Opioid Misuse/Abuse
            • Percentage of MCOs Tracking Physicians Regarding Their Patients' Inappropriate Use of Hospital Resources
            • Impact of Medication Reconciliation on Opioid Prescription Claims
            • MCO Receptivity to Future CMS Measures on Opioid Tracking and Reporting
            • Percentage of MCOs Using Opioid Measures in Physician Performance Programs
            • MCO Awareness of CDC Guidelines Advising Caution Regarding Opioid Prescribing
            • Level of Restrictiveness of MCO Restrictions on Opioids Compared with CDC Guidelines
            • Expected Impact of CDC and FDA Guidelines on MCO Coverage of Analgesics
            • Long-Acting Opioids That Would Receive More Positive Coverage by MCOs
            • MCO Expected Changes in UM Policies to Discourage MCO Misuse/Abuse

      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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