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Why Health Plans Need PDMP Data

Posted by Denika Hockenhull on May 2, 2016 at 9:00 AM

Why Health Plans Need PDMP Data

It’s an inescapable truth that, in healthcare, data matters. For health information technology innovators, data is the window inside a lifecycle of a service, product, or application that can be analyzed for improvement. For providers, data helps the accuracy of diagnoses and creates more effective treatment paths. Health plans benefit from data as well. For plans, data builds actionable information and insights, two important steps in the balance of managing risk for each plan and enhancing outcomes for each member.

Health plans need access to information sources that help build for the future. But this need goes beyond simply connecting to the traditional repositories that capture and store large amounts of information. To optimize our understanding of users, patients, and members, plans must have access to sources beyond claims data. Expanded data sets from non-traditional sources will benefit plans with the right tools to manage collection and analysis.

One such non-traditional, underutilized source is prescription drug monitoring program (PDMP) data. Since the adoption PDMPs, these electronic database systems have amassed a decade’s worth of information regarding prescribing and dispensing behaviors of controlled substances as well as information that can be used to develop baselines for analysis or to monitor trends. There is an industry-wide need to make PDMP data accessible, building towards the goal of creating outcomes-based healthcare.

Building upon current frameworks of data sharing and utilization, we identify the opportunities in which PDMP data can help health plans in the future.

Enhanced interoperability

With the Office of National Coordinator for Health Information Technology (ONC) outlining its Interoperability Roadmap, safe and secure electronic patient information exchange is coming to life

Electronic health information assists providers in managing health at the population level as well as the patient level by providing accurate, relevant information early in the continuum of care. EHR systems are currently more widely affordable and available within hospitals and physician offices than ever before. Seventy-four percent of physicians and ninety-seven percent of hospitals are in possession of certified EHR. These numbers support the trend that many policy makers describe as “integrated delivery systems” where medical groups composed of hospitals, pharmacies, and other facilities share information and coordinate care for their patients. Integrating PDMP data into this system can only propel interoperability plans further. In fact, many states are already considering and implementing laws that mandate the review of PDMP data while treating patients.

Introducing PDMP data into this roadmap will allow critical member information to reach a much wider audience in a shorter amount of time. Having multiple integration points may allow plans to increase the accuracy of information provided for their members, allowing for deeper insight into their own member population.

Increased accuracy in patient profiles

With access to PDMP data, plans and providers haveWhy Health Plans Need PDMP Data better opportunities for bridging gaps in the continuity of care. Rather than preventing medication access, PDMP data helps inform providers of important medical and clinical information with the potential to enhance treatment plans and create appropriate prescribing practices. Data sharing provides necessary information for providers creating more accurate patient profiles. PDMP data can also highlight patient behavior data that describes their activities and preferences within the healthcare system.

PDMP data can help create a more complete, accurate portrait of a patient by providing as much information possible to make more informed prescribing decisions. Having more of the right information means prescribers can act (prescribe) on "better data" so the health plan will be happy to have a healthier member, who typically equates to less medical and pharmacy costs overall. Expanding the information set for providers has the opportunity to increase provider participation as well because the provider does not have to justify or resubmit requests for their member. Better data will be available to help providers make and support their first decision.

But while EHR adoption rates are high, data sharing rates are low. Forty-two percent of physicians share PHI electronically while only twenty-six percent share PHI electronically with outside providers. By standing on the vanguard of performance standards and pushing for further care integration, health plans can help increase these numbers. With inclusion of PDMP data, physicians will be more apt to further share information, creating a deeper window into patient history.

Reduced fraud, waste, and abuse

Reducing misuse and abuse is a consistent goal that aligns all parts of the healthcare community, from plans to state agencies, providers, and patients. PDMP data represents transactional and behavioral data that can be used to understand patterns, actions, processes, and outcomes.

Integrating PDMP data can help alleviate some of the cumbersome processes that prevents members from accessing certain medications. It can also act as an early warning system, potentially further identifying misuse, abuse, and addiction patterns that have costly outcomes. In addition, a full prescription history could allow health plans to implement real-time edits that help govern access to narcotics based on a complete prescription history, thus moderating the prescribing process.

Imagine the state of Florida at the height of their prescription opioid endemic. During this time period, the top 49 of the top 50 oxycodone dispensing clinics resided in Florida alone and dispensed more than 1 million oxycodone pills a month. Much of this excess could be contributed to the patient behavior known as “doctor shopping,” where a single patient will seek multiple providers in an attempt to secure an excess of prescriptions, typically by fraudulent means, with the goal of misuse and abuse. The Florida Department of Health has since enacted a state PDMP and has collected and analyzed nearly 5 years of prescription data. In their 2015 report, the state boasted a 65% reduction in doctor shopping episodes. This type of success is seen as a triumph for population health at the state level and can be repeated easily in other states. Now imagine it at the plan level.

Health plans have an opportunity to create interventions and connect with providers regarding treatment further integrates the health plan into the health care delivery model. Ultimately, reduction in abuse or misuse of any drug is good for member health and for plan health.

Amplified cost management

Managing the cost of prescription drugs is a challenge for many health plans. Over the past three years, we've seen high-cost specialty medications for chronic or rare conditions like hepatitis C driving pharmaceutical prices; and, they are driving them high. Experts believe they may account for more than half of prescription costs by 2020. Wouldn’t it be better to help have access to a system that monitors patients and alerts health plans to potentially aberrant prescribing or usage behaviors as early as possible to help support responsible pharmacy spend?

According to the CDC, PDMP data shows potential strengths that can assist in this purpose. PDMP data’s value lies in the following qualities:

  • It's organic. PDMP data comes directly from the dispenser with specifically outlined data elements.
  • It's representative. PDMP data is population–based rather than based on eligibility.
  • It's timely. PDMP data is uploaded routinely, often daily, meaning it is current. 
  • It's clean. PDMP data is processed through rigorous validation and normalization algorithms. 
  • It's extensive. PDMP data is collected in 49 of 50 states for all residents and all payment types. 
  • It's available. PDMP data is already colleted; connection points already exist and can be leveraged.  

Plans can better support formulary decisions and medication therapy treatments by incorporating PDMP data into health plan management. By having this information available, plans can consider recommending a more cost-effective or clinically-appropriate drug and identify a lower-cost treatment center or clinic that can provide reoccurring treatments. Providing both patient and physicians with options not only reduces patient risk, it also increases the diligence of the health plan to augment quality performance and care from within the healthcare system.


Integrating PDMP data into health plan information systems has the potential to transform care delivery. In addition to supporting physicians and reducing costs, these programs have the potential to save lives and improve patient outcomes. Data helps organizations create a detailed view of effective practices and provides guidance to refine evidence-based decision making.




Topics: pharmacy spend, opioids, prescription drug monitoring, PDMP, health plan management, controlled substances

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