We have that ability so we can do a deeper dive. In looking at the population usage of potentially for a simple therapy pilot, we know a lot of our opioid usage or those with musculoskeletal injuries but what cause we dont know and we looked at it by not job code but department and not necessarily the trades. Well share that with you. The other thing is if its coming from an active injury and i think paige alluded to this it would be under workmans comp and wouldnt be in our numbers. A lot of the questions you ask will come back. Commissioner very good. Thank you. Thank you, paige. We have blue shield, is it . Yes, it is blue shield. Good afternoon. Commissioner good afternoon. Im the director of clinical pharmaceutical programs at blue shield. Im a pharmacist by profession. So you can answer some of the questions. And i want to, today, for having a chance to talk about our narcotic safety initiative. Its a passion project for us, a Passion Program for us. Basically in 2014 we started observing a lot the clerk we have a presentation. Thank you. We starting getting a growing voice of members telling us the prescription. Yesterday opioids were becoming a major concern and being perpetuated. In our efforts what we wanted to do was to evaluate how to reduce overuse for those with nonchronic cancer pain. Our goal is to reduce that amount by 50 by the end of 2018 compared to our baseline 2014. Nord this is quite an aggressive goal. When we first started out we werent sure if wed achieve this but what we decided to do at that time was to implement evidenc evidencebased interventions, helping prescribers, prescription members who were on them to lower and safer doses or maybe to discontinue opioid therapy altogether. Also important is to identify and stop fraud, waste and abuse. And to identify problematic use and deploy resources to help members get to more effective treatments and effect state and National Policies that really impact the crisis. Thank you. Our initiative began with the evaluation of what was happening amongst their members and families who were very much impacted by Substance Use disorder. They were telling us that often times what they were observing is that a prescription was with what started the cascade of events. And then perpetuated by continuing refills for the prescription opioids. We have recently had data shown that a lot of Substance Use disorders started with street drugs. Now were seeing more and more that is starting with a prescription thats prescribed by a physician and filled and dispensed by pharmacies. We believe health plans have an Important Role in helping mitigate the crisis. Not just from the perspective of fulfilling a treatment but understanding our option. With the board approval in 2014 we launched our enterprisewide initiative. What we decided at that time to do was to launch the impactful interventions we felt would make the most difference. Frankly, our approach was to first turn off the tap, so to speak and prevent people from starting prescription opioids if there was other options they could use. And then also to help those people on the other end of the spectrum on the highest doses at the highest risk for imminent harm. Youll see in the presentation over the past three years, our approach has been aligned to those activities. So in 2015 we primarily applied more stringent review of new prescription opioids especially longacting opioids which have the highest risk of chronic use. We also started looking at te data and found most the opioid is with hydrocodone which is a common opioid ingredient found in cough and cold medicine. When you ask the question, what type of person is most likely to be impacted by Substance Use disorder, its any and all and children are very much affected by cough and cold. Teenagers get the cough and cold with the hydrocodone in it and something they can use illicitly at parties and such. In 2016 we narrowed our focus on the analysis and we helped to assess and stratisfy the risk and between last year and this year we completed an analysis of emergency room prescribing of opioids in the l. A. County area. The good news that we found is that over the last three years, the prescribing has been coming down. More importantly, prescribing as come down primarily for prescriptions written for more than a threeday supply. Thats very important because most of peoples chronic use is when they get a chronic prescription that can last a long time. In 2017 this year, we increased our focus on what i call the middle group. Those are the people who have been chronically using opioids in moderate doses. And what were really trying to do is work to address as mentioned earlier access to evidencebased Substance Use disorder programs, alternate Pain Management and to help members manage pain and reduce risk through Pain Management programs and other alternate treatments. Were also continuing those analytic efforts i mentioned earlier. Were partnering with the California HealthCare Foundation and Harvard University in an analysis and hope to vie publication within the next hope to have a publication within the next nine to ten months if not sooner. Were trying to understand the impact of the program or efforts both at a plan level and as well as at a general level, population level. So the good news is for our total book of business at blue shield california medicare and commercial, as of the First Quarter weve observed a 32 reduction in the consumption of opioids. Its not just the number of prescriptions. Thats one thing but you have to take in consideration all the dosing going on. To fentanyl is much more potent than morphine. For every fentanyl prescription you can multiply that and thats your consumption. Were looking at it from a consumption standpoint. Were very much pleased to see not only the 32 reduction but the fact that were tracking to our 50 goal by the end of the next year. To, you know, make improvements, and those partnerships have also been able to help us identify some really unusual outilizization, so what we are starting to see are some really compounded opioi opioids that are questionable in untwebdintended uses, and s were identifying them, were going after those pharmacies. Were also, you know, making sure were employing the right restrictions and levels of protection in place to limit that liability. In 2018, our plan includes continuing to evaluate and expand access to Substance Use disorder and alternate pain treatments and also to medical assisted treatments, so buprenorphine, which is also known as sebaxone, that medication is very important for people who are needing to transition off of opioid therapy, and weve improved access to that. Vivitrol is another one that is helped to commonly control cravings, and methadone, and naloxone is the one if you get into an acute overdose situation, you can use that one to help reverse the effects of that. So were really working to make sure that access is available to all of these treatments and to Pain Management programs. Weve also launched a very successful and well attended provider education series, and were addressing topics such as opioid tapering, concurrent use with other high risk medications, benzodiazepines, muscle relaxers or sleepers, and also locking down unapproved uses with the compounds. We continue to work on policy strategies that have high likelihood of impact. There are a lot of policy proposals, but quite frankly, a lot of them are just you know, thats the existing state today. Its really not impactful. We want to make sure were driving impactful legislation, and finally, but not last, is we continue to partner and collaborate with key stakeholders. We view this as a plan, this is one area where everybody agrees that we really need to partner together to fight the crisis. So im really pleased that i was able to provide a report today of the very positive results for the hss population. We believe so strongly in the efforts here that weve actually incorporated performance guarantees into your 20172018 contract, and we expect to continue to see improvements over time, so with that, ill open it up for questions. Are there questions from members of the board . Yeah, i have one. Yes. When you go to suppose somebody breaks their finger or whatever, and they go to a doctor. So is there a set something set now where theres how much of this drug that they should give to the patient or how do you control that . Well, the cdc has published guidelines for how much and how long anybody should be prescribing an opioid, and what weve been doing is really working with providers to get them to be aware of the guide lines and start prescribing in accordance with the guidelines, so there are a number of ways. Education is the easy passive way, and then, the more physical way, the one that has some impact to members is that you employ restrictions on formulary and benefits, so those are usual ways of dealing with how long, how much. I think probably the more important way is really to plant the seeds with the prescriber because once they really understand and are educated, then, youre not impacting just one person, youre impacting everybody that that person that prescribers taking care of, and weve seen that, you know, with some of our Case Management efforts. As we start to educate the most difficult prescribers, people who have been very entrenched about thinking how you manage pain for people with opioids, once they understand and they know we want to get people to safer space, theyre much more open of doing a different way for managing for pain with other, you know, members. And i is my impression correct that kind of the typical pattern was that youve had an injury that required these types of medications, youve kind of got a ten day supply, and you might be taking it two or three times a day, Something Like that, that was kind of the standard, much more being said. No matter what it was, you got a ten day supply of whatever yes, except that it wasnt a ten day supply, it was a 30day supply. 30day. Exactly, and you know when you are planning a surgery, most surgeons are just automatically prescribing an opioid not every surgery requires an opioid after surgery. You really have to look at the ability for pain tolerance and what the injury or the surgery was, and many nonopioid medications can effectively manage pain. And the cdc guidelines, are they recent, and how recent . The cdc guidelines were, i think, updated last year, and maybe again earlier this year. Theyre very recent. Okay. Thank you. So there isnt anything to say that the physician cant prescribe more, though . No, and thats one of the things that i personally would like to see in other states, theyve enacted legislation and policies to limit the number of days that an opioid prescription can be prescribed for a first time. I personally dont think thats a bad thing, but you know, theres a lot of politics involved in that, but short of that, i think all of the health plans have been working on limiting those the coverage limits for opioids. And we have to be really careful, you know, especially with not i think its easier to do that with new prescriptions, people who have not been on opioids before, but for people who have been, you have to be much more careful because you dont want to create a situation where they decompensate or then, they go to street drugs. Commissioner ferrigno. I know theres some a couple years back with the police department, they had the behavioral science unit, and theres people that have some problems with opioids, and theres some Pain Management medications that you use. Is that hard to get approved, or is that. If youre referring to seboxone, or buprenorphine is one of those other treatments. It acts somewhat like an opioid, but it doesnt have some of the risks that are associated with it, and they use it to help people detox off of opioids, but more recently, the way that practice has been evolving is that theyre starting to use it as maintenance therapy now, so people who used to be on opioids may, instead, be switched to a seboxone drug and maintained on that over time until they can get their Substance Abuse disorder under control, and it may be that they never really get it under control, so you may have to maintain for a long period of time. I just have one more point. Yes, please. I know that you if go and get your teeth pulled, you get a 30day supply, and you dont even need it, you can just take ibuprofen. I think people keep this stuff in their medicine cabinets, and kids take it and take it to parties. Yeah. Thats one of the reasons why we have an opioid epidemic. Yeah, stock piling is one of the things that we addressed, but 30day supplies, if youre giving people 90 day supplies through mail service, thats where you can easily stock pile, and thats where we put a stop to that, as have many other plans, as well. Page, im not sure how were doing that. Is this every plan thats coming in next, on you how are we doing that. United health plan. Good afternoon. Good afternoon, you can raise that microphone slightly. Just there you go, but do talk into it. Thank you. Michael terhare. Im with optimal x under United Health care, and ill be speaking to you about the city plan and the programs that we have in place. I am a registered pharmacist. My role or title is clinical consultant. Ive been a retail pharmacist, and i have been involved with the pbm industry, pharmacy ben fit manager for over 15 years or so. The first slide, weve got a couple of stratistics up there as youve kind of alluded to, you can heavy about this almost every other day. Week nav ago, we heard President Trump speak about it on national television. Last night, on ktvu, there was a little segment about state suing pharma, so we know its there. And heres some of the metrics str statistics every 16 minutes, there can be a death due to overdose from these medications. Its very expensive 78. 5 billion. I think this was, if im not mistaken, 2013. Most of the expenses are because the treatment is so expensive and going up. And 4. 5 million americans, piage already alluded to that number. And heres a big number the u. S. Consumes 80 of the opioids, so. The next slide, what i wanted to do is on the left, we see theres some other statistics. We already covered those. I want to first go over the opioid utilization for the city plan. Weve got some data there. This is for january through september 2017. The plan paid 113,000. That was actually down dramatically from the same period 2016. Now i attribute that a lot to the programs we have in place. Theres a huge awareness out there, too. Were working with physicians, so what were trying to do is bend the trend that Everybody Knows has been going up for frankly, its been two decade does. Thats severe the problem is. The prescription count, 1692, year to date, and member utilization, 491. Tylenol, hydrocodone, fentanyl, youve heard percocet, vicodin. The good news on the top five, theres no long acting opioids, as that was brought out earlier. That is whats killing people. Oxycontin is the top drug in the United States that everybodys taking and having problems with. Lets go to the next slide and see what our program does for the city plan. We have a real wide range of programs here and touch a lot of points. Its a multitiered approach. On the left, ill talk about these programs, what they do is they reduce unnecessary and inappropriate use of these medications, so for instance, we prior off long acting opioids. Thats the oxycontins. Thats whats really driving this. And what we did was we built in those cdc guidelines, and so somebodys wanting to get one of those, per the guidelines, it makes sense. Well maybe you dont need maybe even drug therapy. Maybe theres another modality to try. Okay. That doesnt work. Try it lets try a medication, but maybe not an opioid. Many atlas v. A. Health care system in april came out with a controlled study that said compared opioids versus nonopioids, and back pain and rheumatoid arthritis, so its about the same. It makes sense. If youve really got to go further, lets use a short acting opioid to start out with before you get to the long acting. That is he thats a very important piece we have in here. Other things we have is we limit the fentanyl patch because that is appropriate. There is appropriate times to use this, and thats the key here the appropriate times to use these medications, but have the safeguards in place so you startup above, before you get into the very powerful long acting drugs. In addition, a longacting one, weve put a limit on the daily dose, per cdc guidelines. Now in some cases, cancer, etcetera, thatt makes sense okay. You need more than that . No problem. The other thing we do, weve got it in there for not only the longacting one per day, but were going to add up all the opioids, and if that hits a certain ceiling, were going to reach out to the doctor and make sure thats appropriate. Over on the right side, these programs are mainly we monitor the claims and then identify situations where we can make an impact. So for instance, the high utilizer narcotic program, here, we look at 30days of claims, and if we see a members getting way too many narcotics, numerous pharmacies, numerous physicians, thats a real big red flag. Were going to reach out to those physicians, and they appreciate that, too. They dont know sometimes that the member is going to other physicians. Now, if we see a pattern there, we can even lock in the member to one pharmacy, which makes sense. That pharmacist will have nice monitoring for that member. Im happy to report, also good news on this front, with your plan, the last four quarters, i havent seen any members that have hit this flag, so good news on that. We can identify prescribers that are out liers, so if theyre prescribing way up here, higher doses, longer lasting medication, we reach out to them. We also for high claim cost memo members, somebody thats spending a lot of money on these narcotics, well go ahead and get Case Management involved with them and see how we can help out. Weve got edits in place where sometimes these medications are interacting with other medications, that it should not happen for more than a month or so. Were going to go ahead and then reach out to that physician. We also have a program here, fraught waste abuse. We can look at programs here and say boy, theres a lot of claims coming in from this doctor, and this pharmacist with this doctor, an