The Role of Data in Helping to Fight the Opioid Epidemic

The opioid epidemic continues to increase in scope and severity. According to a 2016 national survey for the Substance Abuse and Mental Health Services Administration, nearly 12 million people were addicted to opioids, leading to 64,000 overdose deaths. President Trump has labeled it a crisis and presented a plan to address opioid abuse. There have been Congressional hearings. And, many in the healthcare industry are being called upon to help out. This includes pharmacies, prescribers, pharmacy benefit managers (PBMs) and health plans. 

When you look at the numbers of people affected and the overall attention the issue is receiving, it is apparent that solving this problem and finding a solution will take a multi-faceted effort. All stakeholders must come together, and it will be critical that data play a role in helping to fight the epidemic. 

Big data and analytics can help the healthcare system reduce health risks and stop fraud, waste and abuse at the entity and cluster levels. By this, we mean the entities, such as high-risk providers, patients and pharmacies – and clusters, AKA, social groups or networks, which drive widespread drug diversion and the proliferation of opioids within the healthcare industry. 

Everyone must work together to help prevent, detect and collaborate in a unified effort to uncover the risky entities, unknown relationships and the social groups that drive the increasing spread of opioid fraud, waste and abuse across the healthcare system.

Our Perspective
LexisNexis Health Care believes that data (both traditional sources and non-medical data) wrapped in analytics – can offer a unique view of how people are engaging with the healthcare system and the communities in which they live. Those data insights then enables extrapolation to identify relationships that are often complex and indicative of abuse or misuse of opioids. Big data and analytics can help uncover the unknown relationships that drive the widespread proliferation of opioids via fraudulent activity. 

Healthcare entities need to be able to visualize the highly suspect and hidden connections between members, doctors and claims across their programs. 

On the government side, key stakeholders helping to address this issue include, state Medicaid Fraud Control Units (MFCUs), the U.S. Department of Justice and the U.S. Department of Health and Human Services (HHS). These investigators typically examine pharmacy and medical claims data, information from Prescription Drug Monitoring Programs and Drug Enforcement Agency data. 

An example of how our organization can help root out such hidden connections is LexisNexis® Relationship Mapping. This tool aggregates, analyzes and links data from vast sources – including customer claims, provider data and socioeconomic data – to provide a view into significant relationships between individuals, businesses, assets and properties that warrant further investigation. 

Benefits of relationship mapping technology include:

• Preventing improper claims payments and overpayments, and improve recoveries
• Uncovering fraud attempts, including larger collusive schemes perpetrated by organized crimes
• Revealing inappropriate or suspect relationships between patients, providers, employers, suppliers and partners
• Discovering non-licensed providers
• Better allocation of valuable resources
• Detecting unusual prescribing habits, aberrant dispensing patterns and drug seeking behavior

Data and analytics also play a role in treating the sick
Social determinants of health (SDOH) can be much more effective when looking at a more complete picture of a person as an individual, which can be formed by utilizing robust identity data sets, such as those in public records.

By using extensive identity data sets, scoring and analytics, a public healthcare agency can better engage an at-risk person by asking key questions:

• Is the patient facing personal hardship, such as a bankruptcy or divorce?
• Does a patient live in a high-risk neighborhood?
• Is the patient isolated from work colleagues, friends and/or family?
• Does the patient’s educational background indicate there may be a low health literacy rate?

By prioritizing those at risk – and those likely to seek help, medical professionals can develop clinical programs and engage additional resources, such as social services programs, based on these socioeconomic needs.

What else is necessary? Payers. Providers. Pharmacies. 

At LexisNexis Health Care, we believe in three core tenets, necessary behaviors that will help solve the opioid epidemic.

They are Prevention. Detection. Collaboration.

Let’s take a deeper look at each one.

• Prevention: This includes identity verification and risk evaluation …
• Conducted by payers at the point of patient enrollment, can reduce patient health risks by identifying historical drug use (or lack thereof), dependent behavior, and/or through preventative programs.
• Conducted by payers at the point of provider enrollment, can reduce provider network risks by identifying historical/emerging abnormal prescriber habits and preventing new or ongoing abuse.
• Conducted by payers/PBMs as they screen their pharmacy network and evaluate at risk locations.
• Conducted by payers as they screen incoming claims for payment, driving claims with associated provider, patient, social group, or pharmacy risk into a prepayment workflow.
• Conducted by providers at the point of prescribing, can prevent individuals from obtaining opioids in situations that are suspicious, inappropriate, or that appear fraudulent or identify first-time drug users.
• Conducted by pharmacies at the point of dispensing, can prevent individuals from obtaining opioids in situations that are suspicious, inappropriate, or that appear fraudulent.

• Detection: This involves analyzing contributed claims, mapping relationships, and leverages outside data assets to help all parties detect and investigate risky entities (providers, patients, and/or pharmacies) and social groups (e.g. clusters) that are perpetrating fraud, waste and abuse.
  
  
• Collaboration: This means that all parties have an opportunity to work together, aggregating data across constituents, to share known risks, entities, insights and emerging trends that can put a stop to the entire cycle of opioid abuse.

And, there is more. For pharmacies and care providers…
LexisNexis is committed to creating solutions and channels that enable all stakeholders across the industry to tackle this very important crisis. If you would like to learn more about LexisNexis Health Care and its plans and solutions to help manage the opioid epidemic, contact us at health.care@lexisnexisrisk.com or our website.