The combination of the two mailings resulted in 118 complete and usable responses, 45 refusals, and two returned surveys from sample members who were not medical directors. The overall response rate was 25.5% (118/463).

Responses were well distributed across the U.S., with 48% (n = 57) of the respondents having members in the northeastern and southeastern states, 34% (n = 40) in the northern and southern central U.S., and 26% (n = 31) in the northwestern and southwestern regions. Some respondents covered more than one region, and four respondents indicated having national representation.

Responses were also well distributed with regard to commercial, Medicaid, and Medicare membership and plan size. Of the 118 respondents, 101 (86%) had commercial members, 67 (57%) had Medicaid members, and 61 (52%) had Medicare members. Of the 101 plans with commercial members, 45 (45%) had fewer than 100,000 commercial members and 35 (35%) had between 100,000 and 500,000 commercial members.

Respondents were asked to estimate the prevalence of chronic pain within their MCO member populations. Sixty-eight respondents (58%) were unable to answer this question or unwilling to guess. For the remaining 50 respondents, responses varied, although the majority indicated that they thought that fewer than 15% of their members suffered from chronic pain (Table 1). This finding is consistent with the literature cited earlier, indicating a broad range of estimates of chronic pain prevalence.

Table 1 Percentage of Members Believed to Be Suffering from Chronic Pain (n = 50)

No.

Percent (%)

2% or less

9

18.0%

Between 3% and 5%, inclusive

20

40.0%

Between 6% and 14%, inclusive

11

22.0%

Between 15% and 19%, inclusive

5

10.0%

20% or greater

5

10.0%

Despite these findings, only 32% (n = 38) of the total sample reported having a mechanism in place at the MCO for identifying patients with chronic pain. The methods used by the 38 MCOs in identifying individuals with chronic pain included monitoring of utilization of chronic pain medications (79%), physician referral for pain management (63%), review of International Classification of Disease (ICD-9) diagnosis codes on claims (37%), and other methods (32%).
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Table 2 Categorization of Pain Medication for Formulary Purposes (n = 118)

No.

Percent (%)

By class

81

68.6%

By brand name vs. generic name

65

55.1%

By route of administration

40

33.9%

By long-acting vs. short-acting type

30

25.4%

Pain medications are not categorized

18

15.3%

By federal and/or state schedule

12

10.2%

By type of pain

8

6.8%

Fewer than one in five of the MCOs (21 out of 118, or 17.8%) reported systematically implementing pain-management clinical practice guidelines in their approach to patient care. Among MCOs using guidelines, a wide variety of authors and sources of guidelines were noted. The most commonly cited guidelines were those disseminated by the U.S. Agency for Healthcare Research and Quality (AHRQ) (eight MCOs, or 38% of those using guidelines), although seven MCOs (33%) reported that they were using guidelines developed in-house, based on principles of evidence-based medicine.

Management of pain medications was much more prevalent than formal methods for identifying members with pain or the use of pain-management clinical guidelines. Respondents reported a wide variety of mechanisms for categorizing pain medications for formulary purposes (Table 2). As evidenced by this study, mechanisms were not mutually exclusive, and most MCOs used several approaches to categorization. The most widely used approaches were to categorize pharmaceuticals by class and by brand name versus generic name.

Table 3 Formulary Controls Used for Pain Medications (n = 118)

No.

Percent (%)

Number of units per month

67

56.8%

Tiered co-pay system

66

55.9%

Prior authorization for specific agents

64

54.2%

Provider prescription profiling reports

49

41.5%

Number of units per prescription

48

40.7%

Concomitant medication profile

35

29.7%

Dose-specific limitations

33

28.0%

None

15

12.7%

National Drug Code (NDC) blocks

15

12.7%

Therapeutic substitution of analgesics

13

11.0%

Analgesic drug therapy selection
guidelines

12

10.2%

Drugs limited to prescribing by
specialty

9

7.6%

Drugs limited to prescribing by
patient diagnosis

9

7.6%

Table 3 presents the wide range of formulary controls that were used by MCOs to control pain medication. Again, survey responses were not mutually exclusive. The most common control mechanisms included:

• monitoring the number of units dispensed per month (57%, n = 67).
• using tiered co-payments (56%, n = 66).
• requiring prior authorization for specific pain medications (54%, n = 64).

Only 15 (13%) respondents were not using any formulary controls for pain medications.
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Table 4 Ratings of Factors* Considered in Formulary Determinations (n = 118)

Factor ImportantNo. (%)

Neutral

No. (%)

Not ImportantNo. (%)

Row Total

No.

Efficacy when compared with other leading analgesics

88

(88%)

7 (7%)

5 (5%)

l00

Side-effect profile and tolerability

75

(82%)

ll (l2%)

5 (5%)

9l

Improvement in patients’ ability to function

64

(76%)

l3 (l5%)

7 (8%)

84

Warnings and contraindications

62

(75%)

l7 (20%)

4 (5%)

83

Cost

74

(74%)

l4 (l4%)

l2 (l2%)

l00

Duration of pain relief

56

(69%)

20 (25%)

5 (6%)

8l

Impact on patients’ health-related quality of life

56

(68%)

l9 (23%)

7 (8%)

82

Drug-interaction profile

55

(68%)

22 (27%)

4 (5%)

8l

Efficacy and safety data across age groups

54

(64%)

l7 (20%)

l3 (l5%)

84

Onset of pain relief

50

(66%)

20 (26%)

6 (8%)

76

Efficacy when compared with placebo

48

(64%)

l3 (l7%)

l4 (l9%)

75

Dosing route

52

(63%)

22 (27%)

8 (l0%)

82

Prevention of more costly services

41

(55%)

2l (28%)

l3 (l7%)

75

Short-term vs. long-term pain-management data

41

(55%)

26 (35%)

7 (9%)

74

Patient satisfaction

35

(51%)

26 (38%)

8 (ll%)

69

Pharmacokinetics

36

(46%)

34 (43%)

9 (ll%)

79

Breadth of indications

34

(42%)

30 (37%)

l6 (20%)

80

Federal and/or state schedules

24

(34%)

24 (34%)

22 (3l%)

70

Pain-management support from manufacturer

7

(l2%)

l2 (20%)

40 (68%)

59

Table 4 presents the factors that respondents considered to be important when making formulary decisions. Each factor was rated on a five-point Likert scale, with “1” being “very important” and “5” being “not at all important.” The leftmost column of numbers shows the percentage of respondents who

• efficacy, when compared with other leading analgesics (88°%, n = 88).
• side-effect profile and tolerability (82%, n = 75).
• improvement in patients’ ability to function (76%, n = 64).
• warning and contraindications (75%, n = 62).
• cost (74%, n = 74).

The project team also examined these results by evaluating plan size, comparing two subgroups: smaller MCOs (having fewer than 100,000 members) and larger MCOs (having 100,000 or more members). As shown in Table 5, the larger plans were more likely to view the listed factors as important in making decisions. Several of these differences were statistically significant at the P < .05 level:
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• efficacy, when compared with that of placebo (58% for larger plans vs. 32% for smaller ones)
• side-effect profile and tolerability (79% vs. 58%)
• warnings and contraindications (65% vs. 42%)
• dosing route (62% vs. 33%)

Almost 90% of respondents indicated that inappropriate utilization of pain medications was a concern for their MCOs (88%, n = 104). Various methods of tracking patterns of use included:

considered a factor “very important” or “important.” Factors that were judged to be most important included:
• monitoring the frequency of refills (83%, n = 86).
• monitoring the quantity per prescription (72%, n = 75).
• monitoring for appropriateness of dose (54%, n = 56).
• matching a medication with a diagnosis (52%, n = 54).

Finally, with regard to the management of pain medications, respondents were asked to identify the greatest challenges currently facing them. As shown in Table 6, patient abuse and misuse of pain drugs were the most common concerns (77%, n = 91), followed by the cost of pain medications (64%, n = 75).

Table 5 Differences in Importance of Formulary Determination Factors by Plan Size

Factor Large MCOs* Small MCOs*
Duration of pain relief

28

(53.8%) 20

(46.5%)

Onset of pain relief

26

(50.0%) l7

(40.5%)

Efficacy compared with
other leading analgesics

45

(86.5%) 33

(76.7%)

Efficacy compared with placebo*

30

(57.7%) l4

(3l.8%)

Pharmacokinetics

19

(36.5%) l3

(30.2%)

Side-effect profile and tolerability*

41

(78.9%) 25

(58.l%)

Drug-interaction profile

28

(53.9%) l9

(44.2%)

Warnings and contraindications*

34

(65.4%) l8

(4l.9%)

Dosing route*

32

(61.5%) l4

(32.6%)

Federal and/or state schedules

7

(l3.5%) l2

(27.9%)

Breadth of indications

16

(30.8%) l8

(40.9%)

Efficacy and safety data
across age groups

30

(57.7%) l9

(44.2%)

Short-term vs. long-term
pain-management data

21

(4l.2%) l3

(30.2%)

Cost

34

(66.7%) 27

(62.8%)

Pain-management support
from manufacturer 4 (7.8%)

3 (7.0%)

Prevention of more costly services

19

(37.3%) l6

(37.2%)

Patient satisfaction

18

(35.3%) l2

(27.9%)

Impact on patients’ health-related
quality of life

25

(49.0%) 25

(56.8%)

Improvement in patient’s ability
to function

28

(54.9%) 26

(60.5%)

Despite the reported attention to the management of pain medications, only one-third (33%, n = 39) of the respondents reported having a comprehensive pain-management program in place or under development. Of those respondents who did not (67%, n = 79), by far the most common reason was that it was a low priority relative to other diseases or conditions. Other reasons included (1) lack of human resources (42%, n = 32), (2) lack of financial resources (29%, n = 23), (3) skepticism regarding benefits (13%, n = 10), (4) perceived intrusion into physician practice (13%, n = 10), (5) organizational barriers (9%, n = 7), and (6) lack of interest (8%, n = 6).
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Table 6 Greatest Challenges in the Management of Pain Medications (n = 118)

No.

Percent (%)

Patient abuse or misuse

91

77.1%

Cost

75

63.6%

Lack of resources to support
appropriate patient-level
intervention

53

44.9%

Lack of national consensus on
pain-management guidelines

51

43.2%

Aggressive detailing by
drug manufacturers

49

41.5%

Undertreatment of pain

45

38.1%

Data programming and analysis
of analgesic use

25

21.2%

Other

12

10.2%

Lack of effective agents

11

9.3%

Lack of well-tolerated drugs

5

4.2%