Gov. Eric Greitens waded into the statehouse debate that had blocked a statewide PDMP for about 12 years — making Missouri the lone remaining state without its own program — signing Executive Order (EO) 17-18 on Tuesday, July 17.
The state’s PDMP is envisioned as a companion vehicle to expanding local efforts spearheaded by St. Louis County that began earlier this year and already cover the majority of the state, Dr. Randall Williams, director of health and senior services, told Government Technology.
After so many years without a way to comprehensively monitor opiates in a state that has roughly 89,000 narcotics prescriptions for every 100,000 residents, Williams said Missouri will “focus on doctor shoppers by going to the very source of who they’re shopping with” — activating its PDMP in less than two months and potentially serving as an example to other states.
State statute forbids Missouri to directly look at patients by using their data, Williams said, so the state is partnering with so-called “pharmacy benefit management organization” Express Scripts Holding Co. to examine other information.
The pharmacy benefit management industry, he said, typically handles prescriptions and pharmaceuticals for insurers. Among its responsibilities, a company might negotiate with the manufacturer of a name-brand drug to obtain a cheaper generic on behalf of an insurer.
“Something that I think will be a national prototype, how can you pull that together in five weeks, and the answer is Express Scripts, and these prescription drug monitors [that] are already doing this in the private sector. Express Scripts is already doing this for 7 million lives in America,” Williams said.
The EO’s cost to date is $425,000, he said: $250,000 to contract with Express Scripts, and $175,000 to hire four new staffers to scrutinize data the company provides.
County efforts, which have expanded to include around 30 counties and more than 60 percent of the state’s population, are more focused toward patient data. By contrast, the state will work on identifying physicians who may be overprescribing and potentially alerting medical boards or law enforcement.
“What I saw was that they are able, through sophisticated data analytics, to literally in front of your eyes show you the doctors, dispensers and patients who are of true, high-risk concern for using, misusing or converting from narcotics,” Williams said.
He described the realization of the possibility in the data from Express Scripts and others as a “Eureka moment,” and a way to avoid the time demands and paperwork that a traditional PDMP may bring with it.
The opioid crisis is “the No. 1 public health crisis in America,” the state health department director said, “so for many of us this is professional as well as personal.”
Currently neither state nor county PDMPs have sunset clauses after which either would expire, or data purge deadlines, at which point information collected would be eliminated. Both issues were sticking points for members of the state Legislature.
State, industry and local officials expressed hope and concern last week following the bill’s passage. State Rep. Holly Rehder, R-Sikeston, introduced House Bill 90, which would have created a statewide PDMP based on data from prescribing physicians.
It ran aground in May, but Rehder, who continues to support efforts to cover the state through county-level PDMPs, told Government Technology she’s enthusiastic about the governor’s EO, calling it “out-of-the-box thinking” for targeting so-called “pill mills” and doctors who overprescribe.
Rehder, whose family members have struggled with addiction, also expressed hope that her fellow legislators may take a somewhat kinder, gentler approach to solving the state’s drug problem.
“My hope with future legislative sessions is we’ll see more money toward long-term treatment than prison,” said Rehder, pointing out that the state of Tennessee has taken such an approach. “Long-term treatment has better outcomes and it’s less expensive."
The Missouri State Medical Association (MSMA) joined other groups in May in withdrawing support from Rehder’s bill as amended, worried it might restrict county PDMPs if passed.
Jeff Howell, MSMA director of government relations, told Government Technology shortly after the governor’s EO that his group was still digesting it, but said the statewide plan appears to be more useful to law enforcement than for patient treatment.
“We like to think part of the reason to have a PDMP is to have a clinical tool that subscribers can use to treat patients,” Howell said.
Dr. Sam Page, a St. Louis County Council member who testified in January to a state Senate committee in support of Rehder’s bill, praised the governor for trying to solve the state’s opiate and prescription drug problem.
But Page also told GovTech that gaps in the EO’s coverage may still remain, and its enforcement could bring unintended consequences.
“What you don’t want to do is have the state kicking down the door of a doctor’s office where they’re caring for folks who have cancer,” Page said.
Williams said the state hopes to contract relatively swiftly with two additional pharmacy benefit management organizations, effectively blanketing the state with this type of PDMP coverage.
He described it as “complementary,” adding: “I think it’s two different tools trying to get to the same place, and we support those. I’m happy to go speak to any city council that is considering this.”
