Gaps & Limitations

Addressing Pain Management & Opioid Use/Abuse

Getting & Using Data: Gaps & Limitations

Data Limitations

As you gather and analyze data related to pain management in your organization, it’s important to be aware of the potential gaps and limitations that exist, especially when analyzing claims data. For example: 1

  • Not all diagnoses are correctly coded and some may not be captured
  • Self-care with over-the-counter (OTC) medications such as acetaminophen (Tylenol®), nonsteroidal anti-inflammatory agents (NSAIDS) or topical patches will not be included in a claims analysis
  • Patients may choose to pay cash for their prescriptions (including opioids) and these claims will not be available through the PBM
  • Data from state monitoring programs are not available to employers

Data integration is critical. Reviewing only pharmacy or medical data will likely provide an incomplete picture of the key issues, making it difficult to determine a strategy and identify what tactics to put in place. If a data management vendor is used, they can obtain this information. You may already be sharing medical/pharmacy data between your health plan and your PBM. Ask what reports they have available using both data sets.


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