Medications have become a hot topic in workers' compensation for many reasons, foremost of which is the increased claim costs associated with prescription drug use. A related issue is the overutilization of certain medications, especially opioids, which typically results in costly medical complications for the injured worker.
Most employers have chosen to contract with pharmacy benefit management programs that use first-fills and point-of-service plans to manage upfront medication costs for injured workers. However, in spite of interventions put into place to manage medications and pharmacy cost, drug use and their associated costs continue to be a problem.
Some of the issues at hand are out of our control
--- such as the increase in drug prices over the last several years. But not all issues are out of managed care's reach. There are ways to fix these medication issues.
A very effective approach is the implementation of client-specific pharmacy programs that target specific problem areas. These include, but are not limited to: management of physician dispensing, compound medication prescriptions reviews, utilization review of opioids, and multiple medication management.
Another successful approach involves facilitating regularly scheduled multi-disciplinary team pharmacy claim reviews using specific case thresholds, such as MED greater than 120 milligrams/day, three or more medication prescriptions, multiple prescribers, or compounded medications. These reviews allow team members to openly discuss identified problematic pharmacy claims, focusing on each team members' area of expertise. Ultimately, these discussions end with an agreed upon action plan, often resulting in a decrease in medication costs or the elimination of pharmacy costs on claims altogether, while advancing the injured worker's well-being.
Based on the literature reviews, the impact of workers' compensation claim costs specific to medications tends to negatively impact the end result of claims progressing toward resolution, especially those claims that require a Medicare Set Aside (MSA). High pharmacy costs, combined with long term use of medications, raise MSA projections. For example, we recently completed an MSA on a high pharmacy spend claim with a life expectancy of 17.6 years. Our team recommended a drug utilization review, which advocated a medication change to an equivalent, more cost
--- effective medication. The change was discussed with the treating medical provider, who agreed with the approach and supported a mail order program, resulting in a savings of over $63,000.00 for the MSA.
Aside from decreasing pharmacy costs, creative medication management programs can also benefit injured employees by ensuring prescribed medication regimens prevent harm to the individual. Too often we hear of unsafe medication practices that result in poor outcomes and sometimes, unfortunately, death. For example, at a recent team meeting, an injured worker's use of Methadone
--- a highly addictive opioid
--- and dosage regimens were discussed. The treating provider suggested a spinal cord stimulator as an effective surgical intervention in the long-term management of the patient's pain. With nurse case management intervention, the injured worker was supported through the process of stimulator placement, weaned off of Methadone, and a replacement medication was prescribed for long-term use, resulting in a successful, healthier outcome.
Medication management programs with pharmacy-dedicated claim reviews add the extra layer of ensuring safety for our clients' employees, which ultimately, is the most important benefit these programs have proven to achieve.