Workers Compensation News From Around the Net

Input Needed in Providers Opioid Audit
 
The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) acknowledges that prescription drug abuse and misuse, including opioids, is a serious issue in all health care delivery systems, including workers’ compensation.
 
 
The TDI-DWC seeks input and suggestions regarding the development of a new Plan-Based Audit for health care providers prescribing opioids. The Plan-Based Audit sets the scope, methodology, selection criteria, and program area responsibilities as laid out in the Medical Quality Review Procedure. A copy of the proposed Health Care Providers Pain Management Services (Opioid) Plan-Based Audit can be viewed at the TDI website here. [WCx] 
 
 
Broadspire Launches BOLD® Rx Network
 
Broadspire, a Crawford Company and TPA of workers compensation claims, liability claims and medical management services, has launched its BOLD Rx Network to help control the medical costs associated with WC claims. See here for more information.[WCx]
 
 
According to Broadspire, the BOLD Rx Network uses a multi-leveled strategy to achieve superior penetration rates and savings compared to the rest of the industry. “Rather than just partnering with one pharmacy benefit management (PBM) company, as is traditionally seen in the marketplace, Broadspire leverages multiple partners based on the value they bring to clients, creating a stronger pharmacy program,” they write.
 
Federal Court Rejects NLRB Authority to Force Posting of Employee Rights Notice
 
According to a well-written newsletter from McGuireWoods, a world-wide lawfirm with 900 lawyers, in Chamber of Commerce of the U.S., et al. v. NLRB (Dist. S.C., April 13, 2012), a South Carolina federal district court held that the National Labor Relations Board (NLRB or the Board) does not have statutory authority to force employers to post notices that the NLRB claims are designed to inform employees of their rights under the National Labor Relations Act.
 
 
McGuireWoods writes, “The Court’s decision directly conflicts with a recent decision from a separate federal court in the District of Columbia. These developments place all employers covered by the Act in a very difficult position.”
 
 
The regulations are to take effect April 30, 2012. “The conflicting court cases make it unclear whether employers will be required to post the NLRB notices on the current April 30, 2012 deadline. (Click here for more),” they write.
 
 
Columbus Dispatch Notices Lawsuits Against Doctors on Decline
 
Columbus Dispatch reporter Alan Johnson writes here that Ohio’s tort-reform law has reduced closed claims by 41 between 2005 and 2010. He discovered average payments for medical malpractice cases have declined 38 percent over that period.
 
 
Johnson writes, “The legal fight over curbing lawsuits and settlements in medical malpractice cases reached a tipping point in 2003 when the General Assembly passed and Gov. Bob Taft signed Senate Bill 281. The law capped non-economic damages, commonly known as ‘pain and suffering,’ at $500,000 per occurrence.”
 
 
Johnson reports that Tim Maglione, of the Ohio State Medical Association says doctors’ medical malpractice rates have dropped more than 26 percent. “It’s not only good news and a good trend, but it is proof that tort reform accomplished what it set out to do — slow the growth of what we thought were runaway lawsuits and to stabilize the market for physicians,” Maglione said. The numbers have also gone down, he said in the article, because doctors and hospitals are working harder to improve safety and cut down on mistakes. “The best error is the one that never happens.”
 
 
Progressive Medical Releases Annual Workers’ Compensation Medication Trends Report
 
According to Progressive Medical, Inc., WC medication spending declined in 2011. Their annual analysis, found here, reveals changes to medication expense patterns in workers’ compensation claims from 2010 to 2011 for Progressive Medical clients, as well as key factors that may influence future expenditures, such as chronic pain, product mix and government activity.
 
 
Key highlights from the 2012 Workers' Compensation Medication Trend Report include:
  1. Although medication AWP inflation was 5.8 percent in 2011, data shows a 1.3 percent reduction in total medication spend per claim.
  2. There was an overall 3.3 percent decrease in utilization per injured worker from 4.3 percent fewer prescriptions and a 1.1 percent decrease in average days of medication supply received.
  3. Across the industry, narcotics account for 35 percent-40 percent of workers' compensation medication spend while Progressive Medical showed a 3.9 percent decrease in total spending per claim in this drug category. Progressive Medical believes this is due to an emphasis on conducting interventions earlier in the lifecycle of a claim.
 
 
Note: If your company has any developments you'd like to share, please send them to us at: RShafer@ReduceYourWorkersComp.com

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Pharmacy Lock-in Program Designed to Assist Injured Workers

Ohio Bureau of Workers Compensation (BWC) Administrator/CEO Steve Buehrer late last month unveiled new measures to improve the safety of medication prescribed to Ohioans recovering from workplace injuries and limit the practice of doctor and pharmacy shopping.

 
 
The Coordinated Services Program is designed to limit the dangers that can arise when medications are prescribed by multiple physicians and are processed in different pharmacies.
 
"There is a point at which prescribed medications move from being a useful and necessary part of a treatment plan to hindering an injured workers' recovery and return to work," said Buehrer. "Identifying where prescriptions are being used in a manner other than medically necessary will set the injured worker on a better path to recovery. It will also assist in our return-to-work effort at BWC by addressing an issue that keeps claims lingering in our system longer than they should."
 
 
The program allows BWC, under certain circumstances, to restrict an injured worker to the use of a single pharmacy for non-emergent prescriptions. The injured worker selects the pharmacy from a list of eligible pharmacies. BWC can also restrict an injured worker convicted of a drug offense to the use of a single prescribing physician, selected by the injured worker from BWC certified physicians, in order to receive reimbursement for non-emergent prescriptions.
 
 
The lock-in program is among several recent improvements made to BWC's pharmacy program, including BWC's first ever outpatient prescription drug formulary, which became effective in September. The industry-standard formulary focuses on the well-being of the injured worker by allowing for a thorough clinical review of each new medication, better monitoring and control of inappropriate use. The formulary is expected to save up to $15 million by the end of 2012.
 
 
BWC is also now requiring, with physician approval, generic medications when available and has established a Pharmacy and Therapeutics Committee comprised of practicing pharmacists and physicians to advise BWC leadership on issues related to the use of medications prescribed to treat injured workers.
 
 

The committee is also conducting relatedness editing to ensure injured workers are receiving medications.

Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: Info@ReduceYourWorkersComp.com.
 
 
WORKERS COMP MANAGEMENT GUIDEBOOK:  www.WCManual.com
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
 
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

5 Ways a Pharmacy Benefit Manager can Control Prescription Costs

 
 
The cost of prescribed drugs, especially narcotic pain medications, is rising in the world of workers' compensation. This cost increase is due to the fact that a drug company is like any other company: When the demand for your product is high, supply lessens, and costs have to increase. And, these medications are not exactly cheap to manufacture. In fact I saw a news report that some cancer fighting drugs are in short supply due to overwhelming demand.
 
 
Think about going to your personal physician for a knee strain you had over the weekend playing football with your family. You probably went to your doctor, and you probably left with a prescription for Motrin buddied up with a short-term prescription for a narcotic pain reliever — even if a cold pack or hot pack and rest would have taken care of the problem. This is the world in which we live. In the past, these pain medications were for extremely acute trauma, such as a car accident or bone fracture. But more and more, medications such as Vicodin, Percocet, Oxycodone, etc are being prescribed for the slightly-above-average diagnosis of lumbar or shoulder strain. (WCxKit)
 
 
Below we discuss five ways you can try to control these associated drug costs when it comes to your workers compensation claims. By no means is this an exact science, but it is certainly one you should look into for help controlling your bottom line.
 
1. Come up with your game plan.

Whether you have five claims a year, or five claims per week, medication cost will be a significant expense of the claim. Many carrier/TPAs are partnering with a Pharmacy Benefit Manager (PBM) to review prescription history and also to provide a reduced cost for medications. These outside vendors attract carrier/TPAs by offering them a discount cost for medications, in exchange for their guaranteed business.

 

Adjusters set claimants up with a drug card from these vendors, and they are widely accepted at many pharmacies nationwide. Furthermore, the PBM will review the injury and the claimant’s individual medication history. They can recommend medications based on the injury type and location. This is an attempt to stop every John Doe back pain sufferer from walking out of his doctor’s office with an RX for Percocet, when he really does not meet the criteria for needing that strong of a medication to begin with. Most strains can resolve by taking a stronger dose of Motrin, an anti-inflammatory medication similar to Advil or Ibuprofen. The PBM will also monitor duration of medication use and quantity limits. Why pay for 90 pills when John Doe should only need 30? Medication costs are associated with dosage as well, so it doesn’t make sense to pay for 90 pills unless they are needed.

 

2.  Start being aggressive at the first prescribed RX.

When a new claim is filed and the adjuster sets the drug card up to be mailed out to the employee, it may already be too late. This is when proper communication is handy. If you have a worse-than-average claim, you can phone your adjuster with the info, and they can get the PBM info right to the claimant.

 

This way they are not getting medication from an occupational clinic or hospital, where the costs are typically the highest. Right off the bat they can use the PBM card, and that reduces cost right from the beginning. This also helps manage future spending on RXs, since they already have the card and should be using it for any medication the claimant is prescribed. Sure, not using the card for your first medication fill is no big deal if you only have one or two claims per year, but if you have one or two claims per week, over the course of a year this can lead to a dramatic savings in medication cost. Every little bit of savings will help in the long run, and it is important not to overlook the small savings that you can implement right away.

 

3. Can you do bulk home delivery?

For those injuries lasting longer than a month, it is worth it to look into home delivery of medications. This increases the discount, because you buy more of the medication at one time, and you do not have to pay the pharmacy overhead for a short-term 30 day fill. Injured workers will appreciate having one less errand to run, especially those who do not have easy transportation readily at hand. At the same point, the PBM will monitor dosage and quantity. Why should you continue to get a medication if it is not helping? Or, if the injured worker is not taking the medication at all? These are leakage costs, and expensive ones at that. The adjuster will ultimately decide if a claim is worthy of needing home delivery, and the delivery will not last forever. If a person has a bad fracture and will need a long-term supply of Motrin, this is a perfect scenario.

 

Adjusters do frown on home delivery of narcotic pain meds. This gives the claimant a large supply of potentially strong medication, which carries the risk of addiction. Home delivery meds are generally milder. Again, even though these drugs may not cost the most, any sort of savings is better than no savings at all.

 

4. Are you using prescription utilization review?

PBM companies use a panel of clinical pharmacists to examine prescription data and injury type to make sure appropriate medication is dispensed. This helps control unnecessary costs due to prescribing incorrect medication. Also, PBM utilization review will help to control fraud by monitoring the date and location of refills. Red flags indicating abuse include early refills, a doctor shopping around to get new prescriptions, or a patient changing pharmacies to get refills. Clinical pharmacists also are useful at catching new medication trends, proper quantities of medications, and future costs/needs for ongoing medications. 
 
By using prospective utilization review, done before the product is used, to avoid the cost, consider prior authorization program. By having an MD on the TPA's staff review the file, many of the medication concerns are addressed proactively. The utilization review company you use, should be URAC certified to ensure quality, credentials and training. A good TPA might even have a chronic pain program to discuss pain issues with an interdisciplinary team of experts. 
 
 
 
 
5. Use a Pharmacy Benefit Manager or vendor to help with repeat offenders and duplicate prescription medications.
 
This use of an outside PBM is effective for many reasons, including catching a doctor prescribing both a short-term and long-term narcotic pain medication, duplicate or similar prescriptions being unnecessarily prescribed, and implementing the use of generics whenever possible. The PBM will also participate in state-wide reporting, which will catch if a claimant has other narcotic pain medication fills before the date of injury. This can show the worker may have a history of requesting certain narcotics — a red flag for abuse.
 
 
Surveillance companies usually have a service that can do a background check of pharmacies, to see if your claimant has had fills of certain medications aside from the meds needed for your specific injury. This fights fraud, and can expose someone that may have a prescription drug problem. An easy way to get strong medication is to file a comp claim, and any weapons you have to fight fraudulent claims are worth it.(WCxKit)
 
 
In summary, a third-party PBM is a useful tool not only for cost-savings but also for catching the many forms of prescription abuse out there. Doctors get lazy when it comes to prescribing medications. Sometimes the answer to every injury is a prescription of Vicodin, Percocet, or some other narcotic when none are needed. Not only are these medications expensive, but they can carry long-term health problems including addiction, which only increase the overall cost of the claim. Using a PBM is another way of being proactive when it comes to handling your claims, and your carrier/TPA will have more information on what you can do to implement a PBM program for use on all of your claims that require prescription medication.
 

Ask your TPA what programs they offer.
 


Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 
 

Our WORKERS COMP BOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

Pharmacy Benefits Management Cost Control Tips

Often overlooked in the on-going battle to control workers compensation cost is the cost of prescriptions. Pharmacy Benefits Managers (PBM) offer the self-insured employer, insurer or third party administrator a way to manage and control the cost of drugs. While PBM provide a cost savings by obtaining a discount on the cost of drugs, the good PBM goes a lot further.

 

 

The PBM that will provide the best results is the one that keeps track of not only the cost savings provided, but also the utilization of prescriptions, especially narcotics. The better PBMs will alert the medical provider and adjuster when there is over-utilization of drugs. (WCxKit)

 

 

The PBM you select should have a national network covering most of the 70,000+ drug stores in the United States. The PBM should have a working relationship with the three major drug store chains which include CVS, Walgreens and Rite-Aid, as well as the local independent drug stores.

 

 

The effectiveness of the PBM can be judged by three different criteria which are  the rate of use by the employees, the ease of use for the adjuster, and their technology interface ability.

 

 

The penetration rate is a measure of how extensively the employees use the pharmacy program. The PBM will often mail the employee a pharmacy benefit card with a cover letter on the pharmacy benefit card use.  Most employees will opt to use the PBM card rather than out of pocket and then having to seek reimbursement. The adjuster should have the ability to suspend the use of pharmacy benefit card when the claim is denied or concluded.

 

 

The PBM should coordinate the prescription with the employee, the pharmacy and the medical provider without involvement of the adjuster. The easier the process is to use, the less the involvement of the adjuster. The better PBM will make the process totally seamless resulting in no involvement for the adjuster, while the adjuster can be assured the cost of the prescriptions and the utilization of the prescriptions is being properly controlled.

 

 

The PBM should provide the user of the service with the ability to review on-line all transactions and to obtain all necessary management reports. The technology interface should allow you to quickly know and understand the prescription drug usage of any employee. This will allow you to identify both the high cost employees and the doctors who prescribe the medications.

 

 

There are numerous ways the PBM can control cost.  Some of the techniques used by PBMs include:      (WCxKit)

 

-The use of generic drugs wherever substitution for patent drugs is permitted.

-A comprehensive, standard formulary specific to workers compensation injuries.

-A pre-negotiated price for each drug in the formulary.

-The ability to provide home delivery for employees who are unable to pick-up the prescribed drugs.

-Mail order services for maintenance drugs.

-The ability to approve or deny the “off-label” use of a drug.

-The ability to prevent consumption of drugs faster than manufacturer recommendations.

-The prevention of multiple, overlapping prescriptions from multiple doctors.

-The prevention of multiple pharmacies filling the same prescription.

-The prevention of filling non-injury related prescriptions.

 

 

The use of a PBM is a great way to reduce the cost of prescriptions and to lower their cost impact on your workers compensation program. To learn more about PBMs and how you can utilize their services to reduce your workers compensation cost, read the chapter on Implementing a Pharmacy Benefits Management Program in our new 2012 edition of Manage Your Workers Compensation Program, Reduce Costs 20-50%. To obtain your copy, please contact us.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.comContact: RShafer@ReduceYourWorkersComp.com.

 

 

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

Info@ReduceYourWorkersComp.com.

 

Solutions to the American Prescription Drug Abuse Epidemic Part III

 
Stuart Colburn, Esq., has done it again with his third installation on prescription drug abuse in America for the LexisNexis Communities on Workers Compensation. Part One explained “the problem”. Part Two identified stakeholders and his final blog offers solutions. You may read his complete blog here or take a look at this brief summary.
 
1. Government Regulation
“Prescription drug abuse and diversion is a problem requiring close interaction between public and private sectors. Stakeholders must work together using tools at their disposal in a coordinated effort to fight supply and demand,” Colburn wrote. He suggests a prescription drug monitoring program (PDMP) that would include:
 
– Scheduled and other highly abusive substances.
– Real time data transmission between stakeholders.
 -A requirement for doctors to check the PDMP database before writing a prescription.
– A requirement for pharmacies to check the PDMP database before dispensing narcotics.
Integration with neighboring states.
 
 
2. Physicians
“The public has an unreasonable view of the knowledge base of healthcare providers. Although every doctor graduated from medical school, knowledge itself comes from specialized training,” he wrote, “Scheduled narcotics should only be prescribed by doctors with the requisite training and experience. Those doctors granted the additional license to prescribe scheduled narcotics would be subject to additional regulation.”
 
 
3. Pharmacies
“Pharmacies should be required to participate in a prescription drug monitoring program for scheduled narcotics before dispensing scheduled narcotics,” Colburn suggested.
 
 
4. Pharmaceutical Companies
Drug companies should design drugs to deter abuse. Drug companies can employ manufacturing techniques, making it more difficult or impossible for drugs to be ground up into a powder,” he added.
 
 
5. Consumers
“Public education about prescription drug abuse should be paramount on billboards and in our school systems. Every day, 7,000 young people abuse prescription narcotics for the first time. Patients who receive a prescription or scheduled narcotics should also undergo approved education and information,” Colburn wrote.
 
 
6. Payers
“Payers should implement strategies designed to identify addicts, diverts and outliers. Payers should urge policy makers to adopt PDMP and common sense laws giving regulators the information and power necessary to fight PDA,” he wrote. “Payers have ever more increasingly sophisticated software able to perform advanced predictive modeling and performance analytics that can identify outlier doctors and possible addicts.”
 
 
© Copyright 2011 Stuart Colburn, Esq. Reprinted with permission.
For more information about LexisNexis products and solutions connect with them and become part of the conversation at Workers Compensation Law Community

This information was provided by attorney Stuart Colburn, a Shareholder at Downs Stanford in Austin, Texas. Colburn has extensive experience in all phases of dispute resolution before the Texas Department of Insurance, Division of Workers Compensation and in district courts across the state. Stuart represents clients regarding workers compensation, non-subscription, subrogation, and bad faith litigation. He is the founder and the first chairman of the State Bar of Texas (SBOT) Workers Compensation Section; course coordinator for the SBOT the Advanced Workers Compensation Seminar; and course coordinator for the Texas Workers Compensation Forum. He can be reached at:  scolburn@downsstanford.com

 
 
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

Ways to Ensure Prescription Medication is Appropriate

The challenge:   A grey zone medication is any type of drug for which special attention is required to determine if it is appropriate for the injured worker based on compensability, relation to injury and medical history. Ensuring medications are appropriate has become increasingly complex due to an aging and unhealthy workforce. Workers who have more simultaneous ailments are leading to the use of medications that are unrelated to the actual injury.
 
The most common grey zone medication categories mirror the prescription trends within workers compensation as a whole; antibiotics, pain medications, hypnotics, anticonvulsants, antidepressants, ulcer medications, cardiovascular medications.
 
The solution: Implementing effective strategies to monitor grey zone medications helps ensure injured worker safety and reduces opportunities for instances of fraud, misuse and abuse.
 
  1. Develop customized medication plans
By working with a pharmacy benefit manager (PBM), payors can create medication plans that are based on specific criteria to ensure that medications are appropriate for the injured worker. Medication plans should be specific to body part and nature of injury, as well as the acute or chronic nature of the injury. PBMs should also offer electronic notification of approved and misaligned medications. This will reduce administrative burdens on claims professionals, allowing them to focus on jurisdictional issues related to the claim while the PBM can focus on medication concerns.
 
  1. Establish comprehensive utilization management programs
Utilization management programs are essential to limit cases of fraud, misuse and abuse and ultimately ensure injured worker safety. A quality program should include working with a clinical staff capable of performing in-depth, injured worker-specific drug utilization reviews. While PBMs offer utilization review programs, payors should also ensure their partner has a process in place that is managed by clinical pharmacists. The clinical utilization review program should use a combination of evidence-based medical guidelines, peer review journals and recommendations provided by government organizations.
 
·    Prospective utilization reviews– A prospective program allows all involved parties to plan for future outcomes with up-front information. Guiding future decisions through historical data and practices allows for the achievement of cost control and utilization control.

 

·   Concurrent utilization reviews– A concurrent program can prevent abuse involving the use of multiple pharmacies and physicians for different medications, or excessive early refill attempts. The PBM can trigger concurrent alerts to inform the dispensing pharmacist about possible reasons a medication should be questioned before filling. This process can ensure that prescriptions are not filled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the payor.
       
 .  
Retrospective drug utilization reviews and clinical intervention programs– Conducting retrospective drug utilization reviews, physician monitoring and clinical intervention programs should be used to continually evaluate claims for grey zone medications and monitor inappropriate and/or excessive use. Staying on top of potential patterns can cut back on unnecessary spending and ensure injured worker safety.

 

·     Retrospective reviews– After a prescription is filled, the PBM’s clinical pharmacist team should audit the claim for indicators of misuse; multiple physicians, duplication of therapy, excessive duration and use.
 
      
 .  Clinical intervention programs– Seek a PBM that offers a wide range of clinical intervention programs to assist with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions and peer reviews. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation.
 
  1. Physician monitoring
It is essential to have a process that monitors an injured worker with multiple physicians. A successful program should be based on established best practices and contain multiple components including:
    • Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines
       
    • Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA approved generic equivalent exists
       
    • Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns
     
    1. Pharmacist support
    The PBM must have a staff of clinical pharmacists available to provide customized support for medication-related decisions. The exchange of medication education between pharmacists and claims professionals is important for both general and injured worker-specific information.
     
    1. Nursing support
    A more holistic clinical picture of the claim should be obtained by the claims professional. Nurses on an experienced clinical services team are uniquely positioned to assist in explaining the details on medical service claims. Having access to experts in non-drug therapy can allow the claims professional to make more informed decisions.
     
    1. Claims professional education
    Effective seminars that train and provide guidance to claims professionals on the payor’s policies for managing grey zone medications should be provided. These sessions should be included within claims professional’s regular education and training,
     
    Summary: Managing medication utilization for injured parties has become increasingly complex for workers compensation payors. As new medications become available, the workforce continues to age and medical histories increase in complexity, navigating the grey zone medication maze will remain a challenge. By putting best practices into place to manage the appropriateness of medications, payors will ultimately ensure injured worker safety while reducing opportunities for fraud, misuse and abuse.
     
    For more detailed information on the definition and classification of grey zone medications and common grey zone drugs please visit Progressive Medical’s Grey Zone Resource Center.
     
     
    Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.
     
     
    About Progressive Medical
    Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.  http://www.workcomptransformation.com/narcotics-quandary/
     
    Our WORKERS COMPENSATION BOOK
    Manage Your Workers Compensation Program:
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    www.WCManual.com
     
     
    Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
     
    ©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

    Florida’s Physician Dispensing Found to Drive Workers Comp Costs Higher

    img1The Workers Compensation Research Institute (WCRI) reports this week in Prescription Benchmarks for Florida – 2nd Edition that physician dispensing is driving up prescription costs in Florida.

     

     

    The study looked at the costs, prices, and distribution of drugs in the state and took a closer look at doctors dispensing medicine there. Findings showed the average payment per claim for prescription drugs in Florida’s workers compensation system was $536. This is 45 percent higher than the median of the states in the study making it number two out of 17 states. The last two years of the study showed an increase of 14 percent in average cost per claim though they were stable in other states in the study.

     

     

    Legislation regarding physician dispensing was vetoed in 2010. Advocates of physician dispensing say it saves money because doctors are more likely to prescribe generics. Advocates also say that patient compliance, and, therefore, positive outcomes are more likely when doctors are doing the drug dispensing.

     

     

    But the study showed this was not the case – generics were prescribed equally from both doctors and pharmacies. Further, even when using generics, the cost per pill was higher at the doctor’s office.

     

     

    Higher and growing costs of prescription drugs in Florida were largely due to more frequent and higher-priced physician dispensing, the study indicates. “Physician-dispensing in Florida’s workers’ compensation system has been taking an increasingly larger share of prescription payments. The percentage of prescription payments for physician-dispensed prescriptions in Florida increased from 17 to 46 percent over a four year period,” according to the WCRI report.

     

    WCRI’s 17-state study also provides some evidence that helps address concerns about legislation (H.B. 5603), passed in 2010, but later vetoed, that would limit reimbursement rates for physician-dispensed prescriptions to the same level as pharmacies for the same medications.

     

     

    Other findings include:

    1. Physician-dispensers received 46 percent of prescription payments in the state.
    2. Average price paid to Florida pharmacies increased by 3 percent over the course of the study.
    3. California passed legislation regulating doctor dispensing and saw a large drop in cost per pill of physician-prescribed muscle relaxants. And physicians prescribed more non-repackaged drugs.

     

     

    The 17 states included in this study are California, Florida, Illinois, Indiana, Iowa, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New York, North Carolina, Pennsylvania, Tennessee, Texas, and Wisconsin.(WCxKit)

     

     

    WCRI is based in Cambridge, MA and is a nonpartisan, not-for-profit membership organization supported in its public policy research by employers, insurers, insurance regulators and state regulatory agencies, as well as several state labor organizations.


    Author Rebecca Shafer
    , JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information.
    Contact: RShafer@ReduceYourWorkersComp.com.

     

    Our WC Book:  http://www.wcmanual.com

    WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

    MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

    WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

    SUBSCRIBE: Workers Comp Resource Center Newsletter

     

    Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

     

    ©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

     

    WCRI Identifies Policies to Hold Down Pharmacy Costs

    pic1Why are prescription costs up to 40 percent lower in Washington state than average?

     

     

    According to the Workers Compensation Research Institute (WCRI), the northwestern state implemented policies that kept these costs down.

     

     

    Prescription Benchmarks for Washington,” points to these four tools:

    1. A formulary of approved drugs and therapeutic interchange.
    2. Lower-than-typical pharmacy fee schedule.
    3. Mandatory generic substitution.
    4. Infrequent physician dispensing.

     

     

    In the study, WCRI looked at 17 other states and found “a wealth of detailed price and utilization statistics that may be useful when debating such issues as: pharmacy fee schedules, physician prescribing patterns, medical cost drivers, and laws that mandate the use of generics.” Other states included in the study were: California, Florida, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Maryland, Michigan, Minnesota, New Jersey, New York, North Carolina, Pennsylvania, Tennessee, Texas, and Wisconsin.

     

     

     

    “There may be some important lessons for policy makers in other states from the regulatory approaches used by Washington State,” said Dr. Richard A. Victor, WCRI’s executive director.

     

     

    Other findings include:

    1. The average prescription cost per claim in Washington was 40 percent lower than the median of the 17 states in the second edition of the WCRI prescription benchmarks—after adjusting for the longer claim duration. Without this duration adjustment, the average prescription cost per claim was 11 percent lower than the 17-state median.
    2. The average price per pill paid to Washington pharmacies was 35 percent lower than the median state as a result of state policies and programs, such as: a formulary of approved drugs and therapeutic interchange, lower than typical pharmacy fee schedule, and mandatory generic substitution. (WCxKit)
    3. Physicians in Washington more often prescribed stronger, Schedule II narcotics, compared to physicians in the other study states.

     

     

    More information on this study, available for purchase, can be found here.


    Author Rebecca Shafer
    , JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

     


    Our WC Book: 
    http://corner.advisen.com/partners_wctoolkit_book.html

    WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

    MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

    WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

    SUBSCRIBE: Workers Comp Resource Center Newsletter

     

    Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

     

    ©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

     

    Using Pharmacy Benefits Management to Control Narcotic Use in Workers Compensation

    Since narcotics play an active role in the treatment of chronic non-malignant pain (including workers compensation injuries), it is essential for payors to take proactive measures in monitoring for opportunities or instances of misuse. An effective means to do this is to partner with a pharmacy benefits manager (PBM) experienced in the workers compensation industry. The remainder of this paper explores that role of the PBM. It also will provide insight on what to look for to ensure your organization reduces fiscal, legal and personal risk resulting from narcotics abuse.

     

     

    The Role of a Pharmacy Benefits Manager (PBM)

    Forming a partnership with a PBM can provide workers compensation payors a valuable resource in controlling narcotics use and thereby reducing risk for all stakeholders. There are eight key best practices PBMs can deploy to assist payors. We discuss the first four here.

     

    Key Best Practices One through Four

    (Key Best Practices 5 to 8 Discussed in Future Blog)

     

    #1: Defining a Strategy

    Getting control of narcotics usage requires a well-defined strategy. The first step in this process is for the PBM to review prescription history. Once the history is reviewed, it should be used to develop a customized narcotics strategy for each medication plan. These plans identify which medications are appropriate for the injury type and body part. They also account for proper duration of use and quantity limits. By defining a narcotics strategy, the workers compensation payor will have put into place the proper mechanisms to begin controlling narcotic use. (WCxKit)

     

     

    #2: Capturing Prescriptions at First Fill

    When new claims are filed, it is important to capture when and what type of medication is filled at the onset of injury. PBMs should have in place a mechanism to capture this prescription information. Often these early prescriptions begin telling the story of the medication history and medication therapy to come. One method to capturing this data is through First Fill cards. These cards are typically distributed by the employer to the injured worker at the point of accident or injury. To ensure both employers and injured workers use the program, PBMs should offer training programs on their use.

     

     

    #3: Offering Home Delivery Programs and Retail Drug Cards

    Both retail and home delivery programs provide the workers compensation payor an effective means to monitor and control an injured worker’s medication utilization. They also provide payors an opportunity to fully leverage pharmacy network participation and discounts, thereby reducing medication expenses.

     

     

    Retail drug cards: When an injured worker requires additional medications, a retail drug card program will give the payor control over what, when and where the prescriptions can be filled. The injured worker should be able to use the retail drug card at the PBM’s retail network pharmacies. Not unlike a first fill prescription card, the retail drug card should contain injured worker-specific drug utilization review information to ensure only appropriate medications are filled.

     

     

    Home delivery programs: A home delivery program offers the injured worker the convenience of ordering prescriptions either online or on the phone while providing the workers compensation payor the ability to engage in proactive utilization review programs. In addition, they also give the payor a mechanism to educate injured workers on the risks associated with narcotics through direct interaction with the pharmacist dispensing the injured worker’s prescriptions. Physician contact is often easier as well since the prescriptions are being managed directly through the mail order facility.

     

     

    #4: Reduce Out-of-Network Bills

    A high number of out-of-network bills can lead to issues with managing utilization of narcotics. Not only are individual out-of-network bills typically higher than those in-network, they are often not included in the utilization process. It is vital for payors to have a process in place for properly driving those bills back into the network. This can be done by working with a PBM offering both paper and electronic out-of-network bill solutions. This will ensure critical injured worker data on number of prescriptions, duration of therapy, doctor information and other related factors are captured to better monitor utilization.

     

     

    However, the best method for controlling out-of-network bills is to make it easier for the injured worker to go in-network as early in the life of the claim as possible. One method for doing this is through First Fill cards, which are distributed by the employer at the onset of the injury. Two other strategies for reducing out-of-network bills are home delivery and retail drug card programs. (WCxKit)

     

    Summary

    It is expected narcotics will continue to play a role in treating pain in workers compensation. While greater oversight of narcotics use is already underway by the FDA through its REMS requirement, workers compensation payors must take proactive measures to reduce misuse and abuse. By doing so, payors decrease risk for litigation, improve injured worker safety and obtain more control over medication expenses.

     

    Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.

    About Progressive Medical
    Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.  http://www.workcomptransformation.com/narcotics-quandary/

    Manage Your Workers Compensation Program:

    Reduce Your Costs 20-50%

    http://corner.advisen.com/partners_wctoolkit_book.html


    WORK COMP CALCULATOR: 
    http://www.LowerWC.com/calculator.php

    MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

    WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

    SUBSCRIBE: Workers Comp Resource Center Newsletter

     

    Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

     

    ©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

     

    Using Utilization Review Programs to Control Narcotic Use in Workers Compensation

    Utilization Review: Role of a Pharmacy Benefits Manager (PBM)

    As discussed previously, forming a partnership with a PBM can provide workers compensation payors a valuable resource in controlling narcotics use and thereby reducing risk for all stakeholders. There are eight key best practices PBMs can deploy to assist payors. We discuss key best practices five through eight here. See previous discussion for best practices one through four.

     

     

    Key Bests Practices Five through Eight

    #5: Managing Prospective and Concurrent Narcotics Utilization Review Programs

    The PBM should have a clinical management process to govern narcotics utilization managed by clinical pharmacists. The clinical drug utilization review (DUR) program should use a combination of evidence-based guidelines, peer review journals and recommendations provided by government organizations. Both prospective and concurrent review processes are essential to a successful program. (WCxKit)

     

     

    Prospective utilization reviews: A prospective program allows all involved parties to plan for future outcomes with up-front information. Historical data and practices guide future decisions at the establishment of the PBM relationship. This prospective process allows for the achievement of cost control and utilization control.

     

     

    Concurrent utilization reviews: The PBM triggers concurrent alerts to inform the dispensing pharmacist about possible reasons a prescription should be questioned further prior to filling. These point-of-sale alerts may establish behaviors that could indicate abuse involving the use of multiple pharmacies and physicians for different narcotics or excessive early refill attempts. The messaging from the PBM ensures that prescriptions for narcotics will not be fulfilled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the payor.

     

     

    #6: Conducting Retrospective Drug Utilization Reviews and Clinical Intervention Programs

    Retrospective reviews: After a prescription is fulfilled, a PBM’s clinical pharmacist team should audit these prescriptions for indicators of inappropriate use. Indicators often include:

    •  Sole use of narcotics as treatment.
    •  Multiple physicians.
    •  Use of multiple short or long acting narcotics.
    •  Excessive duration and use.

     

    These types of utilization review programs are essential to maximize the effectiveness of a narcotics usage strategy and are most effective when leveraged in conjunction with prospective and concurrent drug utilization reviews. PBM programs should be flexible enough to allow for customization of review requirements for clients, as client goals and objectives often vary even within organizations.

     

     

    Physician monitoring: A PBM should continually monitor the use of multiple physicians by one injured worker.

     

    The physician monitoring program should be based on established best practices and contain multiple components including:

    • Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines.
    • Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA-approved generic equivalent exists.
    • Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns.

     

    Clinical intervention programs: The PBM should have a range of clinical intervention programs to assist a client with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions to more detailed evaluations including peer reviews and direct consultation with prescribing physicians. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation through the use of the information gathered in prospective, concurrent and retrospective review processes.

     

     

    One example of these recommendations is physician letters of medical necessity. The use of the letter of medical necessity helps to substantiate the treatment of an illness or injury with particular narcotic or adjunctive medication.

     

     

    If further analysis is required, the PBM should have other program options available. Program options could include a detailed review that contains a summary of the injured worker’s medication history through more in-depth medication evaluation referencing the entire clinical record.

     

     

    #7: Providing Ongoing Consultation

    A quality narcotics utilization program is an essential component of controlling narcotics use. To ensure the utilization program is effective, the pharmacists managing the programs should take proactive measures to continually expand utilization review programs as the workers compensation industry evolves. As changes occur, they should also be available to consult with clients on how to adapt their DUR programs accordingly.

     

     

    When first released, several powerful narcotics such as Actiq® and Fentora® were developed and prescribed to treat terminal cancer pain. Recently these two narcotics, along with others, have been widely prescribed for lower back pain. An effective PBM should continually expand its DUR auditing capabilities to meet this type of changing prescribing pattern. In addition, the PBM should have the capability to audit prescribers for questionable prescribing patterns.

    #8: Validating Narcotics Use through Reporting

    If a DUR program is successful, there will be a reduction in unnecessary medication usage, including narcotic use. A PBM should easily be able to validate those reductions through a wide range of real-time and ad-hoc reports.

     

     

    User-run reports: The PBM should offer a tool that gives a client an option to run a wide range of reports to gain an in-depth understanding of all activity. To maximize the effectiveness and ease of use of the reports, the PBM should ensure the reports are categorized into varying levels depending on how the reports will be used. For example, while all user levels will be able to access savings data, the claims professional should be able to access detailed claims information to help maximize savings opportunities such as individual reports that identify home delivery conversion opportunities, details on narcotics use and details on each injured worker.

     

     

    Management level users should be able to run reports to assist with managing the claims professional, such as a report providing exception or override information as well as a report providing details on actions sent to the PBM.

     

     

    Other available reports should include: savings reports that can be sorted by a range of time periods, jurisdictions, groups and/or branches, pharmacy network utilization and savings reports, generic efficiency and opportunity, as well as a wide range of trending reports including top prescribing physicians, top therapeutic classifications, top pharmacy medications, top ICD-9, top injury type and reports detailing prescribing physician habits.

     

    Drug utilization review report:  To provide information on savings achieved as a result of the program, the PBM should have a detailed DUR report.  This report should provide information on savings achieved as a result of the program and should document savings in distinct areas rather than broad categories in order to provide the complete picture of DUR activity.(WCxKit)

    Ad-hoc reporting: In addition to user-run reports and reports detailing DUR activity and savings, the PBM should have the ability to supply ad-hoc reports to assist with narcotic utilization management. If the PBM captures the data, then the PBM should be able to provide reports based on those data elements.

     

     

    Summary

    By partnering with a PBM, workers compensation payors can put an effective narcotics utilization strategy into place. A relationship with a strong PBM partner experienced in workers compensation will enable the payor to not only monitor utilization but stop point-of-sale fulfillment of unnecessary narcotics.

     

     

    Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.

    Get more information here: http://www.workcomptransformation.com/narcotics-quandary/

    About Progressive Medical
    Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.

    Manage Your Workers Compensation Program:

    Reduce Your Costs 20-50%

    http://corner.advisen.com/partners_wctoolkit_book.html


    WORK COMP CALCULATOR: 
    http://www.LowerWC.com/calculator.php

    MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

    WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

    SUBSCRIBE: Workers Comp Resource Center Newsletter

     

    Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

     

    ©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

     

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