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.
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: firstname.lastname@example.org 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.
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