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:
    Reduce Your Costs 20-50%
    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

    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.

     

    Reducing Narcotics Abuse in Workers Compensation

    On-the-job injuries often involve chronic pain and long-term liability for workers compensation payors. Many times, pain from a chronic injury is treated with narcotics. According to the 2010 Progressive Medical Drug Spend Analysis, narcotic spending accounts for 34 percent of workers compensation medication expenses.1 While narcotics can be beneficial in the treatment plan for a patient in pain, there are serious risks involved when they are not used properly.
    The Centers for Disease Control (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) both indicate increasing misuse and abuse of narcotics over the past decade. SAMHSA data shows there was a significant increase from 2000 to 2006 in the treatment of substance abuse cases related to abuse of opioid analgesics.2 In addition, another study co-released by CDC and SAMHSA found emergency room visits linked to nonmedical use of narcotics rose 111 percent between 2004 and 2008.3
    As the cost of prescriptions, including narcotic medications, directly impacts the cost of a workers compensation claim, insurers are looking for ways to quickly get control of cases of misuse and abuse. One of the most efficient ways to manage narcotic use in a claimant population is to partner with a pharmacy benefit manager (PBM). A PBM can clearly define a strategy for proactively and effectively monitoring narcotics. These plans and strategies help payors ensure injured worker safety and reduce expenses. (WCxKit)
     
    The Workers Compensation Narcotics Quandary
    Narcotics, also referenced as opioids or opiates, have a long history of being used to therapeutically treat pain resulting from on-the-job injuries. They are often prescribed to alleviate pain after an injury first occurs, when other drugs are ineffective for acute pain and in chronic pain cases.
    And, while narcotics are considered safe and effective if used properly, they have the potential for leading to addiction and abuse if not monitored and controlled. Misuse and abuse of narcotics represent three areas of particular concern for workers compensation insurers including:
    1.      Potential for serious health risks.
    2.      Higher percentage of medical expenses as claims age.
    3.      Risk of litigation.
    Potential for Serious Health Risks
    The United States Food and Drug Administration (FDA) has recognized serious risks associated with narcotics use including respiratory depression, central nervous system depression, addiction, and death. Some of these risks are associated with improper dosing, indication, patient selection, abuse, and addiction. As a result of these adverse events, the FDA has begun to take serious steps to monitor whether the benefits of narcotic medications outweigh the risks associated with short- and long-term usage.4
    These steps include an FDA-led panel developing Risk Evaluation and Mitigation Strategy (REMS) for long-acting narcotics. The purpose of REMS is to ensure that prescribers are educated regarding the proper use of narcotics and that benefits outweigh risks associated with:
    1.      Abuse.
    2.      Misuse.
    3.      Overdose, both accidental and intentional.
    Narcotics, including methadone tablets, fentanyl patches and extended-release medications containing morphine, oxymorphone, and oxycodone are among the medications effected by the REMS requirement. Narcotics on the FDA’s list are provided in a table at the end of this article.5
    Recently, the FDA proposed plans to further address the increasing misuse and abuse of narcotics specifically related to extended-release (ER) and immediate-release (IR) opioid analgesics. While a panel committee agreed the goals of the REMS are appropriate, the individual components of the REMS are insufficient to address the misuse and abuse of ER opioid analgesics. It was agreed that these particular REMS plans be tabled until there is a stronger proposal in place.6
    Higher Percentage of Medical Expenses as Claims Age
    While narcotics account for more than a quarter of workers compensation medication spending, even more troubling is the allocation of that spending. In a recent study released by the National Council on Compensation Insurance, narcotics’ total share of medication expenses increases as claims age – from 15 percent in year one to as much as 35 percent in the fifth year of service.7
    The role narcotics play in total workers compensation claims expenses has not gone unnoticed by state workers compensation funds. For example, the Arizona State Compensation Fund noted they were easily able to pinpoint over-prescribing of narcotics as a key source of inflated medical costs.8
    What’s more, the longer an injured worker is on narcotics, the longer the delay in the injured worker’s ability to return to work in a timely fashion. There is also an increased likelihood the payor will need to pay for rehabilitation programs for addiction.
     
     
    Risk of Litigation
    Narcotic abuse poses serious legal risks for workers compensation payors. While much of the litigation to date has been targeted against physicians and pharmacies, there are many experts who believe workers compensation payors will be next. This is because payors have access to data showing patterns of abuse and misuse and may have the duty to warn injured workers and prescribers in cases involving potential misuse.9
    Workers compensation payors who choose not to take proactive measures to monitor utilization or communicate with physicians could face lawsuits for negligence. This is especially critical in cases where one or more narcotics are prescribed for more than six months at a time. (WCxKit)
    With respect to paying questionable claims, many payors have done so rather than face the expense and time of litigation. Morally, this poses a key question for insurers. Is it acceptable for insurers to settle fraudulent claims or does it position them as aiding and abetting the perpetrator? This could change if payors become defendants in lawsuits related to narcotic abuse.
    References
    1. “2010 Workers Compensation Drug Spend Analysis.” Progressive Medical, April 2010.
    2. “Risk Evaluation and Mitigation Strategies for Certain Opioid Drugs; Notice of Public Meeting,” Federal Register, Volume 74, Number 74; Notices, Pages 17967-17970, Department of Health & Human Services, Food and Drug Administration, Docket No: FDA-2—0-N-0143.
    3. “Trends in Emergency Department Visits Involving Nonmedical Use of Narcotic Pain Relievers,” Substance Abuse and Mental Health Services Administration and Centers for Disease Control, http://www.cdc.gov/mmwr(/mmwr/).
    4. Gardiner Harris, “FDA to Place New Limits on Prescriptions of Narcotics,” New York Times, February 9, 2009.
    5. “Opioids Products Chart,” U.S. Food and Drug Administration, http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163654.htm.
    6. “Opioid Drugs and Risk Evaluation and Mitigation Strategies (REMS),” U.S. Food and Drug Administration, http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163647.htm.
    7. Barry Lipton, Chris Laws and Linda Li, “Narcotics in Workers Compensation,” NCCI Research Brief, December 2009 p.5.
    8. “Sky High Out of Control Drug Costs A Threat,” State Compensation Fund of Arizona.
    9. “Prescription for Peril,” December 2007, Coalition Against Insurance Fraud, p. 43.

    Brand Name Opioid Products
    Generic Name
    Trade Name
    Applicant/Sponsors
    Fentanyl
    Duragesic Extended Release Transdermal System
    Ortho McNeil Janssen
    Hydromorphone
    *Palladone Extended Release Capsules
    Purdue Pharma
     
    Methadone
    Dolophine Tablets
    Roxanne
    Morphine
    Avinza® Extended Release Capsules
    King Pharms
     
    Morphine
    Kadian® Extended Release Capsules
    Actavis
     
    Morphine
    MS Contin Extended Release Tablets
    Purdue Pharma
     
    Morphine
    Oramorph Extended Release Tablets
    Xanodyne Pharms
     
    Oxycodone
    OxyContin Extended Release Tablets
    Purdue Pharma
     
    Oxymorphone
    Opana® Extended Release Tablets
    Endo Pharma
     
    *No longer being marketed, but is still approved.
     
    Generic Opioid Products
    Generic Name
    Drug Name
    Applicant/Sponsors
    Fentanyl
    Fentanyl Extended Release Transdermal System
    Actavis
     
    Fentanyl
    Fentanyl Extended Release Transdermal System
    Lavipharm Labs
     
    Fentanyl
    Fentanyl Extended Release Transdermal System
    Mylan Technologies
     
    Fentanyl
    Fentanyl Extended Release Transdermal System
    Teva Pharms
     
    Fentanyl
    Fentanyl Extended Release Transdermal System
    Watson
     
    Methadone
    Methadose[O1]  Tablets
    Mallinckrodt
    Methadone
    Methadone HCL Tablets
    Mallinckrodt
    Methadone
    Methadone HCL Tablets
    Sandoz
    Morphine
    Morphine Sulfate Extended Release Tablets
    Endo
     
    Morphine
    Morphine Sulfate Extended Release Tablets
    KV Pharmaceuticals
     
    Morphine
    Morphine Sulfate Extended Release Tablets
    Mallinckrodt
     
    Morphine
    Morphine Sulfate Extended Release Tablets
    Watson Labs
     
    Oxycodone
    Oxycodone Extended Release Tablets
    Mallinckrodt
     
    Oxycodone
    **Oxycodone Extended Release Tablets
    Impax Labs
     
    Oxycodone
    **Oxycodone Extended Release Tablets
    Teva
     
    ** Discontinued products.

    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/

    Book: Manage Your Workers Compensation Program: Reduce Your Costs 20-50%

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

    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.

     

    Professional Development Resource

    Learn How to Reduce Workers Comp Costs 20% to 50%"Workers Compensation Management Program: Reduce Costs 20% to 50%"
    Lower your workers compensation expense by using the
    guidebook from Advisen and the Workers Comp Resource Center.
    Perfect for promotional distribution by brokers and agents!
    Learn More

    Please don't print this Website

    Unnecessary printing not only means unnecessary cost of paper and inks, but also avoidable environmental impact on producing and shipping these supplies. Reducing printing can make a small but a significant impact.

    Instead use the PDF download option, provided on the page you tried to print.

    Powered by "Unprintable Blog" for Wordpress - www.greencp.de