By Alan Madison, Vice President, Operations, Coventry Workers’ Comp Services
Workers’ Comp Pharmacy Benefit Management (PBM) programs typically capture the majority of prescriptions billed by pharmacies within their network and report network penetration figures in excess of 90%. Unfortunately, this metric simply represents the percent of prescriptions dispensed within retail network pharmacies that are prospectively processed by the PBM. However, true pharmacy penetration and program management must be based upon all prescriptions, not just those processed through the PBM retail network.
Where Are the Missing Pieces?
There are times an injured worker will fill a prescription at a non-network pharmacy, or potentially the network pharmacy will not properly identify that the injured worker falls under a PBM program. When this happens, the script may be submitted directly to the payor or more likely end up in the hands of a third-party biller who assumes the risk and pursues payment. Couple these prescriptions with those dispensed at clinics or in physician offices and more than one quarter of the claim related prescriptions are processed outside your PBM retail network. What does this mean to you? Roughly one in four prescriptions are buried in the medical bill data processed through your bill review program and therefore not taken into account when your PBM analyzes your prescription drug spend or pharmacy utilization. Most importantly, these prescriptions bypass the rigorous edits and clinical programs that are applied to in-network pharmacy bills, and if you are missing one out of four prescriptions your clinical effectiveness is significantly diminished due to the bifurcated prescription billing process.
If You Find Them – The Picture Becomes Much Clearer
Some PBMs have developed a mechanism to capture these prescriptions; however, capturing them is not enough, a PBM must also know how to manage them post dispense or risk significant financial and clinical consequences. Even if a prescription is already in the hands of an injured worker, it is critical that your PBM not only identify these medications post dispense but also apply the clinical oversight to ensure patient safety going forward and drive the best outcomes for the individual, the claim and the program overall.
Consider for a moment this real-life example. A patient is prescribed and is taking a medication dispensed in the office by their orthopedist–codeine — for a work related injury. That same patient then sees their primary care doctor for follow-up a few weeks later. Their primary care physician prescribes hydrocodone. In many cases the dispensing pharmacy will have no record of the potential adverse events the patient may experience when some of the medications are dispensed in the office. However a PBM can clearly support patient safety by aggregating all dispensing data (physician and pharmacy) and managing medication decisioning through a battery of clinical intelligence and alerts – including identifying the patient’s total morphine equivalent dosage (MED). In this situation, the prescription for hydrocodone would have been stopped at the point of sale because of the risk to the patient.
Through strategic data aggregation and appropriate interventions, the PBM can manage against potentially adverse events like excessive morphine equivalent dosage (MED) and promote patient safety and appropriate care. It is impossible to measure accurate morphine equivalent dosage (MED) if the PBM is unaware of opioids prescribed outside the four walls of the retail setting and/or within a limited contracted specialty network.
The Solution is Clear – No Script Unmanaged
Aggregating all prescriptions into a single database ensures that a complete understanding of the prescribing behavior is considered for future dispensing and decisioning. An all-inclusive view of the injured worker’s pharmacy utilization is increasingly critical as we strengthen our focus and controls for opioid utilization. It is only through consolidated management and reporting that you will be able to understand how your total pharmacy risk is being managed.
In addition to safeguarding patient safety and promoting recovery, PBMs can use the same aggregation of data to re-price prescriptions to contracted rates where both jurisdictional rules and direct contracts permit to ensure the lowest defensible rate for medications is paid.
As we continue to combat our national opioid epidemic and escalating pharmacy spend, employers and payors must mandate the use of an integrated pharmacy platform which delivers consolidated processing for all prescriptions and allows for total clinical management ensuring that No script is unmanaged and no Injured Worker is Left Behind.
About Alan Madison
Alan Madison has 25+ years of senior level experience in pharmacy benefit management operations, hospital administration, healthcare IT and broad client service responsibilities at Coventry Workers’ Comp Services, Tucson Medical Center, Intuit, Misys Healthcare and H&R Block where he has held c-level positions. Alan is a master black belt in six-sigma and holds a BA in business administration and an MBA in healthcare administration.
About Coventry Workers’ Comp Services
Coventry Workers’ Comp Services, a division of Coventry Health Care, Inc. (NYSE: CVH), is the leading provider of cost and care management solutions for property and casualty insurance carriers, (workers’ compensation and auto insurers), third-party administrators and self-insured employers. We design best-in-class products and services to help our partners restore the health and productivity of injured workers and insureds as quickly and as cost effectively as possible. We accomplish this by developing and maintaining consultative, trusting partnerships with our clients and stakeholders, built on a foundation of innovative and customized solutions that support the claims management process.
Disclosure:
Coventry WCS is a WorkCompWire Advertising Partner.
This is not a paid placement.