By Robert Goldberg, MD, FACOEM
Chief Medical Officer and Senior Vice President, Healthesystems
In worker’s compensation, insurance executives and claim professionals are often inundated with data on all aspects of their claims operation, typically presented in the form of various reports and spreadsheets. The data is probably relevant, but I sometimes wonder if all that information is helping focus on what is most critical, or if it is just cluttering email inboxes. It often takes considerable analysis of multiple reports and data points to discern what information is truly important. Especially since a lot of the critical information only presents itself when combining overlapping or intersecting data characteristics — the type of analysis that basic reports don’t intuitively provide.
A Multi-Dimensional View In the pharmacy benefits world, many PBMs do a good job of flagging known risks such as high morphine equivalent doses (MED), multiple prescribers and claims involving only opioid therapy. Usually a multitude of reports are made available to alert claims professionals to these risks. Frequently the reports can be overwhelming, especially when they need to read and fully understand the best way to act on the information. Information without guidance on appropriate next steps has limited benefit. There are significant limitations to solely analyzing individual risk characteristics without considering the broader context in which they arise, especially if they don’t identify emerging risks that would enable claims handlers to intervene sooner.
As an occupational medicine specialist who spent many years in clinical practice, I have seen many cases where basic risk characteristics go undetected and stakeholders aren’t alerted about potential opioid abuse, misuse or diversion. I also know the behaviors that signify patients are seeking potentially deadly drug combinations for illicit purposes. These risks often involve the intersection of various isolated circumstances that escape notice by many PBMs because they are not looking for them.
PBMs can help claims professionals make a significant difference to a claim’s outcome, but only if they are capable of analyzing drug therapy data from a multi-dimensional perspective. By applying a clinical understanding of risky patient behaviors and monitoring claims for concurrent events and factors, PBMs should identify and communicate risks as they emerge.
Intersecting Circumstances Signal Risks Early For example, a drug-seeking patient can visit several prescribers over the course of a few months and obtain prescriptions for multiple opioids, a muscle relaxant and an anti-anxiety medication. Individually each prescription may be appropriate, but the combination of these three drug classes should never be prescribed together. The sometimes deadly combination is popular on the street, and has been dubbed the holy trinity for the euphoria it produces. Often a patient obtains the drugs separately from prescribers who are not aware that others are prescribing for the same patient. Another high risk and complementary indicator is when patients methodically refill their prescriptions a little early. Over six or seven months, they can accumulate an extra month’s supply.
These high-risk examples occur in workers’ compensation and unless the PBM and payer are vigilant, the individual circumstances often go unnoticed until after the situation escalates. However, the best solutions are more complex and require an integration of clinical understanding with advanced analytics in order to identify these types of intersecting risk characteristics.
Reports or Useful Information? It is a real concern for payers to have to sift through a multitude of PBM reports that can potentially miss the more complex risks, especially if all recipients are required to have both the time and expertise to decipher their significance.
A better approach is to aggregate data on the most critical emerging drug therapy risks and provide the information in an easy-to-understand format with guidance on applicable next steps. For example, at Healthesystems the clinical and technology teams work collaboratively to employ advanced analytics and present data on emerging risks in formats that are intuitive and useful for all levels of claims professionals. This approach empowers claims executives and claims handlers with critical information to affect better outcomes for injured workers. It also fosters collaboration to develop new strategies for better managing risks and reducing overall prescription drug expenditures.
About Dr. Robert Goldberg
Robert Goldberg, MD, FACOEM, is board certified specialist in occupational medicine, and the Chief Medical Officer at Healthesystems. As a past president of the American College of Occupational and Environmental Medicine, Dr. Goldberg is recognized nationally as an authority on occupational medicine and musculoskeletal injuries. He has an extensive multidisciplinary background that incorporates 25 years of experience in a variety of roles. Dr. Goldberg has treated injured workers in private practice and academic settings and directed the University of California at San Francisco residency training program. He has also served as a researcher, consultant and corporate executive providing clinical direction to the development of evidence-based medical guidelines and workers’ compensation public policy initiatives.
About Healthesystems
Healthesystems is a specialty provider of innovative medical cost management solutions for the workers’ compensation industry. The company’s comprehensive product portfolio includes a leading pharmacy benefit management (PBM) program, expert clinical review services, and a revolutionary ancillary benefits management (ABM) solution for prospectively managing ancillary medical services such as durable medical equipment (DME), home health, transportation and translation services. By leveraging innovation, powerful technology, clinical expertise and enhanced workflow automation tools, Healthesystems provides clients with flexible programs that reduce the total cost of medical care while increasing the quality of care for injured workers. To learn more about Healthesystems or to sign up for newsletters, visit www.healthesystems.com or email info@healthesystems.com.
Disclosure:
Healthesystems is a WorkCompWire ad partner.
This is not a paid placement.