By: Art Lynch, Chief Executive Officer, Coventry Workers’ Comp Services
What business wants to make decisions based on incomplete information? Yet sometimes, we’re forced to do just that. Recently in this space, I wrote about the difficulty of finding answers when it comes to understanding the impact that medical marijuana laws could have on workers’ compensation. Fortunately, when it comes to other pharmaceuticals—and what we spend on them—the answers are available. In fact, employers and payors may be able to achieve greater clarity and control around pharmacy than they realize.
Opening your eyes to the bigger picture
Historically, prescriptions have been split between those submitted through Pharmacy Benefit Management (PBM) and paper bills submitted through bill review. PBM programs have focused on retail network prescriptions – those from contracted network pharmacies. They apply contracted rates to those prescriptions captured within the network—and derive network penetration percentages strictly from PBM transactions. That’s a good start, but employers and payors need to understand that it’s not the entire picture. To get a better handle on prescriptions (and an accurate understanding of total pharmacy spend), it’s necessary to go beyond a retail only view and capture prescriptions filled at non-network pharmacies, through specialty/compounding pharmacies or in the doctor’s office and those that pass through third-party billers. That requires extended network relationships with clinics, physician and other third party billers, mail order pharmacies and compounding networks. Leveraging extended networks through the PBM will drive pharmacy expenses below fee schedule and removes these prescription bills from the bill review process – eliminating bill review fees.
Integrated information increases opportunities
Having an eye on all prescriptions regardless of billing source—PBM, extended networks (both managed by the PBM) and prescription transactions captured in bill review—provides advantages beyond understanding total pharmacy spend. This comprehensive approach offers greater opportunities to impact spending through utilization management (UM) and to improve clinical outcomes.
Of course, the earlier the interaction, the greater the ability to impact the claim, particularly when narcotics are involved. At the point of sale (POS), that can mean alerts, drug utilization review (DUR) edits and application of drug formularies, including formularies specific to the claimant and the injury. But, again, this is just the beginning. This level of impact is only possible with a consolidated drug utilization history. Integrating the prescription data from non-traditional PBM sources, like extended networks and bill review, increases the effectiveness of POS edits before the next fill is dispensed. Further, this integration also supports the most impactful drug utilization assessments and prescriber outreach on otherwise “run-away” cases.
Making a difference where it matters
Cost control is critical, but ideally the goal is a better outcome. Getting a handle on the whole prescription picture provides the information necessary to engage all claim stakeholders and support the timely outreach and interaction necessary to achieve that goal. This is especially true when opioids are involved. Early intervention—whether provider outreach, patient education or interaction with a nurse case manager—can play an important role in helping the injured worker move toward a positive outcome.
Accessing the whole range of prescription information, regardless of where the drugs are dispensed, makes it possible to develop a complete prescription profile that gives the adjuster and case manager more valuable insight than a series of individual PBM alerts can provide. By putting all drug-related information in one place, prescription profiles paint a more accurate picture of risk. Armed with answers to questions about the patient’s history, drug use, comorbidities and more, the adjuster and nurse are better able to select the most effective tools and identify next steps in the plan of action.
Clearly, capturing data from the first script, including every script, not just those filled within the retail network, provides valuable answers to a great many questions. It not only helps control costs and gives a more accurate picture of pharmacy spend, but it also weaves a safety net that helps ensure that no injured worker is left behind.
About Art Lynch
Art Lynch joined Coventry Workers’ Comp Services in 2006 when Coventry Health Care acquired First Health, as Senior Vice President of Account Management and Strategy, overseeing account management and working with his team to develop and maintain strong lasting client relationships. He was named Chief Executive Officer in November of 2013 and is now accountable for the company’s overall revenue, operations, networks, pharmacy and care management products.
Prior to holding various leadership positions at First Health during his 16 year tenure, he led sales and operations for Ebtek, Inc., a firm based in Oak Brook, Illinois, specializing in providing human resources and insurance expertise to small businesses. Lynch received his undergraduate degree in Political Science and Psychology from Columbia University.
About Coventry Workers’ Comp Services
Coventry Workers’ Comp Services, a division of Aetna, 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.