By Silvia Sacalis, PharmD, Vice President of Clinical Services, Healthesystems
There never seems to be a shortage of facts and figures that identify the problems or challenges in the workers’ compensation industry, but all too often solutions are in limited supply. It reminds me of a quote — “Every solution to every problem is simple. It’s the distance between the two where the mystery lies.” This can be true for managing workers’ compensation claims — how quick does it take to find the right answer? Frequently the holistic view of a workers’ compensation patient is incomplete or hidden, but the distance to find the necessary data isn’t far off. Many of the pertinent facts and clues go undetected due to the disparate way healthcare information may be compiled and analyzed. As a result, therapy management decisions are often made in the dark.
A claim file frequently accumulates hundreds of pages of healthcare documents including physician notes and lab results along with treatment billing data and procedure codes. Other than the billing and procedure codes, a large portion of the most critical and useful information is unstructured and therefore frequently isn’t monitored by both payers and providers. In my previous article, I highlighted various characteristics of detecting high risk drug therapies and discussed how applying the power of advanced analytics to claims data can quickly identify opportunities for proactive interventions. However, detection and identification of these risks is only one element in the process. Effective clinical decision support ensures that all the available healthcare data is leveraged in the analytics and clinical review process. Solely focusing on the patient’s drug therapy history will not provide all the necessary information to develop the most successful clinical strategy. For example, in the case of a legacy claim with long term use of opioids, the drug history will highlight the current problem, but it may not illustrate all the contributing factors regarding how it arrived there and what may need to be done to resolve it.
Implementing a holistic care model expands the clinical focus to account for the complete patient profile. It not only brings more visibility into patient risk, including potential misuse or abuse, but also provides a greater understanding of the appropriateness of the recommended care and the patient’s adherence to it.
How does this look in practice? When performing a detailed patient case review, you must engage all the appropriate stakeholders to develop a coordinated and individualized patient care plan. This integrated approach to patient management must include streamlined access to the various data sources for each claim. The expanded view and analysis of healthcare information helps identify potential discrepancies that would otherwise have been missed — for example the assessment provided in a doctor’s note identifies a one-time dosage increase of an opioid, but the subsequent refills were never adjusted accordingly. These notes may also include meaningful information regarding comorbidities that are important when considering treatment options.
This approach has proven successful in:
- optimizing patients’ treatment regimens to ensure the underlying injury is being treated according to evidence-based guidelines
- identifying lack of adherence to prescribed treatment regimens as patients may elect to take medications that provide symptomatic pain relief but do not take those medications that are intended to treat the condition
- observing patterns of prescription misuse as evidenced by unauthorized dose escalations
- detecting potential prescription drug abuse through tools such as a doctor-ordered Urine Drug Screen which has either shown the presence of illicit drugs or the absence of prescribed drugs
Incorporating more comprehensive and actionable data provides valuable insight that enables effective clinical decision support. It delivers value to patients through improved overall outcomes, as well as to payers through lower overall healthcare costs.
This advanced clinical strategy is an evolution of the traditional physician outreach programs that have historically achieved moderate success but occasionally may lack the level of clinical detail necessary to address the ever growing complexities of drug therapy. In addition, this customized, patient-centric approach provides physicians with a more thorough understanding of how the therapy strategy fits into the patient’s overall treatment and addresses the specific injury.
To take a look at our original infographic highlighting high risk drug therapy characteristics, click on the image below. These dimensions of Rx Risk offer insightful statistics to support the importance of an integrated approach, and form the foundation for an advanced clinical strategy and holistic patient approach.
About Silvia Sacalis
Silvia Sacalis, PharmD, provides clinical leadership as Vice President of Clinical Services at Healthesystems. Her experience and clinical expertise span the PBM, retail pharmacy and managed care environments. Leveraging her technology background, clinical skills and management expertise, she helps develop and operationalize strategic clinical initiatives to help workers’ compensation insurance payers maximize the impact of a pharmacy benefit management program. Throughout her career, she has held various leadership roles in which she provided oversight of the development of clinical services programs, and integration of analytics technology with clinical consultative support. Dr. Sacalis received her Bachelor of Science in Computer Science and Doctorate of Pharmacy degrees from the University of Illinois at Chicago.
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.
Disclsoure:
Healthesystems is a WorkCompWire Ad Partner.
This is not a paid placement.