By Don Lipsy, Manager, Regulatory & Pharmacy Communications, First Script
Pharmacy Benefit Managers, employers, and payors have been collectively optimistic that regulatory relief from the practice of physician dispensing in workers’ compensation would be on the horizon when prescriber limiting reform measures were first adopted in Florida in 2013. Yet, despite similar measures in Hawaii, Pennsylvania, and a handful of other states’ efforts to control the unsafe and costly practice of physician dispensing, overall reform in the work comp system on this issue has been slow-moving.
Advocate and act
In early 2014 when a Johns Hopkins University study1 definitively showed some of the negative cost and utilization consequences that can be attributed to prescriber dispensing, it was assumed by proponents of abolishing or severely restricting prescriber dispensing that continued reform was inevitable. The study echoed similar findings by the California Workers’ Compensation Institute in 2013.2 Arguably, both studies helped bolster significant reform measures in Pennsylvania3 and Indiana4 in 2014 where hard caps were placed on the days’ supply when a drug is dispensed by a prescriber.
Unfortunately, in 2015, we have seen regression on the issue of reform for prescriber dispensed medications. In recent months, repackaging entities have been identified as intentionally selecting specific National Drug Codes (NDCs) aimed at artificially inflating costs.5 This activity prompted the Workers Compensation Research Institute to pose the question: “Are Physician Dispensing Reforms Sustainable?”6
Despite material concerns voiced on this topic, reform measures are not happening in great numbers. In fact, the Joint Committee on Workers’ Compensation Benefits & Insurance made a public statement in the pivotal prescriber dispensing battleground state of Maryland that the subcommittee would not seek physician dispensing reform measures for 2015…or 2016.7
Active engagement at a state regulatory level is critical to advocate for physician dispensing reform that seeks to bring about dispensing limits and cost controls. Most would agree that the safest and most cost effective route to pharmaceutical care occurs when medications are dispensed within retail or mail order pharmacy settings. Prescriptions dispensed in this manner are subject to formulary and point-of-sale edits thereby helping to ensure clinically appropriate utilization, as well as the use of generics and less costly therapeutically equivalent medications.
However, establishing contractual relationships with occupational health clinics, dispensing prescribers, and their billing entities is a positive interim tactic pending more meaningful reforms at the legislative level. Prescriptions processed through these “extended” networks can then be reviewed for clinical appropriateness and even reimbursed at contracted rates far lower than the inflated billed charges that have become commonplace. While these prescriptions are not reviewed at the point-of-sale, the pre-payment review is a distinct advantage over prescriptions that are processed within the standard bill review process and are not subject to clinical edits and contractual adjustments.
If you can’t beat them, engage them.
The concept of extended networks entails forging relationships with various stakeholders within the physician dispensing sector. In so doing, it enables a more flexible workers’ compensation platform that allows injured workers to receive medications within the most diverse network possible while minimizing the risk of inappropriate care. Developing strategies to ensure that medications received through all channels are dispensed with controls for patient safety, clinical efficacy, and cost containment is the primary goal, and reduces the risks associated with the unmanaged physician/clinic dispensing scenario that exists today.
Applying clinical protocols to all prescriptions regardless of where they are dispensed allows known prescriber dispensing issues related to utilization and cost to be confronted until regulatory reforms effectively address this practice. Incorporating more strategic interventions such as step-therapy, drug-to-drug interaction control, and monitoring for refills made too soon on these prescriptions will further increase the value of extended network relationships.
Goals must be met – reform or no reform.
Direct and proactive advocating at the state level for reform on the global appropriateness of prescriber dispensing is sure to deliver on our primary goals of patient safety, clinical efficacy, and cost containment. However, it is our collective responsibility to place the most effective interim controls into place now to ensure these goals are met within an environment where physician dispensing practices continue pre-reform.
About Don Lipsy
Don Lipsy is the manager of regulatory & pharmacy communications for Coventry’s pharmacy benefits management program, First Script. In his current role, Don assists Coventry clients in understanding the ever-changing landscape of regulations impacting workers’ compensation pharmacy and assists in designing and implementing real-world solutions that take advantage of that landscape. As a former medical malpractice attorney representing the University of California’s hospitals and physicians, Don has served Coventry in a number of regulatory and legislative capacities since 2007.
Coventry offers workers’ compensation cost and care management solutions for employers, insurance carriers, and third-party administrators. With roots in both clinical and network services, Coventry leverages more than 30 years of industry experience, knowledge, and data analytics. The company offers an integrated suite of solutions, powered by technology to enhance network development, clinical integration and operational efficiencies at the client desktop, with a focus on total claims cost.
2www.cwci.org/research.html (2/25/13, “Differences in Outcomes for Injured Workers Receiving Physician-Dispensed Repackaged Drugs in the California WC System”)
Coventry is a WorkCompWire Ad Partner.
This is not a paid placement.