By Michael Halbach, VP Pharmacy Benefit Management, Coventry Workers’ Comp Services
In last week’s post, we discussed the transparency needed to manage the total pharmacy experience within workers’ compensation. Such transparency is required from both the program level and the claim level to understand your program’s performance as well as to determine what it will take to get better. The focus of this week’s piece is on using this information to achieve lower program risk and better outcomes for injured workers.
For quite some time, Pharmacy Benefit Managers (PBM) have had controls in place such as drug lists or formularies and basic alerts prompted by pharmacy utilization that runs through a retail network, missing out on the total pharmacy experience as well as the overall claim health. While this approach has evolved over time and PBMs have focused more specifically on risk identification and interventions, the limited view in this traditional approach creates gaps in understanding that opens the pharmacy program, and, more importantly, its injured workers, to unnecessary risks.
Now more than ever, with the addition of the total pharmacy experience, risk analytics are required for effective pharmacy management. In addition, a PBM must offer a well-developed and executed model for intervention that measurably influences prescribing patterns and promotes injured worker safety and recovery.
Finally, a PBM must present these complete risk alerts to adjusters with a clear rationale for recommended interventions throughout the life of each claim to promote strategic management.
When Less is More
Experience has taught us that appropriate early intervention can lower claim costs and improve injured worker outcomes. Risk identification that alerts at the exact moment an intervention is needed, not too late (or too soon!) can protect employers and their payors from spending on costly clinical services unnecessarily, as well as protect injured workers by ensuring intervention before adverse claim development occurs.
We’re all aware of the burden of heavy caseloads for adjusters and cases managers, so with all this new data how do we avoid alerts being ignored because there are not enough “hours in the day”? The solution can be found in sophisticated algorithms that uncover the claims needing attention while eliminating the need for adjusters and case managers to review a myriad of individual transactional triggers. Wide-ranging analytics can call attention to multiple and concurrent risk factors and give adjusters and case managers better insight when formulating a claim management strategy. Consolidated notifications and recommendations for intervention not only reduce noise on the desktop, but empower adjusters to take meaningful action.
Seeing Beyond the Medications
The driving principle behind successful data integration and risk analysis is to understand the injured worker holistically. To do so, it is important to see beyond the medications dispensed in the PBM network as well as to understand the injured worker’s health status related to and even beyond the workplace injury. A comprehensive data set, incorporating both managed and unmanaged prescriptions, allows for a more thorough screening for the possibility of harmful drug interactions, misuse, addiction, diversion, waste, and compromised efficacy. The most sophisticated risk identification programs now reach beyond the pharmacy related data into all medical treatments and co-morbid conditions as well as other relevant information provided by claims adjusters.
Recognizing and understanding all of this information can prove daunting, even for managing a single claim. A PBM’s effective presentation of fully integrated data for decision-support across claims empowers adjusters and case managers to focus on helping the injured worker on the path to recovery versus wasting time trying to piece the story together and missing critical and relevant risk factors in the process.
Taking Action
A clear and concise set of clinical recommendations paves the way for an adjuster to take action. For example, in response to a risk alert on certain claims, a comprehensive drug assessment may be recommended to determine if the plan for care is appropriate when prescribing behavior is outside evidenced based standards. A subsequent peer-to-peer discussion with the prescriber is crucial to develop and document a plan for implementing the necessary changes.
Alternative algorithms may identify a patient whose individual risk factors (including pharmacy, medical, and psychiatric) flag them as a candidate for urine drug testing (UDT). Typically, these patients are being prescribed narcotics and other medications that create risk for dependence and misuse. Adjusters need decision-support to understand UDT results and to incorporate the findings within their claim strategies to promote patient safety and recovery. At times, pharmacist or peer outreach to the prescriber is required, to discuss and document agreed upon changes to the prescribing plan.
However, such agreements and plans as outlined above do not guarantee that change occurs. Subsequent oversight for plan adherence and continued management across the injured worker’s total pharmacy utilization must occur to adequately mitigate the identified risks.
Closing the Loop
Robust analytics that translate into easy to understand decision-support can offer adjusters and prescribers a critical line of sight into what is occurring with the injured worker to ensure effective patient and claim management. Employers and their payors need program partners who offer transparency into their total claim experience. A PBM partner must have the access and expertise to collect, analyze, display, and make actionable recommendations based on the complete information available. Once recommendations are agreed upon, they must have the ability to close the loop and ensure that the agreements are followed and reportable at an individual claim and aggregate program level. This understanding and a commitment to utilizing the information across the clinical continuum is the best way to promote patient safety and return our injured workers to health.
About Michael Halbach
Michael Halbach has over 16 years of transactional processing experience in the software industry with the last nine being with Coventry’s First Script Pharmacy Benefit program. Key areas of focus have included management of technical and customer service teams, the development of sales and client related projects, and management of Coventry’s First Script Pharmacy Benefit program. Michael is currently responsible for setting strategy and vision for First Script Operations. He comes to us from First Data Corp, and previously worked for Intuit. Michael has a BA from Syracuse University.
About Coventry Workers’ Comp Services
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.
Disclosure:
Coventry is a WorkCompWire Ad Partner.
This is not a paid placement.