By Ron Skrocki, Senior Vice President, Product Management and Development, Genex Services
Among the many concerns in workers’ compensation, medication safety remains high on the list. While the industry has experienced some success through better pharmacy utilization and pain management alternatives, opioid abuse is still present in up to 41 percent of patients receiving chronic pain treatment. For those whose regimen lasts 90 days or longer, odds of chronic work loss are 11–14 times greater than those not taking opioids.
I could go on and on with statistics, but I’m sure you’re aware of the seriousness of the situation. Instead, let’s focus on what we can do to implement effective measures as part of a better program to sustain health and save lives.
If we stay on the current “siloed” trajectory that many continue to follow, we’re not going to adequately meet this challenge. We’ve got to improve collaboration with all workers’ comp partners — employer, employee, adjuster, provider, case manager, bill review, utilization review, pharmacy benefit manager (PBM) and data analytics — working in unison to better ensure safety and recovery.
This seems obvious to most, yet we continually face obstacles in our efforts to strengthen prescription drug management integration. This includes lack of communication between the PBM and bill-review services; clinicians who aren’t current on utilization issues; lack of strong and direct outreach to providers who prescribe outside of guidelines; and adequate clinical follow-up after revised protocols have been established.
Building enhanced connections between program components and constituents as well as establishing an analytic platform with a baseline to monitor and improve outcomes is not simple, but it is both doable and essential to counteract this costly epidemic.
What needs to change
Unfortunately, change in this area (either self-initiated or mandated by regulation) often comes slowly; frequently after payer, employer and employee experience a considerable amount of pain. Some businesses embrace change if they see an initiative aligning with their culture — it’s the right thing to do for the injured worker — their health, safety and productivity. These alignments open the door for better processes, more integration and program evolution.
In terms of medication management, changing to a more effective approach starts with a clinical program that connects claims, case management, provider evaluations, utilization review, bill review and PBM processes. The connections between these program components must be transparent, efficient and configurable to ensure effective identification and interventions.
This program approach requires an agreement and ongoing dialogue between the claims and medical management organizations to listen, connect and leverage their respective and distinct roles and expertise. The strategy also requires a strong measurement component to allow frequent and honest evaluation of both claims and clinical factors. It should address questions such as: “How are we doing? What have we missed? What are we overworking? Where can we improve?”
Finally (and arguably most importantly), these metrics must tie to the financial scorecard that addresses benefit relative to medical cost, disability durations and indemnity. All of these pieces need to be in place to have the most cost-effective and sustainable model. This problem requires a smarter and better approach than our historical silos are capable of delivering.
Opioids and beyond
How do we know that an integrated program works? We’ve repeatedly seen the numbers improve as a direct result of this approach. Most recently, the scorecard for a large carrier in the Northeast showed a 10 percent reduction in claims with pharmacy prescriptions by using an integrated medication safety program designed to identify, intervene and improve outcomes. This carrier also reported a 30 percent increase in average pharmacy savings, realizing a substantial decline in annual pharmacy spend at a time when many carriers and payers faced year-over-year increases.
The results occurred through early and ongoing monitoring and evaluation using dashboards, analytics, and claims data-driven stewardships to find opportunities to fine-tune and incrementally improve within their medical management and claims practice.
The beauty of this approach is that it goes beyond opioid management and can detect and attack other issues in medical service delivery. The model itself is a framework to integrate not only the medical management silos, but claims management in a way that positions an organization, beyond this opioid crisis, to better navigate in an increasingly complex health care delivery system.
About Ron Skrocki
Ron Skrocki is Senior Vice President, Product Management and Development, where he is responsible for product strategy, compliance, and the analytics practice for Genex Services. He and his group collaborate closely with Genex customers, outside regulators, internal operations, and technology staff to ensure service quality, regulatory compliance, and continuous outcome improvement.
Prior to joining Genex in 2004, Mr. Skrocki held national level leadership positions in information technology, operations, sales, account and product management. He has more than 25 years of managed care industry experience across these multiple disciplines.
After graduating from Philadelphia University with a bachelor’s degree in business management, Mr. Skrocki earned a master’s degree in computer science from Villanova University.
About Genex Services, LLC
Genex Services is the trusted provider of managed care services enabling workers’ compensation payers and risk managers to transform their bottom lines. Genex is a managed care leader with more than 2,900 employees and 47 service locations throughout North America. The company serves 381 of the Fortune 500 companies as well as the top workers’ compensation and disability carriers and third-party administrators in the U.S. In addition, Genex is the only company that delivers high-quality clinical services enhanced by intelligent systems and 360-degree data analysis. The company consistently drives superior results related to medical, wage-loss, and productivity costs associated with claims in the workers’ compensation, disability, health care and automobile systems.
Genex is a WorkCompWire Ad Partner.
This is not a paid placement.