By Joe Anderson, Director of Analytics, Workers’ Comp and Auto No-Fault Division, Optum
A claimant’s pharmacy and demographic factors such as the body part and nature of injury, and their vital statistics (for example, gender, age and geography), provide us with significant insight into a claim. Important insight is also gained from understanding their pharmacy behavior; such as the types of medications being used, how often their prescriptions are refilled and how many pharmacies are used to fill their prescriptions. Yet another source of invaluable information is the prescriber.
Not dissimilar to the individual trees in a forest, these various pharmacy and claim demographic factors are independent. For example, we may see two claimants with the same demographics and pharmacy behavior, but categorize their risk very differently based on the type of prescriber writing their prescriptions. However, data show some interesting insights when prescriber specialties are grouped and evaluated as a cluster (or, to continue the metaphor, as the forest).
The largest group of prescribers, accounting for about 37% of prescriptions in our workers’ compensation book of business, are generalists. This group of prescribers includes general practitioners, family medicine practitioners, physician assistants and nurse practitioners. Because generalists treat a wide variety of patients, their name on a prescription provides the least amount of information for predictive modeling. In aggregate, data indicates this group of prescribers tends to treat injured workers having low and high duration pharmacy claims at about the same rate as the overall population. Thus, the fact that an injured worker is being treated by a generalist doesn’t necessarily raise a red flag in and of itself. Nor does it mean all the injured workers treated by prescribers in this group will close quickly; rather, the data suggests the predictive power of other demographic factors is more significant to predicting whether a claim will become high cost.
The second largest prescriber group accounts for about 33% of prescriptions. These are prescribers with “high cost” specialties, such as physical medicine and rehabilitation, pain medicine, anesthesiology and psychology. Our data show these specialties prescribe more brand-named medications than other prescribers and when opioid analgesics are prescribed, they are stronger and at a higher morphine equivalent dose. Data also indicates injured workers receiving treatment from prescribers in this group have the highest medication utilization and the highest pharmacy costs. As a result, injured workers being treated by “high cost” specialties generally experience longer duration of pharmacy care. They also require more intensive clinical intervention efforts.
The third most common prescriber specialties seen in our workers’ compensation book of business relate to “surgery”. Representing about 16% of prescriptions, specialties in this group of prescribers include general surgery, orthopedic surgery, neurosurgery, neuromusculoskeletal medicine, otolaryngology and dentists. Data show this group of prescribers either write prescriptions for injured workers with relatively low pharmacy claim duration or they see the injured worker early on in their claim. However, they are, more likely to write prescriptions for opioid analgesics; of the specialties in this group, orthopedic surgeons prescribe the most, at 16.4%.
“Internal medicine” specialists, ranked fourth and who write just about 8.5% of prescriptions in our workers’ compensation book of business, are a category of their own. They are more likely to treat injured workers for a longer pharmacy claim duration than any of the groups already discussed, but their utilization is not particularly high. Despite this lower utilization, internal medicine specialists treat patients with similar costs per claimant. They don’t prescribe opioid analgesics particularly often; however, when they do, the average morphine equivalents per prescription is higher than other prescriber groups. They are also more likely to exhibit other behavior associated with long-term claims. For example, internal medicine specialists treating injured workers in our book of business tend to write more home delivery prescriptions and they write more prescriptions for specialty medications. Despite their more frequent involvement with long-term claims, this group of prescribers is underrepresented in our company’s quarterly outlier reports. While our data show some internal medicine prescribers write many more dispense as written (DAW1) and/or compounded medication prescriptions than the average prescriber, they are, for the most part, a low risk category.
The fifth group of prescribers we’ll highlight represents less than 4% of prescriptions in our workers’ compensation book of business. We refer to this group as “one-and-done” prescribers. This is because they tend to see injured workers only once, early in the claim and often only for a single prescription. These prescribers have specialties in emergency medicine, preventive medicine and pathology. More than any other group, they are likely to dispense out of their office (physician-dispensed medications) and data show this group of prescribers is also more likely to prescribe generic medications. Data show more than 96% of medications prescribed by “one-and-done” prescribers in the first year of a claim are generic. As a result, this prescriber group tends to be perceived as low risk and their prescribing practices are often overlooked, if not ignored altogether. However, “one-and-done” prescribers can present as high risk when examined across multiple claimants. This is because dispensing medications out of their office, a clinic or the hospital often leads to higher medication costs than would be otherwise incurred had the injured worker filled their prescription through the more traditional retail or home delivery pharmacy.
This leaves us with the remaining 1% or what we call the “rare” prescribers, which include prescriber specialties such as podiatrists. While infrequently encountered in a workers’ compensation claim, they’re worth differentiating from other prescriber specialties if you can find them in the data. This is because of their tendency to prescribe compounded medications, brand-named and/or specialty medications; all of which are known cost-drivers.
Understanding prescriber specialties leads to better outcomes
Each of the aforementioned prescriber groups present a slightly different challenge for payers. Prescriber specialties such as the “high cost” specialties that frequently result in long-term claims will see their claims benefit significantly from the use of early intervention programs relying on statistical models to identify potential high cost claims. For claims involving specialties not often resulting in high cost claims, such as “generalists,” analysis of individual prescriber behavior can be useful in identifying those exhibiting higher risk than their peers, as well as in facilitating intervention, such as prescriber outreach or peer-to-peer review. Even claims involving specialties prescribing high cost medications for a large number of low-cost claims, such as internal medicine, have been found to benefit from analytics, as data is used to educate and support regulatory reform. Regardless of the challenge, an organization such as a pharmacy benefit manager (PBM) receiving a large amount of data on prescriber behavior has access to a proverbial forest of information. Analytics helps the PBM, and their payer clients, see the trees within the forest and ultimately achieve a better outcome.
About Joe Anderson
As the Director of Analytics, Joe Anderson researches ways to utilize data to develop new services for our clients. These innovative programs utilize historical pharmacy data to predict which injured workers will have long-term pharmacy spend, or long-term complications with prescription drug use or addiction issues. Joe leads a team of statisticians to develop and implement these programs.
Joe is an expert in the predictors of pharmacy spend and addiction issues. Prior to joining Helios, now Optum, in 2010, Joe worked with Stax, a strategy consulting firm, where he performed corporate strategy analytics and private equity due diligence.
Joe Anderson has a bachelor’s degree from the University of Chicago and a Masters of Business Administration from Northwestern University’s Kellogg School of Management.
About Optum for Workers’ Comp and Auto No-Fault
Helios, Healthcare Solutions and their subsidiaries, as Optum, collaborate with clients to
deliver value beyond transactional savings while helping ensure claimants receive safe and effective
clinical care. Our innovative and comprehensive medical cost management programs include pharmacy
benefit management, ancillary benefit management, managed care services, and settlement solutions.
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