By Mitch Freeman, PharmD, Vice President, Chief Clinical Officer, Mitchell International
A Claim Is a Journey
When an employee is injured on the job, it is the beginning of a journey, and it’s not a vacation. Numerous decisions will be made that impact the destination of that journey. Opioid therapy for the treatment of pain is one of the most critical decisions made on the path to recovery. When chosen wisely, they can help an injured worker recover as completely as possible as soon as possible without impacting their long-term health. When poor decisions are made, the results can be disastrous.
Pharmacy benefits managers (PBMs) are the primary partners chosen by payors to help navigate the pitfalls of drug therapy in workers’ compensation. PBMs act as a guide with responsibility to monitor drug therapy, identify when suboptimal or dangerous treatment paths are taken, and work with the prescriber to lead the claimant back to an optimal path. To be an effective guide, and in order to promote the best therapy decisions, it is essential for the PBM to have visibility into as much accurate information as possible.
Payors often contract with separate entities for services like PBM, medical bill review, and managed care services. Having multiple, distinct partners involved in the management of claims can potentially create challenges due to lack of visibility and insight across partners. Comprehensive visibility is essential to maximize the PBM’s ability to guide the claim to an optimal outcome.
Because of the high prevalence of pain associated with injury, the national opioid epidemic has disproportionally impacted workers’ compensation. In response, numerous entities have published guidelines addressing the use of opioids for the treatment of pain. Some of these include ODG, ACOEM, and most recently, the CDC. These recommendations provide guidance in several areas of opioid prescribing including:
- Limiting the number of days supplied for the first opioid prescription
- Limiting the daily amount of opioid to be prescribed with the first prescription
- Using only short-acting opioids for the first prescription and early in the claim (Lortab vs. OxyContin)
- Establishing thresholds of daily opioid intake—defining moderate and high risk
- Avoiding the use of opioids with benzodiazepines (Xanax, Ambien)
Over time, these guidelines have become significantly more restrictive, emphasizing the need to limit the duration and dose of opioids early in the claim to promote a better outcome, a better destination for the injured worker.
However, not all prescriptions in workers’ compensation are captured by the PBM. In most cases, the first prescription is filled before the payor and PBM are even aware that an injury has occurred. These first fills or unidentified fills are frequently billed via paper, circumventing the PBM. These prescriptions are typically processed through medical bill review and are not usually visible to the PBM. PBMs cannot apply opioid guidelines to prescriptions they cannot see. How effective can PBMs be in guiding appropriate drug therapy without early and comprehensive visibility into all prescriptions a claimant may be taking? It is like navigating with an incomplete map.
Integrate to Illuminate the Right Path
The tools and capabilities developed over decades by workers’ compensation PBMs are innovative and impactful. However, these capabilities and tools are only as effective as the data they receive. As the nation and the industry move toward enforceable guidelines for opioid prescribing, it is key that PBMs are able to monitor all prescriptions for the application of the guidelines and identification of risk.
Whether accomplished through truly integrated PBM, bill review, and managed care systems or through robust data exchange among various entities, data integration is key to visibility. Integration enables the PBM to successfully navigate the risks along the claim journey by monitoring potential roadblocks or pitfalls, identifying when any suboptimal or dangerous treatment pathways are taken, and intervening with the prescriber to keep drug therapy on an appropriate path.
It is through these connections that we gain visibility. Through visibility, we support better decisions for better outcomes. Better outcomes are the ultimate goal and a worthy one at that.
About Dr. Mitch Freeman, PharmD
Mitch Freeman is the Chief Clinical Officer for Mitchell International, Pharmacy Solutions. Prior to joining Mitchell, Freemen was the CEO of First Coast Health. He has a wealth of industry expertise and leadership in the workers’ compensation industry including the chief sales and marketing officer of PMSI, vice president of sales at Ameritox, vice president and general manager for ExpressScripts, and president of pharmacy services for MSC.
Freeman is a frequent guest speaker and author and is a graduate of Florida A&M University where he received his doctorate of pharmacy.
Headquartered in San Diego, California, Mitchell International, Inc., delivers smart technology solutions that simplify and accelerate claims handling and repair processes, driving more accurate, consistent and cost-effective resolutions. Mitchell integrates deep industry expertise into its workflow solutions, providing unparalleled access to data, advanced analytics and decision support tools. Mitchell’s comprehensive solution portfolio and robust SaaS infrastructure connect its customers in ways that enable tens of millions of electronic transactions to be processed each month for more than 300 insurance companies, over 30,000 collision repair facilities and countless other Property & Casualty industry supply partners across the Americas and Europe. For more information, please visit http://www.mitchell.com.