By Silvia Sacalis, PharmD, VP of Clinical Services, Healthesystems
Pharmacy is an incredibly dynamic space. It’s one of the reasons I personally was drawn to the practice, and why I continue to have a fulfilling career in it after 17 years. It’s also one of the reasons that continuous analysis, consultation and strategic refinement of formulary and clinical support strategies should be the bedrock of any workers’ compensation PBM offering.
Consider this: The U.S. Food and Drug Administration approved 50 new molecular drug entities in 2021, about 20% of which have the potential to emerge in workers’ comp claims. And this is just the tip of the iceberg. What’s not included in this number: the multitude of generics and biosimilars joining the market every year, the inclusion of new indications for existing therapeutic agents, and the products that the FDA doesn’t approve. An example of this particularly relevant to workers’ compensation are the dozens of private-label topical products available on the market, which are not part of the FDA approval and regulation process but represent a growing portion of workers’ compensation pharmacy spend.
Layer in evolving clinical guidance, regulation, and state-specific rules, and it’s a lot to keep pace with. My clinical team and I work diligently alongside our payer partners for this very reason, to help bring visibility to where the strategies we have in place are working, where we can continue to educate and evolve, and what we need to be considering that’s up ahead.
So, what is up ahead?
Here’s the great news. The overall workers’ compensation claims population, at large, is faring much better in terms of opioid risk compared with fifteen, ten or even five years ago. We’ve seen double digit reductions in the number of opioid claims, spend, and utilization. These improvements within the workers’ comp claim populations are due to a combination of factors and efforts at federal, state, and individual program levels championed by workers’ compensation payers and PBMs.
As we have seen opioids trending down, I’m often asked for my thoughts on what the next 800-pound gorilla in pharmacy might be from a workers’ compensation claims management standpoint. I would say that there is no 800-pound gorilla. Strictly from a pharmacy standpoint, there is no singular trend looming at a scale comparable to the opioid crisis, and for this we can all be thankful. Instead, what we’re seeing are multiple, nuanced trends, some of which are playing out differently at state levels or within specific patient subpopulations – and this amalgamation of trends brings its own complexity.
Some examples of prescribing and dispensing trends we’re keeping a pulse on include, but are not limited to:
- Controlled substances as a broader pool of prescription drug risk. Even with opioids trending down, we don’t want to lose sight of them, as well as neuropathic pain agents such as gabapentin, muscle relaxants, and benzodiazepines. This also includes increased prescribing of buprenorphine products, driven in part by off-label prescribing for pain management.
- Dermatologicals, in part tied to physician dispensing trends of brand name products and/or private-label topicals. There has been a significant trend in physician dispensing of topical diclofenac products, specifically high-strength and high-cost brands such as the Flector Patch, Pennsaid and Solaraze – despite the availability of over-the-counter Voltaren, a more cost-effective topical diclofenac option.
- Novel and costly migraine agents. Specifically, increased prescribing in the newer class of CGRP inhibitors, which includes products like Aimovig, Ajovy and others. This may be in part driven by chronic pain research underway for some migraine agents.
- Nonsteroidal anti-inflammatory drugs (NSAIDs): as opioids have trended down, there has been an increase in NSAID prescribing, which was anticipated. This isn’t necessarily a negative trend, as they are a preferred, first-line option for pain management. But some specific products are slipping through the loopholes. For example, last year the California Workers’ Compensation Institute reported on prescribing trends for ketoprofen and fenoprofen – two low-volume, yet high-cost NSAIDs that were driving costs due to their nonexempt status on the CA formulary. It should be noted that the CA Pharmacy & Therapeutics Committee voted to change their nonexempt status; however, the DWC has yet to adopt this change.
- State- and population-specific trends, for example in states that include presumptions for certain worker classes, such as first-responders. We are also seeing price hikes in brand-name anticoagulants drive a portion of cost where coverage exists for hypertension and other cardiovascular conditions.
Tracking and tackling these multiple cost drivers of course brings its own brand of complexity, as ongoing trend and population monitoring, evolving education and clinical decision support, and strategic and technological nimbleness become even more crucial to pharmacy program success. But these trends can and are being addressed. For example, we’ve seen tremendous success in reducing the volume of clinically unsupported dermatological prescribing through a combination of right-time clinical guidance for claims staff and prescriber outreach programs.
Just as the field of prescription drugs constantly evolves, so must their management. It means never getting complacent; rather, adopting rigor and vigilance to identify those opportunities that will continue moving the needle.
About Silvia Sacalis
Silvia Sacalis, BS, PharmD, provides clinical leadership and strategic direction as Vice President of Clinical Services at Healthesystems. Her healthcare experience and clinical expertise span the PBM, retail pharmacy and managed care environments. Leveraging her technology background, clinical skills and management expertise, she helps develop and operationalize strategic clinical initiatives to help workers’ compensation insurance payers maximize the impact of a pharmacy benefit management program. Throughout her career, she has held various leadership roles in which she provided oversight of clinical services teams, the development of clinical programs, and integration of analytics technology coupled with clinical consultative support. Dr. Sacalis is a national thought leader and contributor to various industry presentations, publications and interviews.
Dr. Sacalis received her Bachelor of Science in Computer Science and Doctorate of Pharmacy degrees from the University of Illinois at Chicago.
Healthesystems is a specialty provider of innovative medical cost management solutions for the workers’ compensation industry. The company’s comprehensive product portfolio includes a leading pharmacy benefit management (PBM) program, expert clinical review services, and a revolutionary ancillary benefits management (ABM) solution for prospectively managing ancillary medical services such as durable medical equipment (DME), home health, physical medicine, transportation and translation services. By leveraging innovation, powerful technology, clinical expertise and enhanced workflow automation tools, Healthesystems provides clients with flexible programs that reduce the total cost of medical care while improving the quality of care for injured workers. To learn more about Healthesystems visit www.healthesystems.com.
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