What is the total potential impact of Pharmacy Benefit Management (PBM) within a workers’ compensation claim lifecycle?
This is the final article in a series of three. To read the first article, please click here. To catch up on the second article, please click here.
When we look at the entire claim lifecycle, many important points stand out along the way. What type of care is the injured worker receiving? What support does he or she have throughout? What successes or problems occurred at various steps? When a claim is prolonged for many months and even years, it can be difficult to see the whole picture. Challenges are addressed as they arise, but this shortsightedness can sometimes inadvertently deter the injured worker from the best path of recovery. Let’s return to our fictional character, Andrew, and his workers’ compensation story. When last we discussed Andrew, he was back at home following an injury earlier in the day. He visited the ER, where he was prescribed a non-steroidal anti-inflammatory drug (NSAID), picked up his prescription and began contemplating the upcoming weeks and months of his recovery. Of importance for later in our story, his physician clearly instructed him how to take the NSAID.
His projected recovery time at this point is six weeks. If he stays on this path, he will return to work and his everyday life quickly and at optimal health. What helps to ensure this is the case? Let’s look at a few factors that can improve or deter his recovery.
Scenario A: The Best Case
Taking smart steps to recovery and always keeping the full claim picture in mind is crucial. Andrew should have several touchpoints throughout his recovery process.
Monitoring
As Andrew continues to visit the doctor and receive care, what monitoring is in place to ensure he is on the right path? Consider:
- What controls are in place to capture any prescriptions that Andrew receives?
- What real-time alerts are available if Andrew’s recovery veers off course?
- Are there any predictors available to alert claims examiners of potential issues in Andrew’s recovery?
- What intervention options are available to get Andrew back on track?
The PBM partner that you choose should be able to provide comprehensive answers and solutions to these questions. Taking the time up front to find the right partner can drastically improve claim outcomes.
Difficulties
A week after his injury, Andrew is still feeling pain in his arm. He visits his doctor again, who prescribes him a long-acting opioid. However, based upon prescribing guidelines, such as the Official Disabilities Guidelines (ODG), and historical data, this is not the best course of action; long-acting opioids are not indicated for short-term injuries. With the proper controls in place, the adjustor on this case receives an alert when Andrew tries to fill this prescription. This prescription requires pre-authorization based upon the formularies developed by the insurance company and its PBM partner, and the adjuster is able to suggest an alternative course of action. The adjuster has many options when a claim needs intervention. Because this case is currently low-risk, the adjuster blocks the medication and Andrew returns to the doctor to receive a few tablets of a schedule IV pain medication. A few weeks later, Andrew is seeing improvement with his injury, but is having trouble sleeping at night due to new neck pain. His physician writes him a prescription for melatonin 3mg tablets. The physician instructs Andrew to take three tablets 30 minutes before bedtime each night. This helps Andrew fall to sleep and the schedule IV pain medication, combined with his NSAID, are helping more with his neck pain.
Scenario A Outcome
Because of the available controls and intervention options, everyone was able to ensure that Andrew stayed on the best path of recovery. After six weeks and only a few small obstacles, Andrew returns to his job at the home improvement store. His neck is no longer sore and his arm is fully healed, allowing him to return to CrossFit and coaching soccer. His family is glad to have his help around the house again and his managers are happy to have their best employee back. Overall, the cost and risk of this claim were low. The adjuster was able to intervene when necessary because of the comprehensive and effective tools at hand.
Without the right people, technology and processes in place, Andrew’s story could have ended much differently.
Let’s now look at the (all too common) alternative.
Scenario B: A Life Stalls Due to Lack of Controls
Unfortunately, not all claims end as smoothly as Andrew’s did in the previous scenario. Often, claims last much longer and cost exorbitantly more than expected because of many issues along the claim lifecycle. A lack of insight, proper intervention capabilities and support means that the injured worker faces a more difficult path to recovery.
Lack of Insight
Let’s go back to Andrew’s date of injury. After he receives his prescription for a non-steroidal anti-inflammatory drug (NSAID), Andrew goes to the pharmacy to fill the medication. If this initial prescription is not captured, Andrew is already at a disadvantage in his recovery process. Without proper insight, other stakeholders do not know what Andrew is already taking and cannot place proper controls on the claim at the right time. Several issues can arise from this lack of insight:
- Andrew is prescribed additional medication that interacts poorly or dangerously with the initial prescription.
- Andrew is prescribed an additional dosage of the medication, which could place him in danger.
- Costs rise as more prescriptions are administered.
Lack of insight can also be a problem throughout the claim. If stakeholders cannot see the whole picture, Andrew could receive several misguided or improper prescriptions and treatments before someone realizes that the claim is spiraling. For instance, as in Scenario A, Andrew is still feeling pain during the second week of his claim. His doctors prescribes an opioid only recommended for severe, long-term pain. If the adjuster does not know that Andrew received the initial prescription, the adjuster cannot see the potential dangers this additional prescription could cause. If there is not initial insight, the claim is already off track. After Andrew receives this prescription, problems escalate. His pain is not subsiding and now he is nauseated and constipated. He is upset that he is not seeing any improvement, even after three weeks, and he is impatient to return to his daily life. The frustration and stress convinces him to go to the doctor again.
Improper Intervention Options
At the doctor’s office, Andrew explains that he has been experiencing. The doctor decides to prescribe him a strong long-acting opioid to combat the neck pain and suggests physical therapy to relieve some of the additional pain and stiffness. While this prescription may be appropriate in some cases, the physician may not be aware of the initial prescription and the one she prescribes could have a very dangerous interaction. This is where intervention could be fast and potentially lifesaving. Should the adjuster have questions about this situation, they can initiate a nurse review, peer-to-peer review or utilization review of these prescriptions. However, if the adjuster does not have the proper tools at hand to do so and is overwhelmed by several other claims, they may be unsure what the appropriate intervention step. If this is the case and the adjuster denies the medication, it does not solve Andrew’s current challenge. He is not only experiencing increasing frustration from the slow recovery, but also neck pain. He is still having trouble sleeping at night and is often irritable around his family. A more holistic solution and visibility could have advised Andrew to take a stool softener as soon as he began to take opioids, along with melatonin or diphenhydramine to help him fall asleep. This would have helped Andrew return to the right track.
Poor Outcomes
Everyone in this scenario is questioning how Andrew is going to return to work and his everyday life. Five months have already passed and little improvement has been made. Andrew is now taking four separate prescriptions and going to physical therapy every other day. Costs are piling up on this claim and no clear path toward full recovery is in sight. This unfortunately is the result for many workers’ compensation claims. Even if a worker eventually returns to their everyday life, the path to get there is often more difficult and costlier than it could be.
An unfortunate reality is that the longer a claim drags on, the more opioids and medications are prescribed.
For instance, according to NCCI and Managed Care Matters, 15-year-old claims see around 2.5 oxycodone pills prescribed per day. Heavy users of opioids also receive multiple additional medications to combat the side effects of the opioids. The amount of non-opioid medications prescribed to these users is about seven for every 10 opioid prescriptions. It's clear from Andrew’s story and these statistics that having full visibility, proper resources and controls in place through the duration of a claim can vastly decrease these numbers and ultimately improve outcomes.
The Bigger Picture
As in any workers’ compensation claim, the goal for Andrew is to get him back to health in the best way possible. With full visibility and an array of tools at the claims examiner’s disposal, Andrew has a much better chance at recovering and returning to his everyday life quickly. When developing a comprehensive program, keep in mind how much of an impact pharmacy management can have on each step of the claims journey. It could make a significant difference on an injured worker’s life.
Discover more insights into improving outcomes:
https://mpower.mitchell.com/understanding-predictive-analytics-workers-compensation/