What is the total potential impact of Pharmacy Benefit Management (PBM) within a workers’ compensation claim lifecycle?
Workers’ compensation claims can extend many months or even years from date of injury until closure. This can make it difficult to pinpoint the most impactful moments of action. In retrospect, we can often see where improvements could have been made, whether that is intervening in the injured workers’ recovery or partnering with companies that set you up for claims success. In our last article, we examined the importance of proactively preparing work-related injuries by partnering with businesses that can provide comprehensive solutions.
In this installment of our claim lifecycle series, we will continue following the claim of our fictional worker, Andrew, on his date of injury and consider the decisions that can be made to improve the overall outcome of his claim.
Improving Outcomes on the Date of Injury
Much of today will be a whirlwind for Andrew and his family. The stress and pain of the situation will be top of mind as they receive doctors’ evaluations, medical equipment and prescriptions. As Andrew listens to his doctor suggest therapy, medication and next steps, he thinks about how he can recover quickly and get back to work and his family. Insurers should be prepared in several ways before an injury like Andrew’s even occurs.
First Touchpoints on the Date of Injury
When Andrew is injured, are there proper procedures in place to ensure he receives proper care in a timely manner? Consider the following:
- Will Andrew will be able to receive the medications that his doctor is prescribing him? Will the process be seamless for him or will he encounter challenges while at the pharmacy? What network penetration does your PBM have to ensure that Andrew’s (and your) experience is seamless?
- Are there are appropriate controls in place to ensure that his prescriptions are properly billed to his employer while taking advantage of all possible discounts?
- Are there proper measures in place to ensure the medication is appropriate for his injury or in alignment with national guidelines as a safe and effective treatment for his injury?
Why does this matter? Take the case of opioids currently raving our country. CNBC reports, “…even legitimate, well-intentioned doctors can fall into the over-prescription trap. A study last year by the National Safety Council found 99 percent of the doctors surveyed were prescribing highly addictive opioids for longer than the three-day period recommended by the Centers for Disease Control and Prevention." Additionally, an injured worker may also already be on a medication that they do not disclose, leading to potential negative drug interactions.
Important Recovery Needs
When Andrew finishes his evaluation, he receives a prescription to manage the pain caused by his injury. After arriving at the pharmacy, Andrew should be able to fill his medication quickly. Using his temporary pharmacy card, Andrew can easily fill his prescription and his insurer is seamlessly billed for the medication. This transaction will be tracked as part of his claim history and available for his adjuster. Having an effective Pharmacy Benefit Management (PBM) partner in place ensures that:
- Andrew receives his medications quickly by using his drug benefit card
- Andrew's adjuster can track his prescriptions from the first fill
- His adjuster can approve or deny medication in real-time, instead of waiting to receive notice of the fill when reviewing bills
In addition to pain medications and anti-inflammatories, Andrew will also need durable medical equipment, such as a neck brace and shoulder sling, to aid his recovery. Any delays in receiving this important equipment may also delay his recovery and further extend his pain. Because of this, it is crucial to have good partners in place who can provide safe, timely and cost-efficient equipment and services to Andrew. Finally, having formulary controls in place throughout Andrew’s recovery will ensure that he is receiving the most appropriate care and medication for his injuries. It’s important to note here that Andrew is not an expert in workers’ compensation. He has never sustained a work-related injury and does not know what is best for his recovery. He has heard a bit about the opioid crisis, but he not familiar with prescribing requirements. He simply wants the pain in his neck and arm to subside and to return to his normal life and duties. Andrew, like most people in this situation, trusts what the doctor suggests. However, if the doctor is not versed in all of the medications and treatments for a workers’ compensation case, Andrew may not receive the best care. It is crucial, then, to have proper controls in place from experts in the field. This includes developing formularies, providing proper education and having integrated technology to aid in every step of the claim.
The Bigger Picture
Andrew has received an evaluation for his injuries and the medications he needs. He is now heading home to face a daunting recovery process. Although the date of injury was relatively smooth because of the prepared stakeholders helping him along the way, there are many obstacles ahead. He worries that he will not be able to return to full health. His managers want him back at work, as he is an excellent employee and has shown strong managerial potential. His family misses out on his participation in his regular daily activities, including the soccer team that he helps to coach. Pharmaceutical management plays a large role in the rest of Andrew’s story. Although much of his experience up until now has been focused on the injury itself and receiving care, the ensuing weeks can be heavily influenced by what medications he receives and the process in which he receives it.
Ultimately, the goal of all stakeholders is to ensure that the injured worker returns to his or her everyday life quickly and in the best way possible.Watch for the next installment of our series, where we compare possible outcomes of Andrew's recovery in relation to the pharmacy management involved in the claim.
For more content:
View our latest Drug Spend Quarterly Overview: https://mpower.mitchell.com/pharmacy-drug-spend-quarter-two/