PBMs: Integrated Solutions for Opioid Management in the Overall Claims Management Process

The opioid crisis has been top of mind for workers’ compensation leaders and claims managers for many years. Last year, the Workers’ Compensation Research Institute (WCRI) found that the newly implemented policies may be helping to curb usage. In the 25 states evaluated, the study found “noticeable decreases” in the amount of opioids prescribed. However, prolific prescribing, widespread abuse and the highly addictive nature of these drugs have contributed to rapid increases in opioid overdose deaths from both prescription opioids and its illegal counterpart, heroin. On average, more than 650,000 opioid prescriptions are dispensed in the U.S. daily. In 2015, more than 52,404 people died from drug overdoses and opioids were involved in 52 percent of those deaths. For context, automobile related deaths were 37,757 in 2015.

On average, more than 650,000 opioid prescriptions are dispensed in the U.S. daily.

From this national perspective, the prescription opioid and heroin epidemic cannot be detached from one another. Four out of five new heroin users report abusing prescription opioids prior to moving on to heroin. The primary reason for the transition to heroin was that heroin is cheaper and easier to obtain than prescription opioids. As an industry, workers’ compensation has responded to the opioid prescription epidemic. State legislation has been passed with states like Utah and Washington leading the way early in the crisis. In addition, independent organizations like the Official Disability Institute (ODG) published by the Work Loss Data Institute and The American College of Occupational & Environmental Medicine (ACOEM) have released industry specific guidelines for prescribers in the appropriate use of opioids for the treatment of pain specific to workplace injuries. In March of 2016, the Centers for Disease Control (CDC) published the CDC Guideline for Prescribing Opioids for Chronic Pain. The CDC‘s stated goal was to improve communication between providers and patients about the risks and benfits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose.

Organizational Imperatives

Given the national focus, guidelines and legislation as well as the general scale of the epidemic—it is imperative that claims organizations continue to have a focus on opioid management. Many payors turn to pharmacy benefit management systems (PBMs) to help monitor drug therapies including opioids. PBMs have the medical knowledge, experience and tools to support claims professionals. They are also partners in driving education and promoting the proper use of prescription medications as part of a comprehensive pain management and recovery plan. However, the challenge with this partnership is twofold. First, the PBM needs to have the right technology and services as part of their core solution and second, they need to be fully integrated to competently monitor, manage and solve opioid abuse. Let us consider the following scenario to tease out how some of these challenges arise: Overall, the example raises many red flags including:

• There are two different prescribers of opioids
• The claimant received an excessive days supply of opioids (30 day’s worth)
• The combination of opioids and benzodiazepines were prescribed (a deadly combination responsible in 30 percent of overdose deaths)
• The total Morphine Equivalent Dose (MED) for the claimant likely exceeds recommendations due to two overlapping opioid prescriptions (one for 30 days supply and one for 14 days supply)

This illustrates the challenges inherent in a siloed system. The bill review system and PBM system can only manage what it can see. For example, there is an inherent delay between the time-of-injury and drug intervention by the PBM. Guidelines such as the CDC’s recommend close evaluation of opioid prescribing early in the claim. The guidelines also include recommended limits on day supply and total dosage. All three of these best practices cannot be applied or enforced when the PBM does not have visibility into these early prescriptions. Opioid guidelines also recommend daily dosing limits. Frequently termed Morphine Equivalent Dose (MED), the daily intake of all opioid prescriptions is calculated and thresholds are applied. Again, lacking visibility into these early prescriptions severely limits the accuracy of these calculations, underestimating the claimants MED.

An Integrated Approach

Many workers’ compensation organizations have seen that a siloed approach is not robust enough to address pervasive and large-scale challenges such as opioid abuse. Instead, they have implemented a fully integrated solution that connects PBM, bill review and managed care. The integration of these traditionally “siloed” components of claims management enables each to function in unison and to address the challenges of drug therapy for injured workers. This approach is better able to identify risks earlier and connects the claim throughout the claimant’s recovery. This enables adjuster to identify dangerous opioid-related issues, enables application of guidelines and allows for a proactive approach that promotes better claim outcomes for both the claimant and insurer.

Managing the Claim Early

As we saw in our example, early intervention can make a significant impact. Clinical controls are the ideal way to identify risks before they become problems. In our example, clinical controls could have been more effective if the PBM had visibility into prescriptions being filled prior to the claim being accepted as compensable. The system would have triggered an alert that the overall MED calculation was too high and that an opioid and benzodiazepine should not be taken concurrently. What about what the PBM cannot see? A traditional, stand-alone PBM can only make recommendations on what it can see. It is relying on the adjuster to term while the problem grows. In an integrated system, bill review data and PBM data is managed from a single platform. This allows for better clinical controls and alerts that help adjuster keep their claimants safe.

Once a risk alert is brought to the attention of an adjuster, they should have the resources to quickly consult with a medical professional through an integrated system.

Effective Claims Management

A single platform also connects these risk alerts to expertise and resources that come from managed care and then back into the system for ongoing monitoring and management. Once a risk alert is brought to the attention of an adjuster, they should have the resources to quickly consult with a medical professional through an integrated system. If an adjuster has access to a sta of nurses with years of Utilization Review (UR) certified experience, they cannot only identify clinical issues with the claim, but can also successfully intervene either through nurse review, physician review, or through other services to make sure the claim stays on the right path. Then, most importantly, the data and recommendation are brought back into the platform. For example, a utilization review would have identified from our scenario, Joe’s use of opioids and benzodiazepines concurrently as a risk and made a recommendation to block the drugs. This could be noted and implemented in the system through formulary controls for both the PBM and bill review.

Integrated Solutions For Success

There are many powerful strategies and tools to help claimants with their recovery including preventing and treating opioid addiction. These strategies have been crafted to help optimize the process and provide data that can have a positive impact on the overall claim. However if the strategies and systems themselves are siloed, there are many opportunities for failure. Integration allows data to ow throughout the entire claim to deliver the visibility, insights and solutions that insurers need to effectively and efficiently manage opioid use and the overall claim. Platforms can provide a uni ed experience that saves lives and results in better outcomes for all.