Technology Integrations Are Transforming How Pharmacy Benefits Managers Monitor Drug Therapies

Technology continues to transform the way we live and work, and the insurance industry is no exception. One way technology advancements are having a positive impact on workers’ compensation payors and enabling them to get their claimants on the road to recovery in a safe and effective manner is by improving visibility into pharmaceutical utilization.

The Claim Journey—an Opportunity for Impact

In workers’ compensation, we often talk about the journey of a claim, but when an employee is injured on the job, it is the beginning of a journey for them, too. Each decision point in the claim lifecycle is an opportunity for the payor to positively impact an injured party’s journey and get them to their final destination—a return to health and work—with less disruption. Pharmaceuticals are among the most critical of these decision points, and opioids are of particular concern. When opioids are appropriately prescribed, they can help an injured worker recover as completely as possible and as soon as possible, without impacting long-term health. When poor decisions are made, the journey has the potential to be much more challenging. Opioid abuse is epidemic in the U.S., and because of the pain associated with injuries, the workers’ compensation industry has been disproportionally impacted by it. In response, a number of organizations have published guidelines on the use of opioids for the treatment of pain—the most prominent of these is the Centers for Disease Control (CDC). Key recommendations from the new CDC Guideline for Prescribing Opioids for Chronic Pain include:

• 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)

The CDC is not the first to issue these guidelines. Other organizations such as ODG and ACOEM have also issued them. In recent years, these guidelines have become increasingly more restrictive, emphasizing the need to limit the duration and dose of opioids early in the claim to promote a better destination for the injured worker and a better outcome overall.

Pharmacy Benefits Managers + Integration for Optimal Visibility

So how can technology support these moments that matter in the claim, including opioid management? For a program to be successful, it is recommended to support adjustors with a combination of technology and services to be able to connect the claim at all these critical points—especially with the speed and volume of claims that most adjustors are experiencing. Continuing with our example, opioid management can be greatly improved with the right technology and service solution. Many payors turn to pharmacy benefits managers (PBMs) to help monitor drug therapies, identify when suboptimal or dangerous treatment paths are taken, and determine when to work with the prescriber to get the claimant back on track. The PBM solution must have the technological tools and flexibility to manage the pharmaceuticals, as well as the ability to connect it back to the overall claim. Additionally, a PBM’s effectiveness depends on the accuracy of the available information, which may not be up to date. If first fills are missed, for example, the opportunity to manage the claim early, as is recommended, may be lost or relegated to later in the claim when it is much more difficult. The old adage applies—you can’t manage what you can’t see. Therefore, it is recommended that payors look for technology solutions and partners that both have the technology and integration to support complicated cases, as in our example.

The Future

As the nation and industry move toward enforceable guidelines for opioid prescribing, it is important that PBMs are able to monitor all prescriptions in order to apply the guidelines and identify risk. One of the most effective ways to do this is through technology integration. Whether accomplished through truly integrated PBM, bill review, and managed care systems or through robust data exchange, data integration enables PBMs to better navigate the risks along the claim journey, identify when suboptimal treatment paths are taken, and intervene with the prescriber to keep drug therapy on an appropriate path. Technology is bringing many changes to workers’ compensation insurers, and with those changes comes the opportunity to improve visibility throughout the claim journey and to positively impact an injured workers’ journey back to health. Learn more about the CDC Opioid Prescribing Guidelines and how they may impact your claims organization.