On-the-job injuries often involve chronic pain for injured workers and long-term liability for workers' compensation self-insured payors. Many times, pain from a chronic injury is treated with narcotics. According to the 2010 Progressive Medical Drug Spend Analysis, narcotic spending accounts for 34 percent of workers' compensation medication expenses.
And while narcotics can be beneficial in the treatment plan for a patient in pain, there are serious risks involved when they are not used properly. The Centers for Disease Control (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) both indicate increasing misuse and abuse of narcotics over the past decade.
SAMHSA data shows that there was a significant increase from 2000 to 2006 in the treatment of substance abuse cases related to abuse of opioid analgesics. In addition, another study co-released by CDC and SAMHSA found that emergency room visits linked to non-medical use of narcotics rose 111 percent between 2004 and 2008.
Risks Associated With Narcotics Abuse
While narcotics are considered safe and effective if used properly, they have the potential for leading to addiction and abuse if their use is not monitored and controlled. Misuse and abuse of narcotics represent three areas of particular concern for workers' compensation self insurers including:
- Potential for serious health risks
- Higher percentage of medical expenses as claims age
- Risk of litigation
As the cost of prescriptions? including narcotic medications? directly impacts the cost of a workers' compensation claim, insurers are looking for ways to quickly get control of cases of misuse and abuse. One of the most efficient ways to manage narcotic use in a claimant population is to partner with a pharmacy benefit manager (PBM).
A PBM can clearly define a strategy for proactively and effectively monitoring narcotics. These plans and strategies help payors ensure injured worker safety and reduce expenses.
Best Practices to Reduce Narcotics Abuse and Manage Expenses
Forming a partnership with a PBM can provide workers' compensation self insurers a valuable resource in controlling narcotics use and thereby reducing risk for all stakeholders. There are several key best practices that can be deployed by PBMs to assist self-insured payors.
Best Practice #1: Defining a strategy
Getting control of narcotics usage requires a well-defined strategy. Once the PBM reviews the prescription history, it should be used to develop a customized narcotics strategy for each medication plan to identify which medications are appropriate for the injury type and body part. They also account for proper duration of use and quantity limits.
Best Practice #2: Capturing prescriptions at first fill
When new claims are filed, it is important to capture when and what type of medication is filled at the onset of injury. PBMs should have in place a mechanism to capture this prescription information. Often these early prescriptions begin telling the story of the medication history and medication therapy to come.
One method to capturing this data is through First Fill cards. These cards are typically distributed by the employer to the injured worker at the point of accident or injury. To ensure that both employers and injured workers use the program, PBMs should offer training programs on their use.
Best Practice #3: Offering home delivery programs and retail drug cards
Both retail and home delivery programs provide the workers' compensation self insurer an effective means to monitor and control an injured worker's medication utilization. They also provide self-insured payors an opportunity to fully leverage pharmacy network participation and discounts, thereby reducing medication expenses.
Retail drug cards. When an injured worker requires additional medications, a retail drug card program will give the self-insured payor control over what, when and where the prescriptions can be filled.
Home delivery programs. A home delivery program offers the injured worker the convenience of ordering prescriptions online or on the phone while providing the workers' compensation self-insured payor the ability to engage in proactive utilization review programs.
They also give the self insurer a mechanism to educate injured workers on the risks associated with narcotics through direct interaction with the pharmacist dispensing the injured worker's prescriptions.
Best Practice #4: Managing prospective and concurrent narcotics utilization review programs
The PBM should have a clinical management process to govern narcotics utilization that is managed by clinical pharmacists. The clinical drug utilization review (DUR) program should use a combination of evidence-based guidelines, peer review journals and recommendations provided by government organizations. Both prospective and concurrent review processes are essential to a successful program:
Prospective utilization reviews. A prospective program allows all involved parties to plan for future outcomes with up-front information. Historical data and practices guide future decisions at the establishment of the PBM relationship. This prospective process allows for the achievement of cost control and utilization control.
Concurrent utilization reviews. The PBM triggers concurrent alerts to inform the dispensing pharmacist about possible reasons a prescription should be questioned further prior to filling. These point-of-sale alerts may establish behaviors that could indicate abuse involving the use of multiple pharmacies and physicians for different narcotics or excessive early refill attempts.
The messaging from the PBM ensures that prescriptions for narcotics will not be fulfilled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the self-insured payor.
Best Practice #5: Conducting retrospective drug utilization reviews and clinical intervention programs
Retrospective reviews. After a prescription is fulfilled, a PBM's clinical pharmacist team should audit these prescriptions for indicators of inappropriate use. Indicators often include:
- Sole use of narcotics as treatment
- Multiple physicians
- Use of multiple short or long acting narcotics
- Excessive duration and use
These types of utilization review programs are essential to maximize the effectiveness of a narcotics usage strategy and are most effective when leveraged in conjunction with prospective and concurrent drug utilization reviews.
PBM programs should be flexible enough to allow for customization of review requirements for clients, as client goals and objectives often vary even within organizations.
Physician monitoring. A PBM should continually monitor the use of multiple physicians by one injured worker.The physician monitoring program should be based on established best practices and contain multiple components including:
- Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines
- Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA-approved generic equivalent exists
- Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns
Clinical intervention programs. The PBM should have a range of clinical intervention programs to assist a client with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions to more detailed evaluations including peer reviews and direct consultation with prescribing physicians.
The PBM's clinical intervention team should provide recommendations for specific claims that require further evaluation through the use of the information gathered in prospective, concurrent and retrospective review processes.
Best Practice #6: Providing ongoing consultation
A quality narcotics utilization program is an essential component of controlling narcotics use. To ensure the utilization program is effective, the pharmacists managing the programs should take proactive measures to continually expand utilization review programs as the workers' compensation industry evolves. As changes occur, they should also be available to consult with clients on how to adapt their DUR programs accordingly.
Best Practice #7: Validating narcotics use through reporting
If a DUR program is successful, there will be a reduction in unnecessary medication usage, including narcotic use. A PBM should easily be able to validate those reductions through a wide range of real-time and ad-hoc reports.
User-run reports. The PBM should offer a tool that gives a client an option to run a wide range of reports to gain an in-depth understanding of all activity. To maximize the effectiveness and ease of use of the reports, the PBM should ensure the reports are categorized into varying levels depending on how the reports will be used.
Management level users should be able to run reports to assist with managing the claims professional, such as a report that provides exception or override information as well as a report that provides details on actions sent to the PBM.
Other available reports should include: savings reports that can be sorted by a range of time periods, jurisdictions, groups and/or branches, pharmacy network utilization and savings reports, generic efficiency and opportunity, as well as a wide range of trending reports including top prescribing physicians, top therapeutic classifications, top pharmacy medications, top ICD-9, top injury type and reports detailing prescribing physician habits.
Drug utilization review report. To provide information on savings achieved as a result of the program, the PBM should have a detailed DUR report. This report should provide information on savings achieved as a result of the program and should document savings in distinct areas rather than broad categories in order to provide the complete picture of DUR activity.
Ad-hoc reporting. The PBM should have the ability to supply ad-hoc reports to assist with narcotic utilization management. If the PBM captures the data, then the PBM should be able to provide reports based on those data elements.
Best Practice #8: Reduce Out-of-Network Bills
A high number of out-of-network bills can lead to issues with managing utilization of narcotics. Not only are individual out-of-network bills typically higher than those in-network, they are often not included in the utilization process. It is vital for payors to have a process in place for properly driving those bills back into the network.
This can be done by working with a PBM that offers both paper and electronic out-of-network bill solutions. This will ensure that critical injured worker data on number of prescriptions, duration of therapy, doctor information and other related factors are captured to better monitor utilization.
However, the best method for controlling out-of-network bills is to make it easier for the injured worker to go in-network as early in the life of the claim as possible by utilizing First Fill cards, which are distributed by the employer at the onset of the injury. Two other strategies for reducing out-of-network bills are home delivery and retail drug card programs.
It is expected that narcotics will continue to play a role in treating pain in workers' compensation, so self insurers must take proactive measures to reduce misuse and abuse. By doing so, they decrease risk for litigation, improve injured worker safety and obtain more control over medication expenses.
By partnering with a PBM, workers' compensation self-insured payors can put an effective narcotics utilization strategy into place. A relationship with a strong PBM partner experienced in workers' compensation will enable the self insurer to not only monitor utilization but stop point-of-sale fulfillment of unnecessary narcotics.
About the Author
Tron Emptage is Chief Clinical and Compliance Officer for Progressive Medical, a leading provider of cost management solutions for the workers' compensation and auto no-fault industries. Emptage can be reached at tron. firstname.lastname@example.org.