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Healthesystems

Healthesystems is a leading provider of Pharmacy Benefit Management (PBM) & Ancillary Benefits Management programs for the workers' compensation industry.

Sponsored: Healthesystems

The Next Wave of Workers’ Comp Medical Cost Savings

Reducing WC claims costs in one area often inflates them in another.
By: | August 4, 2014 • 6 min read

Managing medical costs for workers’ compensation claims is like pushing on a balloon. As you effectively manage expenses in one area, there are bound to be bulges in another.

Over the last decade, great strides have been made in managing many aspects of workers’ compensation medical costs. Case management, bill review and pharmacy benefits management are just a few categories that produce significant returns.

And yet, according to the National Council on Compensation Insurance (NCCI), medical costs remain the largest percentage of workers’ comp expenses. Worse still, medical costs continue to be the fastest growing expense category.

Many medical services are closely managed through provider negotiations, bill review, utilization review, pharmacy benefits management, to name a few. But a large opportunity for medical cost containment remains largely untouched and therefore represents a significant opportunity for cost savings.

Ancillary medical services is a term used to describe specialty or supplemental health care services such as medical supplies, home health care, durable medical equipment, transportation and physical therapy, etc.

According to Clifford James, Vice President of Strategic Development at Healthesystems in Tampa, Fla., modernizing the process for managing ancillary medical services presents compelling opportunities for cost savings and improved patient care.

Source: 2014 Healthesystems Ancillary Medical Services Survey

“The challenge of managing these types of medical products and services is a cumbersome and extremely disconnected process,” James said. “As a result, it represents a missing link in an overall medical cost management strategy, which means it is costing payers money and patients the most optimal care.”

James singled out three key hurdles:

Lack of transparency

As the adage goes, you can only manage what you can measure.

Yet when it comes to the broad range of products and services that comprise ancillary benefits, comprehensive data and benchmarking metrics by which to gauge success are hard to come by.

The problem begins with an antiquated approach to coding medical services that was developed in the 1970s. The coding system falls short in today’s modern health care environment due to its lack of product and service level detail such as consistent units of measure, quantity and descriptors.

As a result, a meaningful percentage of ancillary benefits spending is coded as “miscellaneous,” which means a payer has little to no visibility into what product or service is being delivered — and no way to determine if the correct price is being applied or if the item is even necessary or appropriate.

Source: 2014 Healthesystems Ancillary Medical Services Survey

“It’s a big challenge. Especially when you consider that for many payers, it’s difficult to determine exactly what they are spending, or identify what the major cost drivers are when it comes to ancillary services,” James said. And when frequently over 20 percent of these types of services are billed as miscellaneous, payers have zero visibility to effectively manage these costs.

Measurement and monitoring

Often, performance that is monitored is given the most attention. Therefore, ancillary programs that are closely monitored and measured against objective benchmarks should be the most successful.

However, benchmarks are hard to determine because multiple vendors are frequently involved using disparate data and processes. There isn’t a consistent focus on continuous quality improvement, because each vendor operates off of their own success criteria.

“Leveraging objective competitive comparisons breeds success in any industry. Yet for ancillary services there is very limited data to clearly measure performance across all vendors,” James said. “And for payers, this is a major area of opportunity to promote service and cost containment excellence.”

Source: 2014 Healthesystems Ancillary Medical Services Survey

Inefficiency

If you ask claims executives about their strategies for improving the claims management process, a likely response may be “workload optimization.” The goal for some is to enable claims professionals to handle a maximum case load by minimizing administrative duties so they can leverage their expertise to better manage the outcome of each case.

But the path towards “workload optimization” has many hurdles, especially when you consider what needs to be coordinated and the manual way it frequently is done.

Ancillary benefits are a prime example. For a single case, a claims professional might need to coordinate durable medical equipment, secure translation services, arrange for transportation and confirm the best physical therapy plan. Unfortunately they often don’t have the needed time, or the pertinent information, in order to make quick, yet informed, decisions about the ancillary needs of their claimants.

In addition there is the complexity of managing multiple vendor relationships, juggling various contacts, and accessing multiple platforms and/or making endless phone calls.

SponsoredContent_HES“We’ve been called the ‘industry integrator’ by some people, and that’s accurate. We are delivering a proven platform connecting payers with providers and vendors on the ancillary medical benefit front. It’s never been done before.”
– Clifford James, Vice President of Strategic Development, Healthesystems

Modernizing the process

To the benefit of both payers and vendors, Healthesystems offers Ancillary Benefits Management (ABM).

The breakthrough ABM solution consists of three foundational components — a technological platform, proprietary medical coding system and a comprehensive benefits management methodology.

The technological platform integrates payers and vendors with a standardized architecture and processes. Business rules and edits can be easily managed and applied across all contracted vendors. All processes – from referral to billing and payment – are managed on a single platform, empowering the payer with a centralized tool for managing the quality of all ancillary providers.

But when it comes to ancillary products, the critical and unique challenge Healthesystems had to solve is the antiquated coding system. This was completed by developing a highly granular, product-specific coding system including detailed descriptions and units of measure for all products and services. This coding provides payers with the clearest understanding of all products and services delivered including pricing and all the necessary utilization metrics.

“We bring the highest level of transparency and visibility into all ancillary products and services,” James said, adding that the ABM platform uses an extensive preferred product coding system 15 times more detailed than any other existing system or program.

This combination of sophisticated technology, proprietary coding system and benefit management methodology revolutionizes the ancillary category. Some of the benefits include:

  • Crystal-clear transparency
  • A more detailed and comprehensive view into ancillary products and services
  • An automated process that eliminates billing discrepancies or resubmittals
  • Integrated and consistent processes
  • Strategic program management

Taken together, the system leapfrogs over the existing hurdles while creating entirely new opportunities. It’s a win for vendors and payers, and ultimately for patients, who receive the optimal product or service.

“We’ve been called the ‘industry integrator’ by some people, and that’s accurate,” James said. “We are delivering a proven platform connecting payers with providers and vendors on the ancillary medical benefit front. It’s never been done before.”

To learn more about the Healthesystems Ancillary Benefits Management solution visit: http://www.healthesystems.com/solutions-services/ancillary-benefits

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthesystems. The editorial staff of Risk & Insurance had no role in its preparation.


Healthesystems is a leading provider of Pharmacy Benefit Management (PBM) & Ancillary Benefits Management programs for the workers' compensation industry.
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Sponsored: Healthesystems

A New Paradigm for Pain Management: Thinking Beyond Opioids

It's time to start thinking beyond opioids and adopt a new approach to pain management.
By: | April 7, 2014 • 4 min read
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It is time for workers’ compensation claims organizations to return to the fundamental principles of occupational medicine and shift the focus of care back to restoring function to injured workers. A new approach to pain management that goes beyond opioid therapy is needed, according to Robert Goldberg, MD, FACOEM, an occupational medicine specialist and chief medical officer at workers’ compensation PBM Healthesystems.

“Before opioid prescribing exploded in the workers’ compensation claim population, physicians focused on treating the injury and restoring as much function as possible so patients could return to work quickly. Today we see well-intentioned physicians prescribing opioids soon after an injury,” observed Dr. Goldberg. “That practice can actually impede recovery and return to work, and opens up patients, payers and employers to increased risks. The outcomes data show that this approach is not working. If payers make a fundamental shift back to a holistic treatment approach, the outcomes will improve for everyone.”

A catalyst for change

A new opioids treatment guideline developed by the American College of Occupational and Environmental Medicine (ACOEM) reflects new evidence and supports Dr. Goldberg’s assertion. It guides the use of medication for pain and discusses alternatives to the use of opioids. It also calls for a significant reduction in the recommended maximum morphine equivalent dosage (MED) from what was previously thought safe. Morphine is the standard against which the potency of other opioids is measured.

A past president of ACOEM, Dr. Goldberg expects the new guideline to serve as a springboard for payers to revisit and retool their pain management strategies, policies and procedures.  “When physicians and payers recognize pain management as a tool that can enable patients to participate in treatment and recover, rather than thinking of it as the ultimate goal of treatment, they can begin to take a more comprehensive approach.”

The new evidence-based ACOEM opioids treatment guideline calls for prescribers to initially implement conservative pain management therapy by prescribing non-opioid drugs. Adjunctive therapies such as physical therapy, acupuncture, cognitive behavioral therapy, yoga and massage therapy can be considered if non-opioid therapies do not provide adequate relief. If pain persists, a short term of opioid therapy can be prescribed as long as appropriate screening and assessments have been conducted to guard against potential drug abuse, addiction or other factors that would contraindicate opioids.

SponsoredContent_Healthesystems“If payers make a fundamental shift back to a holistic treatment approach, the outcomes will improve for everyone.”
— Robert Goldberg, MD, FACOEM Chief Medical Officer, Healthesystems

Incorporate guidelines in policies and procedures

Payers need to develop new policies and procedures that incorporate the most current evidence-based guidelines, and work with their PBM to achieve a comprehensive, layered approach to patient care and pain management. Dr. Goldberg offers these considerations for retooling strategy:

  • Engage in clinically supported discussions with prescribers. Providing educational information to physicians has proven to have a positive impact on prescribing patterns.
  • Work with prescribers to set clear expectations with injured workers around pain relief, pain management and return to work. Patients will fare better if they are educated to expect that some pain may continue or even persist.
  • Approve treatment with physical or occupational therapy to speed functional recovery.
  • Approve alternative therapies to reduce reliance on pain medication. Cognitive behavior therapy, massage and yoga can help patients better cope with the presence of some pain. Adjunctive therapies can also include short courses of chiropractic and acupuncture.
  • Approve a short course of opioid therapy only when appropriate, per evidence-based guidelines, such as when non-opioid and alternative therapies do not provide adequate relief.

Everyone benefits

Such policies and procedures will help payers take a more holistic approach to patient care that goes beyond managing opioids. When the focus of care shifts to achieving functional improvement, the patient, payer and employer derive benefits that can include:

  • reduced adverse effects of treatment
  • reduced length and cost of opioid drug treatment
  • decreased temporary and permanent disability
  • enhanced recovery
  • reduced overall medical and case costs
  • increased likelihood that the injured worker will remain at work or return to work quickly

“Medical costs will inevitably come down with this approach because long-term opioid use will decrease and patients will be able to return to productive employment sooner,” commented Dr. Goldberg.

For more information on opioid strategies, read “Focus on the Patient, Not the Pain” and “Opioid Therapy: Effective Case Planning” in the Fall 2013 issue of Healthesystems’ RxInformer clinical journal. Request a subscription at www.healthesystems.com/rxinformer or access the latest issue on our iPad app in the App Store.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthesystems. The editorial staff of Risk & Insurance had no role in its preparation.
 
Healthesystems is a leading provider of Pharmacy Benefit Management (PBM) & Ancillary Benefits Management programs for the workers' compensation industry.
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Sponsored: Healthesystems

Focus on the Patient, Not the Pain

4 key steps to redefine an opioid management strategy.

By: | March 3, 2014 • 4 min read
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The upcoming release of the new ACOEM opioid treatment guideline reflects new evidence associated with opioid risks. Of note, one of the recommendations is to significantly lower the maximum daily morphine equivalent dose (MED) to 50 from the 120 MED recommended in earlier guidelines. Morphine is the standard against which the potency of all other opioids is measured. While it is tempting to focus on the MED reduction, the real story is the opportunity the new guideline presents for payers to redefine their opioid strategy.

Robert Goldberg, MD, FACOEM, an occupational medicine specialist and chief medical officer at workers’ compensation PBM Healthesystems, expects the new guideline to help reshape the opioid discussion. “Once physicians consistently approach pain relief as a tool for helping speed recovery instead of as the ultimate goal of treatment, everything will change,” noted Dr. Goldberg. “When physicians focus on pain relief as the primary goal and prescribe opioids on the first visit, they open up patients and payers to well-documented risks. The outcomes data show that this approach is not working.”

A past president of ACOEM, Dr. Goldberg recommends payers include four key steps when updating or redefining their current opioid strategy. The steps involve developing a new treatment philosophy; gaining access to the right information systems and clinical expertise; establishing new policies and procedures to support the new approach; and deploying precisely timed clinical tools and strategies to keep claims on track.

SponsoredContent_Healthesystems

Step 1 – Refocus treatment goals

The most effective opioid strategy is one that takes a holistic approach and makes recovery and functional improvement the ultimate goal of treatment. Dr. Goldberg advises physicians and payers to refocus the goal of treatment as a critical first step in updating their opioid strategy.

“A key principle in occupational medicine is to minimize the effects of an injury and help injured workers remain at work whenever possible, or regain function and return to work,” explained Dr. Goldberg. In addition to reframing treatment goals, he recommends implementing these supporting strategies:

  • Focus on adequate pain relief — reduce pain sufficiently so that injured workers can participate in treatment plans to speed recovery.
  • Follow the updated opioids guideline — use non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen as a primary treatment and physical therapy when indicated.
  • Incorporate alternative therapies — adjunctive therapies such as cognitive behavioral therapy, massage, yoga, chiropractic and acupuncture can aid in pain relief and help injured workers cope with the presence of some pain.

Step 2 – Gain access to the right information systems and clinical expertise

Another step needed to update an opioid strategy is to ensure that the claims organization has access to the right data and expert analysis so they can identify claims requiring close attention. To achieve this, payers should:

  • Develop state-of-the-art information systems — or rely on a PBM — to provide reliable data that can quickly identify cases that are moving toward prolonged or accelerated use of opioids.
  • Work with a team of well-trained claims professionals and nurse case managers who can coordinate efforts and make good decisions.
  • Tap the expertise of clinical pharmacists and knowledgeable physicians.

SponsoredContent_Healthesystems“The ultimate goal is for a patient to physically recover, not to simply manage their pain. Once physicians consistently approach pain relief as a tool to help speed recovery, everything will change.”
– Dr. Robert Goldberg, Occupational Medicine Specialist and Chief Medical Officer, Healthesystems

Step 3 – Establish new medical policies and procedures

Clear policies and procedures that reflect the most current evidence-based medical guidelines are an important component of an up-to-date opioid strategy. Dr. Goldberg recommends payers revise policies and procedures to:

  • Approve opioids only when appropriate, per current evidence-based guidelines.
  • Approve alternative therapies such as cognitive behavior therapy and physical therapy to reduce reliance on pain medication when appropriate.

New policies and procedures should delineate:

  • The jurisdictional and professional guidelines that will be applied.
  • What circumstances will trigger clinical interventions — such as MED levels, a defined number of prescriptions or prescribers or other factors.
  • Which cases will be escalated for higher level clinical intervention — such as claims that reach a certain dollar value or involve certain complex conditions or injuries.
  • Which tools and interventions will be deployed and by whom.

Step 4 – Deploy precisely timed tools

An updated opioid strategy should include a robust suite of tools and clinical expertise, as well as define how and when to use them to help keep opioid therapies on track. Claims organizations need a strategic PBM partner with a robust toolkit and a deep bench of clinical expertise to guide them in deploying tools such as:

  • Alerts to pharmacies and claims organizations about issues involving prescription dosing, quantities, early refills and other concerns.
  • Monitoring and analyzing MED levels to ensure patient safety.
  • Real-time therapeutic interventions as part of a prior-authorization process to help prevent risks.
  • Letters of medical necessity that document the need for opioid therapy.
  • Informed consent forms that alert injured workers to the risks associated with opioid therapy.
  • Pain contracts with injured workers that detail what is expected of them while they are receiving opioid therapy.
  • Peer-to-peer interventions by clinical pharmacists or physicians.
  • Screening and assessment tools for substance abuse, opioid risks, depression, pain and other conditions that contraindicate opioid therapy.
  • Compliance monitoring programs using urine drug testing.
  • Drug regimen reviews.
SponsoredContent_Healthesystems

Everyone benefits

An opioid strategy that focuses on achieving functional improvement will yield benefits for the payer, patient and employer that include:

  • Reduced length and cost of opioid drug treatment
  • Reduced adverse effects of treatment
  • Enhanced recovery
  • Increased likelihood that the injured worker will return to work quickly
  • Decreased temporary and permanent disability
  • Reduced overall medical and total case costs

For more information on opioid strategies, request a subscription to Healthesystems’ RxInformer clinical journal or access the latest issue on the app for iPad through the App Store.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthesystems. The editorial staff of Risk & Insurance had no role in its preparation.


Healthesystems is a leading provider of Pharmacy Benefit Management (PBM) & Ancillary Benefits Management programs for the workers' compensation industry.
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