What Lies Ahead for Healthcare Solutions
Change is afoot for Healthcare Solutions, the parent company of Cypress Care, Procura Management, ScripNet and Modern Medical. The company’s acquisition by Catamaran closed on April 8. Catamaran, in turn, will be purchased by UnitedHealth, according to a late March announcement. Risk & Insurance® discussed the implications of the Catamaran acquisition with Joe Boures, CEO of Healthcare Solutions.
Healthcare Solutions made a major announcement recently, how do you expect this change to impact your clients?
The acquisition will have a positive long-term impact on our clients but our primary focus right now is making sure that we continue to service our customers with the same discipline and focus as we do today. Our client service model is staying the same so clients should not feel a disruption in service upon close of the acquisition.
Some acquisitions result in the need to re-implement a program as changes occur to the company’s technology platform. In our case, since Healthcare Solutions’ technology platform is already integrated with Catamaran, there is not a need to re-integrate with our customers as a result of the acquisition. This will allow us to stay focused on current initiatives to make our delivery of medical management services as impactful as possible.
How do you see this change playing out for the future of the company?
Without a doubt, the acquisition will have a positive impact on the future of the company. It provides Healthcare Solutions a stable ownership structure in a rapidly consolidating marketplace, along with access to the resources of a $20 billion company.
Catamaran has a long history in the workers’ compensation space and this is an area of investment for the company. Customers will benefit from the combined organization.
Do you expect your role to remain the same?
Yes, I’ll move over as a senior leader of the workers’ compensation business, with similar functions as I have today.
The last few years saw a lot of consolidation in the workers’ comp industry. Do you think we can expect to see more consolidation going forward and why?
Short answer, yes. The primary reason is that there are still a lot of private equity-owned companies with needed exit strategies. There’s also competitive pressures that will ultimately lead to a consolidated marketplace.
You talk to a lot of customers. What are the key challenges your customers tell you they are facing?
Customers continue to be challenged by medical cost inflation coupled with appropriate utilization controls. Healthcare Solutions’ customers are responsible for coordinating appropriate care for injured workers. They are concerned about injured worker safety and outcomes while also being mindful of spend.
If you just look at pharmacy as a microcosm of medical management, customers are concerned about the increase in compound drugs and physician dispensed drugs, as well as the potential over-prescribing of narcotic opioids. These issues alone are concerning to our customers from both a cost and safety point of view.
At the end of the day, customers are looking for how to do more with less. As businesses operate in leaner environments, they are looking for partners and technology solutions they can leverage to have the greatest impact on their programs.
You’ve been in this space for more than 20 years. What is the most significant advancement you’ve seen?
Technology as an enabler to create seamless business processing, which allows many of our products to truly become programs within our customer base. Though we’ve come a long way, there are more efficiencies to be gained. Both claimant-centric and process-centric technology solutions will continue to evolve and add value for customers.
How has your training as an accountant benefited you as a workers’ compensation executive?
The workers’ compensation industry has and will continue to focus on bottom line results. Having an accounting background allows me to deeply understand relationships around how to drive outcomes-based programs in ways others without that experience are at a disadvantage.
But while an accounting background allows one to understand the language of business, there’s so much more to being an effective workers’ compensation executive. Financial spreadsheets don’t allow you to hear the voice of the customer. I believe that you have to spend a lot of time meeting with and listening to customers. Our business is a people business and top leaders need to have both financial discipline and as well as connectivity with their customers.
We know you’re from Philadelphia Joe, so tell us…where do you get the best cheesesteaks?
Without a doubt, Joe’s Steaks + Soda Shop on Torresdale Avenue. Although this isn’t really a fair question, given that my brother-in-law owns the restaurant.
You don’t have to rely on my opinion though, Joe’s Steaks + Soda Shop is consistently acknowledged as one of Philly’s best cheesesteaks by locals.
Early Case Management Speeds RTW, Report Says
Workers’ comp payers need to develop their own tipping points when seemingly routine claims escalate to high-cost levels. That’s among the strategies suggested in a new white paper.
Genex, a managed care firm, analyzed 46,000 claims over 12 months to identify characteristics that may signal a rapid escalation into excessive costs. While admitting there is no magic formula, the company says there are indications that a claim may be one of the estimated 5 percent that will turn into long-term, chronic cases that may cost millions of dollars. Among them are:
- Poor initial physician diagnosis
- Doctor hopping (e.g., three or more specialty physicians)
- Lack of modified work duty options
- Poor employee/employer relationships
- Psycho-social factors, including poor family support
- Preexisting conditions
- Alcohol or drug dependence
“One of the most important steps employers and carriers can take is to analyze claims and to engage telephonic case management for even routine injuries when two or more red flags are identified,” said Pat Chavanu, senior vice president at Genex. “As an industry we have to move away from setting arbitrary dollar figures for when to bring in case management; we need to utilize it earlier when it can make a difference in terms of costs, outcomes and the well-being of the worker.”
According to the analysis, delaying case management for a year can decrease the likelihood of the injured worker returning to work by nearly 20 percent. Claims that use case management in the first nine months are two times more likely to have a successful RTW as those referred three years after the incident.
“This does not mean, however, using case management for all claims,” the paper said. “Benchmarks, data, organizational culture and goals must be defined and incorporated into employer tipping point criteria.”
The company advises payers to hold case management programs accountable. “Look at their costs, how quickly they return employees to work, and whether they help to reduce litigation,” the paper said. “Does the organization also tell you when case management is not necessary? Ask claimants about their experience. Is it positive, negative?”
Payers should develop criteria based on the organization’s RTW goals, the paper advised. Also, they should make sure injured workers have access to a network of savvy workers’ comp providers, and give adjusters tools and resources to identify red flag claim characteristics.
Mitigating Fraud, Waste, and Abuse of Opioid Medications
There’s a fine line between instances of fraud, waste, and abuse. One of the key differences is intent and knowledge. Fraud is knowingly and willfully defrauding a health care benefit program for personal gain or profit. Each of the parties to a claim has opportunity and motive to commit fraud. For example, an injured worker might fill a prescription for pain medication only to sell it to a third party for profit. A prescriber might knowingly write prescriptions for certain pain medications in order to receive a “kickback” by the manufacturer.
Waste is overuse of services and misuse of resources resulting in unnecessary costs, whereas abuse is practices that are inconsistent with professional standards of care, leading to avoidable costs. In both situations, the wrongdoer may not realize the effects of their actions. Examples of waste include under-utilization of generics, either because of an injured worker’s request for brand name medication, or the prescriber writing for such. Examples of abusive behavior are an injured worker requesting refills too soon, and a prescriber billing for services that were not medically necessary.
Actions that Interfere with Opioid Management
Early intervention of potential fraud, waste, and abuse situations is the best way to mitigate its effects. By considering the total pharmacotherapy program of an injured worker, prescribing behaviors of physicians, and pharmacy dispensing patterns, opportunities to intervene, control, and correct behaviors that are counterproductive to treatment and increase costs become possible. Certain behaviors in each community are indicative of potential fraud, waste, and abuse situations. Through their identification, early intervention can begin.
- Prescriber/Pharmacy Shopping – By going to different prescribers or pharmacies, an injured worker can acquire multiple prescriptions for opioids. They may be able to obtain “legitimate” prescriptions, as well as find those physicians who aren’t so diligent in their prescribing practices.
- Utilizing Pill Mills – Pain clinics or pill mills are typically cash-only facilities that bypass physical exams, medical records, and x-rays and prescribe pain medications to anyone—no questions asked.
- Beating the Urine Test – Injured workers can beat the urine drug test by using any of the multiple commercial products available in an attempt to mask results, or declaring religious/moral grounds as a refusal for taking the test. They may also take certain products known to deliver a false positive in order to show compliance. For example, using the over-the-counter Vicks® inhaler will show positive for amphetamines in an in-office test.
- Renting Pills – When prescribers demand an injured worker submit to pill counts (random or not), he or she must bring in their prescription bottles. Rent-a-pill operations allow an injured worker to pay a fee to rent the pills needed for this upcoming office visit.
- Forging or Altering Prescriptions –Today’s technology makes it easy to create and edit prescription pads. The phone number of the prescriber can be easily replaced with that of a friend for verification purposes. Injured workers can also take sheets from a prescription pad while at the physician’s office.
- Over-Prescribing of Controlled Substances – By prescribing high amounts and dosages of opioids, a physician quickly becomes a go-to physician for injured workers seeking opioids.
- Physician dispensing and compounded medication – By dispensing opioids from their office, a physician may benefit from the revenue generated by these medications, and may be prone to prescribe more of these medications for that reason. Additionally, a physician who prescribes compounded medications before a commercially available product is tried may have a financial relationship with a compounding pharmacy.
- Historical Non-Compliance – Physicians who have exhibited potentially high-risk behavior in the past (e.g., sanctions, outlier prescribing patterns compared to their peers, reluctance or refusal to engage in peer-to-peer outreach) are likely to continue aberrant behavior.
- Unnecessary Brand Utilization – Writing prescriptions for brand medication when a generic is available may be an indicator of potential fraud, waste, or abuse.
- Unnecessary Diagnostic Procedures or Surgeries – A physician may require or recommend tests or procedures that are not typical or necessary for the treatment of the injury, which can be wasteful.
- Billing for Services Not Provided – Since the injured worker is not financially responsible for his or her treatment, a physician may mistakenly, or knowingly, bill a payer for services not provided.
- Compounded Medications – Compounded medications are often very costly, more so than other treatments. A pharmacy that dispenses compounded medications may have a financial arrangement with a prescriber.
- Historical Non-Compliance – Like physicians, pharmacies with a history of non-compliance raise a red flag. In states with Prescription Drug Monitoring Programs (PDMPs), pharmacies who fail to consult this database prior to dispensing may be turning a blind eye to injured workers filling multiple prescriptions from multiple physicians.
- Excessive Dispensing of Controlled Substances – Dispensing of a high number of controlled substances could be a sign of aberrant behavior, either on behalf of the pharmacy itself or that injured workers have found this pharmacy to be lenient in its processes.
Clinical Tools for Opioid Management
Once identified, acting on the potential situations of fraud, waste, and abuse should leverage all key stakeholders. Intervention approaches include notifying claims professionals, sending letters to prescribing physicians, performing urine drug testing, reviewing full medical records with peer-to-peer outreach, and referring to payer special investigative unit (SIU) resources. A program that integrates clinical strategies to identify aberrant behavior, alert stakeholders of potential issues, act through intervention, and monitor progress with the injured worker, prescriber, and pharmacy communities can prevent and resolve fraud, waste, and abuse situations.
Proactive Opioid Management Mitigates Fraud, Waste, and Abuse
Opioids can be used safely when properly monitored and controlled. By taking proactive measures to reduce fraud, waste, and abuse of opioids, payers improve injured worker safety and obtain more control over medication expenses. A Pharmacy Benefit Manager (PBM) can offer payers an effective opioid utilization strategy to identify, alert, intervene upon, and monitor potential aberrant behavior, providing a path to brighter outcomes for all.