Learning From the Experts
A focus on employer experiences and expertise is a theme you’ll see throughout this conference. During our 31 breakout sessions, a plethora of employers join workers’ compensation and disability thought leaders to provide targeted insights into the obstacles they’ve faced and the strategies they used to achieve optimal outcomes.
John Smolk, principal manager of workers’ compensation for Southern California Edison joins a panel this morning discussing a workers’ compensation benchmarking study that looked at operational challenges and effective strategies to overcome them. [Session CM1, 11 a.m., Islander A&F].
Also this morning, Randy L. Triplett from The Goodyear Tire & Rubber Co. joins Jane Ish of Liberty Mutual Insurance to address outcomes-based medical networks. [Session MM1, 11 a.m., Islander I], and Bill Wainscott of International Paper teams up with attorney Jeffrey A. Kadis for an in-depth look at worker separation and how to conduct a global settlement to avoid litigation. [Session LR1, 11 a.m., South Pacific Ballroom D].
Later today, Jill Dulich of Marriott joins attorney Richard Lenkov to offer 10 ways employers can reduce — or eliminate — their legal expenses immediately. [Session LR2, 2:30 p.m., South Pacific Ballroom D].
Employers looking at the various risk financing options will find answers in an afternoon session with Mark Walls from Safety National [Session PM2, 2:30 p.m., Islander I], while employers with injured, absent or disconnected workers will appreciate the session on engaging such employees, presented by Kevin Confetti of the University of California along with Dr. Teresa Bartlett of Sedgwick. [Session DM1, 11 a.m., Islander D&E].
Managing medical costs — an increasingly complex task for most employers — is the target of a session specifically focused on the kind of cost control measures which can themselves become part of the problem. [Session MM2, 2:30 p.m., Islander G&H].
At today’s luncheon, conference co-chair Roberto Ceniceros will sit down with this year’s Teddy Award winners to delve into the secrets of their successful programs. A celebrated industry journalist, Ceniceros will be taking over the reins of the NWCDC for the 2015 conference.
And don’t forget to download the conference mobile app to plan out your session strategy and to visit with practitioners who just may have the solution to your biggest headache.
Formularies Could Be ‘Missing Piece’ in Cost Control Puzzle
Should California adopt a Texas- or Washington-type pharmaceutical formulary in its workers’ comp system? The California Workers’ Compensation Institute suggests there is strong evidence to support the idea, including estimated cost savings of up to $420 million per year.
“There are quality-of-care, economic, and other social policy reasons that support the adoption of a formulary within the California workers’ compensation system,” according to a report from the organization. “Combined with other tools, such as fee schedules, evidence-based medical treatment guidelines and the state’s prescription drug monitoring program, formularies may be the missing piece that completes the pharmacy utilization and cost control puzzle.”
Like many jurisdictions, California has implemented a number of measures over the years to curb unnecessary spending on medications in the workers’ comp system. But despite the use of fee schedules, pharmacy networks, chronic pain management guidelines, and the optional use of private formularies, “prescription drug payments have continued to increase and remain a significant and growing cost driver in the workers’ compensation system,” the report says. “For example, the Institute’s most recent analysis, published in July of this year, showed that the average amount paid for workers’ compensation prescription drugs in California increased by 28 percent between 2012 and 2013.”
A state-mandated prescription drug formulary is one of the tools that is gaining attention in other jurisdictions. The formularies are essentially lists of approved drugs that dictate what medications are reimbursable.
The formulary in Texas includes an extensive list of approved medications, so is considered inclusive. On the other hand, Washington state’s formulary is considered more exclusive since it has fewer approved drugs and stricter rules on generic substitution of brand name medications. Both states have reported reduced utilization and costs since implementing the formularies.
The authors used a dataset of 1.6 million California workers’ comp prescriptions filled between January 2012 and June 30, 2013, and applied the formularies from Texas and Washington state to determine which drugs would be restricted or eliminated, which would be prescribed as substitutes, and estimated the impact on pharmacy payments.
“The results showed that applying the Texas formulary to the California workers’ compensation prescriptions would exclude 17 percent of the prescriptions, and 29 percent of the payments,” according to the report. “On the other hand, Washington State’s more restrictive formulary would exclude 39 percent of the prescriptions and 70 percent of the payments.”
Additionally, a formulary could also “sharply reduce the use of controversial opioid painkillers,” the report notes. Adopting the Texas formulary would eliminate 36 percent of the more addictive Schedule II opioids from the California system and 65 percent of the costs while a Washington-type formulary would exclude 45 percent of the drugs and 78 percent of the costs.
Savings through a formulary might also be generated through reduced administrative costs, especially dispute resolution. “A state sponsored formulary could remove much of the confusion and many of the challenges that trigger medical dispute resolutions,” the authors noted. “It could reduce the reliance on medical cost containment protocols by as much as one-third.”
Adopting a formulary would require action by the state legislature or through a regulation. But the authors suggest it bears looking into.
“When compared to current utilization patterns and costs in California workers’ compensation, the study found that the additional controls provided by a formulary could reduce total pharmaceutical payments in the system by 12 percent to 42 percent, which translates to a potential savings of $124 million to $420 million a year,” they say. “In addition, the use of such formularies would clarify the rules for drug selection and likely reduce affiliated ancillary services such as drug testing as well as reduce utilization review and independent medical review expenses.”
Changing the WC Medical Care Mindset
Controlling overall workers’ compensation medical costs has been an elusive target.
Yet, according to medical experts from Healthesystems, the Tampa, Fla.-based specialty provider of innovative medical cost management solutions for the workers’ compensation industry, payers today have more powerful options for both offering the highest quality medical care and controlling costs, but they must be more thoroughly and strategically executed.
Specifically as it relates to optimizing patient outcomes and controlling pharmacy costs, the key, say those experts, is to look beyond the typical clinical pharmacy history review and to incorporate a more holistic picture of the entire medical treatment plan. This means when performing clinical reviews, taking into account more comprehensive information such as lab results, physician notes and other critical medical history data which often identifies significant treatment plan concerns but frequently aren’t effectively monitored in total.
Healthesystems’ Dr. Robert Goldberg, chief medical officer, and Dr. Silvia Sacalis, vice president of clinical services, recently weighed in on how using a more holistic, comprehensive strategy can make the critical difference in the ongoing medical care cost control battle.
Fragmentation, Complexity Obscure the Patient Picture
According to Dr. Goldberg, fragmentation remains one of the biggest obstacles to controlling overall healthcare costs and ensuring the most successful treatment in workers’ compensation.
Robert Goldberg, MD, discusses obstacles to controlling overall medical costs and ensuring the best treatment in workers’ compensation.
“There are several hurdles, but they all relate to the fact that healthcare in workers’ comp is just not very well coordinated,” he said. “For the most part, there is poor communication between all parties involved, but especially between the payer and the provider. Unfortunately, it’s rare that all the stakeholders have a clear, complete picture of what’s happening with the patient.”
Dr. Goldberg explains that health care generally has become a more complex landscape, and workers’ comp adds another level of complexity. Physicians have less time to spend with patients due to work loads and other economic factors, and frequently there isn’t adequate time to develop a patient specific treatment strategy.
“Often we don’t have physicians properly incentivized to do a complete job with patients” he said, adding that extra paperwork and similar hurdles limit communication among payers, nurse case managers and other players.
In fact, Dr. Sacalis emphasized that it’s not only the payer, but often the healthcare provider who is not getting a complete picture. For example, a treating doctor may not be the primary care physician and therefore they may not have access to the total healthcare picture for the injured worker.
“Most of all, payers need to adopt a more collaborative approach in their relationships with physicians, employers and patients, as well as networks involved. It will result in getting people back to work through appropriate medical care and moving the case along to a prompt closure.”
– Robert Goldberg, MD, FACOEM, Chief Medical Officer, Healthesystems
“It’s often difficult for multiple physicians to communicate and collaborate about what’s happening because they may not be aware of each-others involvement in that patient’s care,” she said. “Data sharing is lacking, even in integrated healthcare systems where doctors are in the same group.”
Done Right, Technology Can Bridge the Treatment Strategy Gap
Dr. Sacalis explained the role technology advancements can play in creating a more holistic picture of not only an injured workers’ post-accident state or pace of recovery, but also their overall health history. However, the workers’ comp industry by and large is not there yet.
“Today’s technology can be very useful in providing transparency, but to date the data is still very fragmented,” she said. “With technology advancements, we can get a more holistic patient view. However, it is important that the data is both meaningful and actionable to promote effective clinical decision support.”
Silvia Sacalis, PharmD, explains the role that technology advancements can play in creating a more holistic picture of an injured worker’s overall health.
Healthesystems, for example, offers an advanced clinical solution that incorporates a comprehensive analysis of all relevant data sources including pharmacy, medical and lab data as part of a drug therapy analysis. So, for example, the process could uncover co-morbidities – such as diabetes – that may be unrelated to a workplace injury but should be considered in the overall treatment strategy.
“Healthcare professionals must ensure there are no interactions with any
co-morbidities that may limit or affect the treatment plan,” Dr. Sacalis said.
In the majority of cases where Healthesystems has performed advanced clinical analysis, information gathered from the various sources has uncovered critical information that significantly impacted the overall treatment recommendations. Technology and analytics enable the implementation of best practices.
She cites another example of how a physician may order a urine drug screen (UDS), yet the results indicating the presence of a non prescribed drug were not reflected in the treatment regimen as evidenced by the lack of modification in therapy.
“Visibility and transparency will help with facilitating a truly effective treatment plan,” she said, “Predictive analytics are necessary tools for proactive monitoring and detection of trends as well as early identification of cases for intervention.”
Speaking of Best Practices …
Dr. Goldberg highlighted that the most important overall best practice needed to secure the optimal outcome is centered around getting the right care to the right patient at the right time. To him, that means identifying patients who need adjustments in care and then determining medical necessity during the entire case trajectory.
“It means using evidence-based medical treatment guidelines that are coordinated,” he said.
“You must look at the whole patient, which means avoiding the typical barriers in the workers’ comp treatment system, issues such as delays in authorizations, lengthy UR processes or similar scenarios that are well intentioned but if not performed effectively they can get in the way of expedited care.”
Dr. Goldberg and Silvia Sacalis provide recommendations for critical steps payers should take to achieve the best outcomes for everyone.
Dr. Goldberg noted that seeking out the most effective doctors available in geographic locations is another critical best practice. That requires collecting data on physician performance, patient satisfaction and medical outcomes, so payers and networks can identify and incentivize them accordingly.
“This way, you are getting an alignment of incentives with all parties,” Dr. Goldberg said, adding that it also means removing outlier physicians, those whose tendencies are to over-treat, dispense drugs from their office or order unnecessary durable medical equipment, for example.
“Visibility and transparency will help with facilitating a truly effective treatment plan. Predictive analytics are necessary tools for proactive monitoring and detection of trends as well as early identification of cases for intervention.”
– Silvia Sacalis, PharmD, Vice President of Clinical Services, Healthesystems
“Most of all, payers need to adopt a more collaborative approach in their relationships with physicians, employers and patients, as well as networks involved,” he said. “It will result in getting people back to work through appropriate medical care and moving the case along to a prompt closure.”
Dr. Sacalis added that from a pharmacy perspective, another best practice is becoming more patient-centric, using a customized and flexible approach to help payers optimize outcomes for each patient.
“Focus on patient safety first, and that will naturally drive cost containment,” she said. “Focusing on cost alone can actually drive results in the wrong direction.”
Dr. Goldberg explains how consolidation in the health care and WC markets can impact the landscape and quality of care.
Dr. Goldberg and Silvia Sacalis discuss if injured workers today are getting better treatment than they were twenty years ago.
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.