PBM Legislation Worries Workers’ Comp Payers
Legislation introduced in several states seeking to impose new regulatory authority over group health pharmacy benefit managers could harm workers’ compensation PBMs and claims payers, sources said.
Introduction of similar bills in 11 states has raised concerns among workers’ comp insurers, third party administrators, and some large employers, said Brian Allen, VP of government affairs for Progressive Medical, a workers’ comp PBM.
“We have had customers calling us every day worrying about how it is going to impact us and them,” Allen said. “These are big insurance companies … they are nervous about it and want to know how it’s going to impact them.”
Overall, it appears the bills seek greater transparency in the way group health PBMs set their pricing, said Joe Paduda, principal at Health Strategy Associates. But group health PBM practices differ substantially from those of workers’ comp PBMs and the bills seek to address issues that “have nothing to do with workers’ comp,” he added.
Yet while the bills appear aimed at practices among PBMs serving the group health industry and not workers’ comp PBMs, Allen and others say a spillover into workers’ comp is possible. So several organizations want language inserted into the bills that would clearly exempt workers’ comp PBMs.
“It appears that workers’ compensation PBMs are not the target of this legislation,” the American Insurance Association said in a statement. “That said, AIA supports efforts to include clear exemptions for workers’ compensation PBMs in these bills in order to clarify legislative intent and avoid any confusion down the road.”
“Community” pharmacies seeking more revenue from products they dispense are supporting the bills that would put PBMs under certain state regulatory agencies, such as pharmacy boards, Allen said.
State workers’ comp commissions or insurance departments already regulate workers’ comp PBMs, depending on the jurisdiction, Allen explained. But the legislation could add oversight from additional agencies such as state pharmacy boards.
Complying with regulations developed by two distinct agencies with potentially conflicting goals could cause an administrative burden for workers’ comp PBMs, Allen added.
“We want to make sure we are not swept up into crazy regulatory schemes that would be difficult to manage,” he said.
A new oversight body could also decide to impact workers’ comp PBM pricing, which is already regulated by state fee schedules, Allen said.
“If for some reason the pharmacy board said, ‘you have to pay pharmacists more money,’ that potentially would impact our customers because we would have to pass that cost onto payers,” Allen said.
Health and Safety Success Requires Cultural Change
Dustin G. Richartz spends much of his time lately helping organizations develop the leadership necessary to drive health and safety within their companies.
The senior loss control consultant with Kansas City-based Lockton Companies, Richartz was recently awarded the 2015 Monsanto Queeny Safety Professional of the Year Award by the American Society of Safety Engineers for his work in developing safety and health programs.
Edgar Monsanto Queeny was president of Monsanto in 1947 when an explosion aboard a French freighter destroyed the company’s Texas City plant, killing 512 people, including 145 Monsanto employees. Queeny took the loss and devastation to heart and put greater emphasis on safety in the company’s operations. The company sponsors the Edgar Monsanto Queeny Safety Professional of the Year Award in his memory.
“It’s an extreme honor, as ASSE is one of the largest safety and health organizations with some 37,000 members globally,” he said. “To be recognized as safety professional of the year is a huge honor and one I definitely don’t take lightly.”
Richartz began his career in safety and health in the manufacturing industry and eventually joined the insurance side. He’s helped organizations create programs to keep their employees safe.
“A lot of time is spent on injury prevention programs, developing tools and techniques organizations can use to protect their workers,” he said. “Some are OSHA regulatory programs, and some are environmental programs; environmental evaluations to make sure organizations are adequately protecting their employees. It really is broad based. Safety and health is not just focused on one specific area. A lot of different things go into it.”
In the 15 years he’s been in the safety and health industry, Richartz has seen a change in focus. Keeping workers free of injury and illness now involves all aspects of an organization.
“One of the biggest changes I’ve seen with a lot of organizations, especially those more progressive, is a shifting away from safety and health being a regulatory entity and allowing it to be a component of the business operations and minimizing risk,” Richartz said. “For the first couple of years that was the way the profession was focused — on regulations and compliance rather than on risk mitigation.”
Part of the reason for the shift is because of what Richartz and other safety and health experts say are outdated regulations. Many of the OSHA mandates, for example, were developed in the 1970s and have not been updated to reflect changes in the workplace. Much more is necessary to fully develop an effective safety and health program.
“You’d start with the compliance. It really is a foundational piece,” he said. “Then you’d develop the cultural aspects, leadership that would really help drive the risk unit. So it’s not focused on just the foundation but building it up and integrating it in every aspect of the organization from the front line to your CEO.”
Changing the culture of an organization is not an easy or quick process. It requires the involvement and commitment of organizational leaders.
“Grassroots activities can help move the needle, but it really takes a senior executive to commit to hold their operations teams accountable to make the changes necessary,” Richartz said. “The middle managers influence the activities of the front line workers, but senior executives drive the overall culture.”
Where Richartz often sees companies making the necessary cultural change is in smaller businesses. “They are often more family run organizations,” he said. “Some businesses and industries may push back more than others. But as we see more and more attention placed on occupational safety and health, more organizations are understanding if they don’t do that it will impact their business in a negative way.”
Getting an organization to focus on safety and health requires strong leadership, Richartz explained. It’s an area that can be the key to preventing injuries and illnesses.
“It’s something I’m passionate about,” he said. “It really helps individuals and organizations move the needle, especially if they are stuck in the regulatory mindset. Focusing on developing middle and upper management to understand what it means to lead in safety and get more involvement and buy-in from their mid-level and front line employees. That’s where a lot of my time has been spent with clients and ASSE and other organizations.”
Leadership is one of the qualities that make for an effective safety and health professional, Richartz said. He mentors young people on developing that and other necessary skills.
“A big part is understanding that a lot of occupational safety and health is really based about people and developing soft skills necessary to influence change and influence individuals, not just try and direct but get them to buy into your ideas and thoughts,” Richartz said. “It takes time for you as a professional to develop those skills.”
With aging workers leaving the industry, safety and health professionals are focused on ways to attract new people. Richartz spends much of his time doing just that.
“One of the things I’ve done a lot of work with is partnering with [ASSE’s] Future Safety Leaders Conference Committee to really help develop leaders and invest in those educational programs that are out there to make sure students when they do come out understand the people side as well as the book side,” he said. “A lot of what we do is not just regulatory based … but focuses on the soft skill side.”
Among the changes he sees on the horizon is the trend to focus on the sustainability side of operations, especially for organizations in manufacturing processes and that have global suppliers.
Managing Chronic Pain Requires a Holistic Strategy
Chronic, intractable pain within workers’ compensation is a serious problem.
The National Center for Biotechnology Information, part of the National Institutes of Health, reports that when chronic pain occurs in the context of workers’ comp, greater clinical complexity is almost sure to follow.
At the same time, Workers’ Compensation Research Institute (WCRI) studies show that 75 percent of injured workers get opioids, but don’t get opioid management services. The result is an epidemic of debilitating addiction within the workers’ compensation landscape.
As CEO and founder of Integrated Prescription Solutions Inc. (IPS), Greg Todd understands how pain is a serious challenge for workers’ compensation-related medical care. Todd sees a related, and alarming, trend as well – the incidence rate for injured workers seeking permanent or partial disability because of chronic pain continues to rise.
Challenges aside, managing chronic pain so both the payer and the injured worker can get the best possible outcomes is doable, Todd said, but it requires a holistic, start-to-finish process.
Todd explained that there are several critical components to managing chronic pain, involving both prospective and retrospective solutions.
Prospective View: Fast, Early Action
“Having the wrong treatment protocol on day one can contribute significantly to bad outcomes with injured workers,” Todd said. “Referred to as outliers, many of these ’red flag’ cases never return to work.”
Best practice care begins with the use of evidence-based UR recommendations such as ODG. Using a proven pharmacological safety and monitoring opioid management program is a top priority, but needs to be combined with an evidence-based medical treatment and rehabilitative process-focused plan. That means coordinating every aspect of care, including programs such as quality network diagnostics, in-network physical therapy, appropriate durable medical equipment (DME) and in more severe cases work hardening, which uses work (real or simulated) as a treatment modality.
Todd emphasized working closely with the primary treating physician, getting the doctor on board as soon as possible with plans for proven programs such as opioid Safety and Monitoring, EB PT facilities, patient progress monitoring and return-to-work or modified work duty recommendations.
“It comes down to doing the right thing for the right reasons for the right injury at the right time. To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach.”
— Greg Todd, CEO and founder, Integrated Prescription Solutions Inc. (IPS)
Alternative Pain Management Strategies
Unfortunately, pain management today is practically an automatic move to a narcotic approach, versus a non-invasive, non-narcotic option. To manage that scenario, IPS’ pain management is in line with ODG as the most effective, polymodal approach to treatment. That includes N-drug formularies, adherence to therapy regiment guidelines and inclusive of appropriate alternative physical modalities (electrotherapy, hot/cold therapy, massage, exercise and acupuncture) that may help the claimant mitigate the pain while maximizing their ongoing overall recovery plan.
IPS encourages physicians to consider the least narcotic and non-invasive approach to treatment first and then work up the ladder in strength – versus the other way around.
“You can’t expect that you can give someone Percocet or Oxycontin for two months and then tell them to try Tramadol with NSAIDS or a TENS unit to see which one worked better; it makes no sense,” Todd explained.
He added that in many cases, using a “bottom up” treatment strategy alone can help injured workers return to work in accordance with best practice guidelines. They won’t need to be weaned off a long-acting opioid, which many times they’re prohibited to use while on the job anyway.
Chronic Pain: An Elusive Condition
Soft tissue injuries – whether a tear, sprain or strain – end up with some level of chronic pain. Often, it turns out that it’s due to a vascular component to the pain – not the original cause of the pain resulting from the injury. For example, it can be due to collagen (scar tissue) build up and improper blood flow in the area, particularly in post-surgical cases.
“Pain exists even though the surgery was successful,” Todd said.
The challenge here is simply managing the pain while helping the claimant get back to work. Sometimes the systemic effect of oral opioid-based drugs prohibits the person from going to work by its highly addictive nature. In a 2014 report, “A Nation in Pain,” St. Louis-based Express Scripts found that nearly half of those who took opioid medications for more than a month in their first year of treatment then refilled their prescriptions for three years or longer. Many studies confirm that chronic opioid use has led to declining functionality with reduced ability to recover.
This can be challenging if certain pain killers are being used to manage the pain but are prohibitive in performing work duties. This is where topical compound prescriptions – controversial due to high cost and a lack of control – may be used. IPS works with a reputable, highly cost-effective network of compound prescription providers, with costs about 30-50 percent less than the traditional compound prescription
In particular compounded Non-Systemic Transdermal (NST) pain creams are proving to be an effective treatment for chronic pain syndromes. There is much that is poorly understood about this treatment modality with the science and outcomes now emerging.
Retrospective Strategies: Staying on Top of the Claim
IPS’ retrospective approach includes components such as periodic letters of medical necessity sent to the physician, peer-to-peer and pharmacological reviews when necessary, toxicology monitoring and reporting, and even addiction rehab programs specifically tailored toward injured workers.
Todd said that the most effective WC pharmacy benefit manager (PBM) provides much more than just drug benefits, but rather combines pharmacy benefits with a comprehensive ancillary suite of services in a single portal assisting all medical care from onset of injury to RTW. IPS puts the tools at the adjustor fingertips and automates initial recommendations as soon as the claim in entered into its system through dashboard alerts. Claimant scheduling and progress reporting is made available to clients 24/7/365.
“It comes down to doing the right thing for the right reasons for the right injury at the right time,” Todd said, “To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach,” he said.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with IPS. The editorial staff of Risk & Insurance had no role in its preparation.