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By PETER ROUSMANIERE, an expert on the workers' compensation industry

As pharmacy benefit management firms help insurance carriers monitor and pay for the use of prescription drugs, they've grown beyond their traditional function of negotiating for the best price in search of aggressive discounts.

As PBMs have expanded their focus beyond negotiating lower unit drug costs, they've played a greater role in controlling the amount of prescriptions used by patients. Why? Because managing prescription drug use has a greater impact on drug costs than does managing unit costs, according to the National Council on Compensation Insurance.

Risk and Insurance® talked with Daryl Corr, president of Healthesystems, about the scope of the issues surrounding pain drugs prescribed in workers' comp, and what his firm is doing about it. Corr's focus includes patient safety but extends into correct pain management strategies.

Corr notes that there are a lot of patients who need to have pain drugs, but the drugs are sometimes wrongly prescribed. "One of the primary strategies we have," he says, "is the identification of patients in trouble or headed to trouble."

Patient safety is at the top of the list of Corr's concerns. He has in place controls over the quantity of drugs being prescribed. That's just the start of the firm's oversight. Healthesystem also conducts a great deal of outreach to the prescribing physicians. Many prescribers are primary physicians who need and appreciate coaching on managing their pain cases.

The firm educates them to identify what it perceives as possible, probable or definitely overuse of opioids, identifying various strategies doctors can employ to correct the situation.

"We can recommend a detoxification problem," says Corr. "We are in possession of enough information that the data has the hallmarks of someone who is in trouble. And there are situations where we have to be a little bit more forceful and actually refer to a state medical or pharmacy board."

When it does a full review, Healtheystsems sends an extensive evaluation to the physician and the insurer. It includes a sample opioid agreement for the patient to sign, committing her or him to specific behaviors.The firm also may recommend urine drug testing and pill counts.

"One of the things we do," Corr says, "is to send the copy of the fill or refill records to the physician. It may be quite revealing to the physician, as it allows them to see other prescribers are also involved in the case."

Healthesystem's review of a case can result in a 30-page report for its insurer client, giving direction to on what to do next.

Corr says that the report should be useful to an independent medical examiner, if one is assigned by the insurer to review the claim. The report, says Corr, gives the insurer "literally the questions to ask" the independent medical exam physician.

The report may recommend that the insurer assign a case manager to a high-risk or high-profile case, to make sure they get to their appointments and enroll in physical therapy.

It recently came upon a case in which the cancer-fighting drug Actiq was prescribed. This lollipop-shaped pill is widely used by the medical community for musculoskeletal pain as well. Over a period of time the dosage of all drugs the patient was prescribed was the equivalent of $58,000 per month.

December 1, 2008

Copyright 2008© LRP Publications