The patient, injured as a result of excessive stretching and bending while on the job, suffered hand strain and pain throughout her arms, as well as foot pain. At one point late in the treatment process, OxyContin, a powerful controlled substance painkiller, and Valium were added to Zanaflex and Percocet with no documented rationale by the treating physician. In fact, there were no serious pain levels noted at the time.
The case continued, but eventually, with the help of InterventionRX, a relatively new product from Westerville, Ohio-based Progressive Medical, an intervention team of physicians and pharmacists determined that the added drugs had no reason to be included in treatment. Apart from discontinuing payment for the narcotic medication, they recommended the patient get addiction counseling and help with a more holistic treatment plan.
As cases like this one drag on, medical costs can soar. And in these long-term cases, drugs such as OxyContin more often than not do little to help the patient with their medical conditions, while costs climb.
In fact, according to a National Council on Compensation Insurance (NCCI) 2007 report on prescription drug spending in workers' compensation, in the first year, prescription drugs on average are only 3 percent of medical costs, but by year seven, that number jumps to almost 31 percent of overall medical costs. In these cases, the average annual prescription drug spend is an alarming $27,000.
According to Jason Winters, the pharmacist who manages Progressive Medical's InterventionRX team, the product offers an in-depth medication utilization evaluation completed by a pharmacist alone or in conjunction with a physician. The resulting report ensures that an injured party's medication usage is appropriate, while providing a clinical rationale to support any recommendations regarding appropriate changes in treatment.
"Typically, the InterventionRX level is determined by the number of medications," Winters explains, adding that Progressive Medical's experience has shown that the following types of claims are best suited for this service:
--Claims with excessive medications
--Claims older than three years
--Claims pending litigation and/or settlement
Once a self-insured employer, insurance carrier or third-party administrator (TPA) requests an InterventionRX report, a pharmacist contacts them with a request to provide details for sending the appropriate documents. In addition, there is also an electronic upload process that can be used to send files.
Service level-wise, InterventionRX offers three options, including a Pharmacist Review (clinical analysis and reporting completed by a pharmacist), Pharmacist/Physician Review (clinical analysis and reporting completed by a pharmacist in conjunction with a physician), and an optional physician-to-physician consultation, in addition to the Pharmacist/Physician review, regarding the report conclusions.
Winters explains that Progressive Medical clients use InterventionRX for many reasons, but mostly as a rationale for change in drug therapy that follows established, evidence-based clinical practical guidelines and state regulations. Other reasons for use include quick turnaround (the detailed report with findings will be created within 21 business days), and the information contained in the report can be used as evidence in a court of law.
"This really is a customer-driven product," Winters says. "Our customers are seeing that these cases were eating up a disproportionately large chunk of their workers compensation medical costs, as well as their concern with improving patient care."
Jill Russeau, a claims manager with V&A Risk Services, a workers' compensation claims management provider in Toledo, Ohio, says she first learned of InterventionRX at a 2006 self-insured seminar in Cleveland. V&A was already a Progressive Medical customer, but InterventionRX really struck a chord.
"We definitely need to have this type of review before we suggest a change in medication," Russeau says. "When it was presented, I immediately knew that this would be a good thing to have on our side. What's great is that we have a solid report, based on established clinical guidelines, that says the InterventionRX physician talked to the patient's treating physician. It's all documented.
"Why should we pay these very high bills for over-medicating a patient?" Russeau adds. "And it's not really good for the patient, either."
Russeau says InterventionRX is used selectively, primarily when someone gets too many prescriptions and pain medications for a relatively minor injury.
"It's definitely a helpful tool for claim managers, and well worth the cost," she says. "When you consider costs versus potential savings, it more than pays for itself."
Dr. Bill Hopper, MD, serves as national medical director for Addison, Texas-based Concentra Physician Review, which is one of Progressive Medical's partners in the InterventionRX product. According to Dr. Hopper, who is board certified in Family Medicine and Addiction Medicine, InterventionRX combines a team approach that delivers not only a comprehensive written product, but a telephonic peer-to-peer discussion focused on whether or not the treatment plan is the right one.
"Most of these cases are so-called legacy cases, where the average age of claim is seven or eight years, so the patient often is on a treatment treadmill," he says. "What we offer is a robust, rigorous analysis of the case. We thoroughly review the submitted records, and after the pharmacist makes a recommendation, we apply evidence-based practice and state medical board guidelines for controlled substances."
Hopper adds that while it's a sad statement, many times these guidelines are ignored.
"Most of all, we do not approach the treating physician from an adversarial position, but from a risk management and education standpoint," he says. In fact, in many of these cases, the InterventionRX team also provides referrals for addicted patients, so they can get the best treatment.
Hopper says that the key challenge is that in many of these outlier cases, the treating physicians often have a practice that depends on these types of cases, so it can be difficult communicating the concerns about the treatment plan. And that's where the risk management element comes into play.
"They really could be exposed to vicarious liability in prescribing medications that are not supported by FDA regulations" he says.
However, Hopper says, it's not about dollars and cents. In fact, cost savings are a by-product of InterventionRX's true mission.
"It's about doing the right thing, for the right patient, at the right time," he says. "We approach the process with the patient in mind."
For more information about InterventionRX, contact Linda Kaufmann, Progressive Medical, at (614) 212-8255, or visit progressive-medical.com.
piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for
Insights was written and edited by Risk & Insurance®
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March 25, 2009
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