For many years, Intrathecal injections and pumps have proven an effective way to manage chronic pain in workers' compensation cases. But, as it turns out, Intrathecals can use some managing themselves--both to deliver the best possible quality of life to the patient and to keep costs from skyrocketing.
Intrathecal injections (technically, more pumps than injections) are used in very limited situations compared to other methods of administering pain medication. Even so, they present a risk of being a "hidden spend" for workers compensation payors.
As can happen, explains Tron Emptage, RPh, MA, a pharmacist and vice-president with Westerville, Ohio-based Progressive Medical's Intervention RX program, the high costs for medications administered via Intrathecal pumps often are blended into the treating physician's fees and can be difficult to discern. When you consider that, depending on the provider, a single Intrathecal infusion can cost more than $1,000 (while the medications involved might cost a fraction of that number), it often is an expensive treatment management challenge.
Progressive Medical's Intervention RX offers a team of physicians and pharmacists to help payors maximize both medical care and cost. Progressive Medical helps clients--carriers, self-insured employers and TPAs--get a better handle on managing the potentially high costs of Intrathecals, Emptage explains.
"The cost of Intrathecal injections might be wrapped in with an overall medical bill," says Emptage, who has seven years of home infusion experience using Intrathecals. "It may be part of a clinical invoice and categorized as medical spend and not a pharmacy spend, which can be very hard to determine. Our first step is to bring the situation to the client's attention."
Jason Winters, RPh, pharmacist and clinical manager at Progressive Medical, explains that an "Intrathecal" pump delivers medication into the space surrounding the spinal cord, typically in a spinal anesthesia, chemotherapy or pain management applications. Medication given this way avoids the need to cross the "blood brain" barrier. If administered orally, the same drug enters the blood stream with a much higher likelihood of side-effects and much higher doses.
"Medications delivered Intrathecally must be made up by a pharmacist, technician or physician, because Intrathecals cannot contain any preservative or other potentially harmful inactive ingredients that are sometimes found in standard injectable drug preparations," Winters says.
Intrathecals have been used for some time in pain management procedures, however, with the move back to the physician's office, they can go unmanaged--a factor in rising costs for Intrathecals.
With that trend moving into workers compensation health care, Progressive Medical's (progressive-medical.com) approach is to put more managed care around Intrathecal treatments administered by physicians.
The Intervention RX team offers clinical pharmacists who can bring high-cost procedures such as Intrathecals into direct oversight via the review process. In some cases, the results have been dramatic, as patients have received the same (or even improved) intrathecally delivered medications for 50 percent less than the original cost.
Emptage says it starts with an initial intervention, where the Progressive Medical team works with the compounding pharmacists. The most dramatic results, however, occur when Intervention RX pharmacists work directly with the physician filling Intrathecal pumps in an office setting. Emptage explains that while cost is a consideration, the most important aspect of the Intervention RX process is the ability to assist physicians in helping patients enjoy the best possible quality of life.
"Most of all, it's vital to avoid situations where a patient may not have had a positive outcome," he says.
Winters, who oversees the program directly, explains that some states now have either special language within pharmacy laws or extra certification specifically required for preparation of sterile compounds. As such, Progressive Medical provides any payor wanting more management around an Intrathecal program with the current jurisdictions Progressive is able to service for sterile compounds.
Progressive vendors currently are licensed to fulfill sterile compound prescriptions for claimants receiving care in California, Colorado, Georgia, Florida, Illinois, Indiana, Kansas, Massachusetts, Minnesota, Missouri, Nebraska, North Dakota, North Carolina, New York, Ohio, Oklahoma, Pennsylvania and Texas.
Once a payor identifies a workers' compensation claimant using medications via implanted Intrathecal pump, it refers the claim to Progressive for Drug Utilization Review (DUR).
At this point, Winters says, Progressive mails an introductory letter to the administering physician of Intrathecal medications. This letter offers contact information for Clinical Services and introduces the chosen vendor offering to provide medication fulfillment.
"Every step of the way, our team tracks the process, so there are no surprises or hidden costs and the patients get the best possible outcomes." Emptage says. "What we are doing is bringing more process and control around Intrathecals."
Emptage says that while treating physicians may not be receptive at first, many do see the benefits of working with the Intervention RX team, especially, clinical pharmacists for their expertise around medications and medication therapy management.
"We understand that the physician has trust relationship with the pharmacist down the street," Winters says. "After all, you are injecting a clear liquid into someone in a very delicate procedure. So changing that mindset is a challenge, but it's slowly happening since we began the Intrathecal program in January."
Of course, Winters says, payors can be reluctant to pay for the cost of an Intrathecal implant, but if managed properly, the cost of these therapies can be less expensive than oral medications, and certainly more effective in specific cases.
"Intrathecals are used when a patient has intractable pain," he says. "And they are very effective when administered properly."
Most of all, apart from delivering the best possible medical care, payors need to be aware that Intrathecals, because they are not a mainstream procedure, can get mired in the billing process.
"These usually don't come to us as part of a regular pharmacy bill," he says. "We help payors understand how Intrathecals are billed, because typically they are not being managed as pharma spend by the client or their PBM. We understand the billing, and where to find and reduce these costs, while delivering quality care."
For more information about Progressive Medical's Intrathecal program, contact Jason Winters, RPh, Manager of Clinical Program Development, or Tron Emptage, RPh, EVP, Business Development.
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August 5, 2009
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