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The patient, a 62-year-old woman, injured her back at work. The employer-appointed doctor diagnosed a herniated disc and soon thereafter, she underwent a discectomy and fusion. The patient also complained of severe neck pain, and the result was a final diagnosis of post-laminectomy syndrome--basically pain that occurs post-op.

In the end, this particular case turned out positive for both the employer/payor and the patient because it was properly managed through the entire care lifecycle. PMSI, based in Tampa, Fla., and one of the nation's largest and most experienced providers of specialty products and services for the workers' compensation market, handled this claim using its MedAssess^TM Program. MedAssess offers an integrated program that covers all care levels and manages every stage of the claim lifecycle by assessing and addressing inappropriate utilization in order to reduce costs and improve patient care.

In this case, PMSI delivered dramatic cost reduction. Therapeutic interventions during the injury lifecycle resulted in combined annual savings of nearly $9,000--a 64 percent decrease. In addition, larger savings would likely have been achieved by the avoidance of additional medical visits, ER visits and/or hospitalizations known to occur with high-risk medication use.

"Our clients have told us that medical costs contribute a progressively larger share of their total claims costs," says Dr. Maria Sciame, PharmD, CDE, RRT, PMSI's Director of Clinical Services.

In a 2009 research brief, the National Council on Compensation Insurance (NCCI) reported that the cost of prescription drug therapy, medical supplies and equipment--three of the prime product/services areas PMSI serves--is responsible for more than 50 percent of total workers' compensation medical spending.

NCCI's cost factor breakdown is especially evident as claims continue long term, because managing the cost of care can be a challenge when you consider inflation, the entry of new and more expensive products into market each year, and the aging of the workforce.

Although noncontrollable factors also can affect costs, the PMSI case clearly shows how mitigating inappropriate utilization can have a significant impact. For one, injured workers such as the woman in the PMSI case are using more products and medications, as physicians write more prescriptions. Plus, today's direct-to-consumer marketing has influenced injured workers to request name-brand prescription medications, which drive up costs. Finally, the growth of new ideas and ways to manage pain is causing complexity that can ratchet up costs.

"It wasn't long ago that a physician would prescribe one medication to treat patients," Sciame says. "Now it is common practice to prescribe two or three. Injured workers' prescription requests also often move beyond traditional pain medication into adjunctive or supportive therapy for pain management." For example, rather than a pain medication alone, patients may take antidepressants or anti-convulsants for pain control.

Despite these challenges, there is a positive way to successfully manage costs and ensure maximum patient care, but it takes a progressive, innovative, evidence-based strategy--one that roots out the critical factors that make a real difference in both cost control and patient care.

In the PMSI case, when prescriptions for orphenadrine, ketorolac, Effexor XR and hydrocodone/acetaminophen were prescribed by the employer-appointed physician, PMSI's Utilization Control program through MedAssess engaged prospective drug utilization review (DUR) and the application of a workers' compensation-specific formulary to prevent inappropriate medication utilization.

PMSI determined that all of the patient's prescriptions, with the exception of Effexor XR (an antidepressant), were appropriate. Using PMSI's clinical resources, the claims adjuster decided not to authorize the non-formulary use of Effexor XR, for an annual savings of $1,782.

Despite some improvement, the patient continued to experience pain, received additional prescriptions from another prescriber, and slowly transitioned from the acute to the chronic phase of injury. All along, PMSI's Targeted Intervention level of care through MedAssess identified and addressed therapy concerns, including issuing a letter to the physician indicating that the High-Risk Profiling service had identified a possible risk of complications from duplication of the NSAID medications. As a result, the employer-appointed physician discontinued ketorolac therapy, for annual cost savings of over $1,000 and a better patient outcome.

Three months after the initial injury, the patient also received prescriptions for propoxyphene and Alprazolam from her family physician. Again, MedAssess went to work. The family doctor received a Multiple Prescribers letter alerting him to the presence of other prescribers that the patient was utilizing to obtain opioid pain relievers. The physician then consolidated the patient's opioid regimen to a single short-acting agent and worked with the other prescribers to appoint a lead prescriber for opioids.

As the case grew more complex, PMSI enrolled the patient in its Pain Management program to optimize her therapy and reduce the potential for hospitalization and related costs. PMSI also alerted the claims professional about the need for comprehensive evaluation of the patient's medication regimen via the Medication Review service, part of MedAssess' Care Management program.

The claims adjuster noted the high-risk issues identified by the review and requested that PMSI arrange for physician peer-to-peer outreach in order to facilitate appropriate changes to the patient's medication regimen that resulted in an additional annual savings of $5,785, and the patient's pain was better controlled as well.

"It isn't just about cost savings. It is also about patient outcomes," Sciame says. "Without a comprehensive solution, it would be very easy for the patient in this case and others like her to end up hospitalized with an even worse medical outcome."

The PMSI case clearly demonstrates the effectiveness of MedAssess' Utilization Control, Targeted Intervention and Care Management levels of care, as each played a critical role in bringing both costs down while raising the odds for a positive patient outcome.

"What's unique about MedAssess is our foundation of clinical expertise from our credentialed in-house clinicians and medical advisory committees," Sciame says. "We follow evidence-based clinical guidelines and through our unique data capture capabilities validate the value of our consolidated clinical management model."

PMSI is national in scope, with the ability to comply with the various workers' compensation regulations on a state-by-state basis--a main feature of PMSI's value proposition for insurance carriers, TPA or self-insured employers.

Not only do states have varying workers' compensation regulations and laws, but they also change constantly, and it's important for a payor to know exactly how those changes are unfolding, so they can react. PMSI's solutions can meet those needs, no matter how much they differ from state to state. For instance, some states mandate the dispensing of generic medications when available while other states do not.

"You have to be even more creative in workers' compensation," Sciame says, adding that in workers' compensation, unlike group health, there is little or no economic incentive for patients and prescribers to use the most cost-effective therapies, for example, the use of generic drugs in states that do not mandate generic conversion.

PMSI helps educate clients through continuing education, publications and webinars, so their claims professionals can speak to injured workers about medication issues such as generic use and help boost patient acceptance of generic medications. On the physician level, PMSI's interventions identify opportunities for patient conversion to generics and reach out to prescribers to educate them to encourage conversion to generic alternatives.

Right now, there is much evolution happening in workers' compensation. The industry is becoming savvy, as awareness of clinical solutions and their value in containing costs through utilization management is on the rise. Clients need a partner like PMSI--a leader in helping them address the many complex issues in this changing industry.

"It is our job to create solutions that fit client needs," Sciame concludes. "MedAssess is designed to tackle the issues most important to our clients--cost containment and improved patient outcomes. Through MedAssess we deliver on our commitment to quality programs that bring unparalleled value to our customers."

(The above 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® on behalf of our marketing partner. Additional Insights can be found on our Web site at www.riskandinsurance.com/.)

October 6, 2009

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