"Prescription drugs have consistently accounted for a large percentage of workers' comp medical costs," said Tron Emptage, a pharmacist and chief clinical and compliance officer at Progressive Medical, the Westerville, Ohio-based workers' compensation Pharmacy Benefits Manager (PBM). "But today, there are new, emerging complications arising within these grey zones making it extremely difficult for payors to manage the medications used to treat injured workers."
Historically, significant prescription drug cost drivers included increased utilization and a dramatic rise in physician-dispensed medications. Today and in the future, an aging and increasingly obese workforce create added complications in the war to manage pharmacy expenses - a challenging yet necessary priority for workers' compensation payors.
In fact, according to a recent report by researchers at the Department of Health Policy and Management at Columbia University's Mailman School of Public Health, of the 65 million additional obese people projected in the U.S. in 2030, 24 million would be 60 or older.
Baby boomers, especially those over 60, are already the sickest and most expensive Americans in terms of medical costs. Plus, due to unexpected financial pressures, as well as potential changes to Medicare and social security, many of those aging boomers may put off retirement and remain in the workforce longer than planned.
"One of the trends we've noticed is that because of the aging population there are new issues with compensability of various conditions to an occupation," Emptage said. "Workers are getting older and that means they are more at risk for diabetes, hypertension and other age and weight-related diseases, and those conditions are creeping into workers' compensation, as well as causing potential problems for medication use."
Emptage added that the situation is getting so complex that Progressive Medical recently released a white paper, titled "Strategies for Navigating the Grey Zone Medication Maze," which can be obtained by visiting their Grey Zone Resource Center. The white paper provides insight on which medication situations are classified as grey zones, common drugs and best practices payors can use to manage utilization.
According to Beth Kuschner, PharmD and clinical pharmacist at Progressive Medical, apart from the aging and obesity issues, ensuring medications are compensable, related to the injury and are appropriate for the injured worker based on their medical history has become increasingly complex also due to the use of high-cost brand name medications when there are existing, effective generic medications available. That situation has developed with the growth of:
-- Direct-to-consumer drug advertising
-- Physician prescribing habits that favor newer/non-generic medications and willingness to prescribe medications for off-label use
-- Lack of patient education on generic medications
-- Development of new formulations of existing medications when patents near end
"Implementing effective strategies to monitor grey zone medications helps ensure injured worker safety and reduces opportunities for instances of fraud, misuse and abuse," Kuschner said. "These best practices range from comprehensive utilization management programs to providing claims professionals access to knowledgeable clinical experts."
Grey Zone Medications
So what constitutes a grey zone medication? Kuschner said it is any type of drug in which special attention is required to determine if it is appropriate for the injured worker based on compensability, relation to injury and medical history.
Common Grey Zone Medications
Kuschner explained that the most common grey zone medication categories mirror the prescription trends within workers' compensation as a whole. The categories include antibiotics, pain medications (including opioids, acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs)), hypnotics, anticonvulsants, antidepressants and other medications such as blood pressure or non-sedating antihistamines.
NSAIDs, for example, account for more than 70 million prescriptions annually and are utilized in acute and chronic pain, especially musculoskeletal disorders. They are particularly helpful in treating pain associated with inflammation, such as arthritis. The problem is recent revelations indicate that NSAIDs also may increase the risk of cardiovascular issues and raise blood pressure.
Drug interactions are also possible, particularly among patients using antihypertensives, anticoagulants, corticosteroids and/or daily aspirin therapy.
"Anti-inflammatory drugs, for example, should be used cautiously because numerous studies have shown if you have heart disease, NSAIDs are probably not a good drug for you," Kuschner explained. "More people today have heart disease, so using an anti-inflammatory could cause a heart attack or predispose you to having one.
"Like anything else, you have to decide the risk-reward benefit, and work with clinicians and providers," she said. "With this grey zone category, it's good to have a second set of eyes. Their long-term use should be approached with caution and appropriate monitoring."
Another grey zone prescription drug category worth watching is hypnotics. Many chronic pain patients have difficulty sleeping. Therefore sleep aids, either over-the-counter or prescription, are frequently used.For example, antihistamines such as Nytol®, Unisom® and Tylenol PM®, all sold over the counter, might be used. Then, there are more powerful prescription drugs such as Xanax® and Valium®, both benzodiazepines, and Ambien® and Lunesta®, classified as nonbenzodiazepines.
"Long-term therapy with benzodiazepines and nonbenzodiazepines may result in tolerance and dependence and should be carefully monitored," Kuschner says. "Many hypnotics also are available as generics and should be used to control costs. When encountering hypnotics as part of a workers' compensation claim, payors should ask very specific questions regarding use."
NSAIDs and hypnotics are but two of the many grey zone drug categories that bear watching. Both Emptage and Kuschner recommend that payors develop customized medication plans to track the complexities that can arise.
"Working with their PBM, payors can create medication plans that are based on specific criteria to ensure that medications are appropriate for the injured worker," Emptage explained. "It is essential for payors to seek a PBM that employs medication plans specific to body part and nature of injury, as well as the acute or chronic nature of the injury."
Additionally, Kuschner said that payors should partner with PBMs that offer electronic notification of approved and misaligned medications, to reduce administrative burdens on claims professionals. "This allows them to focus on jurisdictional issues related to the claim while the PBM focuses on the medication issues," Kuschner said.
She added that payors need to establish comprehensive utilization management programs, including prospective utilization reviews, concurrent reviews and retrospective reviews. Another key component is a strong clinical intervention program that offers physician monitoring, pharmacist support, nursing support and claims professional education.
Effectively managing grey zone medications can be done, Emptage said, but the sheer complexity of the grey zone requires a very robust solution.
"Managing medication utilization for injured employees is growing increasingly complex for workers' compensation payors," he said, adding that as even more new medications become available, the workforce continues to age and medical histories increase in complexity, navigating the grey zone medication maze will remain a challenge.
"By putting best practices into place to manage the appropriateness of medications, payors will ultimately ensure injured worker safety while reducing opportunities for fraud, misuse and abuse," Emptage concluded.
Click here to request a copy of "Strategies for Navigating the Grey Zone Medication Maze".To learn more about Progressive Medical call 866.939.5365 or visit www.progressive-medical.com.
(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/.)
September 9, 2011
Copyright 2011© LRP Publications