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By JARED SHELLY, senior editor/web editor of Risk & Insurance®

Whether she was helping new mothers in the delivery room or providing care to critically injured people in the intensive-care unit, Toi Corbett defined her career as a nurse as simply helping people to get healthier one step at a time.

"You still get some of the benefit of helping people get the treatment they need, you're just not rendering it at the bedside," said Corbett, who grew up in Alabama and speaks with more than a hint of a southern Dixie.

After having been raised in Eufaula, Ala., Corbett graduated from the University of Alabama-Birmingham and then went to work as a nurse, a vocation in which she learned a hard lesson. Not everyone can be helped, especially those in the intensive-care unit.

"You've got people in horrendous situations usually," she said. "It's life and death."

She joined Drummond 12 years ago, becoming the company's first medical manager in workers' compensation, something certainly needed considering that the business of coal mining and processing often lends itself to workplace injuries.

Corbett seemed like a great choice, as her nursing background allowed her to develop strategies to aid injured workers in their recoveries and get them back to work quicker.

She built a program to control medical costs and lower indemnities. She added drug and alcohol testing. She developed fitness for duty evaluations and conducted utilization reviews.

But perhaps her greatest contribution at Drummond came after she observed the emerging trend of physicians prescribing drugs to injured workers, then filling those prescriptions at their offices, at two or three times the cost of a retail pharmacy or pharmacy benefit manager.

Part of the high cost comes from repackaging drugs from larger bundles into smaller ones. Physician dispensing has emerged as a trend in certain states, principally California and Florida, but it's become a pain-point for workers' comp insurers.

Seeing her employees and the company's health plan feeling the brunt of the price differential, Corbett refused to sit idly by.

Sure, doctors say that if they can dispense drugs themselves it improves compliance rates, but the 2010 Workers' Compensation Prescription Drug Study by the National Council on Compensation Insurance found that workers' comp costs have been rising dramatically because of physician dispensing, which now comprises more than 20 percent of workers' comp drug expenses.

Corbett frames the problem very simply: "The cost did not in any way compare to a retail pharmacy or going through our pharmacy benefit manager," she said. "It was outrageous. An aspirin is no better at a doctor's office than getting it off the shelf at a retail pharmacy, so why would you pay more?"

Plus, doctors may not know what the pharmacy benefit manager is providing, which may lead to adverse reactions from mixing the wrong drug combinations.

Shane Fordham, regional account executive at Progressive Medical, Drummond's pharmacy benefit manager, did some calculations on what popular drugs cost at the doctor's office compared with the pharmacy benefit manager. The results weren't pretty.

For example, cyclobenzaprine, a muscle relaxer, was approximately $400 at the physician's office, but just $200 when ordered through the benefit manager. The narcotic pain reliever oxycontin cost $415 when priced by doctors but $325 with Progressive.

To combat the high prices of physician dispensing, Corbett originally requested help from the Alabama Medical Services Board, hoping to develop rules around physician dispensing to protect consumers. Her efforts were shut down when the board wouldn't sign off on her proposals, she said.

So she devised a simple, yet effective plan. It entailed talking to doctors. Through "common sense" negotiations, Corbett showed them the cost difference and showed them how their bills can be adjudicated according to Drummond's pharmacy fee schedule.

She could have taken a hard line with the physicians. She could have told them to lower prices or the employer would remove their offices from the Drummond network of doctors. But she decided to do things "her way" instead, focusing on relationships, not drawing lines in the sand.

"If you don't ask you don't know," Corbett said. "I asked to open up that line of communication with them to talk about the ridiculous pricing. I told them: 'We have to be fair to one another.' "

Her relationship-driven plan worked -- so well, in fact, that Corbett said she did not receive backlash from the physicians, and Drummond now pays roughly the same amount for drugs dispensed by physicians as it pays for medications through the pharmacy or the pharmacy benefit manager. "They understand the need to control the cost and be reasonable," she said.

Perhaps Corbett was so successful with the physicians because she has high expectations, something Fordham, and anyone else who's worked with her, knows very well.

"She's very demanding in what she wants, but there's nothing unreasonable about her demands," Fordham said. "She's very thought out."

For example, Corbett remains focused on patient care even though her nursing days are long over. She'll go so far as to call doctors to follow up on visits and learn about the proper course for treatment going forward.

And if health plans and insurers are going to wait weeks and weeks to approve tests and scans, they'll likely deal with Corbett. "We're not waiting around; we want these people to get better as soon as possible," she said.

She also partnered with Progressive Medical to conduct utilization reviews around point-of-service at the doctor's office, which helped to prevent duplicate therapy, early-fill attempts, improper formularies and unnecessary or noncompensable medications.

Despite her efforts, Corbett considers herself a nurse first and a disability manager second. But a loss-control specialist? "Not by any means," she said.

She simply wants people to get better, and that has driven her to work hard and make creative decisions when needed. She considers her current role just an extension of her nursing career. It's just that the moves she makes now help more than one person at one time.

"I try to do what's best for the injured worker and what's best for the company. That's ultimately what's going to keep the costs down in the long run," she said.

She's even spoken publicly about in-office referrals. At the Alabama Self-Insurers Association conference in 2010 she faced off in a point-counterpoint session with a supplier for physicians' offices about physician drug dispensing. She was pleased to get a chance to relay her concerns with an educated audience of hundreds.

Still, Corbett just sees her continual learning as part of the job and a small step in helping Drummond's employees feel better sooner.

"The rules of the game change everyday," she said. "We need to anticipate and constantly be looking for opportunities and making adjustments."

But when asked if she considers herself a thought leader, Corbett's modesty shines through.

"I don't think of myself in that way," she said. "I just try to be on the forefront of news on the subject. A lot of people across the nation have dealt with this and are trying to tackle it. I just did it my way."

She hopes that her efforts to lower the exorbitant price of physician drug dispensing will catch on at other businesses facing the same issue. "It takes a village to get anything done in workers' comp," she said.

November 1, 2011

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