Newsletter Sign-up

Seems logical enough, yet, according to Beth Kuschner, PharmD and clinical pharmacist at Progressive Medical, the Westerville, Ohio-based workers' compensation Pharmacy Benefits Manager (PBM), it often doesn't happen within the claims process.

"The value of eliminating inappropriate medications not only makes for the best treatment path for injured workers, but it also offers immediate cost savings for payors," Kuschner said. "Unfortunately, there is no guarantee claims are getting that type of management, unless there is an effective process in place to achieve that goal."

What's the best way to ensure the right medication is being prescribed for the right injury or condition? Kuschner said it is achievable by using specially designed medication plans aligned with each specific injury or condition.

"Workers' compensation-specific medication plans eliminate medications that might be fraudulent, wasteful or abusive, or just plain wrong for the injury," Kuschner said, adding that with older claims in particular, the real value of medication plans lies in appropriately assigning the client to the proper long-term plan.

"More than 90 percent of workers' compensation medical spending is on claims over 90 days old," Kuschner noted.

Kuschner said that medication plans are more effective than the standard formulary approach to managing medication costs because the former ensure that only medications related to a specific injury are dispensed during the claim process -- not always the case in group health situations.

For example, a medication prescribed for a head injury often would be very different than a medication prescribed for a back sprain. An effective medication plan will account for various injury types that, in most cases, are specific to workers' compensation injuries, providing the payor with the ability to manage costs by only paying for appropriate medications.

Kuschner added that it's also very important to determine if the medication plan is First Fill, Acute or Long Term. Also, the medication plan needs to be able to apply a category of Allowed, Prior Authorization Required or Excluded.

In addition, effective medication plans should use National Council of Compensation Insurance (NCCI) standards codes of body part, date of injury, ICD-9 codes, or custom defined codes and nature of injury, instead of using a broad formulary approach typical of group health care treatment strategies.

Compared to the more straightforward group health formulary approach, where one prescription drug list would cover everyoneregardless of diagnosis, Progressive Medical offers multiple medication plans, which is a more comprehensive approach to determine appropriateness.

"We know with injured workers' in workers' compensation it's a very different landscape from group health," she said. "So we offer multiple plans instead of a single overall plan trying to cover every scenario, the standard formulary approach, which just won't work for workers' compensation."

With group health, the range is to cover entire body, including conditions such as diabetes or high cholesterol. But with workers' compensation, the goal is to make sure medications are right for a specific injury. Having said that, Progressive Medial does have employers who have claims with heart attack or respiratory disease as covered conditions for workers' compensation, so medication plans do need to take these injury types into account. Also, there could be multiple injuries on the same claim, which also creates the need for flexibility with medication plans.

Another important success factor is flexibility and knowledge.

"Our clinical staff is on top of guidelines and evaluate them on a constant basis," Kuschner said. "When guidelines change or new drugs are released into the marketplace, we look at the medication plans. Our medication plans are part of a living, breathing program. They are not static because that would make them ineffective."

Progressive Medical's medication plans, for example, offer the flexibility of using ether ICD-9 codes or NCCI codes, allowing the firm to customize therapeutic drug classes to specific injury types and disease states for each injured worker.

"This functionality allows us to stop the processing of medications outside specific therapeutic drug classes for injured workers, as indicated on their specific claim," Kuschner said. "We are also able to stop the processing of medications at the most detailed level."

Current Progressive Medical clients, Kuschner said, can use these functions to assist in managing their costs.For those clients, information on prescription coverage is critical to the pharmacist to process accurate online prescriptions. As a result, ICD-9 relatedness denials and approvals can be communicated to the pharmacy via specialized messaging as allowed within the National Council for Prescription Drug Programs (NCPDP) standards in effect today.

"We use these specialized medication alerts and NCPDP standards in the processing of all client prescriptions," Kuschner said.

Kuschner explained that when an injured worker from a Progressive Medical client fills a prescription, the pharmacy is sent electronic messaging so the appropriate medication plan is applied. Within the various workers' compensation-specific medication plans, there are three categories: First Fill, Acute and Long Term. Progressive Medical's First Fill program notifies the pharmacy to use the First Fill Medication Plan. The use of Acute or Long Term Medication Plans is determined from the date of injury.

"Our medication plans are based on body part, date of injury and nature of injury, and provide increased control compared to a broad formulary for multiple body parts and injury types," Kuschner said.

Another important aspect of medication plans at Progressive Medical is ensuring that its clinicians, in collaboration with the company's Pharmacy and Therapeutics Committee, provide ongoing management to ensure that clients receive a cost effective pharmacy benefit management program while the injured worker receives appropriate care.

Finally, there is a strong educational component to Progressive Medical's medication plan process, as the company looks to keep payors, claim professionals and medical providers up to date through multiple methods of education.

For example, the company sends out weekly eblasts called Friday Fast Facts, relaying information about new medications, new generic drugs, or updates on FDA status, so there are no surprises when a medication plan requires a change. To subscribe, visit http://www.progressive-medical.com/WorkersCompensation/News/IndustryHeadlines.aspx.

"Also, claims professionals can contact us directly regarding whether or not a drug would be appropriate," Kuschner said. "Often, there are medications on the plan that fall into a gray area and could be used to treat an unrelated condition, something that would require prior authorization. If they have any questions, we are available for open discussion."

Progressive Medical additionally provides continuing education programs, such as webinars, and has its clinical staff available for inpatient situations if requested.

Kuschner explained that Progressive Medical moved to the medication plan strategy several years ago after taking a hard look at workers' compensation medical industry trends, and determining that a single medication plan is not the most effective solution.

"From a clinical perspective, that broad based approach didn't work. Moving to injury-specific medication plans, we lead the charge within the industry," Kuschner said. "It was an evolutionary change, but when we looked at the big picture and saw where workers' compensation drug spend was going, utilization control was and remains a hot button issue.Prescription medication utilization needed more focus; a narrower approach and medication plans deliver on that need."

For more information on medication plans, visit http://www.workcomptransformation.com/medication-plans/

(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/.)

November 16, 2011

Copyright 2011© LRP Publications