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When it comes to prescription medications, pharmacy benefit management (PBM) firms have some effective tools in their arsenal to assist payors with influencing the way physicians prescribe. These tools include DAW's, LMN's, and Peer-to-Peer Reviews. The DAW is a written communication to prescribing physicians when brand medications are written with a Dispensed as Written directive and a generic alternative is available and is therapeutically equivalent. If the DAW proves to be unsuccessful then an automated , LMN (Letter of Medical Necessity) is sent to the physician to gain the documentation as to why the physician remains committed to the brand drug. Medical appropriateness can also be validated by a third party physician in a "Physician Pharmacy Review" and if warranted, a Peer-to-Peer Review and consultation would be scheduled. These solutions are critical components in the effort to maintain that delicate balance between patient, medical provider and payor.

Dr. Avrom Gart is the Medical Director at Integrated Prescription Solutions (IPS), a PBM and ancillary services provider located in Costa Mesa, California. IPS partners with workers compensation and auto insurance carriers, as well as self-insured employers and TPAs who specialize in workers compensation benefits management.

"Peer-to-peer reviews that we do can really deliver excellent results, but very often no action is taken on them," said Dr. Gart. He also noted that when taking over a new program, for example, IPS often encounters completed peer-to-peer reviews that were allowed to languish because the former PBM did not have much existing interaction or communication between itself, the claims professionals and the physician.

Unfortunately, says a 21-year veteran of the workers compensation insurance industry, while top-level PBMs offer these tools, they typically stop short of using them in their most effective manner. Those particular solutions can deliver high-quality, actionable data to claim professionals and nurse case managers. Yet, in most cases the data is never utilized. This is usually based on the claim professional's restrictions set by the payor. Naturally, that scenario helps no one. Costs continue to rise and potentially injured workers do not receive the most effective medical care.

"This is something that cuts across the entire workers compensation and PBM sectors," says Dr. Mike McQuilken, senior vice president, sales, at IPS. "While the information that these processes can offer are often invaluable, they too often end up unused," he said.

McQuilken, who is a PharmD, explained PBMs who rank among the industry leaders (should) focus on the "follow up" after a DAW, LMN, or a Peer-to-Peer Review has been completed and given to the adjuster or other claim professional. PBMs who do not make a strong effort to link the results with an action plan are not really delivering true value to their direct customers, the payors, or to injured workers, the ultimate customer.

For example, with LMNs, IPS automatically generates a letter to the prescribing physician asking the prescriber to show the relationship of a particular medication to an occupational injury, as well as how long the prescriber anticipates the therapy will continue. When the signed LMN is received back from the prescriber, IPS alerts the adjustor or nurse case manager that the LMN is available.

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McQuilken further explained that Peer-to-Peer Reviews are excellent tools and can greatly influence a prescribing physician and the cost savings associated with those reviews. However, the emphasis also needs to be laser focused on the execution of any recommendations.

"That's the key to having success," he said.

Of course, the critical target of the DAW, LMN, and Peer-to-Peer Review is the physician. Even so, it's not about dictating care, according to McQuilken. It's about educating the medical provider with other available options, such as generic drugs in place of brand drugs. It's also about persuading the ways that a physician prescribing medications can understand there may be a different path to restoring the patient to productivity.

McQuilken said that the critical success factor is gaining cooperation of the treating physician, adding there is little doubt that peer-to-peer consultations with the treating physician have the greatest impact in any retrospective suite of services.

"Care is improved, safety is increased, addictions are avoided and last, but not least, fraud and abuse is curbed," he said.

"We deliver peer-to-peer results to an adjustor or a nurse case manager, and while it can be difficult to get involved at times, we try our best in convincing them to get the message to the physician," Dr. Gart explained. "Of course, if the physician is uncooperative then the payor has to react or nothing will come of it. We work hard not to let that happen."

McQuilken said that historically, treating physicians have been in the driver's seat and mostly immune to questions or concerns regarding which turns to take when it came to specific patient care. He quickly adds, however, that PBMs like IPS are not trying to dictate, they are trying "to inform, to educate." The problem is making that connection with the physicians, letting them know that there may be an alternate, more effective route for a patient's treatment plan.

"Mainly, we want them to know that there is an issue that exists," he said.

McQuilken attended a recent industry conference and spoke with medical directors from insurance carriers across the country. They discussed how to curtail rising costs while ensuring the most effective patient care. All agreed that for the most part, Peer-to-Peer Reviews and LMNs exist primarily to let the physicians know they are not working in a vacuum.

"Their feeling was that at least the physician will get the idea that they are being monitored," McQuilken said. "But clearly that is just one part of it. There still needs to be payors who will act on good information that can impact a course of care for the betterment of the patient. PBMs need to encourage the payor to move forward with an action plan."

Also, in IPS' experience, 95 percent of the time their panel will uncover opportunities for improvement and cost savings.

"The return on investment is good, but that isn't the primary issue," he said. "The issue is whether nurse case managers or adjustors will develop a new course of action for the claimant that the treating physician will agree to. And will the physicians respond? It's a great service to offer, a solid professional service. What we are doing is really summarizing for the physician what he or she may not be aware of in a given claim."

McQuilken challenges payors to use their power to help manage claims because only they are in a position to do it directly with medical providers. In the end, connecting the dots within the workers compensation industry is critical.

"It's something the entire industry must think about," he said. "It's good for the claimant. It's good for the doctors who are very busy and can use help. And it's good the payors. In the end, tools such as peer-to-peer and LMN really are critical to everyone's objective -- an optimal healthcare outcome."

(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 12, 2012

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