Keith Rosenblum, senior risk consultant for Lockton Cos., said all of the following steps are the essential pillars of a pharmacy benefit management program:
Firstly, employers and their service providers must ensure that third-party administrators and claims managers get 100 percent visibility of prescribed drugs.Right now, only about 40 percent to 60 percent of prescribed drugs are channeled through employers' pharmacy benefit management programs, Lockton found, and that means there are literally "millions of prescriptions for injured workers annually with little to no clinical oversight," said Rosenblum. Physicians who bypass employers' pharmacy benefit managers and directly dispense drugs to patients can generate as much as $75,000 to $125,000 in additional income, he said.
When a drug is not recognized as a treatment for the patient's injury, and has been deemed "out of formulary," the standard PBM practice is to send an email to the claims adjuster seeking either approval or continued denial of the drug's continued use.
"This is an inefficient and non-efficacious practice that somewhere around one-half the time results in a quick approval without valid consideration of recommended pharmacy guidelines," said Rosenblum, who believes this decision should only be left to a nurse or to pharmacists who take the time to review the injury before rendering a decision.
Employers should also create clear claims-handling guidelines for adjusters who must ensure, so far as possible, that baseline and random urine drug screens where opioids are prescribed are administered beyond the acute phase of an injury or post-operation, he said.
Employers should insist that their insurance carrier or TPA "break the mold" as to how their PBM reacts to physician prescribing patterns that may not be in the best interest of their employees.Overall, the record of claims adjusters reacting to PBM red flags has not been acceptable.PBMs should be given carte blanche in initiating, at their discretion, drug regimen reviews with treating physicians.
Though nearly every PBM permits clients to customize the clinical intervention process, many PBM "edits" are too little, too late, said Rosenblum. If the PBM protocol is to wait until a claimant has been on high doses of opioids for at least 90 days before intervention, the horse is already out of the barn. By that time, tolerance or even addiction for many is quite possible. Frequently, a clinical pharmacist must take action to address physician-prescribing patterns of concern involving not only opioids, but possibly hypnotics, muscle relaxants and high doses of Acetaminophen.Employers should not automatically assume their TPA or carrier's clinical utilization review and intervention process has been stepped-up to best practices.
Lastly, it might help for patients to understand the similarity between prescription opioids and their mother's milk -- heroin.
Rosenblum often quotes Dr. Michael Nguyen, director of clinical pharmacy with PBM myMatrixx, who has pointed out that opioids are all derived from morphine or other alkaloids of the opium. "So whether we call it heroin, oxycodone, oxymorphone, etc., we can think of all these synthetic compounds as part of a band of destructive, evil brothers born from the same mother."
Whether you are taking a small pill or injecting a form of the white powder itself, "The body knows no difference," said Nguyen.
--By Janet Aschkenasy
March 1, 2013
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