Today's workers' compensation claims environment requires a PBM to provide pharmacologic expertise, a robust network and service excellence while melding together the characteristics of analyst, clinician, processor, service representative, problem solver, educator, mentor, advocate, investigator, researcher and partner into one solution.
For even the most experienced this can be quite a challenge. Progressive Medical, however, is one PBM rising to the occasion.
Recognizing the ability to create enhanced patient outcomes and more cohesive, efficient and automated processes between workers' compensation providers and payors, the company successfully integrated the best aspects of both PBM and third-party billing programs into one seamless solution back in 2011. Since then, they've expanded their network's reach to include non-traditional dispensing entities and augmented their overall utilization management capabilities by integrating an advanced statistical model that identifies potential high-cost, high-risk claims earlier in the life of the claim.
They've also augmented their utilization management offering by formalizing a nationwide urine drug monitoring (UDM) network and adding a unique method of smart clinical triage to make certain the tools and expertise are applied to the right claims at precisely the time they're needed.
Payors, pharmacies and injured workers alike are already reaping the benefits of streamlined processes, administrative efficiencies, increased cost savings, early intervention opportunities and deep clinical insight as a result of the company's evolution. Meanwhile, the industry has also advanced as goals that once diverged are aligned for everyone's mutual benefit.
STARTS WITH THE FIRST FILL
Electronic connectivity from pharmacy to payor drives consistency, promotes efficiency and eliminates surprises. By leveraging their deep, long-standing relationships and connectivity with 96% of the nation's pharmacies, Progressive Medical virtually guarantees in-network capture. Their robust conversion program electronically adjudicates pharmacy transactions in real-time by applying client-specific business rules, medication plans, drug utilization review criteria and network discounts at the point of sale. Bills from non-traditional dispensers also come under greater utilization control as a result of being part of the specialty network, with scripts adjudicated against the same criteria as their retail counterparts. A meaningful first step toward successful utilization management is taken, not only from a clinical standpoint but financially too, as payors not only realize cost savings but also experience administrative efficiencies as paper bills are all but eliminated. Meanwhile, claims professionals are positioned to act earlier and injured workers receive the right drug at the right time.
Moving beyond the pharmacy, data gathered during the electronic adjudication process (at the first fill and subsequently) dynamically combines with various demographic factors to fuel a multivariate log-linear statistical model that calculates a risk score for a claim. These risk scores are then used to guide clinical decision-making, with the insight gained facilitating a more holistic view of the claim while simultaneously fostering more effective collaboration between clinicians, claims professionals and treating physicians.
"Our utilization management programs promote efficiency, encourage collaboration and augment savings by helping our clients avoid paying for the most expensive prescription medications ? the ones that should have never been filled in the first place," said Tron Emptage, chief clinical officer of Progressive Medical.
ONGOING UTILIZATION MANAGEMENT AND COLLABORATION YIELD BETTER OUTCOMES
Management of individual medications and overall medication therapy is undoubtedly a key to reducing costs and achieving better outcomes. The company's programs and processes dovetail with those of the payor to do just that. Provided prospectively, concurrently and retrospectively, the company's comprehensive, evidence-based approach to global utilization management pursues the safest, most effective medication therapy for the injured worker while also looking out for the payor's bottom line.
"It's important to realize that a number of medications can be costly and dangerous when misused or abused," said Emptage. "Opioid analgesics are a focus of both our nation and our industry because of the scale of the problem, their high propensity to risk and the overall severity of the impact on the entire claim ecosystem."
The reality is that any claim may demonstrate characteristics of being a future long-term or high-cost claim at any time. Similarly, signs of potential misuse or abuse may become evident early on in the acute phase of an injury or later on in the long-term or chronic phase, regardless of the medication therapy involved.
"Our global utilization management strategy and triaging helps to mitigate the risk of adverse impacts while promoting the rational, safe and responsible use of all medications," Emptage said.
The benefit of ongoing management, oversight and proactive collaboration are well documented in many, if not all facets of claim management. Stakeholders throughout the industry consistently advocate for proactive engagement, prompt communication and rigorous oversight as part of claim handling best practices and overall cost containment. This undoubtedly holds true when it comes to pharmacy-related claims expense. Progressive Medical, through their experience and advanced analysis, knows that pharmacy utilization and costs can be highly effective early predictors of long-term overall claim cost, not just long-term pharmacy cost. And using their integrated early intervention program as a proxy for overall claim spend is proving to be an invaluable resource for the claims professional. Earlier this year the company reported that the deliberate synchronization of network, analytics and clinical programs has been attributed (with a 96% statistical confidence) to a reduction in the prescription cost per claim, shorter claim duration and a decrease in the frequency and severity of misuse/abuse situations.
The company's 2013 Drug Trends Report also reported a 4.2% reduction in the prescription costs per claim of opioid analgesics and an overall 0.5% reduction in total prescription cost per claim for clients, despite adverse external influences, such as escalating drug prices. Add to the mix the company's operational excellence, highly engaged government affairs team, robust quality assurance program and the service-driven mindset of its people, dramatic results for clients are a natural outcome -- proof positive that a PBM can make a difference by moving beyond simply processing scripts.
For more information about Progressive Medical please visit www.progressive-medical.com.
(The above piece is part of our continuing Perspectives series designed to highlight key products and services to our readers. This paid-for Perspective was written and edited by Risk & Insurance®
on behalf of our marketing partner. Additional Perspectives can be found on our Web site at www.riskandinsurance.com/.)
October 15, 2013
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