Mail order pharmacy for workers' compensation is a proven cost saver over traditional retail environments. Additionally, it provides the convenience of home delivery of medications into the injured worker's mailbox, negating the necessity of leaving home to fill a prescription. It is especially suited for injured workers with chronic conditions and long-term medication needs, enabling maximum control and quality of care in addition to the convenience and cost savings.
Despite these benefits, mail order pharmacy for workers' compensation has caused some industry controversy with potential abuse situations, which can contradict the proven value of this type of program as a cost-reducer. With advancements in the industry, leading providers are now approaching workers' compensation pharmacy benefit management (PBM) for mail order from an end-to-end claims perspective -- applying integrated adjudication, clinical oversight, and total cost control through conversion to mail order.
Clinically Focused Approach
Workers' compensation PBMs with a core competency in mail order have elevated their approach to include clinical management capabilities, which improve quality of care for injured workers and promote return to work while assisting claims adjusters in providing a higher level of services. These programs are managed by clinical pharmacists and supporting pharmacy technicians with specific experience in the management of pain and other chronic medication.
In contrast with traditional workers' compensation pharmacy where prescriptions are filled with little or no insight of other medication claim activities, a clinically based management program can provide full visibility into injured workers' medication history, minimize risk, and provide utilization control. These programs can identify high-risk injured workers based on past prescription data and provide interventions such as:
- Transitioning injured workers using multiple physicians for narcotics prescriptions to a single prescriber
- Providing a comprehensive assessment by a clinical pharmacist of high-risk injured worker's pharmacy and medical records
- Deterring drug abuse and diversion while promoting appropriate use of narcotic medications
A clinical pharmacy program enables maximum quality control and adherence to rigorous standards established to guarantee the accuracy and efficiency of dispensed medications. Additionally, monitoring prescription refills helps to facilitate injured workers' compliance with prescribed therapies -- a key component of improved clinical outcomes.
Advancements in Technology
Some of the more robust claims management tools in the industry provide online, real-time claims management technology for the unique needs of individual clients throughout the lifecycle of a claim. These tools provide information about each injured worker's case and transaction history and an enhanced way to review and approve pharmacy and other service requests along with detailed reporting from the initial point of care until the claim is closed.
Conversion Programs Drive Utilization
As mail order has become more sophisticated in terms of clinical focus, enhanced controls and innovative technology, so have the programs designed to recruit the injured worker to a mail order program.
The conversion process begins with the identification of appropriate candidates, working with the payer to customize the selection criteria. Candidates also can be identified through referrals by the payer.
Following identification, a multi-pronged approach is initiated; components can include outreach to the injured worker by telephonic and direct mail communications. If needed, adjuster approval is secured prior to initiating contact with the candidate. Once the worker agrees, the prescribing physician(s) are contacted to provide a new prescription for mail order fulfillment.
As price pressures lead to an increased need for transition to mail order pharmacy, enhancements to mail order allows payers to control their bottom line. Advanced mail order programs can achieve 20 to 25 percent cost savings over traditional retail environments -- and assure that injured workers receive intelligent prescription management.
Lori Daugherty is president of pharmacy services for PMSI, one of the nation's largest full-service providers of services for pharmacy, medical services and equipment and settlement solutions. Company information is available at www.pmsionline.com.