Editor's note: Tron Emptage is chief clinical officer, Progressive Medical/PMSI, soon to be known as Helios

Anne loved the hustle and bustle of her job. However, one day in 2004, she hurt her lower back, left knee and right ankle at work.

From that point on, things were very different. Over the next several years, she sustained further injuries from falls, underwent lumbar surgery and had two unsuccessful spinal cord stimulator trials. At one point, she was on very high doses of narcotic medications and even went through inpatient detoxification. Today, at 57, Anne lives with chronic pain.

Most patients enter the workers' compensation system due to physical injury, which often requires treatment for pain. As a result, a significant proportion of workers' compensation pharmacy spend relates to the treatment of pain. Moreover, the medication therapy regimen commonly includes opioid analgesics.

These medications can be used successfully for short-term pain relief, however, their long-term use has been associated with several potentially serious side effects, as well as aberrant drug-related behaviors, addiction and diversion. A recent Centers for Disease Control and Prevention (CDC) report illustrates this point: 46 people die every day from an overdose of prescription painkillers in the United States, and, in 2012, 259 million prescriptions for painkillers were written—enough for every American adult to have a bottle of pills.

A report in the 2009 Journal of the International Association for the Study of Pain further stated that when a workers' compensation claim involved opioid analgesics, the claim costs averaged nearly $20,000 more than claims without opioid analgesics. Moreover, the odds of chronic work loss were six times greater when opioid analgesics were used.

However, claims do not have to become high-cost, high-risk situations. Resources are available to payers and injured workers that can effectively keep, or if needed redirect, a claim on a path that leads to a positive outcome. The key is to assemble the various products, services, expertise, tools and resources in such a way that better decisions are made earlier on and throughout the claim.

Pre-dispense controls

Before Anne even entered the workers' comp system, her employer, along with its claim administrator and pharmacy benefit manager (PBM), established programs, processes and procedures to help ensure that any employee, should they become injured, would receive the right medications at the right time. At the foundation of these efforts are pre-dispense controls.

Pre-dispense controls help claims professionals review and manage medication utilization throughout the life of a claim. Useful in both acute and chronic injuries, these controls monitor triggers such as high-risk medication therapy, use of non-formulary medications (i.e. compounded medications) and therapy duplication. Some of the pre-dispense controls include medication plans and formularies, drug utilization review, and step therapy.

Medication plans and formularies, often considered “the first line of defense,” define approved medications for workplace injuries based on medical evidence and approved medical guidelines. Their use promotes appropriate medication utilization by requiring authorization for medications that may not be injury related.
Drug utilization review (DUR)is a process used to alert the pharmacist of potential clinical and eligibility issues related to an injured worker. A payer's approach to medication plans and formularies, jurisdictional guidelines, and other business rules influences DUR, as do advances in medicine, legislative policy and changes in medical guidelines.
Step therapy draws from clinical guidelines to identify options for dispensing lower cost, yet therapeutically equivalent first-line medications to injured workers. For example, if Anne presents a prescription for a brand name medication when a first-line and/or generic medication is therapeutically equivalent and has not been tried, the pharmacist may contact the prescriber and recommend a switch to an alternative medication.

Use of these, and other pre-dispense controls help prevent unnecessary medication spend and promote optimal medication therapy starting with the first fill.

Claim escalation

As Anne's injury and chronic pain persists, new medications and treatments are tried. This can escalate cost and introduce new risks to the claim. Signs of a potential clinical concern include the presence of multiple prescribers and/or dispensers of opioid analgesic medications, use of high-cost brand name medications and prescription therapy exceeding recommended clinical guidelines, to name a few. Once identified, intervention of one type or another may be appropriate.

For example, medication monitoring through urine drug testing can deliver accurate information on whether the injured worker is following the prescribed therapy. Testing can identify aberrant medication use (i.e., not taking prescribed medications) and non-prescribed substance use, whether illicit or prescription medication.

A maturing or escalating claim might also benefit from psychological intervention. Depression is a recognized co-morbid condition, commonly encountered in chronic pain claims. Feeling depressed can exacerbate the pain experience, preclude completion of daily activities and delay (if not impede) recovery. The educational and emotional support provided by a psychologist can make a positive difference in a claim, equipping the patient with coping skills to reframe catastrophic thinking into positive thoughts and to offer relaxation techniques that reduce feelings of fear.

Staying on a path toward better outcomes

The use of pre-dispense controls establishes a foundation for keeping a claim on the right path from the very first fill. It sets the stage for open communication, collaboration and coordinated processes that emphasize timely, cost-effective treatment of the injured worker to achieve better outcomes. As a claim matures, using all available tools and resources to improve the quality of care and overall efficacy of treatment, particularly medication therapy, can help assure claims follow the right path towards maximum medical improvement, and ultimately, settlement and/or return to work. The key is proactive coordination of resources, collaboration and open communication among all involved throughout the life of a pharmacy claim.

Special Reports /

Managing pharmaceuticals: A life of claim experience

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