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rxplan(blue)_ID-100143327In part one of this blog discussion, we began to explore the reasons why employers today are looking for ways to more effectively manage drug utilization – particularly for costly and potentially addictive narcotics – within their workers’ compensation programs. Let’s take a look at some of the more advanced, proven strategies and solutions that can be integrated to help manage costs and performance as part of a comprehensive and effective drug management program.

Use of formularies
One of the first steps to managing drug costs is the creation and use of an effective workers’ compensation formulary.  In its broadest sense, a workers’ compensation formulary is a list of approved generic and brand named drugs approved to treat work related injuries.

Some of the formularies are evolving to be injury specific and can even be tailored to address acute and chronic pain.  These more focused formularies are aimed at appropriateness of medication therapy at a given point in time rather than simply addressing a diagnosis.  This helps to manage drug utilization through every stage of the injury and recovery.

Authorization alerts
Another proven drug management strategy is the use of authorization alerts.  When drugs are outside of the formulary, authorization alerts ensure claims examiners and nurse case managers receive notification based on select triggers.  Review and approval is then required before the prescription can be filled at the retail pharmacy.

Case history reviews
In the event a narcotic is prescribed, it is also helpful to review the injured worker’s complete medical history, using both in network and out of network transactions.  The review should also examine non-occupational medications to evaluate actual medication use and ensure appropriate utilization.

Close narcotic monitoring
Additionally, close monitoring should be utilized when narcotics or opioids are prescribed.  It will be important to determine if pain has diminished and if the injured worker can return to work.  Nurses can develop alternative therapeutic plans should the initial therapy not perform to clinical expectations.

Follow-up appointments
Another way to optimize use of medications is to require follow up appointments within three days and only authorize three days of initial treatment.  This approach is designed to assist with determining whether or not the medication has improved pain, control, and function.

Employee education
Educating and informing employees of the benefits, dangers, and alternatives for narcotics and opioids is another effective technique used to mitigate drug misuse or abuse.  Such initiatives typically include:

  • Training about a medication’s adverse side effects and alternative options
  • Required screenings for risk of addiction or abuse
  • Agreement/contract related to the use of narcotics or opioids

Pharmacy clinical review
Successful drug management programs also typically include a pharmacy clinical review component.  A number of factors will trigger pharmacy clinical reviews including:

  • Narcotic class medications for the treatment of pain
  • Use of multiple medications excessively or from multiple therapeutic classes
  • Using medications not typical for the treatment of workers’ compensation claims
  • High cost medications
  • Receiving high doses of morphine equivalents daily for treatment of chronic pain
  • Using three or more narcotic analgesics
  • Receiving duplicate therapy with NSAIDs, muscle relaxants, or sedatives
  • Using both sedatives and stimulants concurrently
  • Using compounded medications instead of commercially available products

Network of pharmacies and prescribing providers
Another proven component of a drug management program is the use of a comprehensive and focused network of pharmacies and prescribing providers.  Such a network drives non-formulary point of sale prescription requests and offers an option to re-price those prescriptions.  This creates an opportunity to coordinate utilize providers who participate in a network which ultimately helps ensure that more prescriptions are going through review, analysis, and pricing discounts.

Technology
Successful companies also rely on advanced technology systems.  These systems provide access to information that nurses and examiners need to do their jobs quickly and appropriately to controls costs.  Instead of going to multiple websites to secure information on eligibility, history, formulary or utilization, technology advancements allow nurses and examiners to access the information in one central location.

Managing narcotics is not about removing viable medications used to alleviate pain for work-related injuries.  It is about ensuring use of effective and appropriate medications for these types of conditions.  The injured employee’s well-being must remain at the forefront of any such initiative.

Ultimately, successful employers rely on evidence-based guidelines to ensure the appropriate use of medications.  Compassionate care and healing remain at the heart of any successful program.  It is the use of these strategies that not only prevents the potential misuse or abuse of narcotics and prescription drugs, but also fosters cost savings and boosts performance.

Kimberly George, SVP, Managed Care Practices and Client Services

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One Response to Managing the pain of prescription drug costs: Defining the solutions

  1. Lee @ Addiction Blog says:

    Unfortunately, because insurance coverage for substance abuse screening is so little reimbursed, prescribing MDs have little to no financial incentive to intervene or refer potential addicts to treatment.

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