A Healthesystems publication

Fall 2015

Making The Most of Drug Utilization Management Tools


Managing the clinical appropriateness of prescription medications is a critical component of controlling quality and cost of care in workers’ compensation, but all too often utilization management tools are not applied in a way that taps into their full potential. Earlier and more aggressive application of utilization management tools can have a profound impact on improving patient care and achieving cost containment.

There is significant opportunity to enhance the way in which drug utilization management tools are applied to better manage overall claim costs and improve patient care. With rising generic drug prices, along with the volume of new drugs being introduced to the market, improving the impact of clinical management becomes increasingly important as payers seek every opportunity to control costs.

The concept of utilization management seems intuitive: by delivering the most appropriate care to a patient, better outcomes – and thus, lower associated claim costs – will follow. And utilization management tools have been used traditionally throughout the workers’ compensation industry as a concerted effort between the PBM and payer. But a truly impactful clinical management strategy depends upon when and how these tools are applied. Having these tools in the arsenal is not enough to drive results. The payer must take full advantage by using them – earlier, and more aggressively. The key to success is the ability of the claims professional to take quick action. And this requires a comprehensive strategy that deploys tools as needed throughout the care continuum.




Managing pharmacy costs isn’t limited to looking at the "sticker price" of medications. It requires understanding the overall picture, applying evidence-based knowledge to ensure the most appropriate care for the best outcomes. This means shorter claim durations, a lower likelihood of chronic treatment, and fewer complications requiring additional treatment. Earlier interventions that lower patient risk offer the biggest potential to shift the trajectory of a claim and avoid excessive claim costs.



 The fact is many aspects of patient risk can be mitigated before they even become a concern. But failing to apply utilization management strategies aggressively enough can result in suboptimal risk management, leading to avoidable and excessive costs.




Claims professionals serve as the front-line decision maker in claims management, and this provides them with the perfect opportunity to make decisions that will have a positive impact on claims outcomes. Here is where the PBM can effectively support the role of the claims professional by providing the right mix of education, clinical decision support, and tools.  

The following are some examples of drug utilization management tools that can have a significant impact on patient safety and overall claim costs when applied aggressively by the claims professional.

Prescriber Communications

 Employment of an LOMN strategy by Healthesystems customers led to a prescription change in 2 out of 3 instances, resulting in an average per-drug savings of $244.00.1


 Automated Clinical Escalation

A clinically trained individual is more likely to uphold the decision not to approve inappropriate medications. In fact, a prior authorization reject is twice as likely to be upheld with application of this automated clinical escalation process.1


 Prescriber Education



Successful application of a drug management strategy relies upon having the right supportive infrastructure in place. Utilization management tools are only as effective as a payer’s ability to implement and use them.


Healthesystems goes beyond processing prescription drug transactions to proactively manage patient risk and control pharmacy spend. By integrating clinical expertise and advanced technological capabilities, we ensure that injured workers receive quality care, while eliminating cost drivers. Visit www.healthesystems.com/solutions-services/pbm to learn more about our comprehensive PBM solution.




1 -Healthesystems data.
2 -Coalition Against Insurance Fraud. By the numbers: fraud statistics. http://www.insurancefraud.org/statistics.htm#.Vfh2VflVhBc. Accessed September 18, 2015.
3 -Lavin RA, Tao X, Yuspeh L, Bernacki EJ. Impact of the combined use of benzodiazepines and opioids on workers’ compensation claim cost. J Occup Environ Med. 2014;56:973-8.
4 -IMS Institute for Healthcare Informatics. Avoidable Costs in Healthcare. June 2013.
5 -Pergolizzi JV Jr, Ma L, Foster DR, et al. The prevalence of opioid-related major potential drug-drug interactions and their impact on health care costs in chronic pain patients. J Manag Care Spec Pharm. 2014;20:467-76.
6 -Wan Y, Corman S, Gao X, et al. Economic burden of opioid-induced constipation among long-term opioid users with noncancer pain. Am Health Drug Benefits. 2015;8:93-102.
7 -Tao X, Lavin RA, Yuspeh L, et al. The association of the use of opioid and psychotropic medications with workers’ compensation claim costs and lost work time. J Occup Environ Med. 2015;57:196-201.
8 -White AG, Birnbaum HG, Schiller M, et al. Economic impact of opioid abuse, dependence, and misuse. Am J Pharm Benefits. 2011;3:e59-e70.
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