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.
PROSPECTIVE RISK MANAGEMENT
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.
USE IT OR LOSE IT
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.
REINFORCING THE FRONT LINE
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.
- WHAT: Providing claims professionals with tools, such as a Letter of Medical Necessity (LOMN) can empower claims professionals to evaluate clinically inappropriate or off-formulary prescriptions.
- WHEN AND HOW: Intervening with the prescriber doesn’t have to wait until the patient has already received treatment. An LOMN provides the opportunity for claims professionals to initiate communication with the prescribing physician regarding appropriateness of a medication at the prior authorization stage. In many cases, this can result in a change in the prescribed medication regimen to an appropriate alternative.
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
- WHAT: The decision to approve coverage of a high-risk or potentially inappropriate drug can benefit from a higher level of clinical expertise, especially when a more complex clinical decision is needed.
- WHEN AND HOW: Applying an automated process at prior authorization that allows a clinically trained individual to be incorporated into the decision-making process regarding high-risk or inappropriate medications provides an additional patient safeguard, as well as tighter prior authorization protocols.
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
- WHAT: Prescriber education is crucial to ensuring patient safety and associated costs. There are a number of factors influencing a patient’s recovery that prescribers may not be considering or may even be unaware of: for example, if the patient is receiving medications from another physician.
- WHEN AND HOW: Therapeutic red flags can arise at any point among the care continuum, and having the ability to intervene at the right time is critical to managing patient safety. Therapeutic alert communications that are automatically triggered by red flags – such as multiple prescribers, the presence of a topical compound, or prolonged use of opioids, benzodiazepines or other high-risk medications – are another interventional strategy that can successfully impact the trajectory of a patient’s claim. In many cases, prescribers are amenable to modifying a medication regimen when they are alerted to potential risk within a claim.
IT’S ALL IN THE DELIVERY
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.