How Utilization Review Programs are Lowering Soaring Workers’ Comp Drug Costs

| URAC Staff

Innovative utilization review strategies are putting a big dent in soaring workers’ compensation drug costs, particularly when it comes to opioids.

Although workers’ compensation drug costs declined 11 percent over the last four years, opioids are among the most expensive and highly used class of drugs prescribed for work-related injuries, accounting for nearly 27 percent of per-user, per-year spend, according to Express Scripts 2016 Workers Comp Drug Trend Report.

Poor management of pharmaceutical benefits is a primary driver of this spending, but drug utilization reviews are helping. Memphis-based Sedgwick Claims Management Services decreased its pharmacy costs for clients who take advantage of the program by 52 percent last year, primarily by focusing on the alarming number of injured workers who are prescribed opioids—often unnecessarily or for far too long. A key part of its pharmacy clinical review program: Navigate injured workers away from the “90-day cliff” that seems to all but guarantee addiction.

“About 60% of people who are still taking an opioid after 90 days will still be taking it five years later,” says Cynthia Jaggers, vice president of Sedgwick’s National Utilization Review & Clinical Pharmacy Program. “We’re trying to prevent that.”

Teams of nurses, pharmacists and physicians intervene by reaching out to the prescriber and injured worker at the 42-day mark to develop a weaning program and to discuss other alternatives. “With the most recent data coming out of the CDC, we are now moving our intervention to begin closer to the first prescription” says Jaggers.

It’s part of the Sedgwick’s integrated strategy to place the injured worker at the center of care by providing personalized outreach. Other strategies include: 

Acute, chronic and injury-specific formularies: A team of seven pharmacists developed and constantly tweak the formularies, which include preferred drugs for acute and chronic injuries to maximize drug utilization.

Point-of-sale pharmacy program: If a newly prescribed or existing medication isn’t appropriate for the injury and age of the claim, a nurse intervenes to head off unnecessary narcotic use. Dangerous drug combinations that are particularly scrutinized—and denied—include opioids (Vicodin), benzodiazepine BZD (Xanax) and Carisoprodol (SOMA); methadone and medications cardiovascular or respiratory medications; and Tramadol and SSRI medications. With an eye toward patient safety, these types of interventions resulted in the denial of approximately 40 percent of the 100,000 medications reviewed last year, Jaggers says.

Complex pharmacy management program: Nurses review claims to identify patients who have recently developed an adverse trend, such as a daily morphine-milligram equivalent (MME) dose that exceeds the CDC’s recommended 50 MME per day. 

“We have seen patients with an MME of 3,000 or higher—a clear and dangerous indication of addiction or abuse,” Jaggers says. Pharmacists then work with the prescriber to develop a comprehensive weaning program. As a result, Sedgwick has reduced the number of injured employees using opioids by 27 percent and in 2015 decreased the use of morphine-equivalent doses by 50 percent.

States are also putting more emphasis on drug utilization
Drug utilization programs like Sedgwick’s are directly impacting claims costs, but not all programs are created equal. A growing number of states are realizing that accreditation by an independent organization is an effective way to ensure that utilization management programs adhere to quality standards and best practices, particularly in areas such as clinical review and timeliness to access and claims appeals, says Aaron Turner-Phifer, URAC’s director of government relations.

California is the most recent example. A new law requires accreditation by July 2018 of all organizations that conduct utilization review for California’s workers’ compensation program. It specifically names URAC as the designated accreditation organization. The mandate was in response to the state’s record-high worker’s compensation premium rate, which in 2014 was the highest in the nation. Delaware, Illinois, New York and the District of Columbia have similar laws. 

“URAC provides guidance to us, requiring that we have policy and procedures in place and ensuring that we follow them. This is especially helpful with our quality improvement projects,” commented Jaggers about Sedgwick Claim’s Management Services’ URAC accreditation for Workers’ Compensation Utilization Management. “It’s been important to have a second set of eyes and give us feedback on our processes to drive improvement.”

Click to learn about URAC's Health Utilization Management Accreditation and Workers' Compensation Utilization Management Workshop on October 11, 2018.

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