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Keeping ahead of the curve saves money, boosts care in the fast-changing world of Workers’ Compensation

Professionals in the workers’ compensation world see it happen time and again. Claims best practices have proven early intervention greatly increases the probability for a win-win result. Patients are provided a more appropriate treatment path and payers get the most efficient outcome.

Similarly, when you look at the complexities of prescription drug trends in the workers’ compensation arena, getting the most effective results for both the patients and payers requires a proactive strategy, one that gets out ahead of any upcoming trends. The result? Unexpected costs are minimized and patient care maximized.

“In the past few years there have been an enormous amount of changes impacting prescription drugs in workers’ compensation,” says Daryl Corr, president of Healthesystems, the Tampa, Fla., provider of workers’ compensation pharmacy and ancillary benefits management solutions. Corr lists issues such as new medications, off-label drug use, the growth in alternative dispensing channels, such as compounds, repackaged drugs and medical foods, and an ever-changing regulatory landscape. This complex array of issues, and others, has given PBMs several critical fronts in the battle to manage costs and maximize care.

“PBMs must stay ahead of the curve, be more multi-dimensional,” he says. “There always is something coming down the pike, and PBMs need to ramp up and get ahead of the curve to mitigate those challenges for both themselves and their customers before they cause problems.”


For example, he says, “it’s amazing to see the amount of significant legislative activity occurring that can impact the workers’ compensation claim process. At the same time, the landscape for new drugs and complex drug treatments keeps growing.” Both situations can either create great opportunities for payers to improve their results or create new obstacles, depending on whether they and their PBMs are following them closely and proactively developing new solutions.


For example, a number of new medications have been approved and introduced into the marketplace with the potential to impact costs to workers’ compensation payers. In 2010 alone, the Food and Drug Administration (FDA) approved four new generic formulations and at least 13 new drugs that are likely to be seen as contributors to workers’ compensation drug spend.

Corr says that there were three new opioid products – including Exalgo™ (hydromorphone extended-release), the reformulated, abuse-deterrent Oxycontin® (oxycodone extended-release) and a generic version of Opana IR® (oxymorphone immediate-release) – that are now on the radar screen and warrant close monitoring.

Plus, already in the first three months of 2011, the FDA approved five new medications that have a likelihood of being used to treat workers’ compensation patients. Three of these are “drugs to watch” as they emerge in the marketplace:

  • Viibryd, an antidepressant that was approved for the treatment of major depressive disorder, is expected to be launched in the second quarter. Among other things, the labeling contains a boxed warning concerning suicidality, as well as caution concerning serotonin syndrome.
  • Gralise, an extended-release version of Neurontin® (gabapentin) approved for the treatment of post-herpetic neuralgia, has no launch date currently scheduled, but is anticipated in late 2011. The drug could likely be extensively used off-label for the treatment of neuropathic pain as an alternative to gabapentin and Lyrica®.
  • Abstral, an oral fentanyl product that falls into the same category as Actiq®, Fentora® and Onsolis®, like these other oral fentanyl products, is only approved for treating pain in cancer patients — but may be seen used off-label in workers’ compensation cases. Similar to the other oral fentanyl products mentioned, Healthesystems recommends that payers carefully consider whether the use of this drug within the workers’ compensation environment is appropriate.

Other drug industry news worth noting includes the FDA’s January 13, 2011 recommendation to pharmaceutical manufacturers that all prescription drug products containing acetaminophen be limited to no more than 325mg of acetaminophen per dosage unit. In addition, a boxed warning noting the potential for severe liver damage and a Warning concerning the potential for severe allergic reactions will be added to the labeling of all prescription acetaminophen-containing products.

The move is an effort to help reduce the risk of severe liver injury and allergic reactions resulting from the overuse of the drug, which, according to several studies, have been significantly on the rise.

“This is a critical topic for workers’ compensation payers since acetaminophen is frequently included in therapy for work related injuries,” Corr says. “The overuse of acetaminophen is especially problematic with fixed-dose combination products that also contain an opioid analgesic.”

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In fact, acetaminophen is used in many of the most commonly prescribed medications for workers’ compensation patients, including hydrocodone with acetaminophen (Vicodin®, Lortab®) and oxycodone with acetaminophen (Tylox®, Percocet®). Often, the amount of acetaminophen in each tablet is greater than 325mg and can be up to 750mg per tablet. For example, Vicodin, contains 500mg of acetaminophen in each tablet. The challenge is magnified since there are over 600 over-the-counter (OTC) medications that contain acetaminophen. In many cases the possibility of overdosing can be overlooked especially when patients are purchasing frequently used items like cold medicines or when multiple physicians are prescribing drugs unaware of overlapping therapies. Drug manufacturers will have three years to limit the amount of acetaminophen in their products (deadline: January 14, 2014).  They will either have to pull their product from the market or reformulate it before this date.

In keeping with its proactive stance, Healthesystems long ago identified the risks associated with their patients taking more of the combination products than prescribed, and has been targeting these scenarios as part of its VigilantRx clinical program. In this scenario, this highly successful program quickly identifies patients who are taking excessive and potentially toxic doses of acetaminophen containing medications and uses tools like their independent pharmacotherapy evaluations (IPEs) and therapeutic alerts to communicate this information directly to prescribers.

“Our clinical staff monitors the pharmaceutical marketplace continuously for new drugs and new information such as the acetaminophen situation, in order to evaluate the potential for adverse reactions and inappropriate use for the workers’ compensation patient population,” Corr says. “Proactive oversight allows us to keep our clients informed and prepared for whatever impact a new drug or trend may have for patient and payer alike.”

In addition to keeping a close eye on developments with prescription drugs, as part of its proactive philosophy, Healthesystems also closely monitors legislative developments across the country, and constantly interacts with policy makers to ensure they are being presented with “real world” information to use when deliberating what issues need to be addressed and how to implement the most effective solutions.

Corr referenced a few states among several others such as Georgia and Maryland, where recent focus has turned to address workers’ compensation prescription drug issues.

  • In Georgia, the state’s Board of Workers’ Compensation has adopted changes to the Pharmaceutical section of the Medical Fee Schedule that became effective on April 1. As a result, dispense fees were increased slightly and new language was adopted that addresses the reimbursement of repackaged drugs at the original packager’s National Drug Code (NDC) reimbursement rate.
  • In Maryland, the state’s Workers’ Compensation Commission (WCC) scheduled a public hearing in Baltimore for April 14 to discuss a recent proposal to implement a pharmacy fee schedule. Maryland currently uses “usual and customary” reimbursement rules. The WCC has also recommended language on the reimbursement of repackaged and compounded medications.

“Our Compliance & Government Affairs department has submitted comments in preparation for attending the Maryland hearing. It’s great to see more states pursuing measures to control the challenges created from repackaged and compound medications,” Corr says.

In recent months several state agencies and legislators have begun the difficult task of attempting to close loopholes in workers’ compensation regulations and statutes regarding repackaged medication reimbursements. At the end of 2010, only four states—Arizona, California, Mississippi and New York—had language specific to repackaged medications in their pharmacy fee schedules.

“It’s surprising there hasn’t been more legislative activity, considering the frequent mention of repackaged medications as a cost driver in research reports published by industry groups like the National Council on Compensation Insurance,” Corr says. “Left unchecked and unregulated, this practice can drive costs up dramatically.”

“As part of our focus on being proactive, we’ll continue efforts to educate and advocate for changes where there is potential for abuse occurring in the system,” Corr explains.

In the end, Healthesystems believes that while predicting the future is impossible, doing the best to get ahead of upcoming changes through expertise and innovation, and then meeting those challenges, is not.

“We don’t believe in surprises for our clients,” Corr says. “We do our best to make sure they don’t happen.”

For more information about Healthesystems programs, visit Healthesystems.com or contact the company at info@healthesystems.com.


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