Workers' Comp

Enlyte Experts Discuss the Benefit of a Holistic Approach to Pharmacy

June 24, 2024

Nikki Wilson, Pharm.D./MBA

Senior Director of Clinical Pharmacy Services

Dr. Mitch Freeman, Pharm.D.

Chief Clinical Officer

Seizing opportunity within the complexities of workers’ comp prescription utilization requires a holistic approach that manages all transactions to gain the full picture of medications being utilized. This Enlytening Conversation covers key factors for payers to consider that impact pharmacy utilization and cost, including legislative and regulatory challenges, physician dispensing, utilization controls, complex billing issues and cost management solutions that consider therapy as a whole.


Mitch Freeman (MF): Navigating the cost of workers' compensation can be really challenging. There's a lot of different factors that impact cost, and a lot of those have to do with jurisdictional differences. So you know, each jurisdiction has unique legislative challenges and regulatory challenges. And that means that each jurisdiction you really have to treat differently.

MF: Traditionally, if you look back, PBMs have really operated in silos and have considered medications that are billed outside of the PBM, they've been considered uncontrollable.

MF: And so, you know, as we learned, you really can't manage cost unless you have a holistic view of everything that you're paying for from a pharmaceutical standpoint. So it's very important to see all those transactions that may be going out of network that includes, you know, prescriptions filled from out-of-network pharmacies, physician dispensing. And all those kind of roll back to the original point where what kind of tools do you have jurisdictionally to be able to control those? And so in some states, you can direct care from pharmacy, and you can say that, you know, people have to utilize your network in other states, you don't have that control. And so it's very important to have a good grasp on the regulatory differences, and then implement strategies in order to control that out of network.

MF: So the thought of out of network being non-controllable just doesn't fit anymore. If you're gonna manage your pharmacy spend, you have to manage all of it. And that's, you know, definitely from a price perspective, but from the other perspective, you need to have good controls on what the patients are actually taking.

MF: I'd say the other thing is the days of evaluating each prescription individually and saying is this an appropriate drug on its own, instead of stepping back and treating injured workers as patients that are taking therapy as a whole and not just an individual prescription, is extremely important because these are patients and we have to treat them as patients. All that is around price, but that doesn't even get into utilization and watching out what are the patients taking and how what they are taking really impacts that claim overall.

Nikki Wilson (NW): I agree. And I think one of the things we always get asked is why is this important? Why is it important to manage out-of-network dispensing? Why can't physicians dispense out of their office?

NW: And you hit on a lot of those points. Certainly, we're worried about inappropriate utilization and controls and price and whatnot so that holistic view is important. So we're seeing every channel and pharmacy that a client is experiencing as well, not just retail mail order, but getting into those clinic dispensings, but the biggest one, I think for me, and maybe for you too as a clinician is understanding those safety edits that they may be missing by just giving their patient that medication and not understanding the full picture. So when we see those things come through, if we're able to get that holistic view of every transaction that's being processed, we're able to apply safety and clinical controls, and some of our program edits, through pharmacy benefit management to better serve that claim overall.

MF: We do. We see that a lot. We see you know, a patient will go into their doctor and they'll prescribe a benzodiazepine or something like that. But they'll give them a prescription for an opioid to take into the pharmacy.

MF: So if you don't have that holistic view that's a very serious drug interaction. Yep. It can be fatal and deadly from an overdose, but you would never see that because those are filled through two different channels. One physician dispensing and then the other through a retail network.

NW: Right. And I think another critical point is when we have physician's bills that'll come in, so there's been an office visit the patient may have gotten a medication to go home with. Maybe they also got an injection while they were in the office. And those don't come through as a traditional pharmacy billing, where typically we have codes like national drug codes where we can grab and identify, what is the drug that's dispensed?

NW: J-codes or HCPCS codes that don't flag necessarily as medications for most billing systems that are out there can present additional challenges. So being able to understand what those look like repricing with the correct units and getting that full picture like you're saying into what that patient's received can be very important. One example we use a lot is the nonsteroidal anti-inflammatory drug, ketorolac.

NW: It is a very potent anti-inflammatory pain med. You can get it as an injectable but the limitation is five days total of therapy, both oral, injectable, etc. So if the patient gets a ketorolac injection, and then they go to the pharmacy to fill an oral or another NSAID that could be a dangerous combo if we don't see everything that took place in that visit.

MF: Definitely. You know, another challenge is, a lot of the physician dispensing when the invoicing occurs. They're commingling and mixing office charges with those prescriptions that they're dispensing out of their office.

MF: And if you think about the challenges of being able to only focus on the pharmacy within that invoice, and then still have the rest of the bill flow through, you know, that's a big challenge. And that takes very, very specialized technology to be able to pull that bill apart, evaluate the prescriptions on that invoice, put that bill back together so that it can flow through the rest of a typical bill review process, you know, apply PPO discounts, and then have all the EOR codes match and be compliant, you know, for those denials. So it really is a challenge, and it, you know, it takes that very specialized technology to be able to handle all of physician dispensing, all of out-of-network pharmacy, as well as the traditional retail pharmacy and mail order that typically flows in network.