Download Handout Reducing the Cost of Prescription Medications in Workers' Compen...

Reducing the Cost of Prescription
Medications in Workers’
Compensation Cases and MSAs
Presented by:
Melisa C. Zwilling, Esq.
Carr Allison Medicare Compliance Group
[email protected]
www.carrallisonmsa.com
Jeff Carlisle
Carlisle & Associates
[email protected]
www.carlislemedical.com
Exceeding Expectations . . . Delivering Results
Welcome!

Webinar approved for CE credit in Alabama, California,
Florida, Georgia, North Carolina and Texas

Handouts will be emailed

Information will be submitted for CE credit


If you did not indicate which states you need credit for or
provide your license number and/or NPN during
registration, please email that information to me as soon
as possible
Must be attentive to qualify for CE credit, per state rules
2
Medicare Secondary Payer Act

Medicare may not make payments if “payment has been
made or can reasonably be expected to be made” by a
“primary plan”

WC insurers, self-insured employers, no-fault insurers,
automobile or liability insurers, group health plans

If payment is made, it is “conditioned” upon
reimbursement

If U.S. must file lawsuit, may recover double damages

May collect from “any entity that has received payment
from a primary plan or from the proceeds of a primary
plan’s payment to any such entity”
3
MSPA Compliance
Future Medical
Expenses
Medicare
Conditional
Payment Claims
MAPs and PDPs
Section 111
4
Future Medicals
5
WC Medicare Set-asides (MSAs)

Money for future medical expenses Medicare would
otherwise pay

MSAs are not required by law, however, the burden of paying
future medical expenses may not be shifted from a primary
payer to Medicare

MSAs help ensure that Medicare is not called upon to pay
medical expenses that primary payer should, or arguably
should, pay

MSAs are established at the time of settlement

May be submitted to CMS for approval
6
Aggressive Approach to Submissions

Reduced dosage or frequency


Pain medications, sleep medications, NSAIDS, muscle
relaxants, anxiety medications
Supporting evidence
7
Difficulties with CMS Approval

Lifelong medications

Added cost of opioids, even if actual medication cost is
low

CMS generally requires quarterly physician visits and urine
drug screens

Single opioid prescription with relatively low lifetime costs
can increase a set-aside significantly
8
Liability Settlement Allocations

Less formal than workers’ compensation

CMS approval not available

May take defenses available under state law into
account

Must still include reasonable amount of money to cover
prescriptions
9
Pharmacist Rx
Review and Reduction
10
Case Management Prescription Review Services
A comprehensive clinical review regarding an injured
worker’s medication usage is completed. The review
includes:

Opioid monitoring and identification for early intervention

Generic alternatives when brand name medications are prescribed

Evaluation for possible duplication of drug therapy

Cost-effective medication alternatives prepared for physician
consideration

Inquire as to the appropriateness of drug therapy in relation to diagnosis

Optional consultation with the provider where allowed

Assist with catastrophic or long-term maintenance claims

Identifies potential opioid weaning plans
11
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Case Management Prescription Review Services
Checklist to Determine the Need for a Case Management Prescription
Review

Claimant’s monthly medication cost exceeds $500

Claimant taking brand name medications that have a generic
equivalent

Claimant taking two (2) or more medications in the same
therapeutic class

Claimant taking medication that appears to be unrelated to
his/her injury

Medical Only file that has been open for over five (5) years

Claim approaching settlement

Medicare Set-Aside being arranged for this claimant

Two (2) or more treating physicians on a file
12
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Case Management Prescription Review Services
Comparing Clinical Interventions

Case Management Prescription
Review

Case Management Opioid
Weaning Plan

Drug Utilization Review

Peer Review

Task Assignment
13
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Case Management Prescription Review Services
Review Steps
2. Pharmacist and
case manager review
medication history
and prepare
alternatives for the
report
1. Claims
approaching
settlement/MSA with
qualifying indicators
4. Upon approval, case
manager consults with
physician to discuss
options and facilitates
changes
3. RX Review
discussed with
adjuster /Medicare
compliance group and
case manager consult
suggested
5. Injured worker
receives approved new
medications and
savings are realized
ongoing monthly
6. Pharmacy
Program alerts case
manager of any
treatment plan
changes
14
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Why the Consulting Case Manager Should Present
3. RX
Review
Historical tracking shows that the mailing or faxing of a prescription
review
to a
discussed with
physician only facilitated the requested changes 15% of the time.
In contrast,
adjuster
/Medicare
utilizing a case manager to present the prescription review and
discuss
compliance alternatives
group and
case
manager
consult to
yields a success rate of 80%. The reasons for increased success can be attributed
suggested
a few key points:
•
•
Information is provided clearly and concisely in an easy to read report from the
worker
4. Upon uses
approval,
case to discuss5.aInjured
pharmacist. The case manager
the report
future
plan
of care
receives approved new
manager consults with
that includes alternativesphysician
to the current
medication regimen.
medications and
to discuss
savings are realized
options and facilitates
ongoing
The case managers ability to dialogue
clarifymonthly
any concerns
changeswith the provider can
about the efficacy of possible changes and focuses attention on the task at
hand.
•
6. Pharmacy
The case manager will coordinate changes
with Retail
Network
Program
alerts
case and/or Home
manager of any
Delivery.
treatment plan
changes
15
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Mail vs.
In
Person
Success
Rate
Case Management Prescription Review Services
Brand vs. Generic
➢
Brand/Generic
➢
Lyrica 100mg
➢
Pregabalin 100mg $192.10
➢
Percocet 10/325 $2,419.45
➢
Endocet 10/325
$513.74
$183.90
16
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Case Management Prescription Review Services

Topicals

Pennsaid Sol 2% - 112gms
$2,989.90

Voltaren Gel OTC
300gms
$49.44 (Walmart + tax)
150gms
$24.72 (Walmart + tax)
100gms
$19.77 (Walmart + tax)

PRN Use (as needed)

Exceeding CDC/Manufacturer Guidelines
17
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Case Management Prescription Review Services
Therapeutic Equivalents
Formulation Change

Tizanidine 4mg capsules
$90.70

Tizanidine 4mg tablets
$29.97
Extended-release to Immediate-release

Amrix 30mg
$1,324.53

Cyclobenzaprine ER 30mg $1,182.73

Cyclobenzaprine 10mg
$48.60
Combination Drugs

Duexis 800/26.6mg $2,592.42

Ibuprofen 800mg
$35.23

Famotidine 20mg
$108.81
18
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Cost Drivers Associated With Opioid Use
19
Opioids

Increased claim costs

Increased time off of work

Cost of opioid

Increased prescription count

Lower cost alternatives

Weaning Protocol
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
CDC Opioid Prescribing Guidelines

Opioids are not first-line or routine therapy for chronic pain

Goals for pain and function

Realistic benefits vs risk

Clinically meaningful improvement in pain/function

Lowest effective dose (start low/go slow)

Check prescription drug monitoring programs (PDMP)

Urine drug screening

Treatment for opioids use disorder if needed
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
20
Common Side Effects of Opioids
21

Drowsiness

Itching

Physical dependence

Increased sensitivity to pain (hyperalgesia)

Confusion

Dizziness

Constipation

GI upset, nausea

Decrease in testosterone
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Overdose can lead to death
Cost Drivers Associated With Opioid Use
22
Long-Term Opioid Side Effect Cost Drivers
Constipation
Drowsiness

Movantik $444

Armodafinil(Nuvigil) $628

Relistor $2,426

Modafinil(Provigil) $757
Decreased Testosterone

Testosterone Inj $226

Testosterone Gel $106

Sildenafil (Viagra) $321
This Photo by Unknown Author is licensed under CC BY-NC-ND
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Abuse-Deterrent Formulations Raise Cost

Per FDA, abuse-deterrent properties are defined
as those properties shown to meaningfully deter
abuse, even if they do not fully prevent abuse

Abuse-deterrent DOES NOT mean abuse PROOF

Abuse-deterrent formulations are often more
costly
OxyContin $755
Xtampza $1029
VS.
Oxycodone $231
Morphabond $1143
VS.
Morphine Sulfate ER $194
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Zohydro $761
Hysingla $930
VS.
Hydrocodone/APAP $130
23
Case Management Prescription Review Services
Review Example
Yearly Savings
$35,791.80
24
Case Management Prescription Review Services
Review Example
Yearly Savings
$29,915.40
25
Case Management Prescription Review Services
2020 Case Study Reviews
Claimant
Potential
Monthly
Savings
Angela
$1,844.95
$819,157.80
3
$231.33
37
$102,710.52
COST SAVINGS ACHIEVED
John
$492.67
$35,472.24
0
$0.00
6
$0.00
NO SAVINGS ACHIEVED
Sandra
$2,013.21
$676,438.56
3
$1,880.60
28
$631,881.60
COST SAVINGS ACHIEVED
Steve
$309.22
$63,080.88
1
$297.00
17
$60,588.00
COST SAVINGS ACHIEVED
Vickie
$790.53
$284,590.80
3
$792.15
30
$285,174.00
COST SAVINGS ACHIEVED
Dennis
$779.66
$140,338.80
2
$412.42
15
$74,235.60
COST SAVINGS ACHIEVED
Avis
$3,497.66
$755,494.56
3
$3,298.44
18
$712,463.04
COST SAVINGS ACHIEVED
Frances
$679.38
$146,746.08
0
$0.00
18
$0.00
NO SAVINGS ACHIEVED
Daniel
$422.05
$106,356.60
1
$3.52
21
$887.04
COST SAVINGS ACHIEVED
Willie
$2,375.93
$342,133.92
3
$1,734.23
12
$249,729.12
COST SAVINGS ACHIEVED
Baron
$1,579.70
$511,822.80
2
$575.99
27
$186,620.76
COST SAVINGS ACHIEVED
Saundra
$1,841.37
$861,761.16
3
$1,096.01
39
$512,932.68
COST SAVINGS ACHIEVED
Martha
$3,146.15
$453,045.60
1
$2,492.95
12
$358,984.80
COST SAVINGS ACHIEVED
Jennifer
John
(reopened)
$4,339.02
$2,291,002.56
2
$707.13
44
$373,364.64
COST SAVINGS ACHIEVED
$625.48
$135,104.40
0
$0.00
18
$0.00
NO SAVINGS ACHIEVED
Thomas
$289.75
$62,586.00
1
$21.98
18
$4,747.68
COST SAVINGS ACHIEVED
Potential Life
Medications
Expectancy Savings Changed
Realized
Monthly
Savings
Life
Expectancy
Lifetime
Savings
Result
Michele
$956.45
$344,322.00
1
$971.75
30
$349,830.00
COST SAVINGS ACHIEVED
Gregory
$271.14
$104,117.76
1
$223.15
32
$85,689.60
COST SAVINGS ACHIEVED
Christa
Mennie
$826.16
$1,638.35
$386,642.88
$157,281.60
3
2
$381.53
$551.17
39
8
$178,556.04
$52,912.52
COST SAVINGS ACHIEVED
COST SAVINGS ACHIEVED
$8,677,497.00
35
$15,671.35
Totals: 20 $28,718.83
$4,221,307.64
26
Realized
16
Not Realized 3
Open
1
20
Success Rate
80%
Case Management Prescription Review Services
2020 Case Study Savings Summary
Realized
16
Not Realized 3
Open
1
20
Success Rate
80%
27
Copyright 2021 Carlisle Medical, Inc. All Rights Reserved.
Questions?
28