Insight, analysis & opinion from Joe Paduda
The efforts by third party billers and their partners to overturn a key part of the NY workers comp reform package appear to be gathering strength. Two legislators have introduced a bill that would kill the ability of payers to direct injured workers to specific pharmacies.
The rationale, that the pharmacies would somehow deny scripts, is ludicrous.
If you want to know why you are getting more physician bills with meds on them, it’s simple – physician dispensing generates big profits.
Pharmacy and Therapeutics committees have been around for ages in the provider community – they are the “link between medicine and pharmacy”. In the managed care world, P&T committees take on a somewhat different role, establishing formularies, reviewing medical device reimbursement (at some health plans), contributing to coverage determinations and benefit design.
Mostly, they provide the health plan or insurer with an expert opinion on most things pharmacy-related. Without a P&T Committee, these decisions often are left to a medical director, or worse, claims adjuster (in the P&C world), individuals who are not equiped to make educated decisions about pharmaceuticals.
The manufacturer of oxycontin agreed to pay $20 million in penalties for encouraging docs to prescribe the drug more often than approved by the FDA.
And that’s just for starters.
Actiq has hit the big-time.
Newsweek’s latest edition will feature an article on the off-label prescribing of the highly potent narcotic lollypop, an article noting that as much as 80% of scripts for Actiq are for off-label use.
Sources indicate this was brought to the reporter’s attention by an unusual source – the risk management department of The Washington Post, Newsweek’s sister publication, noticed a high incidence of Actiq scripts among its workers comp patients, and started digging into the issue.
Pharmacy chains demand higher payment for workers comp scripts. WC takes more work, as the pharm tech has to determine eligibility and do more work to get a script processed. Therefore, it’s logical that the chains charge more for WC.
Except that isn’t what’s happening.
Dozens of brand spanking new workers comp pharmacy benefit managers (PBMs). Last year at RIMS every aisle was packed with shiny new booths staffed by folks who, as swiftly became painfully obvious, were rather new to WC.
Either they didn’t want to come to New Orleans (they are definitely missing out) or they are out of business, or out of the comp business. Most likely they found their group health contracts, systems and processes, and cost management techniques just didn’t work in the highly-regulated, state-specific, first-dollar-every-dollar world of WC.
We’ll miss their enthusaism and humor-generating ability (“and how many members do you have? what kind of tiered copays are you using? let me tell you about our unique formulary that controls costs!”) and trinkets.
Sort of.
Big pharma woos docs with free food, trips, and samples. Now that’s a “dog bites man” story. The reason for the ongoing marketing to docs is obvious – more contact, more drugs sold.
But the world is starting to look much more closely at the pharma-physician relationship, and that examination is likely to bring changes.
OK, another trip down Esoteric Lane, into the wierd world of WC drug management…
When states set high workers comp fee schedules for drugs, WC medical costs go up, and too many dollars are taken from employers and given to pharmacies and PBMs.
That’s exactly what an organization with the seemingly innocent title “Workers Comp Pharmacy Alliance” is working towards.
Insurance companies, employers, and TPAs rely on vendors to process bills, build and operate networks, manage prescriptions and PT, support litigation, and provide expert advice on problematic medical issues. In many instances the vendors are selected thru a competitive bidding process, wherein the lowest bidder gets the deal, or at the least has a much better chance of landing the business than their more costly competitors.
But in others, the selection process goes on seemingly without end.