27 payers were kind enough to participate in this year’s Annual Survey of Prescription Drug Management in Workers’ Compensation.  I’m working thru the data now…here are a few highlights. (The Survey falls under CompPharma, a workers’ comp pharmacy consultancy; as always, responses are confidential and not shared with anyone or any entity)

Overall, pretty darn positive (but premature as some data is still coming in) results…

Opioids

Across all 27 respondents, opioids accounted for 18.7% of drug spend, a drop of half a point over the last 2 years.  That’s good news indeed…but there are caveats which we will get into in a future post.

One thing to note – there was a good bit of concern last year that the COVID thing might/would increase opioid usage; that didn’t happen. Again, good news.

Drug spend 

Overall drug spend decreased 12.3% from 2020 to 2021; about half of the respondents attributed the drop at least in part to fewer claims. In turn, most tied the drop in claim count to COVID.

Over the last decade, work comp pharmacy costs have dropped 9 out of the ten years.

Generics

Generic drugs accounted for 89.3% of all scripts, with generic efficiency ( the percentage of all drugs dispensed as generics that could have been generics) averaging just under 98%.

Again, an improvement over 2018’s 87% generic fill percentage.

PBM ratings

Once again respondents rated myMatrixx as the top PBM with 3.7 out of a possible 5 points, with market-share leader Optum trailing by a half-point. Mitchell is tied with Optum, while Coventry’s First Script lags another half-point behind. (Mitchell recently acquired Coventry)

Again, data is preliminary and subject to change.

More to come; as always a big thank you to the respondents who will each received a detailed copy of the Survey report; a public version will also be prepared and available at no cost to all.

Note – myMatrixx is an HSA consulting client; myMatrixx was not involved in conducting the Survey.

I’m almost halfway thru the 17th (!!) annual survey of Pharmacy Benefit Management in Workers’ Comp.  Here are some VERY preliminary results (which are almost certain to change).

If you are a WC payer and want to participate, drop me a note in the Comments section.  Public versions of past surveys are here, respondents receive a much more detailed version.

Findings

All but one respondent saw a drop in drug spend from 2019 to 2020; the biggest cost reduction driver was fewer claims.

Despite a 7+ year trend of declining drug costs, respondents view prescription drug issues as somewhat more important than other medical issues. This is likely driven by drugs’ impact on recovery and return to work.

Transparency remains a significant concern, with only 2 respondents having full visibility into drug costs. Most want more transparency and no one is really comfortable with AWP.

Opioid spend continues to decline...which is the good news.  Not-so-good is the continued problem of helping long-term users reduce or eliminate opioids. Prescriber intransigence is the major obstacle followed by attorneys blocking access to patients.

Few payers have audited their PBM and those that have are (mostly) just checking AWP pricing compliance.

Several noted out-of-state mail order pharmacies – mostly IWP and entities in Pennsylvania – continue to be a sore spot, adding cost, negatively affecting clinical management, and wasting adjuster time.

What does this mean for you?

Costs are down, but pharmacy is about much more than the price of the pill. 

It sure looks like they/you have.

WCRI’s latest report finds:

• Physician-dispensed drugs (PDDs) accounted for more than half of drug costs per claim in Q1 2020 in four states – Florida, Georgia, Illinois, and Maryland.
• In 12 states, doc-dispensed dermatological agents accounted for most payments for this drug class.
• Louisiana is worst-off, with employers paying $190 per claim for dermo drugs in the 1st quarter of 2020…Illinois is right behind at $181.
• Kansas and Connecticut saw payments for those dermo drugs triple from Q1 2017 to Q1 2020.

That profit-sucking prescribing by docs in Connecticut is why total drug spend increased 30% in the Nutmeg State – making it one of two states that had drug spend increases. Florida – the home state of PDD – was the other. (Across all subject states, drug costs dropped 41%.)

Having lived in CT for over 20 years, I’m really stumped by the precipitous increase in skin care drugs.

What could POSSIBLY be driving this massive need for occupationally-driven skin care/topicals?

Did sun spots create a pandemic of skin cancer but somehow only affect the second-smallest state?

Did a massive refinery accident expose tens of thousands of workers to burns or skin infections?

Did a hyper-virulent new breed of poison ivy run rampant, affecting thousands of landscaping and municipal workers?

Did the emerging cannabis industry fail to protect its workers from fertilizer burns, exposing thousands of workers to painful blisters?

Did everyone in Connecticut suddenly become unable to swallow a pill?

Of course not.

The real question is this:

why haven’t insurers, TPAs, and self-insured employers used CT’s Medical Care Plan to ban physician dispensing? Payers including the Workers’ Comp Trust of CT have pretty much eliminated physician dispensing.

It’s not just Connecticut.  PDD costs are outrageous, and all credible research indicates PDD is totally unnecessary, increases medical costs, and prolongs disability.

WCRI’s research should be a call to action.  Legislators, regulators, and payers are doing their policyholders and clients a disservice by failing to aggressively attack physician dispensing.

And those clients and policyholders are equally at fault – it is up to you to work with your PBM and payer to stop this rampant profiteering. 

What does this mean for you?

Yeah, I know it’s hard. Most important things are. Get to it.

Hospital in patient and outpatient, surgery, DME/home health, PT, pharmacy, imaging, lab…

Which one is NOT like the others??

That’s easy – when it comes to impact on legacy/older claims, it’s all about pharmacy. The older a claim is, the greater the percentage of spend is for drugs.

The older and more costly the claim, the greater the percentage of spend is for drugs (except for those cat claims needing long-term home health/facility care).

And, the higher the reserves, the greater the percentage of those reserves is for drugs (except for those cat claims needing long-term home health/facility care).

Both graphs from NCCI; Medical Services by Size of Claim—2011 Update.

Updated information from NCCI...shows drugs continue to be a major driver of claim costs in older claims…excellent research by NCCI’s Matt Schutz…

especially for those really expensive claims.

But that’s only half the story.  The other half is the impact the type of drugs has on claim outcomes. Most simply, most patients on opioids after 8 years need a lot of help, assistance, patience, and support to recover functionality. Some can do well on opioids – most do not.

What does this mean for you?

So, how are you buying PBM services? 

Do you even ask how the PBM will help reduce long-term drug spend?

Do you ask to see data on their results by age of claim?

Do you dive deep into their abilities, tools, programs and approaches to addressing long-term claims?

Does their reporting support this by identifying, tracking, and quantifying results?

If you aren’t focusing on the PBM’s impact on long-term claims, you’re doing it wrong.

myMatrixx’ Drug Trends Report is out  – here are my key takeaways.

Behavioral Health

Kudos to the authors for the comprehensively addressing behavioral health (BH) issues. Among the takeaways are:

• Not addressing the mental health of injured workers can delay return-to-work, increase the risk of opioid addiction or both.
• Although mental health conditions rarely can be proven as work-related on their own, they often arise as a result of work-related injuries. (italics added)
• The older the claim, the more likely psychotropic medications were prescribed.

What this means

Claim closure and settlement are driven by the recovery of the patient. You are not going to get those claims closed or settled unless and until BH issues are resolved.

Opioids and benzos drive claim outcomes

The Report referenced a 2014 JOEM study noting the more dangerous drugs a patient is prescribed, the higher the claim cost – and the longer the claim is open.

While there’s certainly a severity issue at play here, the central takeaway is minimizing the inappropriate use of short- and long-acting opioids and benzodiazepines is key to patient recovery.

What this means

If your PBM and clinical staff aren’t on top of opioids and benzos – as in instantly aware of scripts and able to deploy clinical support expertise – those patients are far less likely to recover – and you’re going to pay dearly.  

Both of these issues – behavioral health and dangerous drugs – are critically important to patient recovery and claim closure.

As I noted yesterday, far too often WC payers choose vendors/partners based on the wrong criteria.

Nowhere is this more common than for pharmacy management. Price is important, and service is key – but both are secondary to the impact of pharmacy on claim outcomes.

What this means for you.

More than any other service, PBMs drive claim outcomes – for better or worse.  

note – myMatrixx is an HSA consulting client. I’m honored to work with them.

Optum’s work comp folks inform us that prices for some brand name drugs went up in January. The list includes medications that often appear on Medicare Set-aside cost projections – including some new-to-the-market meds that are pretty expensive.

As in $34.50 per pill expensive for Vivlodex, indicated for osteoarthritis and pain and almost 50 bucks per tablet for Vimovo, also for arthritis and pain.  As in a 5% increase for OxyContin, 10% jump for Nucynta, and 5% for a brand form of Opioid Use Disorder medication suboxone.

Two takeaways.

First, at least two of these meds should/must be replaced with generics.

VivlodexTM is a brand version of meloxicam, which is available in a generic form at a tiny fraction of the cost. drugs.com indicates pricing is about 13 cents per tablet…

meloxicam oral tablet 15 mg is around $13 for a supply of 100 tablets

Similarly, there are also generic substitutes for VimovoTM -which is simply a combination of naproxen (aka AleveTM) and omeprazole (aka PrilosecTM). The “substitute” would be to buy these two over-the-counter medications…

[Embarrassing disclosure time – I consulted for Vimovo’s manufacturer for a while till I figured out what the drug really was. Ouch. Lesson learned.]

Second, the price increases noted in Optum’s post do NOT reflect rebates. These can amount to 1/3 or more of a brand drug’s retail price, dollars that flow to the PBM and other entities on the supply chain.  As we’ve learned, all the news about drug price increases must be considered in the context of rebates.

courtesy Adam Fein PhD’s Drug Channels

The left most column reflects rebates etc paid to commercial insurers/PBMs etc

What does this mean for you?

Ask about rebates. There’s beaucoup bucks there.