Workers’ comp pharmacy costs represent approximately 18% of total medical spend. That translates to $5 billion in pharmacy spend nationwide.1 Most employers and payors utilize Pharmacy Benefit Managers (PBMs) which offer an excellent line of defense in managing these ever-increasing pharmacy costs. But PBMs, by design, only manage the pharmacy related aspects of a claim. What if you could extend the reach of your PBM by combining it with the knowledge, care and one-on-one delivery model used in case management? With a pharmacy nurse, you can.
What is a pharmacy nurse?
A pharmacy nurse is a specially trained case management nurse who communicates with prescribing physicians, injured workers and claims professionals to positively impact drug utilization on a claim. Analysis of drug treatment and prescribing patterns, along with patient demographic information and categorized loss information is conducted to determine the most appropriate candidates for intervention.
Involvement may be initiated by a variety of triggers, including:
The role of the pharmacy nurse
- Claim level alerts based on dosage, particularly MED measurement
- Potentially dangerous combinations of medications, such as opioids with a benzodiazepine and/or muscle relaxer
- Multiple prescribing physicians and overlapping drug therapies
- Costly medications with little medical efficacy with reasonably priced substitutes, such as compound kits, compound medications and physician dispensed topical medications
- Refusal by a prescriber to participate in a peer to peer conversation following a Drug Utilization Review
- Claims handler referral for intervention
A typical intervention involves contact with the prescriber, including discussion of the medication(s) in question, education regarding medication cost and potential dangers, and request for prescriber agreement with recommended changes. Educating the injured worker is another key role of the pharmacy nurse and includes providing information on the safe and appropriate use of medications, and ongoing patient engagement to answer questions and ensure compliance with an appropriate medication regimen. The claims handler and case manager are notified of the intervention results, and appropriate edits are placed in point of sale to impact future transactions. In addition, the pharmacy nurse may facilitate and monitor urine drug testing, monitor a weaning program and/or coordinate additional physician outreach with an assigned field or telephonic case manager.
Benefits of having a pharmacy nurse analyze a claim
Benefits of pharmacy nurse involvement include improved medical outcomes, patient education and safety, timely return to work, reduction in potential addiction issues, lower claim costs and reduced financial impact of a subsequent MSA. Recent results from Coventry’s pharmacy nurse program called “RxRN” over one year with one client indicate an opioid cost per script reduction of 8.6%, compared with a book of business reduction of 3.4%, and an average opioid cost per claim reduction of 20.6%, compared with a 17.2% reduction for the book of business. The program ROI during a one-year period was 10:1, based on individual case savings and projected Medicare Set Aside Arrangements (MSA
) Lifetime Medical cost reductions.
1Source: NCCI Workers Compensation Prescription Drug Study 2013 Update