Jim Andrews of Cypress Care (a consulting client and WC PBM) gave a talk yesterday about some of the differences between drug spend in WC and group health. Here are a few of the main points I picked up.
The drugs that consume the most dollars in WC are rarely in the health world’s top 50. Examples include Skelaxin, duragesic patches, Lyrica, and Actiq.
Pain drugs account for the vast majority of WC scripts. The list of pain drugs includes narcotic opioids, NSAIDS, and anticonvulsants.
The amount of fentanyl (a powerful narcotic opioid) prescribed is just stunning. And the physicians responsible for most of it are typically PM&R docs and anesthesiologists.
By the effective use of data mining to identify off-label usage of drugs and peer review to intervene where appropriate, fully two-thirds of the patients on Actiq can be converted to a less powerful, less addictive, much less expensive drug. (Actiq scripts typically run $2500 per month)
Fentora is essentially a new formulation of Actiq, with a new patent protection period and a cheaper price (actually not much cheaper, especially considering Actiq’s price went up 100% last year). In its first three months of sales, Fentora racked up almost $30 million.
What does this mean for you?
Managing drugs in workers comp is much much different than in the group health or Part D worlds. If you are using a PBM that focuses on group health…
I am one of your reported work-injured workers on Lyrica. One fact you failed to mention is that Lyrica is a fairly new drug. It does take a while for drugs to climb the ratings after introduction I am sure. When I first started taking it, I considered it a MIRACLE drug as to this point I had had virutally CONSTANT nerve pain which 3 operations failed to correct. I am on muscle relaxants and pain medications in addition to Lyrica. I continue taking it to this day and refuse to consider being put off of it because it might not be in the “top 50.” What relevance is that to me if it works? With this drug, I am more able to function fully and work full time since I have no option of not working. I am not opposed to trying to save $$ on WC; I am just not willing to switch to something cheaper that doesn’t work just for the sake of some “top 50.” Why don’t some of the highly paid WC executives/administrators volunteer to take a paycut to save $$ on WC? In California’s most recent WC cuts, workers’ benefits were the only thing cut back on; administration expenses were allowed to mount and escalate. How fair is that?