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.
The WCPA was formed some time ago, in part to lobby against a very low fee schedule contemplated by the state of California. Their efforts were for nought, as California adopted a fee schedule based on the Medi-Cal reimbursement rate, which resulted in the nation’s lowest reimbursement levels.
From those humble beginnings, the WCPA expanded its efforts, and is now actively involved in lobbying in several states. We’re not talking nickels and dimes here; official sources show the WCPA spent almost a million dollars last year on their lobbying efforts in a single state – Pennsylvania.
Yep, a million bucks in one state.
Sources indicate the WCPA is primarily working to keep drug fee schedules high. While this might make sense for two of the WCPA’s backers, third party billers Third Party Solutions and WorkingRx, it is a bit more problematic for WCPA supporters that are WC PBMs.
If a WC PBM successfully lobbies for high fee schedules, their payer customers (insurance companies and self-insured employers) will pay more for drugs that don’t come through the PBM.
And that’s not all of the picture.
The TPBs are asking PBMs to sign contracts that don’t allow the PBM to cut the bill for any script (that comes thru the TPB to the PBM) to the PBM’s contracted rate for the first 21 days of the claim.
The combination of the two means that payers will be forced to pay a higher rate for drugs, in part due to the lobbying efforts of their PBM.
The good news? Most of the WC PBMs, including Cypress Care, Progressive, MSC, Express Scripts, ScripNet, and FirstScript are steering well clear of the WCPA.
The new firm Cambridge Services are trying to cut me off my pain RX’s. Their cost is approx.650.00 amonth compared to having a Morphine pump implanted in my body and a monthly cost of 1500.00 to have it refilled and the cost of surgury.My RX’s work fine. How are they going to save money by cutting me off pain meds that have vastly improved my quaality of live and expect to save money by insstalling aa pump .I called Cambridge and was told by the person that the Morphine pumps didn’t work. My DR has requested twice to comp for me to go to the Pain center,got back first letter and was told that the Pain Centervisit was being withheld pending a Brickstreet Examiners findings. I have been to the Center for Pain and was told 3 times that if my RX’s were working stay on them,and now because I am a chronic pain patient what am supposed to do.They don’t want me taking medicine that helps they want me to be used as a patsy and try the pump.But now the lady who I talked to said the pump wil not work,so I find myself in a catch 22 situtation