Insight, analysis & opinion from Joe Paduda
My firm has conducted a survey of pharmacy benefit management in workers comp each year for the past four, and the latest has been completed. Executives in managed care and claims as well as program managers from 20+ payers responded to the Survey, some for the fourth time.
Here are a few of the highlights.
Continue reading Pharmacy benefit management in Workers Comp – Survey results
Here’s a shocker – quoted from a FierceHealthcare piece last November.
“oncologists accounted for only 1 percent of the 187,076 Actiq prescriptions filled at retail pharmacies in the U.S. during the first six months of 2006, The Wall Street Journal reported.”
Actiq is only FDA approved for breakthrough cancer pain.
My firm’s research indicates that Actiq is among the top three drugs in dollar volume dispensed to workers comp patients. The incidence of cancer in WC is so low as to be unmeasurable.
Back and neck injuries account for a third of all workers comp claims costs. That’s no surprise to industry types, and is a further affirmation of how tough it can be to manage comp claims.
Back injuries can be notoriously difficult to resolve, expensive to treat and impossible to determine if a back injury was related to employment.
If you’re wondering why your company’s drug costs are going up, one likely contributor is the dramatic increase in the use of pain medications. Retail sales of five leading pain drugs jumped 90% from 1997 to 2005 led by oxycodone’s six-fold increase.
The NY WC reforms are going to significantly reduce workers comp premiums –a point that many of the legislation’s critics are all but ignoring.
Restaurants, dry cleaners, and health clubs will see a 40% reduction; nursing home premiums will drop 37%, tool manufacturers 38%. These cuts will improve the viability of these businesses, and in the case of manufacturers, potentially keep jobs in the Empire State. Nursing home margins have been suffering for several years; WC premiums are a significant cost so the reform is quite meaningful.
We’re getting a clearer picture of the implications of NY’s adoption of a (very low) fee schedule for WC prescription drugs. As I’ve noted before, the WCB has clearly stated its opinion that the regs do not allow for reimbursement above the fee schedule.
The initial reaction to the news from several large pharmacy chains (at the National Association of Chain Drug Stores conference in Boston) ranged from disappointed acceptance to belligerent rejection.
Work comp claim frequency is down, but severity (claims costs) is up.
What to make of this?
The recent imposition of a work comp pharmacy fee schedule in New York has shaken the industry – and that’s not hyperbole. The latest news out of Albany is likely to intensify the aftershocks.
The preliminary guidance from the State is PBMs cannot charge more than the fee schedule, and cannot pay pharmacies more than the fee schedule.
Continue reading NY’s workers comp fee schedule – further developments
The adage goes something like – when the US sneezes, the world catches a cold, signifying just how much influence this country has on the rest of the world.
That’s analogous to Medicare’s impact on the health care sector. And Medicare is about to change the way it pays hospitals, a change that will have a dramatic effect on every private payer from HMO to individual carrier to workers comp insurer to self-insured employer.
The latest shot in the battle against drug costs comes from the Centers for Medicaid and Medicare Services, which is reported to be denying coverage for off-label use of drugs such as Actiq and Fentora.
Whenever CMS moves, the healthcare world shakes, and this is no exception. There are a host of possible ‘downstream implications’ in areas as diverse as workers comp, formulary management, and hospice.