Pharmacy Cost Control

Addressing the Physician Dispensing Challenge

Dispensers are using loopholes to circumvent reforms. But PBMs and payers are pushing back.
By: | August 24, 2017 • 9 min read

Although many states have enacted regulations to curb physician dispensing, doctors are finding ways to get around restrictions — driving up costs for workers’ compensation systems.

Advertisement




That’s a key conclusion of the recent report, “A Multistate Perspective on Physician Dispensing, 2011—2014,” by Cambridge, Mass.-based Workers Compensation Research Institute.

WCRI analyzed the prevalence and costs of physician dispensing across 26 state workers’ comp systems, comparing post-reform states with the states where no reforms were made, or where there were reforms but the data reflect pre-reform experiences.

The study found that, in post-reform states, the average price per pill for existing drugs decreased after reforms. However, physicians are bypassing the reimbursement rules that specifically target repackaged drugs by dispensing newer, higher-priced drugs.

That has offset the cost savings of reforms, actually driving up the average price per physician-dispensed pill in some states — particularly in California, Florida, and Illinois.

Prior to reforms, physicians often sold repackaged drugs, the average wholesale prices of which are typically higher than the original drug as packaged by the manufacturer.

Repackaged drugs are not addressed in pharmacy fee schedules — which are based on average wholesale prices of the drugs dispensed. So physicians who dispense repackaged drugs are paid higher prices than those who dispense the drug as originally packaged.

Dongchun Wang, economist, WCRI

Reforms capped the maximum reimbursement amount for repackaged drugs to the average wholesale price of the original.

“Facing a substantial price reduction, some physician dispensers might have tried to find a way to maintain the income they had from dispensing repackaged drugs prior to the reforms,” said Dongchun Wang, an economist at WCRI and author of the report.

“Those higher-priced new strength drug products provided a means for them to do so.”

WCRI said while some physicians dispensing the new strengths may have been motivated by the desire to provide benefits for their patients, “we are not aware of any scientific studies that support this,” said Wang.

“Our data show that the higher-priced new strengths were chosen by physicians who dispense drugs, not by those who write prescriptions and send their patients to a retail pharmacy. We rarely see these new strength products in pharmacy-dispensed prescriptions.”

The report cites evidence that other physician dispensing reforms in Florida, Indiana, Kentucky, and Tennessee might have some impact on these concerns.

“These more recent reforms either limit physicians’ ability to dispense certain drugs or limit the timeframe over which physicians are allowed to be reimbursed for drugs they dispense,” Wang said. “This may be one area to look into to gain additional insights.”

Dr. Robert L. Goldberg, chief medical officer for Tampa-based Healthesystems, said there is still a very limited role for physician dispensing as it serves patient convenience and access to medications during an initial visit for an injury.

“Employers enjoy the benefits of patients being able to come back to work after that visit instead of having to wait an hour or two at the pharmacy,” Goldberg said.

“Unfortunately, for many physicians, dispensing has become a revenue enhancer. That’s a problem as it’s become a big cost to the workers’ comp system — to employers and payers — because there’s a whole industry growing around physician dispensing to take advantage of the opportunity.”

Safety at Risk

There are other issues in addition to the cost — first and foremost, patient safety, Goldberg said. Early on, the treating physician may not necessarily have the full medical history of patients, and the patient doesn’t always know the name of the other medications he or she may also be taking.

“Drug interactions are common and are often unrecognized, but when patients go to the same pharmacist, that pharmacist should have their medication history and is responsible for checking to see whether there may be any potential drug interactions,” Goldberg said.

“And even if a physician has access to a patient’s full medical history, unfortunately some are not always up-to-date on drug interactions — but most pharmacists are.”

There’s also the issue of utilization of medication when it goes out the door of the physician’s office or clinic — “in essence, no one is keeping an eye on the dosage, the quantity and the duration,” he said.

“They could also be taking an off-the-shelf topical and making it higher strength and turning it into a faux prescription — changing the cost from $7.50 a tube to $750 a tube.” — Dr. Robert L. Goldberg, chief medical officer, Healthesystems

However, if the prescription is being processed by a PBM that is serving the interests of the payer and employer, that PBM will develop transaction and medication histories, as well as be familiar with state and payer formularies, Goldberg said.

Advertisement




Those formularies may have edits, step therapy, and certain quantity, duration and dosage limits — which can answer the question of whether a patient needs to go out the door with 30 or 60 days’ worth of medication, or whether it should be five or seven days’ worth or none at all.

“These checks on dosage, quantity, duration and drug interactions are important, particularly in a workers’ comp environment where there are no copays and deductibles for patients,” he said.

“If they are injured or ill and just handed bottles of medication, they are going to take it no matter what the doctor is giving them.”

Numerous Loopholes

Data published by Healthesystems shows that when physicians are dispensing medications, claim costs, medical costs and indemnity costs go up, Goldberg said.

“Physicians who dispense often are prolonging the use of the medical model by continuing to have patients take the medications longer than they might really need to for their injury — and if opioids are given, it really increases the total costs,” he said.

Doctors are finding a number of ways get around the physician dispensing reforms, Goldberg said. First, there’s “new, not novel” medications. An example would be a medication that’s typically in a 5 mg or 10 mg pill, approved by the FDA and authorized for treatment. But then a manufacturer produces a 7.5 mg pill that is not recognized by any system, with no average wholesale price, and it can then be priced at “whatever.”

“The older pill might cost $1 a pill, but the new, not novel pill — with the same chemicals but different dosage — can be selling for $10 or $100 a pill,” he said. “There’s no way to actually stop that from happening unless it ends up on a formulary or state-approved fee schedule.”

Dr. Robert L. Goldberg, chief medical officer, Healthesystems

Compounding is another way to get around the reforms, Goldberg said. Drugs are put in some concoction, and the impacts of the dosage form or combination can be unknown and outside of any cost-control mechanism.

The latest phenomenon is private-label topicals, he said. A drug that in and of itself is known to be useful or effective at a certain dosage strength may be perfectly safe, but then its manufacturer makes it a unique product by converting it into a topical that is not well known — and which costs more.

“They could also be taking an off-the-shelf topical and making it higher strength and turning it into a faux prescription — changing the cost from $7.50 a tube to $750 a tube,” Goldberg said.

Formulary adoption usually says what can and can’t be used, but depending on how specific those state formularies become, these items could potentially still get through, he said. Formularies now have to become even more specific, such as banning specific compounds and private-label topicals, and new definitions of “new, not novel.”

Formularies that say drugs at certain dosages such as 5 and 10 mg are acceptable, should also specifically exclude those drugs at 7.5 mg.

“California’s formulary is getting ready to be adopted.  It has an approved, or exempt, list of medications, but even that does not address new, not novel drugs until the state includes the dosages,” Goldberg said.

“California’s formulary also states that compounds need to be pre-authorized — they can’t just go out the door and have people trying to catch up with them later.”

A number of states (those cited in WCRI’s report), are also now requiring doctors as well as workers’ comp systems to limit the quantities of all medications and limit the timeframe they can be given.

“California’s proposal for physician dispensing is limited to initial treatment, and only one fill for the first seven days of injury,” Goldberg said. “That alone would knock out most physician dispensing or unsafe dispensing, and reduce a lot of the problems.”

Brigette Nelson, senior vice president, Workers’ Compensation Clinical Management at Express Scripts in Scottsdale, Az., said that physician dispensing continues to be a problem in workers’ comp.

“The costs of medications are significantly higher, but the other thing to be concerned about is that physicians doing this often don’t have the full prescribing history from other physicians, so drug interaction screening and safety screening is missed,” Nelson said.

Regulations are “all over the board” in post-reform states, ranging from prohibiting dispensing of certain types of medications, limiting quantities, or establishing fee schedule caps, she said.

The battle against problems stemming from continued dispensing by physicians should really be about continuing to “put more teeth” in regulations.

“From our perspective at Express Scripts, even in states where there are fee schedule caps, we can still see issues,” Nelson said.

“The quickest way is to prohibit it. But if it’s not prohibited, states should try to encourage injured workers to use a retail pharmacy which can perform the appropriate patient safety screening.”

As part of its physician dispensing solution, Express Scripts sends a letter to patients, providing them with information on the potential safety issues, and letting them know how expensive physician dispensing can be and “to do their part to keep costs down.”

Advertisement




“Perhaps more important, when we get a claim with physician-dispensed medications, we bounce it up against the plan design with formulary edits that had to come through a retail pharmacist — the same ones that would have been in place at the retail pharmacy,” she said.

“We look at safety issues, and we make a determination to cut the fee schedule or not pay if the state says the practice is prohibited.”

Using its physician dispensing solution, Express Scripts can bring the physician-dispensed medication back into the retail or mail order network.

“We give the payer the information they need, to not let this go through physician dispensing the next time there is a prescription,” Nelson said.

Katie Kuehner-Hebert is a freelance writer based in California. She has more than two decades of journalism experience and expertise in financial writing. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Property

Insurers Take to the Skies

This year’s hurricane season sees the use of drones and other aerial intelligence gathering systems as insurers seek to estimate claims costs.
By: | November 1, 2017 • 6 min read

For Southern communities, current recovery efforts in the wake of Hurricane Harvey will recall the painful devastation of 2005, when Katrina and Wilma struck. But those who look skyward will notice one conspicuous difference this time around: drones.

Advertisement




Much has changed since Katrina and Wilma, both economically and technologically. The insurance industry evolved as well. Drones and other visual intelligence systems (VIS) are set to play an increasing role in loss assessment, claims handling and underwriting.

Farmers Insurance, which announced in August it launched a fleet of drones to enhance weather-related property damage claim assessment, confirmed it deployed its fleet in the aftermath of Harvey.

“The pent-up demand for drones, particularly from a claims-processing standpoint, has been accumulating for almost two years now,” said George Mathew, CEO of Kespry, Farmers’ drone and aerial intelligence platform provider partner.

“The current wind and hail damage season that we are entering is when many of the insurance carriers are switching from proof of concept work to full production rollout.”

 According to Mathew, Farmers’ fleet focused on wind damage in and around Corpus Christi, Texas, at the time of this writing. “Additional work is already underway in the greater Houston area and will expand in the coming weeks and months,” he added.

No doubt other carriers have fleets in the air. AIG, for example, occupied the forefront of VIS since winning its drone operation license in 2015. It deployed drones to inspections sites in the U.S. and abroad, including stadiums, hotels, office buildings, private homes, construction sites and energy plants.

Claims Response

At present, insurers are primarily using VIS for CAT loss assessment. After a catastrophe, access is often prohibited or impossible. Drones allow access for assessing damage over potentially vast areas in a more cost-effective and time-sensitive manner than sending human inspectors with clipboards and cameras.

“Drones improve risk analysis by providing a more efficient alternative to capturing aerial photos from a sky-view. They allow insurers to rapidly assess the scope of damages and provide access that may not otherwise be available,” explained Chris Luck, national practice leader of Advocacy at JLT Specialty USA.

“The pent-up demand for drones, particularly from a claims-processing standpoint, has been accumulating for almost two years now.” — George Mathew, CEO, Kespry

“In our experience, competitive advantage is gained mostly by claims departments and third-party administrators. Having the capability to provide exact measurements and details from photos taken by drones allows insurers to expedite the claim processing time,” he added.

Indeed, as tech becomes more disruptive, insurers will increasingly seek to take advantage of VIS technologies to help them provide faster, more accurate and more efficient insurance solutions.

Duncan Ellis, U.S. property practice leader, Marsh

One way Farmers is differentiating its drone program is by employing its own FAA-licensed drone operators, who are also Farmers-trained claim representatives.

Keith Daly, E.V.P. and chief claims officer for Farmers Insurance, said when launching the program that this sets Farmers apart from most carriers, who typically engage third-party drone pilots to conduct evaluations.

“In the end, it’s all about the experience for the policyholder who has their claim adjudicated in the most expeditious manner possible,” said Mathew.

“The technology should simply work and just melt away into the background. That’s why we don’t just focus on building an industrial-grade drone, but a complete aerial intelligence platform for — in this case — claims management.”

Insurance Applications

Duncan Ellis, U.S. property practice leader at Marsh, believes that, while currently employed primarily to assess catastrophic damage, VIS will increasingly be employed to inspect standard property damage claims.

However, he admitted that at this stage they are better at identifying binary factors such as the area affected by a peril rather than complex assessments, since VIS cannot look inside structures nor assess their structural integrity.

“If a chemical plant suffers an explosion, it might be difficult to say whether the plant is fully or partially out of operation, for example, which would affect a business interruption claim dramatically.

Advertisement




“But for simpler assessments, such as identifying how many houses or industrial units have been destroyed by a tornado, or how many rental cars in a lot have suffered hail damage from a storm, a VIS drone could do this easily, and the insurer can calculate its estimated losses from there,” he said.

In addition,VIS possess powerful applications for pre-loss risk assessment and underwriting. The high-end drones used by insurers can capture not just visual images, but mapping heat, moisture or 3D topography, among other variables.

This has clear applications in the assessment and completion of claims, but also in potentially mitigating risk before an event happens, and pricing insurance accordingly.

“VIS and drones will play an increasing underwriting support role as they can help underwriters get a better idea of the risk — a picture tells a thousand words and is so much better than a report,” said Ellis.

VIS images allow underwriters to see risks in real time, and to visually spot risk factors that could get overlooked using traditional checks or even mature visual technologies like satellites. For example, VIS could map thermal hotspots that could signal danger or poor maintenance at a chemical plant.

Chris Luck, national practice leader of Advocacy, JLT Specialty USA

“Risk and underwriting are very natural adjacencies, especially when high risk/high value policies are being underwritten,” said Mathew.

“We are in a transformational moment in insurance where claims processing, risk management and underwriting can be reimagined with entirely new sources of data. The drone just happens to be one of most compelling of those sources.”

Ellis added that drones also could be employed to monitor supplies in the marine, agriculture or oil sectors, for example, to ensure shipments, inventories and supply chains are running uninterrupted.

“However, we’re still mainly seeing insurers using VIS drones for loss assessment and estimates, and it’s not even clear how extensively they are using drones for that purpose at this point,” he noted.

“Insurers are experimenting with this technology, but given that some of the laws around drone use are still developing and restrictions are often placed on using drones [after] a CAT event, the extent to which VIS is being used is not made overly public.”

Drone inspections could raise liability risks of their own, particularly if undertaken in busy spaces in which they could cause human injury.

Privacy issues also are a potential stumbling block, so insurers are dipping their toes into the water carefully.

Risk Improvement

There is no doubt, however, that VIS use will increase among insurers.

Advertisement




“Although our clients do not have tremendous experience utilizing drones, this technology is beneficial in many ways, from providing security monitoring of their perimeter to loss control inspections of areas that would otherwise require more costly inspections using heavy equipment or climbers,” said Luck.

In other words, drones could help insurance buyers spot weaknesses, mitigate risk and ultimately win more favorable coverage from their insurers.

“Some risks will see pricing and coverage improvements because the information and data provided by drones will put underwriters at ease and reduce uncertainty,” said Ellis.

The flip-side, he noted, is that there will be fewer places to hide for companies with poor risk management that may have been benefiting from underwriters not being able to access the full picture.

Either way, drones will increasingly help insurers differentiate good risks from bad. In time, they may also help insurance buyers differentiate between carriers, too. &

Antony Ireland is a London-based financial journalist. He can be reached at [email protected]