Pharmacy Benefits

Data Key for Claims Control

Sophisticated pharmacy data allows workers’ comp payers to spot utilization red flags.
By: | October 15, 2015 • 9 min read

To keep pharmacy spend under control, workers’ comp payers have to be able to identify claimants utilizing high-cost drugs or juggling multiple prescriptions, and then intervene if expensive treatment isn’t achieving the desired result of getting that worker back in the game quickly.


To make those calls, employers need data. A lot of it.

“It’s all about the data,” said Vincent Foderingham, vice president of risk management for Feld Entertainment. “I use data as a way to draw the right conclusions and make decisions that give me the best outcome possible.”

Making decisions to alter treatment in a claim is rarely black and white, though, and collecting all the data necessary to build a detailed patient profile and make an informed decision can be a monumental task.

Pulling the Pieces Together

“We want to capture as much data as we can, to build the most complete and comprehensive of a picture as we can for each patient,” said Dr. Silvia Sacalis, vice president of clinical services at Healthesystems.

That includes traditional prescription data — the type of drug dispensed, its National Drug Code and schedule classification, the dosage, morphine equivalent dose, acetaminophen content and number of refills. Pharmacy utilization review looks at any opioid usage longer than 90 days, any prescription “cocktails” that combine drugs from different classes, and chronic use of a narcotic, especially if no complementary therapies are being used to wean a patient off a painkiller.

Taking additional therapies and treatments into account is critical to understanding the utilization of the prescription itself.

“In the past, the focus was on the individual drugs, and of course drugs are always evolving — new drugs, new combinations of drugs, new classifications — but we can now also look at what is peripheral to the utilization of that drug,” said Glen Pitruzzello, vice president of workers’ comp and group benefits claim practices for The Hartford. “There’s been an evolution in the way pharmaceutical data is used.”

 Glen Pitruzzello, vice president of workers’ comp and group benefits claim practices, The Hartford

Glen Pitruzzello, vice president of workers’ comp and group benefits claim practices, The Hartford

While employers often provide claimants’ medical records to their PBMs or case managers, information about other treatments or procedures can be gleaned from the bill review process. PBMs also encourage claimants to share any medical history their employer may not be aware of directly with them.

“We look at other medical services being rendered, like advanced radiology, any inpatient stays — all of that builds context around the pharmacy usage, so we can better understand their need for a narcotic,” said Anne Levins, director, product development information strategy at Coventry.

Drug utilization needs to be placed in the context of other medical treatments in order to determine whether or not a prescription is appropriate.

“For example, if we see a narcotic pop up on a claim 90 days into treatment, it may not raise a red flag if we also see a surgery on day 89. So we may not choose to act on that claim then, because of that information,” Levins said.

A very serious injury that leaves a patient in chronic pain would be another example. That person would unfortunately be a high utilizer of pain medications quite possibly for the rest of their lives. If a pharmacist conducting a utilization review for a PBM looks only at drug data without complete information on the nature of the injury, he might recommend an intervention where it’s not necessary.

That distracts attention and resources away from the claims that truly do need help.

“We also look at indicators of prior substance abuse, comorbid psychiatric conditions, and high risk diagnoses like chronic pain.” — Dannielle Foroozandeh, director of pharmacy product development, Coventry

Patient-specific data can also help payers understand whether a prescription or drug utilization pattern should be cause for concern.


“We also look at indicators of prior substance abuse, comorbid psychiatric conditions, and high risk diagnoses like chronic pain,” said Dannielle Foroozandeh, Coventry’s director of pharmacy product development. “We’re also working on collecting demographic information for some areas, to see if we find any correlations with pharmacy usage, and if we can then use those points of data to predict anything about a claim we might have.”

Once the pieces are pulled together — drug data, peripheral medical usage, patient history and demographics — the trick is collating them into one platform where everything can be checked together.

“More data, when compiled into a structured and actionable format, allows you to make more informed decisions and conduct timely intervention,” Sacalis of Healthesystems said.

“We as a PBM have built tools that capture all of that data into the same environment, so it can be utilized effectively. That has an important impact on the patient’s treatment plan.”

Errors and Obstacles

With payers relying so heavily on data to drive decisions, having incomplete or inaccurate data is not an option.

But gaps can sneak in anyway.

Out-of-network drug data that comes in through a PBM’s bill review might not be uniform with how in-network transactions are processed. For example, out-of-network pharmacists might bill a compound drug as a single ingredient, with one price, which gives reviewers no indication of what the individual components of that medication are or how each contributes to the overall cost.

That not only makes it harder to understand the compound’s cost, but creates a patient safety risk because it doesn’t allow a case manager to spot potential drug interactions between the compound’s individual ingredients and any other medications a claimant is taking.

“As an employer, you have to hold your vendors accountable to make sure you get all the data that’s available in a usable format so that it is accurate and credible.” — Vincent Foderingham, director of risk management, Feld Entertainment

Error can also be introduced through poor quality control on the part of a PBM, claims adjusters or nurse case managers who enter data inconsistently or without attention to the minute details of a claimant’s history.

“You have the human element involved in entering data into a system, so if the information is not consistent or there are not strong quality controls in place, it turns into the old saying: garbage in, garbage out,” Foderingham of Feld Entertainment said. “As an employer, you have to hold your vendors accountable to make sure you get all the data that’s available in a usable format so that it is accurate and credible.”

The PDMP Problem

Perhaps a bigger problem than inaccurate data, though, is third-party payers’ lack of access to state prescription drug monitoring programs (PDMPs), which house a gold mine of prescription history that can be hard for workers’ comp specialists to get their hands on.

These databases keep a record of every controlled substance dispensed in a particular state, regardless of whether it was processed through workers’ comp, a group health plan, Medicaid or cash-paid.

Unfortunately, only the treating physician, dispensing pharmacists and law enforcement (with cause) can pull up a patient’s records.

“The prescriber isn’t always aware of the risk a particular combination of drugs may present to the patient.”– Dr. Marcos Iglesias, vice president and medical director for The Hartford.

“That sounds reasonable as a way to protect patient privacy, but then you think about how the practice of pharmacy has changed,” said Phil Walls, chief clinical officer for MyMatrixx.

“I have over a dozen clinical pharmacists involved in medication therapy management reviews that don’t actually dispense, so they don’t have access. Efforts to increase access to PDMPs by third-party payers and PBMs are necessary to permit these clinical pharmacists to have a complete view of a patient’s regimen regardless of whether that drug was paid for by cash, group health, workers’ compensation, Medicaid, Medicare, etc.”

The PDMP Center of Excellence at Brandeis University in Waltham, Mass., released a report in April 2014, advocating for third-party access to these data warehouses. It cited an analysis from the Coalition Against Insurance Fraud stating that a single “doctor shopper,” who receives medically unnecessary prescriptions from multiple prescribers and pharmacies, costs insurers up to $15,000 every year.


“Given the costs of unnecessary prescribing and the extra medical care often associated with opioid abusers, estimated at over $17,000 annually, identification of such individuals can lead to appropriate intervention, help ensure safer prescribing, and bring significant savings to third-party payers,” the report said.

In total “the costs stemming from the non-medical use of prescription opioids — in lost productivity, law enforcement, drug abuse treatment and medical complications — have been estimated at over $50 billion annually.”

After Washington State began to allow data sharing with its Medicaid and workers’ comp programs, the state conducted an investigation and found that over a seven-month period in 2012, more than 2,000 clients had been dispensed Medicaid and cash-paid controlled substance prescriptions on the same day.

The state’s workers’ compensation program also found that some claimants had been prescribed high doses of opioids in the three months prior to an injury.

“If a patient goes to a retail chain pharmacy and uses their MyMatrixx card when they pick up their prescription, I get all that data,” Walls said. “But if they used group health or Medicaid, because of HIPAA and privacy concerns, I have no access to that. A state-mandated PDMP is the only way to get it.”

“Today, you can complain about anything and get a pill for it.” — Vincent Foderingham, vice president of risk management for Feld Entertainment.

Few states mandate the use of a PDMP by prescribing physicians, but more consistent usage and expanded access could be a boon for workers’ comp providers in identifying their costliest claimants.

The National Association of Boards of Pharmacy have made moves to that end by establishing a data-sharing program called InterConnect, which facilitates communication among different state PDMPs. Thirty states currently participate.

Data-Driven Action

Once all the available data on a claimant is compiled, how does it go to work helping the payer control drug costs?

Dr. Silvia Sacalis, vice president of clinical services, Healthesystems

Dr. Silvia Sacalis, vice president of clinical services, Healthesystems

“It’s key to incorporate evidence-based guidelines into our data system,” Healthesystems’ Sacalis said. Drug data can then be run against those guidelines to identify areas where a claim needs to be reined in.

Long-term opioid use is an obvious red flag, but case managers and reviewers also look for certain combinations — like a benzodiazepine paired with a skeletal muscle relaxant — that pose a safety risk with little evidence to support efficacy.

“Simply phoning the providers and letting them know about prescriptions that don’t work well together is an effective first step,” said Dr. Marcos Iglesias, vice president and medical director for The Hartford. “The prescriber isn’t always aware of the risk a particular combination of drugs may present to the patient.”

Most of the time, when physicians receive recommendations to decrease their prescribing or switch to a safer drug, “they agree with us and prescribe fewer drugs, and patient outcomes usually improve,” Walls said.

Repackaged drugs also signal a cost-saving opportunity. Breaking down a repackaged medication — often dispensed directly by physicians — into its underlying NDC level often reveals a large cost discrepancy and gives a pharmacy benefits manager leverage to seek a lower price.


Unusual changes in utilization might also call for an intervention, such as a switch from short- to long-acting opioids, said Levins of Coventry. In that case, she might recommend adding a nurse case manager to the claim, who can ask critical questions of the physician that the patient may not think of.

Patients with a history of substance abuse might also prompt a recommendation for drug testing.

All of these interventions ultimately aim to keep unnecessary drugs or improper dosages out of the picture, which not only eliminates some costs up-front, but also improves overall outcomes and curtails the need for additional treatments as the claim progresses.

“Today, you can complain about anything and get a pill for it,” Foderingham said. “With pain meds, you run the risk of an employee getting into a habit-forming situation if you’re not managing the situation or paying attention.”



Part I: The Pharmacy Cost Creep

Spending on prescription drugs accounts for a large share of workers’ comp medical costs, but utilization can be controlled.

R10-15-15p30-32_5Cost_inDep.inddPart II: Data Key for Claims Controls

Sophisticated pharmacy data allows workers’ comp payers to spot utilization red flags.

112015_10_indepth_150pxPart III: The PBM Evolution

Pharmacy benefit managers are becoming a greater force in clinical case management, adapting to higher customer expectations.

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]

More from Risk & Insurance

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The Profession

For This Pharmaceutical Risk Director, Managing Risk Means Being Part of the Mission to Save Lives

Meet Eric Dobkin, director, insurance and risk management, for Merck & Co. Inc.
By: | September 28, 2018 • 5 min read

R&I: What was your first job?
My first job out of undergrad was as an actuarial trainee at Chubb.I was a math major in school, and I think the options for a math major coming out are either a teacher or an actuary, right? Anyway, I was really happy when the opportunity at Chubb presented itself. Fantastic company. I learned a lot there.

R&I: How did you come to work in risk management?
After I went back to get my MBA, I decided I wanted to work in corporate finance. When I was interviewing, one of the opportunities was with Merck. I really liked their mission, and things worked out. Given my background, they thought a good starting job would be in Merck’s risk management group. I started there, rotated through other areas within Merck finance but ultimately came back to the Insurance & Risk Management group. I guess I’m just one of those people who enjoy this type of work.


R&I: What is risk management doing right?
I think the community is doing a good job of promoting education, sharing ideas and advancing knowledge. Opportunities like this help make us all better business partners. We can take these ideas and translate them into actionable solutions to help our companies.

R&I: What could the risk management community be doing a better job of?
I think we have made good advancements in articulating the value proposition of investing in risk management, but much more can be done. Sometimes there is such a focus on delivering immediate value, such as cost savings, that risk management does not get appropriate attention (until something happens). We need to develop better tools that can reinforce that risk management is value-creating and good for operational efficiency, customers and shareholders.

R&I: What’s been the biggest change in the risk management and insurance industry since you’ve been in it?
I’d actually say there hasn’t been as much change as I would have hoped. I think the industry speaks about innovation more often than it does it. To be fair, at Merck we do have key partners that are innovators, but some in the industry are less enthusiastic to consider new approaches. I think there is a real need to find new and relevant solutions for large, complex risks.

R&I: What emerging commercial risk most concerns you?
Cyber risk. While it’s not emerging anymore, it’s evolving, dynamic and deserves the attention it gets. Merck was an early adopter of risk transfer solutions for cyber risk, and we continue to see insurance as an important component of the overall cyber risk management framework. From my perspective, this risk, more than any other, demands continuous forward-thinking to ensure we evolve solutions.

R&I: What’s the biggest challenge you’ve faced in your career?
Sticking with the cyber theme, I’d say navigating through a cyber incident is right up there. In June 2017, Merck experienced a network cyber attack that led to a disruption of its worldwide operations, including manufacturing, research and sales. It was a very challenging environment. And managing the insurance claim that resulted has been extremely complex. But at the same time, I have learned a tremendous amount in terms of how to think about the risk, enterprise resiliency and how to manage through a cyber incident.

R&I: What advice might you give to students or other aspiring risk managers?
Have strong intellectual curiosity. Always be willing to listen and learn. Ask “why?” We deal with a lot of ambiguity in our business, and the more you seek to understand, the better you will be able to apply those learnings toward developing solutions that meet the evolving risk landscape and needs of the business.


R&I: What role does technology play in your company’s approach to risk management?
We’re continuing to look for ways to apply technology. For example, being able to extract and leverage data that resides in our systems to evaluate risk, drive efficiencies and make things like property-value reporting easier. We’re also looking to utilize data visualization tools to help gain insights into our risks.

R&I: What are your goals for the next five to 10 years of your career?
I think, at this time, I would like to continue to learn and grow in the type of work I do and broaden my scope of responsibilities. There are many opportunities to deliver value. I want to continue to focus on becoming a stronger business partner and help enable growth.

R&I: What is your favorite book or movie?
I’d say right now Star Wars is top on my list. It has been magical re-watching and re-living the series I watched as a kid through the eyes of my children.

R&I: What is the riskiest activity you ever engaged in? When I was about 15, I went to a New York Rangers versus Philadelphia Flyers game at the Philadelphia Spectrum. I wore my Rangers jersey. I would not do that again.

Eric Dobkin, director, insurance & risk management, Merck & Co. Inc

R&I: What is it about this work you find most fulfilling or rewarding?
I am passionate about Merck’s mission of saving and improving lives. “Inventing for Life” is Merck’s tagline. It’s funny, but most people don’t associate “inventing” with medicine. But Merck has been inventing medicines and vaccines for many of the world’s most challenging diseases for a long time. It’s amazing to think the products we make can help people fight terrible diseases like cancer. Whatever little bit I can do to help advance that mission is very fulfilling and rewarding.

R&I: What do your friends and family think you do?
Ha! My kids think I make medicine. I guess they think that because I work for Merck. I suppose if even in a small way I can contribute to Merck’s mission of saving and improving lives, I am good with that. &

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]