5 Advanced Ways Clinical Expertise Can Improve Workers’ Comp Outcomes
Determining the best course of treatment for a workers’ comp patient is so often constrained by regulation. State laws, formularies, utilization review and the need for layers of authorization can make it difficult for case managers to balance the needs of the injured worker against the requirements set forth by the system.
For that reason, managing workers’ comp claims can become robotic and transactional. Instead of putting health and recovery first, claims become a series of checklist items. PBMs in particular process a lot of transactions, ensuring that medications make their way to injured workers in a timely manner. But that doesn’t mean that a PBM has to be a transaction-based company.
“PBMS can leverage their clinical expertise from the very beginning of a claim to coordinate the best care and improve outcomes – both for the injured party and for the employer,” said Tron Emptage, Chief Clinical Officer, Optum Workers’ Compensation and Auto No-Fault.
Here are five ways that applying a clinical approach to pharmacy benefit management from the initial injury report can drive better outcomes in workers’ comp:
1) Clinical experts can spot complexity bubbling beneath the surface of a claim.
No injury heals in a vacuum. Healing one body part requires consideration of many other factors that might impair recovery, including past and present medical conditions as well as psychosocial characteristics.
“There’s so much more underneath the surface of a claim. What I see from a physician standpoint is these patients are coming in with more complexity to them beyond their injury,” Dr. Robert Hall, Medical Director, Optum Workers’ Compensation and Auto No-Fault. “Often times that complexity can be found in other underlying diseases or disorders. Knowing about those conditions and the interaction they can have with that injury is critical to the clinical approach.”
Physical comorbid conditions like obesity and diabetes complicate the path to recovery, as do psychological issues like catastrophic thinking. There may be potential for harmful drug interactions if claims specialists are not aware of an injured worker’s current medications.
But not all of these clues may appear in an initial injury report. It takes the eye of an experienced nurse, physician or clinical pharmacist to catch these factors and address them early.
“We can look at other symptoms or injuries that they’ve had in the past that could be related to the current injury. There might be evidence in the claim as to what treatments the patient responded to previously and which ones failed. Having a clinical perspective will help identify the best path forward while avoiding unnecessary treatment,” Emptage said.
2) An initial prescription provides clues about a claim’s trajectory and helps clinicians take a longitudinal view.
Clinicians can tell a lot about a claim just from the first medication prescribed. Ibuprofen or acetaminophen, for example, are first-line pharmaceuticals for pain. They indicate a relatively low level of injury severity.
“But if that first prescription is for an opioid analgesic, then that tells us this claim is already headed in a different direction,” Emptage said.
“In workers’ comp, we have to think with the end in mind. This claim will have some resolution, whether that’s return-to-work, maximum medical improvement, or a settlement. So we have to take the long view and determine what treatment will be most effective to move the injured worker toward that resolution. The first prescription often times indicates what that path will look like.”
An opioid analgesic prescription for a knee injury, for example, suggests there may also be a need for physical therapy and perhaps a medical device like crutches or a wheelchair. Having the foresight to anticipate these needs – all from that first script- means a PBM can work with providers proactively to make sure those resources can be made available to the injured worker at the right time.
3) Interdisciplinary teams make drug formularies work for the benefit of the injured worker.
Drug formularies designed on evidence-based guidelines provide a framework for safe and effective pharmaceutical treatment. However, an injured worker’s needs will change over time as their injury improves. Multi-disciplinary clinical expertise is necessary to determine which types of medications will be best suited for an individual as an injury changes.
“We’re able to employ our nursing, pharmacist and case management expertise to help us make decisions on medications that may not seem like the obvious choice, but are most appropriate for the injury,” Hall said.
Topical compounds are one example. By most formulary rules, topical compound creams would not be recommended as a pain treatment and, when claims are handled from a transactional perspective, would automatically be denied based only on those rules. But the circumstances matter.
“The injured worker may be using that compound to wean himself off of opioids. Or because it will not interact with other medications they are taking,” Hall said. “It’s important to escalate these decisions to a clinician who can better judge what is most appropriate in a specific scenario.”
4) Clinical data insights drive more informed decisions on a broader scale.
Every interaction an injured worker has with a nurse, physician or pharmacist yields information that helps to create a whole picture of the worker’s health. Capturing that data and having a way to apply it meaningfully across the patient population requires not just the technological tools, but also the expertise to interpret and act on data insights.
“We get eligibility data for new patients, which includes the nature of injury, the body part, the diagnosis code – foundational pieces of information we need to process the right prescriptions,” Emptage said. “But you start to identify issues that may not come over in an eligibility file. There may not be a data element for a mental health issue like addiction, or for smoking risk or cardiac risk, but you learn about these elements through provider communication.”
Building a rich data set encompassing these factors allows predictive analytics platforms to make more accurate determinations about where a patient may be headed. That gives PBMs the ability to better understand which clinical resources should be employed for a particular claim, which could include nurse monitoring or drug testing, for example.
“It’s about utilizing our clinical experiences to say that the characteristics we see on this claim and in our data set indicate certain needs. We’re using insights gathered at the macro-level to drive actions on individual claims in an effort to bring about global change and better medical management,” Emptage said.
5) A holistic view of clinical care helps stay ahead of the next crisis beyond opioids.
In the past five years, healthcare providers have begun to take control of opioid overprescribing. While addiction to both prescribed and illicit opioids remains a public health crisis, “we’re getting ahead of it, and we’re starting to see some changes,” Hall said.
However, that’s no reason for case managers to breathe a sigh of relief. There is always potential for medication abuse or misuse, and PBMs must apply lessons learned from the opioid crisis to proactively communicate with providers about any red flags to avoid similar problems.
“We see other medications that should be weaned as well. Benzodiazepines, for instance. We should be able to use the same type of approach from an education standpoint, to tell providers, ‘Here’s really what we should be thinking about from a best practice standpoint and from a safety standpoint,’” Emptage said.
“We’ve learned a lot in terms of how to have those discussions and how to provide educational resources and guidance to providers,” Hall said.
A Clinically-Focused PBM Partner Coordinates Better Care
A best-in-class PBM partner will help to get the right resources to the injured worker at the right time. Optum Workers’ Compensation and Auto No-Fault draws on a suite of clinical programs to help connect patients to these resources.
Through regular claim roundtables, clinical liaisons can identify cases that require a different approach as well as which products and services will move the injured worker forward. These include pharmacist and nurse monitoring programs, drug testing, provider outreach, and analytical platforms that spot red flags and identify potential care paths. Ancillary services like home health care, medical equipment and supplies, translation and transportation services also round out a comprehensive approach to care.
“By taking a more holistic view of injured worker recovery rather than a transactional approach, we can do far more than just approve or deny medication authorizations,” Emptage said.
Combining clinical expertise with efficient case management ultimately brings injured workers back to function faster, speeds up claim resolution, and saves, time, frustration and dollars for workers and employers alike.
To learn more, visit https://workcompauto.optum.com.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Optum Workers’ Compensation and Auto No-Fault. The editorial staff of Risk & Insurance had no role in its preparation.