The Potentially Problematic Products Pharmacy Benefit Managers Are Monitoring

Pharmacy benefit managers (PBMs) were heralded as some of the most active advocates for additional controls across the health system, and within workers’ compensation, during the height of the opioid epidemic in the 2010s. 

But as with all aspects of health care, the landscape shifts constantly, leaving claims managers to find their footing. 

Non-Narcotic But Still Active

Among the new classes of drugs to treat pain are common prescriptions that are used off label and become ripe for combined therapy. And although opioid scrutiny remains a point of focus for PBMs, non-steroidal anti-inflammatory drugs, known in the industry as NSAIDs, are increasingly a concern.

That being said, the industry believes it has built the analytics structure to battle upcoming threats to injured worker safety.

“PBM data, because of the way the technical architecture is built out from an IT standpoint, it’s hyper efficient, it’s one language, so it really does become, in my opinion, the source of truth for health care interactions,” said Gerry Stanley, chief medical officer for Harvard MedTech. 

“I think it’s easy to identify a couple of classes as potentially dangerous because of their addictive nature, but I think it’s also important to look at it not just in terms of class but in terms of prescribing habits.” 

Stanley also advised watching out for polypharmacy, in which patients are prescribed low doses of a wide variety of drugs, especially when one drug is treating the side effect of another — like stimulants to treat lethargy from muscle relaxers.

Other leaders in the space agree. 

“The use of a diverse set of drug classes that are not narcotic, but do have effects on the brain, is something we’re watching closely,” said Liberty Mutual national medical director, Mary Capelli-Schellpfeffer. 

“These are the drug classes that include anticonvulsants, anti-inflammatories, the musculoskeletal agents that create a relaxation effect, as well as antidepressant drugs. These are increasing in their impact on claims.”

A 2021 study from the California Workers’ Compensation Institute (CWCI), a private research organization which analyzes trends in the largest workers’ comp market in the country, revealed NSAIDs surpassed opioids as the top drug group back in 2015. 

In both 2019 and the first half of 2020, they accounted for more than a third of all prescriptions dispensed to injured workers. CWCI noted that this is twice the prevalence of 2010 prescriptions. 

Anticonvulsants, dermatologicals, and antidepressants were the remainder of the top five drug groups. 

This data tracks with what PBMs themselves are observing.

“We’re looking at a lot of the topicals, including topical pain creams, that are available in the marketplace today,” said Tron Emptage, chief clinical officer for Optum Workers’ Comp and Auto No-Fault. 

“We’re also looking at nonsteroidals. We’ve found that some of the nonsteroidal anti-inflammatory drugs have come into the market and caused an increase in the economics, so pricing, for a variety of reasons. 

“We’re also interested in monitoring some of the adjunctive 

therapies, which include benzodiazepines, anticonvulsants and antidepressants.”

Pain creams, everything from the standard camphor/menthol-based OTC lotions to bespoke compound medications sold only via mail order, were raised repeatedly as trends to watch from a cost perspective. 

“Topical medications are a great alternative to oral opioids, but many have the same price variance with little advantage for higher-cost versions,” said Jill Falb, CorVel’s vice president of pharmacy services.  

“Diclofenac 3% gel is intended for skin inflammation issues but is often prescribed off label for pain. It can run up to $3,000 for a 30-day supply. Diclofenac 1%, intended for pain, is $40,” Falb added.

“As we have seen a move away from opioids, we are now seeing additional problematic drug classes that are still not preventing the development of chronic pain,” said Melissa Burke, a vice president with AmTrust Financial Services. 

“As more and more restrictions have been placed on opioid prescribing, providers are increasingly prescribing drugs such as topical branded medications, physician dispensed doses of traditional medications and medical marijuana.”

This is the case with dermatologics in workers’ comp, Burke explained. 

“We have seen dermatologics climb to the top of the therapeutic class by spend, outpacing analgesics and anticonvulsants. Topical diclofenac is prescribed off label and many times with oral anti-inflammatories, which can create a duplicate therapy issue,” she said. 

“Overall, we see an overprescribing of medications that are not effective for pain control and not paired with non-pharmacologic treatment. We still continue to see injections and DME products that are not impacting outcomes. It was anticipated we would see an increase in biologics, but that has not occurred in workers’ compensation yet.”

PBMs’ other major role aside from cost management is safety. 

Topicals are considered safer, but additional rising classes of drugs identified as substitutes for opioids are not without risk.

“While evidence-based use of non-opioid analgesics is definitely a positive thing, we have remained vigilant of impending risks with other pharmaceutical categories that have their own potential for abuse and/or have very little therapeutic advantages,” said Nikki Wilson, director, clinical product pharmacy solutions at Mitchell. 

Cannabis Emerges from the Shadows

The workers’ comp system remains in a holding pattern in regards to cannabis, which despite a legal medical market in many states, remains a Schedule I drug. 

“The growing popularity of various forms of cannabis, including CBD products, increases the likelihood that their use will become a bigger consideration within workers’ comp in the coming years,” said Wilson. 

She pointed to astounding growth in the form of recent statistics publicized by the medical marijuana industry itself, and the exponential growth of product types and their requisite online advertising campaigns as a driving force. 

Analysis released by Verified Market Research in late 2021 found that the legal cannabis market was valued at $20.73 billion in 2020 and is projected to reach $111.31 billion by 2028.

The sector may be taking off like a rocket in terms of consumption volume, but many in the workers’ compensation claims management business remain steadfast in casting a critical eye at this reefer madness, especially as it relates to its potential use or misuse on worksites.

“As much as we don’t want to see it, the country continues to permit medical marijuana despite the lack of science to support its impact on injured employee pain management,” Burke said.

“As a workers’ compensation carrier, I think our goal remains the same; to ensure a medically appropriate and safe return to work. Marijuana on the job site does not support a safe environment and it prevents return to work in many situations,” she added.

“Our goal is to address each individual injured employee’s needs and provide them the support they need to return to work. If the use of medical marijuana is court ordered, we look to ensure there is evidence of pain improvement and the injured employee has increasing functional capabilities. Ultimately, we want to improve the quality of their life,” she said.

More Trends to Watch

Aside from specific areas of concern, PBMs and the leaders they serve in the workers’ compensation industry say that the sheer speed at which prescribing behavior and technology is changing is a trend in and of itself.

“One of the most important shifts is that treatment has been evolving fairly quickly as the regulation of opioids has become more deeply and widely felt,” said Liberty Mutual’s Capelli-Schellpfeffer. 

She continued, “We’re seeing this across the board, both from medication prescribed in a regional pharmacy to medication that’s delivered via surgical or interventional procedure.

“We’re seeing new and emerging techniques to get medication to patients that avoid the risk of opioids and yet deliver relief for their pain. That trend means that there’s a lot of shifting where pharmacy spend actually is happening between facility-based reimbursements for pharmaceuticals versus the retail pharmacy setting.”

Wilson and Falb expressed similar observations, encouraging claims managers to think about high impact pharmaceuticals and dispensing channels, as well as the tech front. 

Data will continue to rule the day, which in some cases, is positive. 

“I think claims managers should be tracking  navigating prescription digital therapeutics,” said Wilson. 

“Medical and health apps and technology that may support or enhance a patient’s experience with pharmaceutical treatment or be used in conjunction with a broader treatment program.”

One such product is Stanley’s virtual reality platform designed to address pain, anxiety, depression, PTSD, and sleep (namely, those conditions for which the drug classes of concern are geared) by providing injured workers with a VR headset that is used at their will. 

Stanley noted that this method restores the “locus of control” that can be stripped from an injured worker bogged down in the workers’ comp system. 

The platform utilizes basic concepts of neuroplasticity, in which the body will privilege certain types of stimuli over others, to reduce pain over time using a goal setting care plan.

Yet another trend that will have a say in how pharmacy benefit managers interact with their clients is the ongoing reality of mergers and acquisitions.

AmTrust’s Burke said this could have the counterintutive impact of leading to innovations, as smaller PBMs attempt to carve out space and make their mark in the market.

“We have seen more and more creative pricing options with the mergers and acquisitions and the introduction of smaller PBMs,” Burke said.

“I think the market is also responding to the need for the use of data and analytics as well as pharmacy management with a holistic approach.

“Although there are fewer large PBMs, the generation of new ideas and how to stand out has been fueled by the new generation of PBMs,” she said.

Experts in the pharmacy space give claims managers the same advice they’d give a treating physician, emphasizing the ever present social determinants of health conversation, which can be revealed by PBM data. 

“It’s really important for the claims professional to continue to look at pharmacy, to utilize whatever PBM program you’re using to the fullest, monitor alerts presented to you, review educational or informational pieces and act on the information coming your way,” said Emptage. 

As the PBM market continues to grow and consolidate, that factor allows the humans administering and approving care to balance cost, safety and best practices. &