September 22, 2015
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Prospective Management of Compounds

Cost Containment
, Network Solutions
, Pharmacy

Three in four injured workers received opioids for pain relief in a study of 21 states conducted by the Workers’ Compensation Research Institute (WCRI). As the growing epidemic of opioid usage within workers’ compensation pain treatment continues to garner public attention – including the DEA’s recent reclassification of hydrocodone to a Schedule II drug – another pharmacy cost driver is also on the rise. Compounded medications, created as one-of-a-kind prescriptions, are becoming a suspicion within the healthcare management industry due to recent increases in usage and their corresponding high costs.

To combat this issue, proactive management of compounds must take place to ensure the scripts for compounds that are being filled are medically necessary, safe for the individual and not just high-cost equivalents for what is already available in mass quantities in the marketplace. Such management can also return an injured employee to the workforce, as in the following case study.

Case Synopsis

A female employee was injured at work and required surgery. Following her procedure, she was unable to walk up and down stairs without medication to manage her pain. The patient wanted to return to work and worked with her case manager to follow a treatment plan that would allow her to return to her job as soon as medically possible.

After seeking further treatment including physical therapy, the patient’s physical therapist wanted the patient to try a compounded medication to manage her pain while working. Given current medications that the patient was already taking, the physical therapist believed the patient should not be prescribed narcotic pain medication, hence the compound recommendation. He hoped the cream would be effective in managing her pain and allow her to perform her job.

Proactive Management

As the treating physician also wanted to avoid the use of narcotics, he prescribed a compound medication for the patient. Upon receiving the script, the compound pharmacy received an alert to contact CorVel and CorVel’s pharmacy system immediately sent a compound notification to the patient’s employer.

CorVel worked with the employer to determine how they wanted to handle the compound prescription. The employer chose to request a Statement of Medical Necessity before filling the script, which was sent to the treating physician in real time, in addition to FDA-Approved medication alternatives.

The physical therapist was also contacted to understand the reason the compound would be necessary for the patient’s pain management. After learning the rationale behind the compound was to avoid taking narcotics, CorVel reached out to the employer to review the prescription. Since both CorVel and the physician were most interested in effectively managing the patient’s pain, they discussed the possibility of using different inactive ingredients, while maintaining the integrity of the active ingredients, to which all parties came to a consensus.

CorVel worked with the pharmacy to authorize a small amount of the medication to see if it could meet the therapy goals and coordinated with the employer to approve a one-time fill of the medication for this purpose, with the priority being a timely return to work for the patient.

CorVel worked with the treating physician to get the compound reduced to a similar compound which reduced the cost from nearly $16,000 to $1,700. Using the compound, the patient was able to return to work and successfully manage her pain.

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“CorVel went above and beyond in helping us work out a situation with a compound cream.” – Christine M. Curtis, RN, BSW, CCM, Manager of Medical Services, School Claims Services, LLC.

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Conclusion

All stakeholders involved in this case had the same end goal in mind – returning the patient to better health and enabling her to go back to work. With CorVel’s integrated program, CorVel has complete visibility to all prescriptions. With a prospective management model, CorVel can reclassify a transaction and manage the prescription throughout the life of the claim, beginning before the first fill. By sending out communication, all stakeholders including the employer and the adjuster are aware of compound utilization. Required justification and attestations ensure patient safety is at the forefront and timely return to work remains priority one. (Learn more about compounds and CorVel's prospective management by reading their whitepaper, "Monitoring Compounds in Workers' Compensation.")

When trying to reclassify a transaction through a compounding pharmacy or feed from a third party, the opportunity to prospectively manage the claim and the patient’s recovery on the front-end is lost. 

Through prospective management, CorVel was also able to save the client over $14,000 on a single fill, by rebuilding the compound with the same active ingredients, but also substituting certain inactive ingredients including the base ingredient.