© 2014 Helios 1 Managing Pharmacy Care New Hampshire Commission to Recommend Reforms to Reduce Workers’ Compensation Medical Costs.

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Presentation transcript:

© 2014 Helios 1 Managing Pharmacy Care New Hampshire Commission to Recommend Reforms to Reduce Workers’ Compensation Medical Costs

© 2014 Helios 2 Managed Pharmacy Care Basics ► Pharmacy Benefit Management (PBM) – the heart of managed pharmacy care ► Pharmacy Network - Contracted rates ► Clinical Management of Pharmacy Care − Preferred medications − Injury specific − Driven by evidence-based medicine

© 2014 Helios 3 Processing the Prescription ► Out-of-Network − Third-Party Billers − Specialty Pharmacy − Physician Dispensers ► In-Network − Electronic Connectivity: Pharmacy-PBM-Payer − Real-Time Adjudication − Prior-Authorization for Non-Preferred Medication

© 2014 Helios 4 The Managed Care Difference ► Cost Containment − Contracted Rates − Preferred Medications Delivering the right medication for the injury at the right time Steering away from opioids, compounded medications, and other problematic medications − Generic Mandate Adherence ► Clinical Support − Analysis of efficacy of medication therapy − Recommendations to adjuster − Physicians and clinical pharmacists − Alternatives to opioids - Urine Drug Monitoring for injured workers taking opioids ► Predictive Analysis - Early identification of potentially problematic claims

© 2014 Helios 5 The Managed Care Difference ► Injured Worker Support − Right medications for the injury at the right time − Convenience Factor - generally can use their regular pharmacy − Mail-order service available if preferred by injured worker − Monitoring and managing adherence ► Data Support - Trend identification ► Managing and Countering External Influences − Legislative and regulatory education/advocacy − Identifying and managing loopholes − Lifestyle factors

© 2014 Helios 6 The Liberty Mutual Experience ► Retail pharmacy spend represents 9% of total medical loss compared to industry average of double digits ► Penetration percentage consistently in the high 80s ► Generic efficiency percentage consistently in the high 90s ► Medications not authorized at the “point of sale” in “Medication Strategies” delivering over $7M in savings annually ► Narcotic oversight and management continues to receive considerable attention with enhanced RX alerts and claims/provider narcotic education ► Piloting predictive analytics to identify high-risk pharmacy claims for clinical interventions ► Physician Dispensed Pharmacy (PDP) solution in 21 states where re-pricing legislation provides control, yielding $2M in annual savings

© 2014 Helios 7 Opioid Management and Initiatives ► Medication Strategies - Specific to injured worker’s body part and nature of injury and includes quantity and utilization limitations ► Clinical Alerts - Focused on morphine equivalent dose per day/per month, long-term use of opiods, long-acting vs. short-acting opioids, and specialized medications (Suboxone, Actiq) ► Clinical Reviews - Evaluate appropriateness of medications, identify potential clinical concerns, provide recommendations to changes in therapy ► Opioid Letter Prescribing Physician Campaign - Initial opioid use, long-term use, and high-dose use ► Opioid Training Curriculum − Injured worker letters − Webinars for claims and nurse professionals ► Reports/audits focused on concerning narcotic usage, early use and ongoing use ► Risk Assessment/Scoring - Predictive analytics to identify high-risk pharmacy claims and implement specified level of clinical intervention

© 2014 Helios 8 The On-going Quest for Improvement ► Highly competitive pricing ► Increasing focus on clinical tools ► Constantly seeking innovation edge ► PBM customers are results focused

© 2014 Helios 9 Questions?