Guiding Principles for Prescription Drug Management

I’ve advised insurers, employers, and TPAs to “get to work on a market-driven solution” for prescription drug management (both in person and in this blog on numerous occasions).  While Mark and I strive to ensure Evidence Based does not become a venue through which we promote PRIUM’s services, we have learned a few things from our experiences on the thousands of claims in which PRIUM has intervened.  While our program is built around these guiding principles, Mark and I share a broader desire to move the industry in the right direction.  So whether you use us or not, these are the hallmarks of a strong prescription drug utilization management program that results in positive clinical and financial outcomes:

1)      Discussion: This should be peer-to-peer.  Perhaps having pharmacists and/or nurses engage in initial discussion works from time to time, but the most reliable, replicable and appropriate physician outreach is one conducted by a peer.  The conversation should be collegial and it should be grounded in evidence-based medicine (with specific emphasis on jurisdictionally-specific guidelines). 

2)      Enforcement: While your PBM might be taking the lead on your drug utilization management program, this won’t always be the case (and even if they do, it might not always be effective).  Integrating the results of the peer-to-peer conversation into the point of sale system is critical (blocks, exclusions, prior-auths, etc.)

3)      Oversight: This step should also be clinician-led.  We’ve found that the best approach is to employ nurses with work comp case management experience who are dedicated to doing everything possible to ensure implementation of treatment changes agreed upon in the peer-to-peer conversation.  This oversight has to be consistent, it must rely on the peer review as a roadmap, and it must be focused on facilitating the weaning and discontinuation of medically unnecessary drugs.

4)      Education: Foundational to any strong drug utilization management program is education that is focused on the prescriber, the patient, and the adjuster/claims manager.  Weaning patients off of highly addictive prescription narcotics is clinically challenging.  Preventing the patient from becoming addicted in the first place is equally challenging.  Education is the key to helping all parties understand what the process looks like and where the potential pitfalls exist.  

Each of these steps is important unto itself, but the integration and coordination amongst these guiding principles is the real secret to success.  And when these attempts at collegial interaction don’t yield results, it’s time to use “the hammer.”  While the handshake should be preferred over the hammer (which varies by jurisdiction), don’t be afraid to deploy utilization review, direction of care, court motions, IME, dispute resolution, etc. to ensure that medically unnecessary drugs disappear and don’t come back.

This is a rare instance in health care where clinical and financial incentives completely align.  Make sure you're using every tool at your disposal to get the outcomes you need (and the outcomes your claimants need). 

Michael  
On Twitter @PRIUM1