Friday, April 20, 2012

Express Script's WC Drug Trend Report: Something Missing

I'm working my way through all of the drug trend reports released within the last week.  I plan to provide a general overview of those within the next week or so (lots of data to sort through).  I just got through the highlights from ESI, though, and found the approach interesting - and troubling.

The overview I read starts with "2011 Highlights" on page 1.  And the overarching theme of the highlights is waste... $2.1 billion worth of waste in work comp.  They define waste as "any additional spend on pharmacy costs that provides no incremental gain in health outcomes."  Great definition. 

But the report goes on to emphasize three major areas where waste occurs:
1) Utilization of high-cost brand medications when lower-cost therapeutic alternatives are available;
2) Not enough use of mail order as a mode of drug delivery (retail is more expensive);
3) Processing of prescriptions through out-of-network pharmacies and third party billers.

Those of you that know PRIUM know that I'm a bit... let's just say "focused"... but what about utilization of prescription drugs that are not medically necessary according to clinical guidelines (guidelines which, in many states, are statutorily recognized)? 

Would ESI really have us believe that the way to limit inappropriate use of narcotics and other drugs can be summed up in "generics, mail order, and networks"? 

Later in the report, in much smaller font, there's a section on "Narcotics Abuse and Misuse" that at least acknowledges what the CDC has called an "epidemic," but ESI offers no direct solutions.  I think there's a simple reason for this: it's complicated to try to solve the problem of prescription drug abuse and misuse.

Across the thousands of reviews PRIUM has conducted over the last few years, we've found that approximately 73% of the drugs we've reviewed are not medically necessary.  Granted, there's selection bias here - PRIUM is often brought it when help is clearly needed on a claim.  But cut that number in half... or by two-thirds... that's still a big number.

I completely agree with ESI's definition of waste, but I think they've missed a core component of that waste.  When it comes to your PBM services, don't settle for reports.  Demand solutions.  Demand solutions that tackle head-on the issue of medical appropriateness, abuse, and misuse.   

On Twitter @PRIUM1


  1. Thank you for your interest in the Express Scripts’ Workers’ Compensation Drug Trend Report. The research-driven report provides insight and analysis of pharmacy spending trends in the workers’ comp industry. This year’s report, for the first time in the industry, quantified the amount of waste in pharmacy spending in workers’ compensation.

    At Express Scripts, we leverage our research capabilities to develop innovative solutions to help workers’ comp payers meet the challenges facing the industry today. We think waste through the use of higher-cost medications and delivery channels, is one such challenge.

    We agree that narcotics are another major challenge in the workers’ compensation industry and it is in fact, a key area of focus for Express Scripts.

    The company offers several opioid utilization management programs to help deter misuse of narcotics.

    This includes our recently announced workers’ compensation Fraud, Waste and Abuse (FWA) program. Our FWA program goes farther than any other program in the industry today to help workers’ comp payers fight narcotic abuse by identifying potential cases of abuse through proprietary data analytics and detailed investigations including communications with physicians, pharmacists and injured workers. The program then provides a detailed recommendation of potential actions and interventions the client can implement. More information is available on the Express Scripts website (

    Our ScriptAlert and early intervention programs alert clients to potentially problematic patterns of narcotic prescribing and use including high dosage. Other Express Scripts programs include parallel prescriptions alerts, point-of-sale and retro DUR, pharmacist review of scripts and physician communications programs.

    We are always happy to see other companies, who like us, are working to fight the challenge of prescription drug abuse.

  2. I appreciate ESI weighing in on my post. I stand by my original position, though, that despite the programs ESI claims to have (see comment above), the solutions offered in the drug trends report do not address the concept of medical necessity.