The Nurse Case Manager (NCM) role supports the reduction in pharmacy costs in workers compensation

posted in: Workers' Comp | 0

The decrease in pharmacy costs in workers compensation has been directly attributed to the significantly lower use of opioids and other long term pain medications. Let’s examine why utilization has dropped so dramatically- no real surprise but rather a combination of several initiatives which now are resulting in decreased costs:

  • Most states now have stricter prescribing regulations with most now limiting a fill to 3- 5 days.
  • The in troduction of drug formularies has had an impact on costs requiring greater use of generics and lower cost drugs.
  • Technology has also enhanced the ability of a pharmacy to monitor prescriptions in compliance with the regulations – allowing them to deny the dispensing of medications beyond approved limits.
  • Greater education among providers, legislators and insurers has also had an impact.

While all of this is true and in combination has resulted in ever increasing cost savings, the role of the NCM, especially those of us at The Kingstree Group Inc., cannot be overlooked. NCM’s are in a unique position with direct patient contact and close coordination with employers and providers. Advocacy is an integral part of nurse case management and combined with the use of medical guidelines and a focus on a return to full functioning workers it completes the cycle.

At the Kingstree Group, we have had our eye on pharmacy management issues since 2015 and in fact we designed and implemented a process within our proprietary system to track prescription drug utilization as well as to question the rationale for early opioid prescribing and ensuring that all guidelines AMA, jurisdictional and best practices are followed. Our system continually evolves with a powerful database that tracks utilization on a patient by patient basis and includes all state regulations which impact prescribing habits. With our proprietary analytics, we further drill down impact based specific client driven data points. The Kingstree NCM’s actively review this data and work with providers to ensure guidelines and regulations are being followed. In addition, through their role as patient advocates, NCM’s are able to educate and assist patients in the most effective way to return to work.

There is little doubt that workers comp will continue to focus on ways to reduce opioid and other potentially addictive pain medications over the coming months and years. The almost daily news stories regarding the opioid crisis will serve to keep the issue in the forefront. Things to keep an eye on: the increasing number of states allowing the use of medical marijuana (now 30 states and growing), the increased use of formularies for not only pain medications but also other widely prescribed medications. We believe that as utilization continues to drop new approaches and education will be forthcoming.

To find out more about the Kingstree Pharma Trak Program or our Nurse Case Management Services, contact us at 888-853-6412.

Karin Maynard, V. P., Marketing

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