Tag Archives: formularies

Healthcare Buyers Need Clearer Choices

Over the past decade, many industries have made tremendous progress when it comes to offering consumer choice. Just look at the travel industry. Twenty years ago, it wasn’t possible to search for a flight, compare dozens of different options side-by-side and tailor your selection to match your specific needs. Shopping experiences across many categories are now offering choices — and making those choices clear. The healthcare industry, however, is lagging behind. And when it comes to something as critical as healthcare, clear choices are imperative. Consumers who make a less-than-optimum insurance choice face higher costs, less satisfaction and poorer health when an issue that should be looked after gets ignored because it’s not covered.

These Six Factors Make Clear Choices Imperative for Health Insurance Shoppers

1. Cost

When most individuals shop for a new plan, it’s not just a matter of going with the option that comes with the lowest monthly premium. There’s always a juggling act between the monthly premium and out-of-pocket costs. If the co-pays and deductibles are too high, if there are services that individuals use that aren’t covered, the lowest-cost plan may well end up costing the consumer more. Consumers need to understand their total cost of healthcare with any given plan.

See also: Key Misconceptions on Health Insurance  

2. What’s Covered

After the basics, individuals may have a wide range of services for which they seek coverage, and every healthcare consumer will have different needs. One individual may require mental health services, another physical therapy. For yet another, it’s audiology services. Even if a certain service is covered at some level, there will likely be different limits (e.g., the number of physical therapy sessions allowed) from one plan to the next. While it’s not possible for individuals to anticipate everything that they might need in a year, consumers should be experts in their current requirements.

3. Prescription Drug Coverage

Formularies listing the prescription drugs covered under each insurance plan can be extensive. And when they’re on paper, they can be very difficult to navigate. However, consumers are quickly learning the importance of determining whether the drugs they take are covered by their health insurance plans. Given last year’s unexpected cost increases for the EpiPen, consumers are wising up. Looking through the formulary and not finding an expensive drug they need to take regularly may knock a plan out of consideration.

4. Provider Network

Whether a healthcare provider is in-network is a big deal to consumers. In fact, when it comes to choosing a physician, it may be the biggest deal. A 2015 survey of more than a thousand patients showed that 90% of consumers reported that the most important attribute of a physician is whether they accept the individual’s health insurance – more important even than the physician’s clinical experience. Consumers need to know what happens when they see a physician or other provider, or use a hospital, that’s outside of their network: The costs may be untenable. Consumers might be okay with switching from a primary care physician to someone new if they only see them once a year for a regular physical. But if they’ve developed a close relationship with their pediatrician – someone they like and trust – they’ll want to make sure that their provider is in-network.

5. Unique Elements

Consumers are taking more ownership of their own healthcare. These days, when shopping for health insurance, they are now factoring in all of the details that make them unique. For example, if their kids play sports, they’re thinking about ER visits. When they’re planning an addition to the family, they’re doing research to see if the facility where they want to have their baby is covered by their health plan. There are many unique elements that require choice. Health insurance is not a one-size fits all solution.

6. Overall Risk Aversion

When it comes to choosing a health insurance plan, risk aversion is really about what level of financial risk an individual is able to accept. And, in this regard, every individual is different. The lower-cost premium plan might be fine if there’s a low probability of something occurring that is not covered. But if you’re likely to be making frequent ER trips with your kids, that low-premium plan may not be so attractive. It’s up to the individual to determine how risk-averse they are.

Insurance customers are desperate for clear choices that are easy to understand. They need them because everyone is unique and living a different situation. And, given the wide range of choices that are available to consumers in so many other aspects of their lives, they expect options. Choices provide an opportunity for your customers to find the best-fitting health insurance plan. Are you offering enough choices?

See also: The Basic Problem for Health Insurance  

Clearly presenting the information that today’s healthcare consumers require can be overwhelming. After all, carriers are experts in insurance, not in software application development and data presentation. Fortunately, in the 21st century, data is highly digestible, usable and transparent. Health insurtech companies across the nation are making sure of that. As insurance carriers and health insurtech companies work together, slowly but surely, the industry will progress, offering more clearly defined choices for today’s consumers.

Opportunities for Treatment Guidelines

Medical treatment guidelines can be a great benefit to any workers’ compensation system. They can prevent unnecessary medical procedures and the prescribing of potentially harmful medications. However, they are not all the same, nor are they without challenges. Understanding a jurisdiction’s strengths and shortcomings, taking a strategic approach to developing treatment guidelines and following some common-sense tips can lead to better outcomes for injured workers — and, ultimately, lower costs for payers.

That’s the view of workers’ compensation experts who spoke during our Out Front Ideas webinar on the subject. The panel included representatives from the regulatory, medical, pharmacy benefit management and third-party administrator communities. They were:

  • Amy Lee – special advisor, Texas Department of Insurance, Division of Workers Compensation
  • Dr. Douglas Benner, MD – chief medical officer from EK Health and national medical director of Macy’s Inc, Claims Services
  • Mark Pew – senior vice president, PRIUM
  • Darrell Brown – executive vice president, chief claims officer – Sedgwick.

Dr. Benner brought a unique and important viewpoint to the panel. As a practicing physician for over 30 years, he has firsthand experience practicing medicine under guidelines. He has also been involved in the development of treatment guidelines for both the Official Disability Guidelines (ODG) and the American College of Occupational and Environmental Medicine (ACOEM).

A majority of states now have some type of medical treatment or return-to-work guidelines in their workers’ compensation systems, and nearly half either have or are considering drug formularies. But there is some confusion about how they work within various jurisdictions and how effective they are. The speakers gave us great insights to better understand how to develop and implement successful treatment guidelines and how to get the most out of them.

Texas’ Example

Many in our industry look to Texas as a state with highly effective treatment guidelines. Texas had some of the highest workers’ compensation costs in the nation, along with some of the poorest return-to-work and patient satisfaction outcomes. After implementing treatment guidelines and a drug formulary, the state now boasts some of the best workers’ compensation outcomes in the nation, as well as lower costs.

But the Texas story is not quite as simple or transferrable as you may think. As our panel explained, it took a multi-year, painstaking effort by representatives in all facets of the system to develop and implement the model now in place. The change also required a deep understanding of the workers’ compensation system as it existed in Texas for the treatment guidelines to get to the point they did.

The changes in Texas began with legislative reforms in 2005. It would be two more years before the treatment guidelines were implemented and three years after that for the drug formulary to begin being phased in — first with new claims, then with legacy claims. One of the keys to Texas’ success was a change to include evidence-based medicine in the guidelines.

See also: Texas Work Comp: Rising Above Critics  

EBM

Evidence-based medicine (EBM) is a term we hear often these days, but there’s disagreement about what it truly means. Texas sought to clarify the issue by including a statutory definition in the treatment guidelines, so it defined EBM as follows:

“Evidence-based medicine means the use of current best quality scientific and medical evidence formulated from credible scientific studies, including peer-reviewed medical literature and other current scientifically based texts, and treatment and practice guidelines in making decisions about the care of individual patients.”

Texas switched to basing the guidelines on EBM to reform the previous consensus-based model, which was perceived as allowing for too much unnecessary medical care. EBM was chosen as the standard for selecting treatment guidelines, return-to-work guidelines and adjudicating claim level disputes on medical care. It is also the standard expected from healthcare providers, payers and others.

The idea of EBM is to provide a systematic approach to treating injured workers based on the best available science. Ideally, medical providers should base their treatment regimens on EBM, although it is also important to consider the specific needs of each individual patient.

Unfortunately, some of the most pervasive medical conditions among injured workers have not been as heavily researched as other ailments, such as heart disease or hypertension. This means EBM is not the basis for every single medical condition. The developers of EBM for workers’ compensation consider all available research, ‘weigh it’ in terms of quality then fill in the ‘gaps’ with a consensus of expert panels. That does not mean those particular guidelines are not scientific. For example, there is little research indicating someone with chest pains should undergo an electrocardiogram (EKG), but medical common sense dictates that is the appropriate action to take.

Formularies

Ensuring injured workers are given the most appropriate medications for their conditions is, or should be, the goal of drug formularies in workers’ compensation, according to the panelists. Not all drug formularies are the same, and it is helpful to understand their differences.

As we learned in the webinar, drug formularies started in the group health area and were primarily a way to reduce costs, because out-of-pocket expenses are involved. There are different tiers to guide the best drug for the patients with the aim of finding the one that is the least expensive.

Because workers’ compensation does not typically include co-pays, the goal for many jurisdictions is clinical efficacy — finding the medication that will result in the best outcome for the injured worker and get him or her back to function and, ultimately, work.

See also: States of Confusion: Workers Comp Extraterritorial Issues

States such as Texas have a “closed” drug formulary, although compared to closed formularies in group health, it is not the same. Whereas in the group health context, some medications will be disallowed in terms of reimbursement, formularies in workers’ compensation instead require pre-authorization for certain medications. The term “preferred drug list” is more appropriate for workers’ compensation.

Texas uses the Official Disability Guidelines for its list of “Y” and “N” drugs. All FDA-approved drugs are included, but those on the “N” list are not automatically paid for through the workers’ compensation system.

Almost immediately after Texas implemented its drug formulary, prescribing patterns changed. Physicians began prescribing more medications on the “Y” list, rather than justifying the use of those on the “N” list. That was among the main goals of the drug formulary — to get prescribers to avoid prescribing opioids and other potentially dangerous drugs right from the start.

The formularies in workers’ compensation systems in other states differ. However, the goal is the same: to encourage providers and others to prescribe medications that are the best for the injured worker, considering his or her injury and any comorbid conditions. Patient safety, rather than lower costs, should be the goal.

Many in the industry are closely watching California as it faces a summer deadline to finalize its drug formulary. There are estimates that the state could see about 25% of its currently-prescribed medications put on the fast track for approval and thus avoid delays from utilization review once the formulary is implemented.

Challenges

Having heard about the many potential benefits of treatment guidelines, we then turned to the panelists to discuss some of the obstacles and how to overcome them. Educating all stakeholders was among the most important strategies they mentioned.

For example, a claims examiner may not see a recommended treatment in the guidelines for a particular jurisdiction and issue a denial for a requested procedure. But, upon further investigation, the treatment requested by the provider may be the best for all considered.

In a California case, a claim was halted for several years — with indemnity expenses continuing to be paid — as the parties awaited the outcome of a dispute over an MRI scan. The case points to the need for those involved in a claim to be flexible. While following the guidelines should be the general rule of thumb, it’s also important that those overseeing a claim take a holistic approach and see what really makes sense for the injured worker.

It is also vital to educate physicians on what to do to gain approval for treatments that stray from treatment guidelines. Often, little or no explanation is provided as to why a particular patient needs a certain procedure or medication. Without complete information, the rate of denials increases. Texas took the unique step of implementing Appendix B to provide guidance to physicians on how to document exceptions to its guidelines.

The consistency (or lack thereof) of guidelines can be frustrating, especially for organizations that operate in multiple jurisdictions. Again, those involved in the claim need to be informed about the guidelines used in each.

It is important that everyone involved in reviewing treatment recommendations — including claims examiners, nurses, physicians and even administrative judges — understand the treatment guidelines and their limits for the jurisdictions in which they operate. The decisions each person makes must be consistent for the guidelines to be most effective.

Keeping the guidelines current is another challenge for some jurisdictions. With medical science changing rapidly, it’s best if jurisdictions find a way to get updated information published as soon as possible and make it easily accessible.

The Future

While a majority of states have medical treatment guidelines in their workers’ compensation systems, 21 did not at the time of the webinar. About 20 states either have or are considering drug formularies.

There are additional efforts underway on the state level to address medical care for injured workers. Several Northeastern states, for example, have placed limits on the number of days for which opioids can be prescribed. Some have limited it to seven days, while New Jersey is imposing a five-day limit. That trend is expected to continue.

See also: 25 Axioms Of Medical Care In The Workers Compensation System  

Other states are looking at helping wean injured workers off opioids. New York recently rolled out a new hearing process to address claims that involve problematic drug taking.

Progress is being made to improve injured workers’ outcomes and treatment guidelines, and drug formularies are a big part of these efforts. The goals of better safety and clinical outcomes, quicker return-to-work, shorter treatment periods and better overall outcomes should drive the conversations going forward.

To listen to the complete Out Front Ideas with Kimberly and Mark webinar on this subject, please visit Out Front.

The WC Mistakes That States Make

As 2017 gets rolling, state legislatures are convening all over the country. Several of them are about to make mistakes in the area of medication management in workers’ compensation.

My colleague, Mark Pew, and I have written and spoken extensively on the topic of drug formularies. And we’re currently working, formally and informally, with regulators and other stakeholders in jurisdictions across the country on approaches that make sense for employers, doctors, pharmacists and, most importantly, injured workers. While there’s not a lot to be gained for any of us in calling out individual states, there’s a great deal at stake for all of us in the successes and failures of drug formulary implementations. A failure (perceived or real) in one jurisdiction can lead another jurisdiction to delay its own attempt at a formulary — or to scrap it altogether.

So how can we tell if a law or rule set is headed in the right direction? Or, alternatively, if a state’s efforts are more likely to lead to sub-optimal results? Here’s a quick litmus test that you can apply to make your own determination:

1. Will the formulary rely on independent, third-party medical treatment guidelines?

There’s a great deal of industry discussion surrounding this topic, mostly focused on the definition of “evidence-based medicine.” While that conversation is interesting, it’s not the critical factor in overall formulary success. The crucial questions are twofold: First, will there be room for political influence in the formation of the guidelines? Second, will the guidelines be updated with sufficient frequency?

See also: How Should Workers’ Compensation Evolve?  

2. Does the formulary process build off of existing dispute resolution processes?

States that have successfully implemented drug formularies thus far have done so by relying on existing rules regarding resolution of medical treatment disputes. States that try to simultaneously create a formulary and new dispute resolution processes to support it are, in reality, trying to do two things at once. Not impossible, but certainly creates execution risk.

3. Does the formulary allow for a remediation period for legacy claims? 

On the one hand, a single effective date creates chaos as employers and physicians try to figure out how to address legacy claims, which tend to be more complicated. On the other hand, applying new rules to new injuries creates two standards of care within a workers’ compensation system, where an injured worker’s treatment plan is driven entirely by the date on which he was injured (which makes no clinical sense). I look for regulatory language that takes a balanced approach — an initial implementation date for new injuries, followed by a remediation period for legacy claims, followed by a fully effective date for new rules and all claims.

4. Is the formulary process scalable?  

I always look to see if the dispute resolution process can stand up to a significant volume of cases. While the goal of any formulary adoption should be to streamline access to medically necessary medications for injured workers, states should take a “hope for the best, plan for the worst” approach. Dispute resolution processes that rely on one individual or one office for ultimate resolution may lead to bottlenecks and, in a worst-case scenario, undue influence. I always ask myself, what will this look like if there are more disputes than the state expects?

See also: Five Workers’ Compensation Myths

One bad apple can spoil the bunch. Let’s get this right.

The article was originally published here.