Pharmacy Management’s Evolution: Optimizing Today’s Programs for Tomorrow’s Outcomes

In CorVel’s “Beyond the Script” webinar, experts presented the current landscape of workers’ compensation pharmacy management and emphasized the importance of a holistic approach to achieving program success. This strategy not only enhances cost efficiency but also improves clinical outcomes and supports the well-being of injured workers. In this recap, we’ll highlight key insights from the session, showcasing advancements in pharmacy management and offering actionable tips for organizations and carriers looking to optimize their pharmacy programs for lasting, positive results.

The Evolution of Pharmacy Management

Today, pharmacy management in healthcare reflects a highly complex, integrated system focused on reducing prescription costs and ensuring patient safety in accordance with industry regulations. In recent years, technology, including advanced data analytics, has accelerated efforts to support real-time prescription monitoring, clinical modeling, and risk assessment. However, the industry was not always this structured.

Historically, pharmacy management resembled a “Wild West,” characterized by limited regulatory oversight, resulting in minimal medication cost controls and scarce support for drug utilization management. Major developments, such as the rapid rise in prescription drug costs in the 1990s, signaled a turning point. Managed care organizations and carriers sought solutions to manage workers’ compensation pharmacy costs and prevent misuse, leading to the emergence of pharmacy benefit managers (PBMs). With the modern imperative to minimize costs while facilitating quality care, these organizations can enhance pharmacy outcomes by optimizing four key areas of pharmacy management.

Patient Safety and Outcomes

Medication misuse and negative drug interactions can have devastating consequences for patient well-being, making a focus on patient safety critical to the success of pharmacy programs. To prevent adverse events, pharmacy solutions can mitigate the risk of errors by engaging the injured worker’s local retail pharmacy early in the claims process. Local pharmacists possess valuable insights into a worker’s medical profile (e.g., allergies, disease states, and drug history), allowing them to identify inappropriate prescriptions and educate injured workers on proper medication use.

The local pharmacist’s oversight is further enhanced through drug utilization review (DUR) enforced by pharmacy solutions. DUR ensures that prescriptions are checked against established criteria, such as therapy duplication or early refills, and can be stopped at the point of sale if flagged. CorVel’s Pharmacy Solution employs a team of clinicians engaged in the DUR process, with PharmD’s engaged in complex cases. This collaboration leads to improved outcomes, decreased opioid fills, and reduced opioid dependence risk, while achieving cost savings.

Cost-Effective Medication Management

CorVel takes a proactive approach to tackle the escalating costs of high-priced medications. By analyzing both in-network and out-of-network pharmacy data, CorVel identifies patterns in prescription practices and collaborates with dispensing pharmacies and prescribers to transition high-cost prescriptions to equally effective and economically viable alternatives. This includes recommending lower-cost formulations and engaging providers and pharmacies to promote cost-conscious decisions, ensuring that patients receive efficient and cost-effective pain management therapies.

When a prior authorization request is received, CorVel’s team understand the necessity to first confirm work relatedness. CorVel’s pharmacy clinician’s utilize an integrated data set that provides a complete view of the claimant’s current medications—both in-network and out-of-network—along with injury diagnosis codes and a list of compensable body parts. These efforts help prevent high-cost dispensing and mitigate unnecessary medication expenses, contributing to overall claims savings.

Program Efficiency

Optimizing costs at the claim level leads to a more cost-effective pharmacy program overall. A “sum of its parts” approach can enhance the program further. For instance, leveraging integrated data for each claim increases visibility across teams (e.g., case managers, legal and compliance personnel, ancillary services), enabling stakeholders to make informed medication decisions that improve claim outcomes and program effectiveness.

However, these data assets are only as valuable as the staff interpreting them. Onboarding personnel adept at translating insights into actionable recommendations is critical for pharmacy program efficiency. Certified Pharmacy Technicians play a vital role, applying their knowledge of medications, generic alternatives, and pharmacy operations to advocate for both injured workers and managed care organizations. Additional strategies for program-wide success include:

• Implementing First-Fill Utilization: The first 24 hours of a claim set the foundation for overall outcomes. Providing immediate assistance to injured workers through quick, in-network medication fills is essential. Nurse triage programs, such as CorVel’s Advocacy 24/7 Nurse Hotline, can facilitate first-fill utilization by assessing the worker’s injury and determining if medication therapy is needed, promptly sending processing information to key stakeholders.
• Exercising Formulary Management: A comprehensive formulary supports state and federal treatment guidelines. While keeping up with new formulary requirements can burden internal risk and workers’ compensation teams, PBMs offer specialized expertise across the country. CorVel’s closed or preferred formulary ensures compliance with state requirements and mandates the dispensing of generic alternatives once standard DUR edits are resolved.
• Maintaining Regulatory Compliance: State and federal laws in the workers’ compensation space are constantly evolving. While navigating these regulations can be challenging, maintaining compliance is essential for pharmacy program efficiency and helps mitigate costly penalties associated with noncompliance.

Claim Benchmarks

Managed care organizations must track industry and company-specific outcomes to measure the success of their pharmacy programs, as varying workforce considerations impact these metrics. Key claims metrics serve as foundational benchmarks for enhancing worker outcomes, minimizing costs, and streamlining operations.

Return-to-work statistics reflect how quickly injured workers receive the critical care needed to re-enter the workforce. Successful pharmacy programs focus on optimizing this metric through ongoing case reviews. Additionally, return-to-work outcomes are directly influenced by the time it takes to resolve claims, so case duration metrics provide insights into how pharmacy programs can streamline care and prevent extended medical treatments or prolonged injuries. Measuring the percentage of pharmacy spending compared to overall medical expenses can also highlight opportunities for optimizing program costs across medications, facilities, and ancillary services.

Finally, the Total Cost of Risk (TCOR) metric provides a comprehensive view of all costs related to workers’ compensation pharmacy utilization claims. This includes medication costs, claim duration, recovery time, and non-clinical expenses (such as administrative and legal costs) that affect pharmacy program outcomes and ultimately impact the organization’s bottom line.

Looking to the Future of Pharmacy Management

Modern pharmacy management is crucial for controlling workers’ compensation pharmacy costs while supporting optimal recovery outcomes for injured workers. Looking ahead, CorVel anticipates a growing demand for more personalized care and is actively optimizing client programs to address evolving trends, including the increasing need for specialty medications, the expansion of state fee schedules and formularies, and the potential for AI to streamline claims and pharmacy management.