Pharmaceutical Reviews Target Workers’ Compensation Drug Costs

With prescription drug costs in workers’ compensation mounting at an annual rate of 13 percent, Professional Reviews Inc., a physician peer review company based in Atlanta, has launched Physician Pharmaceutical Reviews or PPRs.

The PPR is designed to provide an objective, qualified review of the pain management program especially the medication regimen on a workers’ compensation case. Insurance carriers, self-insured employers and other payers can use the PPR to modify the treatment program or to deny payment for inappropriate drug costs. Some jurisdictions require a medical doctor’s opinion in order to modify pharmaceutical care or deny payment.

How PPRs work
A physician reviewer, who has expertise in the diagnosis and access to the latest pharmaceutical research, evaluates the claimant’s medical history, status and prognosis. This involves a thorough understanding of the mechanism of injury, diagnosis, medications and other treatments prescribed. The reviewer refers to a number of pharmacological resources, Food and Drug Administration literature, evidenced-based medical guidelines and other research related to the prescribed drugs and their typical off-label usages to evaluate the overall treatment plan.

The physician reviewer may also discuss the case with the treating physician to better understand the patient’s history and any influencing factors. Then the reviewer provides the insurance carrier or self-insured employer a written recommendation regarding the pharmacy portion of the treatment plan.

Utilization as cost driver
“The PPR focuses on two major areas of drug utilization management – multiple prescriptions from multiple providers and changing the prescribing behavior of physicians,” said Debra Borger-Cerrato, president of PRI. “These seem to be the key influencers of cost and utilization.”

It is not the price-per-prescription that drives much of drug cost inflation, according to workers’ compensation payers surveyed by Health Strategy Associates (www.healthstrategyassoc.com), a health care management consulting firm based in Madison, Conn. Instead, industry leaders pointed to utilization — the volume of prescriptions written — as the main problem. In addition, they perceived treating physicians as the key drivers of prescription costs because the physician has more control over the drugs prescribed.

PPRs present a unique opportunity to influence physician prescribing behavior, according to Borger-Cerrato. “Physicians are much more likely to listen to another medical doctor, than to a nurse case manager or pharmacist, in part, because the physician can incorporate the pharmacy plan into the entire care regimen for the specific patient,” she said. “Many actually appreciate the reviewer’s participation because they often lack time to keep abreast of the latest research.”

A six-month statistical review of 163 PPRs conducted in Texas by PRI showed that in 41 percent of the cases, peer review discussion produced a consensus to modify the treatment plan or discontinue a certain medication.

PPRs are priced on a case-by-case basis and while costs vary according to the complexity of the case, they usually range from $500 to $700 per claim.

Founded in 1987 and based in Atlanta, PRI (www.prium.net) provides objective peer-to-peer clinical consulting and medical services surrounding medical necessity, causality and appropriateness of care for injured people. It has been accredited by the Utilization Review Accreditation Committee since 1998 and provides peer review to the workers’ compensation industry along with the automotive, general liability, and personal injury lines of insurance. The company serves payers of medical claims, including insurance carriers, self-insured employers, third-party administrators, and managed care companies.