Examining the Effects of Price-Focused Reform

Workers Compensation Research Institute (WCRI) recently conducted a series of studies aimed at examining the effects that federal and state regulations are having on the reduction of pharma spend. What the industry is seeing is an emerging trend in physician prescription reimbursement that begs the question, is price-focused reform effective?

One particular regulation, enacted to cap prices paid by tying the maximum reimbursement to average whole price (AWP) has left physicians in certain states dispensing new drug strengths and formulations at higher prices in efforts to compensate for lost revenue. AWP is set by the original drug manufacturer, however new strengths/formulations are seen as generic, not repackaged. This technical distinction allows the new “manufacturer” to set a new, much higher, AWP, sidestepping reforms. Highlighted in the report, Physician Dispensing of Higher-Priced New Drug Strengths and Formulation, the muscle relaxant cyclobenzaprine, one of several drugs prescribed in this manner, illustrates the effects of such dispensing practices (sales from the first quarter of 2014, post-reform):

• California
  • Typical 5-10mg dose: $0.38-0.39 per pill
  • New 7.5mg product: $3.01 per pill
  • Prescription increase (in same quarter): 55%
• Florida
  • Typical 5-10mg dose: $1.29-1.75 per pill
  • New 7.5mg product: $4.11 per pill
  • Prescription increase: 49%
• Illinois
  • Typical 5-10mg dose: $1.25-1.55 per pill
  • New 7.5mg product: $3.86 per pill
  • Prescription increase: 22%
• Tennessee
  • Typical 5-10mg dose: $1.08 per pill
  • New 7.5mg product: $3.97 per pill
  • Prescription increase: 19%

How can you reduce large loss claim outcomes in the face of these cost drivers?
This trend is driving up medical costs not just in the workers compensation industry, but in the healthcare industry as a whole. With our proprietary pharmacotherapy review, ANS is able to cut through the red tape and provide our clients with quantifiable results. The results achieved not only lower financial costs, but dramatically improve the quality of life and care for the injured worker.

Get on the road to settlement to day with ANS Solutions.

Original Content posted on http://ans-solutions.com/examining-the-effects-of-price-focused-reform.

How Common is Illegal Drug Use Among Pain Patients?

At the American Pain Society’s 35th Annual Scientific Meeting in Austin, findings were released on the use of illicit substances among chronic pain patients. Of 450,081 patients included in a study by Baltimore-based pain medication monitoring firm Ameritox, 10.4% of urine samples tested positive for the use of at least one illicit substance.

How Many of Those Identified Were Workers Comp Patients?
Workers compensation was the primary payer for 22,525 of the 450,081 patients in the study, conducted between January 2013 and July 2015, which showed the use of illicit substances 8.4% of the time in workers comp patients. The group with the highest level of detection, at 16.4%, was Medicaid patients. The lowest: Medicare at 8.1%. Commercially insured individuals were detected at 8.4%, and patient paid tests at 12.5%, respectively. Of those receiving opioid pain treatment drugs, the use of illicit substances was detected at the following rate:

• For patients prescribed Hydrocodone – 10.9%
• For patients prescribed Codeine – 10.7%
• For patients prescribed Oxymorphone – 8.2%

Risk Mitigation and Pharmacotherapy Review
With the use of highly addictive opioids in the treatment of pain, a lack of utilization and/or awareness of risk mitigation strategies is a common driver for poor outcomes. Often times the potential for addiction or the existence of past drug abuse and even behavior consistent with drug abuse are over looked. When this happens the quality of treatment and life in large loss workers compensations claims are severely compromised while associated treatment costs continue to rise.

At ANS, our highly credentialed Legal nurse consultants develop actionable treatment recommendations to enhance the quality of life of injured workers while also ensuring optimal financial outcomes through:

• Comprehensive, holistic medical records reviews and treatment assessments.
• The identification of at-risk individuals and dangerous or deadly drug interactions.
• Uncovering of unnecessary opioid treatment regimens and baseless dosage increases.
• The recommended use of equally effective, less risky, alternative treatment methods where applicable.
• Compliance protocols for monitoring the usage of habit-forming medications, such as opioids.
• Opioid tapering/weaning programs to curb the risk of opioid addiction.

Improve outcomes and reduce costs with the most effective pharma cost containment strategies in the industry. Contact http://www.ans-solutions.com today.

Content was originally published at  http://ans-solutions.com/how-common-is-illegal-drug-use-among-pain-patients/.

Medical Cost Containment Does Not Mean Compromised Care

The existing way that the workers’ compensation industry handles large loss claims has been contributing to diminished quality in care for injured workers, increased costs associated with treatments, and poorly coordinated care. Care delivery within workers’ compensation programs is arguably even more inefficient than in general healthcare but it does NOT have to be this way. Payers can have the best of both worlds with medical cost containment strategies that provide quantifiable outcomes that positively impact the patient’s health while also driving down associated treatment costs.

How does Medical Cost Containment Improve the Quality of Care for Injured Workers?

Interventions with prescribers can be instrumental in improving the quality of life and treatment for patients. ANS PharmaIntervention is designed to help treating physicians detect and correct underlying problems, promote functional improvement and reduce narcotic usage. Our legal nurse experts conduct comprehensive reviews of a patient’s medical history often uncovering risk factors and other considerations that can be overlooked by treating physicians. They are then able to collaborate with treating physicians to improve the current treatment plan based on actionable, evidence based recommendations. The benefits to the injured worker include but are not limited to:

• Reduced risk for prescription opioid painkiller addiction.
• A modified treatment program based on recovery.
• A modified treatment program based on the availability of alternative treatments and therapies that may be more effective, and have fewer side effects.

All of which contributes to measurable improvements in quality of care and life for the injured worker- even increasing the likelihood of returning to work sooner.

How Does Medical Cost Containment Positively Impact Your Bottom Line?

Ensuring injured workers receive the right care at the right time from treating physicians, minimizes the financial impact of catastrophic injuries. The goal of ANS PharmIntervention is to improve quality of care by applying expert clinical knowledge and experience to recommend, where appropriate, alternative treatments and therapies. The financial benefits of the ANS PharmIntervention strategy stem from its ability to aid treating physicians in:

• Improving opioid painkiller practices.
• Avoiding unnecessary or inappropriate pharmaceutical and medical treatments.
• Avoiding duplicate therapies in the event of multiple treating physicians.

When done correctly, medical cost containment ensures that patients receive the highest quality of care balanced with the necessary cost controls.

Care without Compromise

ANS Legal Nurse Consultants provide comprehensive reviews of large loss claims while delivering optimized financial results and quality of care for injured workers. To learn more about our medical cost containment strategies visit our website at www.ans-solutions.com.
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The Human Side of Medical Cost Management

When we talk about the costly nature of large loss Workers’ Comp claims, it is sometimes hard to think beyond the financial impact.  Further to this point, when medical cost containment strategies are discussed they are often geared toward addressing the clinical and pharmaceutical treatment programs for injured workers from a financial perspective. What about the less tangible side of medical cost containment-the human costs which are equally as significant and damaging?

Addressing Human Costs in Medical Cost Containment

When we talk about the human cost of large loss claims, we are really talking about the effect a case has on the quality of life for an injured worker and their family. While all medical cost containment strategies focus on financial cost drivers, not all strategies address human costs. There are many drivers that can contribute to compromising an injured worker’s quality of life. These human cost drivers include, but are not limited to:

·         Pain treatment through highly addictive opioids, coupled with a lack of patient education on the risks and dangers of these drugs, subjects injured workers to a path of drug addiction which may hinder or prevent their recovery.

·         Lack of appropriate physician monitoring and/or patient compliance to a prescribed medical treatment regimen can contribute to a longer recovery period.

·         Lack of monitoring patient’s treatment program and progress results in missing the warning signs of drug abuse and addiction, missed opportunities to modify a treatment program based on patient’s recovery, lost opportunities to modify treatment based on the availability of alternative treatments and therapies that may be more effective, and have fewer side effects.

·         Lack of coordination between multiple treating physicians can attribute to greater increase for drug abuse or unnecessary or inappropriate pharmaceutical and medical treatments.

ANS Cost Containment Strategies

The ANS PharmacotherpyReview Program is the most advanced and results-oriented cost containment strategy in the industry. At the first of three stages, we assess the existing treatment program using evidence based reviews to assess medical necessity. We also identify duplicate therapies, excessive dosages and alternate medication regimens. Our experts then make actionable treatment modification recommendations that ensure optimal outcomes for the patient. This includes consolidating and coordinating drug therapies between multiple prescribers.  In the second stage, our nurse experts work with treating physicians to obtain commitment on a modified future course of treatment. For a positive therapeutic outcome, we move to stage three where an ANS Clinical Liaison Officer proactively manages each case to ensure physician and patient compliance with the revised course of treatment.

ANS Solutions

Our approach to cost containment was uniquely developed to simultaneously ensure a medically appropriate and cost effective treatment program and enhanced quality of life and care for the injured worker. For more information on our industry leading cost containment strategies visit us at www.ans-solutions.com. 

This content was originally published at www.ans-solutions.com.

 

The Medical Legal Nurse Consultant – A Jack of All Trades

Medical legal claims typically involve complicated, long-term medical issues and represent an enormous financial burden for Payers. In order to mitigate this financial exposure it is crucial for Payers to accurately assess the true value of alleged damages. But this is no small task and it often requires extensive investigation and expert interpretation. Let’s be honest, mitigating financial exposure can only effectively be done by a highly credentialed few, those with a hybrid skillset of healthcare expertise, specialized legal training, and first-hand experience in complex liability matters such as GL, toxic exposure, personal injury, and malpractice. 

With qualifications in both medical and legal fields the Legal Nurse Consultant is perfectly poised to aid insurance companies who want to optimize their results and settle large claims once and for all. By definition, a Legal Nurse Consultant is an individual with healthcare expertise who has taken additional specialized legal training so that they can consult as an expert on medical cases, but this is just the tip of the iceberg.

Medical Legal Nurse Consultant Litigation Support

In litigation support, the data and reporting generated by legal nurse consultants can provide an extraordinarily powerful legal instrument in the negotiation of a claim. At ANS, our strategy for mitigating and defending medical legal claims involves a host of strategic activities including:

• The critical analysis and review of initial complaints, supporting medical & legal documentation and pricing to allow for an accurate assessment of true damages.   
• Review of medical causation and exposure to effectively gauge merits of alleged injuries while identifying any missing medical information that may prove valuable to the claim.
• Generating an expert assessment and opinion based on a detail of record and all documented encounters with medical systems. 
• Uncovering causation, mitigating factors, unreasonable medical charges, inappropriate/red flag patterns of care, and unnecessary and unrelated care issues are exposed
• Providing a counter analysis in the event that a plaintiff future cost of care report is submitted.

Medical Class Action & the Medical Legal Nurse Consultant

Navigating a medical claim involved in a class action is difficult to say the least. Class actions are very large in scope requiring the dissection and digestion of thousands of pages of legal and medical documentation. Fortunately, medical class actions are another area of support fielded by ANS’s legal nurse consultants.  We have extensive experience in handling class action and large tort cases. If you have a medical legal claim involved in a medical class action case, our medical legal nurse consultants can assist by providing:

• Initial screening for merit and damages.
• Analysis of massive amounts of data quickly and accurately creating a snapshot of the case.
• Recommendation for appropriate next steps based on medical review.

At ANS, our team of nurse experts, are highly credentialed and wield an average of 25 years in specialized nursing experience. In addition, their scope of jurisdictional expertise yields unparalleled results. To find out more about ANS Solutions’ superior medical legal nurse consulting services visit us at http://www.ans-solutions.com.

This content was originally posted on http://www.ans-solutions.com.

The Medical Legal Nurse Consultant – A Jack of All Trades

Medical legal claims typically involve complicated, long-term medical issues and represent an enormous financial burden for Payers. In order to mitigate this financial exposure it is crucial for Payers to accurately assess the true value of alleged damages. But this is no small task and it often requires extensive investigation and expert interpretation. Let’s be honest, mitigating financial exposure can only effectively be done by a highly credentialed few, those with a hybrid skillset of healthcare expertise, specialized legal training, and first-hand experience in complex liability matters such as GL, toxic exposure, personal injury, and malpractice. 

With qualifications in both medical and legal fields the Legal Nurse Consultant is perfectly poised to aid insurance companies who want to optimize their results and settle large claims once and for all. By definition, a Legal Nurse Consultant is an individual with healthcare expertise who has taken additional specialized legal training so that they can consult as an expert on medical cases, but this is just the tip of the iceberg.

Medical Legal Nurse Consultant Litigation Support

In litigation support, the data and reporting generated by legal nurse consultants can provide an extraordinarily powerful legal instrument in the negotiation of a claim. At ANS, our strategy for mitigating and defending medical legal claims involves a host of strategic activities including:

·         The critical analysis and review of initial complaints, supporting medical & legal documentation and pricing to allow for an accurate assessment of true damages.   

·         Review of medical causation and exposure to effectively gauge merits of alleged injuries while identifying any missing medical information that may prove valuable to the claim.

·         Generating an expert assessment and opinion based on a detail of record and all documented encounters with medical systems. 

·         Uncovering causation, mitigating factors, unreasonable medical charges, inappropriate/red flag patterns of care, and unnecessary and unrelated care issues are exposed

·         Providing a counter analysis in the event that a plaintiff future cost of care report is submitted.

Medical Class Action & the Medical Legal Nurse Consultant

Navigating a medical claim involved in a class action is difficult to say the least. Class actions are very large in scope requiring the dissection and digestion of thousands of pages of legal and medical documentation. Fortunately, medical class actions are another area of support fielded by ANS’s legal nurse consultants.  We have extensive experience in handling class action and large tort cases. If you have a medical legal claim involved in a medical class action case, our medical legal nurse consultants can assist by providing:

• Initial screening for merit and damages.
• Analysis of massive amounts of data quickly and accurately creating a snapshot of the case.
• Recommendation for appropriate next steps based on medical review.

At ANS, our team of nurse experts, are highly credentialed and wield an average of 25 years in specialized nursing experience. In addition, their scope of jurisdictional expertise yields unparalleled results. To find out more about ANS Solutions’ superior medical legal nurse consulting services visit us at http://www.ans-solutions.com.

This content was originally posted on http://www.ans-solutions.com.

The Financial Repercussions of MSAs on Large Loss Claims

Medicare recommends an allocation of funds in a Workers’ Compensation settlement that is set aside to ensure that the injured party’s qualified medical expenses are funded, also known as Medicare Set Aside. These funds must be used to pay for treatment related to the Workers’ Compensation injury, that would otherwise be paid for by Medicare. The financial repercussions of MSAs on settlements can be significant.

Part D Exposure

As part of the Medicare Modernization act of 2003, Medicare indoctrinated what is known as Part D prescription drug coverage beginning in 2006. In other words, an allocation must be made for future prescription drug treatment in a Medicare Set-Aside. Rising pharmacy costs, including medications an injured worker may have been prescribed once in the previous 2 years, along with treatment, has created an environment in which Payers are subject to unreasonably high claim settlements.  The “Prescription Affliction” suffered by Payers is lovingly referred to as Part D exposure and it leads to claims staying open longer or not settling at all. As a result, these claims rack up millions of dollars in cost for Workers’ Compensation Payers.

Reducing Medicare Set Aside and Part D Exposure

A proactive approach is necessary before settlement and preferably early in the process for optimal results. At ANS, we mitigate Medicare Part D exposure with a three pronged approach:

• PharmReview – during this stage, the injured worker’s existing pharmaceutical regimen is assessed and modification recommendations are determined.
• PharmIntervention – a face-to-face discussion with the treating physician to achieve consensus on a modified medication regimen and commitment on a future course of treatment.
• PharmCompliance- an ANS Clinical Liaison Officer ensures compliance with the new prescription treatment plan. This provides a proactive management of the case to optimize hard cost savings.

Only highly credentialed legal nurse experts who are experienced in the treatment of catastrophic injuries, such as those employed by ANS, can provide actionable recommendations based on the individual patient and engage effectively with treating physicians. This technique yields a clear medical action plan that drives down costs while simultaneously improving the quality of care for the injured worker, allowing for reasonable settlement of the claim.

ANS’s pharmaceutical cost containment technique has reduced pharma costs by up to 25%. To find out more about reducing MSA and Part D exposure, contact us today.

This post was originally published at http://ans-solutions.com/.