The Complex Landscape Surrounding High-Impact Drugs and Worker Compensation

Although high costs and other challenges remain a concern, specialty medications, including biologics and biosimilars, should be continually evaluated for potential benefits for injured workers, as they may provide relief than traditional therapies. can not. (Credit: Kenishhirotie/

When we talk about addressing pharmacy issues in workers’ compensation programs, opioid concerns are often at the top of the agenda, and while opioid management remains a high priority, it is not isn’t the only pharmacy trend we need to watch closely.

High-impact categories such as topicals, compound kits, combination packs, and specialty drugs represent proportionately low usage, however, they can be associated with exponentially higher costs. In order to effectively manage clinically relevant utilization and savings within these classes, it is important to recognize the trends associated with each of these cost drivers.

In recent years, the industry has seen the use of topical medications, which are applied to the skin or mucous membranes, increase. These drugs are now a leader in expenditure and a growing source of concern in the field of workers’ compensation. The category appears to be the next horizon that billers and dispensers, especially dispensing physicians, will look to as a money-making opportunity and stands out as an ongoing trend.

Topicals are being prescribed in workers’ prescriptions with increasing frequency – ranking third among major therapeutic classes with 12.4% of total drug cost and 5.7% of total prescriptions. Within this class, some cost factors stand out, such as private label topical analgesics (PLTA), which are associated with limited clinical efficacy and exorbitant prices that often rule them out as a first-line treatment option. favorable line. Examples include Velma, Lidopro and New Terocin.

Also, under the category of topical and dermatological medications are topical prescription medications, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as Voltaren Gel and Pennsaid, as well as some topical anesthetics such as ZTLido and Lidoderm, and these contain specific and limited foods and foods. Drug Administration (FDA) approval for use to be considered with appropriate venue and therapy.

Conversely, PLTAs are not FDA approved and are not evaluated for compliance with applicable regulations and policies for safe and effective use. These products are also not recommended as first-line treatment.

Additionally, they rarely offer greater clinical benefit over comparable, more cost-effective over-the-counter (OTC) alternatives and often contain the same ingredients. Creating further challenges, most of these products are marketed directly to physicians’ offices for distribution, creating paper bills and out-of-network issues regarding cost management and circumvention of security and clinical controls.

Although topical medications may have several benefits and be a viable option for some patients, they require careful monitoring. In many cases, their lack of demonstrated superiority, efficacy, and price impact supports the case for consideration of therapeutic ingredient equivalents, which produce lower costs and/or clinically effective results. .

The high price of combo packs

We also see high priced compound kits and combo packs where the individual components are available separately or in different formulations at a much lower cost. Compound kits contain two or more premeasured drug ingredients that must be combined immediately prior to use based on a prescription and are sold together as a single product, usually under a National Drug Code (NDC). Combination packs consist of several commercially available products that are conveniently packaged together for sale with a common therapeutic purpose.

An example that illustrates the extreme price markup for products in a combo pack involves an OTC topical gel combined with alcohol wipes packaged as a single product. When distributed separately, they have an average wholesale price (AWP) of around $15 combined. However, as a combo pack product co-packaged under an NDC, the price of these same products now represents an AWP of approximately $3,400.

Fortunately, we are seeing downward trends in the combo pack category, in part due to the implementation of various programs and checks used to address them specifically. Unfortunately, the inflated cost associated with these products, which average around $2,100 per prescription, speaks to the importance of a continued focus on this area and the impacts it can have.

Similar to some of the other categories discussed, the specialty drug category, which includes drugs that are typically used to treat complex chronic conditions, and represents a major area of ​​pharmaceutical development with significant costs.

Specialty drugs

There is no universal specialty drug list that easily identifies this group of relatively low-volume and expensive drugs. Most entities establish their own definition of what should be included in the category, which typically includes a combination of criteria involving drugs used to treat rare complex conditions, considerations for special storage and handling requirements, cost and various clinical applications of use, such as administration difficulties, patient compliance, specific testing and monitoring requirements, and patient safety and immunogenicity issues.

Given this, the specialty category includes a broader definition of products that fall under this set of criteria, as well as biologics and biosimilars defined by the FDA to include vaccines, viruses, therapeutic serums, toxins, blood or its derivatives, allergenic and other products. . In workers’ compensation, for example, the specialty category often represents injectables used to manage inflammatory conditions or various types of joint pain.

Additionally, for workers’ compensation, specialty drugs can be particularly challenging because they are prescribed to treat conditions that may be directly or even indirectly related to workplace injuries or illnesses. Different distribution channels also pose additional challenges, with around half of these drugs being dispensed through doctors’ surgeries, clinics and hospitals, as opposed to traditional pharmacies. Additionally, many of these products are billed using J codes.

Even though many of these drugs are prescribed to manage complex, often chronic conditions, there are some notable medical conditions that are trending in the workers’ compensation space. The top five medical conditions account for over 60% of all specialty drug costs and usage. The majority are used as blood clotting treatment and preventative medications, including medications that prevent and treat deep vein thrombosis and pulmonary embolism like Eliquis or Xarelto. Other categories of disease states among the top five were determined by drugs used to treat HIV or AIDS, primarily antiviral drugs, which are currently used for post-exposure prophylaxis following a needle stick injury of needle. Cancer drugs, autoimmune disorders and migraine medications, including new therapeutic class injectables – such as Ajovy, Emgality and Aimovig – round out the top five conditions.

Although high costs and other challenges remain a concern, specialty medications, including biologics and biosimilars, should be continually evaluated for potential benefits for injured workers, as they may provide relief than traditional therapies. can’t, which could result in a better quality of life as well as fewer hospital admissions, emergency room visits, and lab tests. However, in other cases, less expensive but equally effective alternative therapies might offer a better choice.

Targeted solutions for pharmaceutical challenges

When it comes to addressing these high-impact pharmaceutical challenges, the best approach is to deploy targeted clinical solutions that leverage three strategies to optimize pharmacy programs.

First, identifying these difficult, high-impact pharmaceutical categories is critical, as they are not easily identifiable in the data. Additionally, a pharmacy program should include options for proactive solutions for post-dispensing review, plan changes, medication list control or formulary management, as well as medication decision support. prior authorization of medicines which includes both clinical and regulatory aspects that strengthen utilization management and billing controls.

Second, follow the evidence. Apply clinical controls that target these categories and scenarios for interventions to promote more cost-effective first-line alternatives through timely clinical review and recommendations, drug utilization evaluations, and formal usage review. Integrate these categories into predictive and demonstrative risk modeling to establish clinical solutions that address patient safety, align with evidence-based treatment recommendations, and apply various treatment guidelines such as the Official Guidelines on the disability (ODG). Follow up by supporting ongoing clinician engagement, monitoring, education and coordination.

Finally, use reporting and data analysis tools to continually improve customer collaboration through training, support, and partnership review to address areas of opportunity.

Nikki Wilson, Pharm.D./MBA, is Senior Director of Clinical Pharmacy Services at Mitchell, an Enlyte company. As a licensed pharmacist, Wilson has over 13 years of comprehensive industry experience through leadership roles overseeing home prescription delivery programs, clinical pharmacy operations and benefits management. social and product development.

The opinions expressed here are those of the author.


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