The Payer and the Pharmacy Benefit Manager

More than 3 million workers’ compensation claims occur in any given year. Medical costs account for roughly 60 percent of the overall claim cost; of this amount, the pharmacy-related claims expense represents nearly 20 percent. Suffice it to say that a payer’s ability to adjudicate these claims in a cost-effective and appropriate manner is no small task. Fortunately, payers have a powerful ally in the pharmacy benefit manager.

The pharmacy benefit management industry’s role in workers’ compensation was formed more than 20 years ago to serve a logistical gap between pharmacies and payers. Injured workers benefited from expanded access while payers experienced cost savings and processing efficiencies as the pharmacy benefit manager (PBM) created and managed the pharmacy network. Friendly customer service and a network discount were the hallmarks of a quality provider.

Fast forward to 2013 and the PBM has evolved into a highly sophisticated, multifaceted, full-service organization. Gone are the days of simply processing scripts. The PBM of today must meld the attributes of a processor, pharmacist, analyst, service representative, professor, advocate, investigator, researcher, and partner all into one while simultaneously serving payers, pharmacists, and injured workers. Add the third-party billing company into the mix, and managing expectations that are often at odds can be quite a challenge, though not one that is insurmountable, particularly when a PBM’s products and services are not only aligned but well integrated.

The Traditional Payer-PBM Dynamic Evolves

All PBMs provide a network, benefit development, clinical expertise, data analysis, reports, communication portals, and customer service operations. Most offer some level of insight into legislative matters and government affairs. In the last 12 months, some have augmented their program to include analytic capabilities. And while on the surface there is a tremendous amount of parity from one PBM to the next, deeper inspection reveals this is not always the case. Not only is there significant variation in the products and services offered but also in the PBM’s ability to walk alongside the payer as a partner.

A willingness among all parties to collaborate for a common goal—to do what’s right for the injured worker—is the key to optimizing impact, gaining more control and achieving better outcomes.

The Network Role

The network is a central element of the PBM program and the foundation upon which all other activities are based. All effective cost-containment strategies start with the network. Not only must the network have national reach, but it must also offer an online, real-time connection with retail pharmacies and include nontraditional dispensers that will honor negotiated discounts and other program parameters.

A payer can influence network penetration through participation in first-fill programs (when available) and by ensuring that workers receive information about pharmacy benefits at the time their injury is reported. They can also share information about out-of-network provider activities with the PBM and help expand the network itself by making introductions and facilitating conversations, particularly with nontraditional dispensers.

Clinical Expertise

Recognizing that no two claims are alike, it’s important that medication therapy reflects generally accepted, evidenced-based practices, as well as both nationally and regionally approved medical guidelines. A PBM is well positioned to offer valuable insight, expertise, resources, tools, and programs to help claims professionals make more informed decisions. Clinical services are typically provided by credentialed, experienced pharmacists and nurses, and therapy committees are often in place to ensure policies, utilization protocols, and formularies reflect current best practices.

As with most relationships, collaboration fosters success. Actively engaged payers tend to reap greater benefits from a PBM’s clinical expertise than those less involved—or less inclined to rely on the wealth of expertise that exists. Encouraging claims professionals to reach out to clinicians to discuss claim circumstances is important. A payer is also a critical influence when it comes to program compliance, whether related to a claims professional’s participation in a training session or responding to prompts or alerts from the PBM on claim-specific matters. The more closely claims professionals and the clinical team work together, the better the outcome for all involved, especially for the injured worker.

Operational Excellence

Whether conducted by phone, email, fax, Web portal, or face-to-face meeting, communication between payers, injured workers, third-party billers, and the PBM is critical to keeping the program on track and moving forward. Associates must be responsive and accessible. Systems must be secure and easy to navigate. Products and services must be reliable, of high quality, and timely in their delivery.

Regularly scheduled stewardship meetings with the PBM are a valuable tool for payers, especially when the information shared delves not only into the “what” but the “why “of claims. Payers should feel comfortable sharing feedback and asking questions and be open to new ideas that may serve to improve the program’s efficacy. Opportunities to tour the PBM’s facility should be attended as they offer the payer a chance to see the PBM in action and can lend perspective on both the overall organization and the team.

Realizing the Powerful Alliance

It’s difficult to put a price on the knowledge that claims decisions are being made based on relevant, evidence-based medical guidance; to have full confidence that your team’s actions are well timed and well informed; and that monies spent on cost containment services and the claims themselves are appropriate and effective.

Injured workers returning to work sooner and claims closing more quickly are the true indications of a PBM’s value. By ensuring that services are orchestrated precisely with passion and an unyielding commitment to doing what’s right, you will experience the maximum benefits of a PBM and unleash the powerful alliance that is possible.