Workers’ Compensation Rx Spend Increased 1.9% in 2014

Apr 21, 2015

While rising costs per prescription is still a concern, Express Scripts’ effective utilization management programs helped to stabilize the increase in drug trend.

  • Workers' Compensation Insurance
  • Compound Medications
  • Hepatitis C
  • Pain

Overall drug trend for workers' compensation increased 1.9%, according to the 9th Annual Express Scripts Workers' Compensation Drug Trend Report.

A 5.4% decrease in utilization helped offset a 7% increase in the cost per prescription.

Workers Comp Components and Drivers of Trend for the Top 10 Workers Compensation Therapy Classes 14

Opioid Management Mitigates Spend Increases

The modest increase in overall pharmacy spend demonstrates the effectiveness of Express Scripts utilization management programs. In fact, opioid utilization among injured workers decreased nearly 11% in 2014.

As drug prices continue to increase, payers – now more than ever – are looking to contain costs by implementing effective programs that ensure safe and appropriate use of opioids.

Our data-driven solutions help payers meet this goal. For example, the Express Scripts Morphine Equivalent Dose (MED) Management program allows our clients to set maximum threshold levels for the amount of opioid medications an injured worker can fill. Amounts exceeding MED program levels undergo a review process by the client before the medication is dispensed.

According to the Washington State Agency Medical Directors’ Group (AMDG), patients receiving an MED of 100mg or more per day had a nine-fold increase in overdose risk. Our research found that more than one fifth of patients with work-related injuries longer than 15 years exceeded the MED of 120mg per day on more than half of the days for which opioid medications were being filled.

Percentage of Injured Workers Prescribed MED Greater Than 120 MG on 1 Out of Every 2 Rx

Although older injuries may require higher doses of opioids because the patient has become tolerant to previous doses, patients receiving an MED of 100mg or more raises serious concerns about the potential of addiction and abuse. Better management of opioid use among injured workers helps to reduce abuse, limit addiction and control costs.

Combatting Rising Compounded Medication Costs

For the second year in a row, compounded medications were one of the top 10 costliest therapy classes for workers’ compensation payers.

Unsustainable pricing greatly impacted the overall trend, and the average cost of compounds per prescription in 2014 was $1,696.99.

Our research found that pharmacies who compound more than two-thirds of their total prescriptions increased their prices 51.5% in 2014. Low-compounding pharmacies – or those that compounded less than 67% of their total prescriptions – averaged only a 9.7% price increase.

Median Costs of Prescriptions Filled at High Compounding Pharmacies vs Low Compounding Pharmacies

Our research also found that 10% of compound utilizers did not receive a traditional prescription before receiving their compounded medication – that is, they used a compounded medication as the first prescription for their injury.

This raises the question of why first-line therapies were not tried first. While accommodating needs for a patient who cannot ingest or is allergic to available alternatives is appropriate, there is no clinical evidence that compounded medications are more effective than FDA-approved, commercially available drugs.

Compound Management Solution

At the point of sale, Express Scripts workers’ compensation clients are given the option of reviewing all compounds for authorization. Retrospectively, we communicate to physicians and injured workers encouraging the use of commercially available, cost-effective alternatives where appropriate.

When payers implement the physician communications program, 46.6% of their injured workers discontinued filling unnecessary compounded medications.

Reining in the Cost of Physician Dispensing

Medication dispensed through a physician’s office not only has a higher cost than if dispensed through a retail pharmacy, it also lacks a comprehensive view of a patient’s prescription history and profile. Without the checks and balances between prescriptions and pharmacists, injured workers are at risk for medication errors, drug interactions and duplicate dosing.

Our research found that the average cost of a physician-dispensed medication in 2014 was $173.75, compared to $111.68 for a pharmacy-dispensed medication.

This means that Express Scripts Workers' Compensation clients paid an average premium of about $62 per prescription for physician-dispensed medications.

Express Scripts’ Physician Dispensed Medication Solution helps to tackle the cost and utilization of physician dispensing.

The Reality Behind Generic Drug Inflation

Although price inflation for a few generic drugs has captured media attention recently, it is not a new phenomenon. There are two primary drivers of the inflation in generic drug pricing: manufacturer consolidation and temporary shortages of active ingredients.

While it’s true that the price for some generics have increased, on the whole, generic medications continue to deliver significant cost savings by providing cost-effective alternatives to brand name medications. Consider that since 2008, the average price of brand drugs has almost doubled, while the average price of generic drugs has been cut roughly in half.

Prescription Price Index 2014

Express Scripts helps lower drug costs by driving competition in the market and by leveraging our scale to drive the best prices for payers. In general, encouraging use of generics over more expensive brand alternatives, when clinically appropriate, is still an effective way for payers to keep costs down.

Understanding Specialty Trend

Specialty medications treat relatively small groups of patients with complex, chronic conditions. These drugs are typically are very expensive and most have special-handling requirements. In addition, patients taking specialty medications may need ongoing clinical monitoring and more-intensive assistance and guidance from pharmacists or other caregivers.

Many occupations have specific risks such as HIV, hepatitis C, or other blood-borne pathogens resulting from needle sticks or other exposures (healthcare providers and first responders), black lung disease (coal miners), and Lyme disease (outdoor workers/landscapers or park employees). Additionally, some consequential conditions, including post-operative blood clots, osteoarthritis knee pain and even organ failure, are treated with specialty medications.

Although specialty medications represent less than 1% of all medications used by injured workers, they have the potential to increase drug spend significantly because their costs are rising rapidly. Between 2013 and 2014, spend on specialty medications increased 30.4%. New specialty medications offer clinical options for the treatment of occupational injuries and the hope of improved medical outcomes, but the cost pressures they present prove challenging to payers in the management of these medications.

For example, drugs to treat hepatitis C, Sovaldi® (sofosbuvir) and Olysio® (simeprevir), had the highest cost per prescription, with average cost upwards of $20,000 per 28-day prescription. Sovaldi alone accounted for more than 57% of the new-drug contribution to 2014 PUPY specialty spend.

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