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Three Imperatives to Managing Risk

In our latest (m)Power Podcast, Dr. Mitch Freeman discusses risk management strategies.

Risk is a major factor in today’s workers’ compensation environment. Ensuring that injured workers stay on the path to recovery can often be a difficult task. In our latest interview with Mitchell’s chief clinical officer, Mitch Freeman, PharmD., we discuss how holistic risk management and intervention with medical management can help to improve outcomes for those involved in a claim.

 

When managing a claim involving drug therapy, there is always some degree of risk that should be considered. “All medications have a component of risk… but we do know that drugs like opioids and combinations of certain drugs increase the level of risk that can cause catastrophic events and poor outcomes,” says Freeman. Having knowledge of these medications and combinations allows us to construct ways to minimize that risk.

According to Freeman, there are three key steps to reducing risk throughout a claim: monitoring, providing guidance and intervening.

Monitoring

Monitoring requires knowledge of the risk present. Freeman says a main component in developing this knowledge and ensuring better outcomes is the use of formularies. Although PBM’s have utilized formularies for several years, many states have implemented and are continuing to develop them as we learn more about medications.

State mandated formularies “clearly spell out what drugs are appropriate… and what drugs should not be used,” says Freeman. Mitchell can then work beyond that to create customized formularies for clients that can adapt to the client’s workflow and each individual injury.

While formularies can help to address risk up front, much of risk monitoring and management occurs during the lifetime of a claim. Freeman highlights the importance of looking at a claim through a holistic lens, rather than by individual medications or treatments.

“Individually, prescriptions can be appropriate for the injured worker, but sometimes when you step back, you see drug therapy issues in the therapy as a whole. That’s why, when you’re managing ongoing therapy, it’s very important to take a holistic view of the claimant to make sure that there aren’t drug-to-drug interactions and dangerous combinations, as well as ensuring that you don’t have multiple prescribers.”

As Freeman puts it, you can’t manage what you don’t know about. Visibility during the claim process is one of the most vital factors in reducing risk.

“If you don’t have visibility into all the therapy going on within the injured workers’ drug regiment, then you’re missing a lot of risk that needs to be addressed,” says Freeman.

Guidance

Once a claims examiner has knowledge of the situation and the proper tools to monitor the claim, the next important aspect of managing the risk at hand is providing appropriate guidance.  It can be difficult to ascertain what is appropriate for an injured worker and where to navigate the claim next, especially if the adjuster is not trained in the medical profession. The variety of tools offered by pharmacy benefit managers and medical management give the adjuster better visibility into the claim and help them feel confident in their decision-making.

This is where medical management comes in. Medical management professionals are well positioned to offer guidance on the next steps in reconciling drug therapy risks. Services such as utilization review, pharmD. review and peer-to-peer review  help determine any necessary changes to the injured worker’s treatment plan.

The recommendations from these services may lead to the final step in returning an injured worker back to the best path of recovery: intervention.

Intervention

Intervening with case management can help facilitate appropriate prescription usage and develop weaning programs when appropriate.

“It’s very important to close that loop, to identify, provide guidance and actually act to intervene,” says Freeman.

Such a strategy in risk management provides a variety of benefits, from workflow efficiencies to the ability to address drug therapy issues. Additionally, we have seen a major decrease in opioid use through the implementation of these intervention and medical management strategies.

As we look toward the future of risk management, we expect many capabilities to develop through technologies such as machine learning. “In the near future we are going to be able to know who is at high risk for having these drug therapy issues even before they take their prescriptions,” says Freeman. Developments like this will help us to identify risk earlier and ultimately improve outcomes for everyone involved.


Listen to Mitch Freeman’s last (m)Power Podcast, where he discusses medical marijuana and its affect on workers’ compensation.

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