Atlanta RIMS March 19, 2015

Transcription

1 Elements of Good Claims Management for Pain Management Atlanta RIMS March 19, 2015 Ron Warble, Executive Vice President AmeriSys

2 What do you do?

3 Select the Best Answer Call the American Sniper Go see The Judge (Robert Duval may not give you the answer your looking to receive) Throw The Theory of Everything at the issue Vantage Point

4 It s going to happen 90% of all illnesses and disease have pain as a symptom of that disease or injury process Statistics indicate that approximately $630 billion is spent annually in costs related to pain In 2011 it was reported that the U.S. makes up only 4.6% of the world s population but consumes 80% of its opioids and 99% of the world s hydrocodone

5 Which one has a plan?

6 Unintended Consequences

7 The Elements of a Good Claims Management Program for Pain Claims Right Claims Oversight

8 Right Claim Oversight Expecting the Claim Right Predictors PBM alerts and triggers 2 nd Opioid Rx or Refill Pain Survey Tools Identify those injured workers that have a potential for issues for pain. Analytical data tools Mechanisms to assure the injured worker is receiving treatment according to protocols

9 The Elements of a Good Claims Management Program for Pain Claims Right Claims Oversight Provider Selection Process

10 Selection Process Carefully selected, trained and contracted Network or list of Pain Management Specialists

11 Selection Process Rehab Physiatry Physical medicine and rehabilitation (PM&R), also known as physiatry or rehabilitation medicine, is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities.

12 Selection Process Interventional Pain Management PH Interventional pain management or interventional pain medicine is a subspecialty of the medical specialty, pain management, devoted to the use of invasive techniques such as facet joint injections, nerve blocks (interrupting the flow of pain signals along specific nervous system pathways), neuroaugmentation (including spinal cord stimulation and peripheral nerve stimulation), and implantable drug delivery systems.

13 Protocols Step Program Mechanism to Request Variances Agreed Upon Formulary Use of Drug Screens Patient Contracts Better Outcomes Protocols

14 The Elements of a Good Claims Management Program for Pain Claims Right Claims Oversight Provider Selection Process Pharmacy Controls

15 Pharmacy Controls Pharmacy controls that include a PBM that has an aggressive and experienced approach who will work closely with your claims program to support and operate as the alert and alarm system for red flags

16 Alerts from your Rx Partner Pharmacy Controls Early Fills Narcotics Second Fill Morphine Equivalent Calculations At Pharmacy Alerts Pharmacist who will work with physicians

17 The Elements of a Good Claims Management Program for Pain Claims Right Claims Oversight Selection Process Patient Education Pharmacy Controls

18 Patient Education & Controls Disease Process Common Medications with link to pharmacy Risk associated with Opioids and long term use Treatment Modalities (conservative vs. surgical) Self Assessment Quiz

19 Employee Education Employee Education

20 Employee Education

21 Employee Education

22 Employee Education

23 Employee Education

24 Employee Education

25 Employee Education Quiz

26 Employee Education Quiz

27 The Elements of a Good Claims Management Program for Pain Claims Right Claims Oversight SAW/RTW Selection Process Patient Education Pharmacy Controls

28 Stay at Work Return to Work What is Stay at Work/Return to Work (SAW/RTW)? SAW/RTW is the proactive, comprehensive program for employees with work related injuries and/or illnesses. SAW/RTW is a way to provide meaningful and productive temporary transitional duty as a bridge back to full normal employment, as quickly as medically possible during the healing period. Why should we have a SAW/RTW Program? A SAW/RTW Program is designed to reduce the negative impact of work-related injuries and illnesses for injured workers. In addition, it provides injured workers and their health care providers support in proactively planning their return to full duty work when they are ready. What benefits do injured workers get from a SAW/RTW program? Providing injured workers with suitable transitional duty facilitates recovery, assists in maintaining job skills, and reduces the impact of the work-related injury/illness on the injured worker s family and income. Stay At Work / Return to Work Frequently Asked Questions

29 The Elements of a Good Claims Management Program for Pain Claims Measuring & Tracking Outcomes Right Claims Oversight SAW / RTW Selection Process Patient Education Pharmacy Controls

30 Economic Measuring & Tracking Outcomes Reduce indemnity cost secondary to RTW Reduction in Medication costs/spend Elimination or avoidance of secondary issues related to opioid utilization Depression Lower testosterone levels Pulmonary function Hyperalgesia Elimination in back fill costs Loss of libido Weaken the immune system Liver functions Constipation Reduction in Physician Care Duration / Cost

31 Measuring & Tracking Outcomes Functional SAW or RTW earlier Operating with less restrictions Higher functioning - personal and work activities Less medication utilization - Reduced MEC - Reduction of numbers of prescriptions - Elimination of opioids as pain managers Patient Satisfaction

32 The Elements of a Good Claims Management Program for Pain Claims Measuring & Tracking Outcomes Right Claims Oversight SAW / RTW Selection Process Patient Education Pharmacy Controls

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34 Ron Warble, Executive Vice President x3150