2015 FALL CONFERENCE & TRAINING SEMINAR The Implications of a California Pharmacy Formulary CAJPA...

2015 FALL CONFERENCE & TRAINING SEMINAR

The Implications of aCalifornia Pharmacy Formulary

CAJPA Fall ConferenceSeptember 17, 2015

Your Panelists

• Moderator: Lori Kammerer– President, Kammerer & Company

• Rupali Das, MD, MPH– Executive Medical Director at the Division of Workers' Compensation,

California Department of Industrial Relations

• Bernyce Peplowski, DO, MS, FACOEM• Mark Pew

– Senior Vice President, PRIUM

“The Implications of a California Pharmacy Formulary”Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Learning Objectives

• Define a pharmacy formulary

• Identify legislative and statutory steps needed to successfully implement a state pharmacy formulary

• Define the potential impact of a pharmacy formulary on patient safety, prescribing behavior, claims cost, and pharmacy cost, including limitations and challenges

• Outline how a California workers’ compensation pharmacy formulary would work


Take Aways

• A drug formulary is not just a list of drugs

• Changing / influencing prescribing behavior is complicated and unpredictable

• Changes in prescribing behavior need to be linked to the full treatment plan / EBM


What is a pharmacy formulary?


Definition

• A list of drugs that are either included or excluded from coverage / reimbursement

• Used extensively outside of Work Comp

• Types include Closed, Open, Cost-Based, Retail, Preferred Drug List


Benefits

• Facilitates timely provision of medical treatment– Require a clinical rationale for others

• Add evidence-based practices to prescription choices– Clarify the difference between a specific drug,

alternative drug options, alternatives to drugs– Reduce drug-to-drug interactions


Benefits (continued)

• Drives evidence-based prescribing practices– Prompts reflection

• Improve treatment outcomes for patients– Trends towards more conservative options

• Reduce costs, increase settlements– More accurate calculations, better treatment


What are legislative and statutory steps needed to successfully implement a state pharmacy formulary?


Laying the Foundation

• Develop consensus among stakeholders– Employers (payers)– Employees (labor)

• Develop open lines of frequent communication among all stakeholders


Laying the Foundation (continued)

• Identify EBM / strength of evidence guidelines– Formulary integrated with total care plan

• Establish maintenance plan– Minimum of quarterly, preferably monthly

• Define dispute resolution process– Include quick process for medical emergencies



• Define enforcement process– Pharmacy Point-of-Sale, third-party billing

• Define implementation process– New claims– “Legacy” claims

• Define how to measure success“The Implications of a California Pharmacy Formulary”

Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew


• Incentives– Rapid approval of treatment/care– More use of EBM practices– Discourage improper incentives– Easier choices due to formulary structure


What are the potential impacts on patient safety, prescribing behavior, claims cost, and pharmacy cost?


Potential Impacts

• Patient safety– Talk about return to function

• Focus on life

– Promote (and approve) more conservative options• NSAID’s, exercise, Yoga, CBT

– Biopsychosocial• Deal with their attitude about pain


Potential Impacts

• Prescribing behavior– Choose the best options

• Require clinical rationale for exceptions

– Educate on options• No longer “that’s how it’s always been done”

– Inspire prescriber-patient conversations• Office visits no longer just about refills

– Change one, change all• Future patients reap the benefits


Potential Impacts

• Claims / pharmacy cost– Reduce number of drugs / classifications– Reduce utilization, dosage, quantity– Reduce use of compounds

– Reduce disability, co-morbidities, indemnity– Reduce friction costs


Limitations & Challenges

• Crosswalk to ICD’s / treatment guidelines– Otherwise just a list of drugs

• Risk of auto approval for drugs which could be inappropriate for the diagnosis– e.g. Vicodin for ankle sprain


How would a California workers’ compensation pharmacy formulary work?


Take Aways

• A drug formulary is not just a list of drugs

• Changing / influencing prescribing behavior is complicated and unpredictable

• Changes in prescribing behavior need to be linked to the full treatment plan / EBM


2015 FALL CONFERENCE & TRAINING SEMINAR The Implications of a California Pharmacy Formulary CAJPA...

Documents

Transcript of 2015 FALL CONFERENCE & TRAINING SEMINAR The Implications of a California Pharmacy Formulary CAJPA...