Physician Dispensing in Work Comp

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Physician Dispensing in Work CompImpact of the practice on overall costs and exposureTips on how to manage it


Hospital and Facility

Physician ServicesPharmacy

Physical Medicine

Imaging DMEPharmacy drives 10-20% of your unit cost as a percent of total

medical.

Source: 2011 NCCI Issues Report

What percent of your total exposure relates

to claims with prescription meds and

IWs suffering from pain?


Physician Dispensing Price Difference: TramadolTramadol

50 MG

Manufacturer/ Labeler

AWP Price per Pill

AWP Price - 60 Pills

Package Size Dispensed Mark-up*

00093-0058-05 Teva USA $ .83 $ 49.80 500 60 0%

65162-0627-50 Amneal $ .83 $ 49.80 500 60 0%

36329-2868-02 Bryant Ranch $1.61 $ 96.60 60 60 194%

33261-0105-60 Aidarex Pharm $1.62 $ 97.20 60 60 195%

42549-0527-60 Stat Rx USA $1.66 $ 99.60 60 60 200%

55045-2928-09 DRX $1.55 $ 93.00 60 60 187%

60760-0377-60 St. Mary’s $1.41 $ 84.60 60 60 170%

66336-0915-60 Dispensing Solutions $1.55 $ 93.00 60 60 187%

* Percent of mark-up measured against original manufacturers’ AWP.


Release of Study Medical Costs

Indemnity Costs

Source

CA Feb 2013 +17% +13% http://www.cwci.org/press_release.html?id=318

IL May 2014 +39% +27% (JOEM _ Volume 56, Number 5, May 2014 Physician-Dispensed Medication and Workers’ Compensation Claim Outcomes)

IL May 2014 opioids

+78% +57% (JOEM _ Volume 56, Number 5, May 2014 Physician-Dispensed Medication and Workers’ Compensation Claim Outcomes)

What the studies say:Impact of Physician Dispensing on Total Claim Costs

http://www.cwci.org/press_release.html?id=318


Questions for the Audience

• Where do we see “third party billing?” Retail, Physician Dispensing, Everywhere!

Stone River (retail and physicians), Prescription Partners


Questions for the Audience• Where do we see “third party

• Partners• What is the legal status of the third party biller?

Assignee• What are the obligations of an assignee?

Identical to the underlying provider


Questions for the Audience• Where do we see “third party

• eywhertail and p• What are the obligations of an assignee?

Identical to the underlying provider


The FactsAssignees are ALREADY OBLIGATED!

• PBM Contracts with underlying pharmacies• PPO Contracts with underlying prescribers


The Facts

Assignees are ALREADY OBLIGATED!• PBM Contracts with underlying pharmacies• PPO Contracts with underlying prescribers

Impact of contracts with assigneesGrant them rights and frees them from obligations Disables Prospective Mgt/ Enables more retro PBM re-sells transaction at a spreadExpedient? Right thing to do?


What you can do

Apply underlying PPO discount• Can I?• Everywhere?• Yes you can!

Deny subsequent transactions based on PPO contractual obligations

• Can I?• Everywhere?• PPO - Utilization Mgt or specific prohibition• Contractually yes, but leverage is the issue• Requires notice• Re


Question for the Audience

What presents more risk in terms of your cost drivers?

• Unit price?• Utilization?

• The unknown?


Identify providers who dispense meds in office

• Leverage bill review • Manage the data

Maximize provider selection tools• Include a physician dispensing indicator • Layer the order based on criteria• Preclude panel populating • Educate your PPO providers• Re

You can make the unknown more known!


Search Results – Make them meaningful


Appendix


Agenda

Physician Dispensing in Work Comp

Documents

Transcript of Physician Dispensing in Work Comp