Opioids situation improves, but workers' comp pharmacy faces new challenges

In workers’ comp pharmacy management, opioids often get the lion’s share of attention, and for good reason. As a nation, we’re still challenged to ensure safe and effective application of prescriptions amid an opioid epidemic. But numbers are moving in the right direction. While opioids continue to be the most-utilized therapeutic class among our injured workers in 2022, there were declines in both utilization (7.7%) and cost (14.7%) per claim, and there’s been a steady decline for the past eight years in the morphine equivalent dose (MED) prescribed to patients.

While we still need to pay close attention to opioids to keep improving the situation, opioids are far from the only challenge that workers’ comp pharmacy faces. Topicals, for example, now rank as the top spend among therapeutic classes, and they’re being prescribed in workers’ comp with greater frequency. In 2022, topicals accounted for 18.5% of total drug cost and 7.2% of total prescriptions.

Rapid growth of topicals

There are some notable benefits to topicals when they are deemed medically necessary, such as lower systemic absorption, which means less of the medication gets into the bloodstream leading to a lower incidence of side effects and fewer interactions with other drugs.

Topicals may also be a preferable alternative for patients with confounding comorbid conditions or for whom the oral alternatives are not an option. But in many cases, topicals are not recommended as first-line therapy and offer no greater clinical benefit than more cost-effective, comparable alternatives.

In particular, many of the prescription topical medications we see in comp such as Lidoderm and Pennsaid carry specific, limited FDA-approved uses that should be considered along with appropriate place in therapy for select patients. By contrast, private-label topical analgesics (PLTAs) are not FDA-approved, and there’s no evidence that they’re any more effective than over-the-counter treatments. In fact, the active ingredients are often identical, but the cost differential compared to their OTC counterparts is significant.

PLTAs are marketed directly to physicians for dispensing, which means they’re more challenging to manage both clinically and from a cost and utilization standpoint, as they represent pharmacy channels that are out of network. Careful oversight and attention should be paid to topicals, both to improve patient outcomes and reduce costs.

Costly compound kits and combo packs

Another challenge is the rise of compound kits and combo packs. A compound kit contains multiple premeasured drug ingredients that must be combined immediately prior to use based on a prescription order. Combo packs, on the other hand, package together a number of commercially available products for sale with an intended common therapeutic use. In both cases, the products are exorbitantly priced and significantly drive spend when often the same components are available separately, or in a different formulation, at a much lower cost.

For example, one combo pack currently on the market contains diclofenac 1% gel (100g) and a 100-count box of alcohol prep wipes, which, if purchased separately over-the-counter, would yield a total under $15. The combo pack costs $3,350, roughly a 22,000% markup in price.

Specialty drugs

There’s no universal list to identify specialty drugs, but generally speaking, these are defined using a combination criteria that may look at low-volume, high-cost medications; those used to treat rare or complex conditions; consideration of special storage and handling requirements; and clinical applications for use such as administration concerns, patient adherence, specific testing and monitoring requirements and, sometimes, patient safety and immunogenicity concerns. This category often also includes biologics, biosimilars, and other injectables.

These can be difficult to manage, since about half of specialty medications are dispensed directly through the physician’s office instead of through a traditional pharmacy, and they’re usually prescribed to manage involved and often chronic conditions such as deep vein thrombosis, migraines, and cancer. Additionally, many are billed with “J codes” and are administered by a medical professional during an office visit, meaning they would be part of a co-mingled bill with medical-, professional-, and pharmacy-related line items, making them challenging to capture under pharmacy benefit management.

While costs and other challenges are likely to remain a concern, specialty drugs continue to be researched for these and other conditions and may provide relief that traditional therapies cannot, which could potentially result in better quality of life as well as fewer hospital admissions, emergency room visits and laboratory tests. In other cases, less expensive but equally effective alternative therapies might offer a better choice.

Containing costs, providing excellent outcomes

Every organization wants an optimized program that produces the best outcomes at the lowest cost. The challenges listed above make this seem formidable, but there are targeted clinical strategies that can help.

The first step, unsurprisingly, is to identify these challenging categories of high-impact pharmaceuticals, which isn’t easy because they’re not obviously identifiable in the data — you really need to know what you’re looking for to find them. But once you’ve done this, you can put proactive solutions in place, as well as post-dispense review, plan edits, drug list control (formulary management) and prior authorization decision support to help apply utilization management and billing controls.

Second, follow the evidence and enforce clinical controls for intervention that promote first-line, more cost-effective alternatives that also provide excellent outcomes. Establish clinical solutions to address patient safety that align with evidence-based treatment recommendations.

Finally, once your program is established, always look for opportunities to improve – collaborating closely with your clients and leveraging education, reporting tools, and data analytics.

The world of pharmacy management is constantly changing, but as long as we build our programs using evidence-based criteria that seeks to provide excellent clinical care for patients at the best cost, we can overcome these new and emerging challenges.

Nikki Wilson, Pharm.D./MBA, provides clinical leadership and strategic direction as senior director of clinical pharmacy services at Enlyte.

These views are the author’s own.

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