Healthcare news today is dominated by one thing: pricing, pricing, pricing.
Whether it’s waging the drug price debate on the floors of Congress, thought leaders focusing on new and emerging cost drivers, or data experts looking for new savings opportunities, there is no escaping the scramble to lower the ever-rising costs of care.
In early 2019, Healthesystems published our 2019 Workers’ Comp Industry Insights Survey, asking over 500 workers’ comp professionals to weigh in on their top industry concerns, challenges, and successes. We quickly found cost containment to be a top priority among those we surveyed, but as we looked at their other priorities it became clear that their secondary concerns, which were focused on patient care, directly contributed to increasing costs.
Concerns such as comorbidities and worker health, opioids and substance abuse, mental health, clinical management, and program efficiencies all contribute to higher costs when left unmanaged, for they hamper recovery and expose patients to harmful complications that can cause unnecessary pain and suffering.
Not only is it our duty to help patients, but it makes financial sense; when patients face additional, unnecessary complications in care, the lives of their claims are extended, often with extra services and prescriptions, severely increasing costs. Approximately 30% of every healthcare dollar is wasted in the U.S. due to factors such as system inefficiencies and unnecessary or wasteful services. If we want to reduce costs, what we really need to do is focus on creating a better model of managed care.
This issue of RxInformer may focus on pricing, but at its heart is the concept of improving care delivery to better serve patients. The savings are simply a byproduct of providing patients the appropriate services at the appropriate time. We must never forget to put the injured worker at the center of everything we do, while also supporting the stakeholders who help us serve patients.
A great example of how helping patients can reduce costs can be found on page 30 of this publication. Better Care = Lower Costs: Best Practices in Medical Claims Management offers claims professionals ten simple tips that can improve patient safety to prevent harmful and costly complications down the line. Something as simple as paying attention to opioid alerts within PBM claims management software can save not just money from unnecessary spending and costly complications, but it could even save lives.
Keeping patients safe and on an effective road to recovery must be our top priority, but accomplishing this task comes with many obstacles, which we address in this issue of RxInformer.
Physical medicine services may increase claims costs upfront, but their inclusion in a treatment plan can quicken return to work, decrease disability scores, and reduce prescription drug usage, all of which contribute to lower cost of care. But these benefits can only be attained when physical medicine programs are effectively operated with evidence-based medicine and strong metrics.
Interventions that fail to benefit patients not only waste time and delay recovery, but they contribute to higher costs via overutilization and extended claim durations. By ensuring that scheduled appointments are clinically appropriate, and by embracing a more dynamic system of clinical metrics to create a clearer picture of program performance, we can drive educated care decisions that improve claims outcomes.
For more on this topic, please see page 32 for the article Rehabilitating Your Rehab Program: Better Metrics for Physical Medicine.
Not only are large portions of the workforce getting older, but so are doctors and nurses. Over 50% of U.S. physicians are over the age of 50, and one third will be over 65 in the next decade. With many providers expected to retire in the coming years, patients may have difficulty accessing care in a timely and effective manner, leading to delays in care and extended claim durations, potentially increasing costs.
Managed care programs will have to help pick up the slack to better assist patients. This can include program augmentations such as patient engagement and wellness programs to aid recovery and prevent complications, improving referral and claims adjudication processes to help with care delivery, and utilizing pharmacists for clinical oversight and intervention programs to fill gaps between provider appointments.
For more on this topic, turn to page 26 for the article When Demand Exceeds Supply: Older Patients and Fewer Physicians in Workers’ Comp.
Even as we strive to optimize care delivery, there are other issues impacting care costs for which we must remain on guard.
Understanding the drug price issue is of great importance to us all, for sometimes the most clinically appropriate medication for a patient will come with an incredibly high cost. On page 14, you’ll find The Ups and Downs of Drug Prices: Keeping Up with Cost Challenges in Workers’ Comp. This article explores the history of increasing drug prices, while also discussing how successful cost containment can be achieved with vigilant attention to the factors that contribute to high drug spend.
Another article that advocates vigilance around larger trends is Questioning Costs: A Field Guide to Fee Schedules on page 22. Often, not enough attention is paid to the fees associated with professional services and medical equipment. When armed with a solid understanding of how fee schedules work, payers are empowered to influence the rulemaking process during public commentary periods, as well as identify fee schedule manipulation via ambiguous codes that increase costs without offering additional patient benefit.
But this spirit of vigilance isn’t just something we should apply to cost trends – no, it’s something we must keep with us always. We must constantly ask how a prescription will benefit the patient, if a workflow is expediting treatment, or if a new law will impact the delivery of care. By constantly striving to best serve the patient, we can eliminate obstacles to effective care.
Daryl Corr is Chief Executive Officer at Healthesystems. Mr. Corr has long been a technology innovator developing new ways in which to improve the delivery and quality of medical services. His focus on innovation has helped improve performance across the industry by automating various manual functions and improving transaction efficiency. His efforts to make disparate processes and systems work together helped transform the organizations he managed. Under Mr. Corr’s leadership, Healthesystems has grown into one of the largest workers’ compensation pharmacy and ancillary medical benefits management providers in the market.
