An Engaged Carrier Can Improve Care While Lowering Pharmacy Costs

16 Jul, 2013 Bob Wilson


There was a truly enlightening session today at the AASCIF 2013 conference in Austin, TX. Dr. Nicholas Tsourmas, Medical Director for Texas Mutual, gave an in depth look at the program his company used to reduce pharmaceutical abuses that were both costing them money and hurting injured workers care. Bottom line? An engaged company can and will make a critical difference in this area. 

Texas Mutual is saving millions of dollars and providing more focused, results oriented care as a result of its efforts. In fact, Tsourmas held no punches, telling the audience that they were partly responsible for the explosive growth in pharmacy abuses across the country. Specifically by ignoring the problem or sticking it's head in the sand, the insurance industry has become an unwilling accomplice to this burgeoning issue 

So, what has Texas Mutual done that is so special? Tsourmas covered their actions in detail, which included several steps. They first identified the problem cases that needed prompt attention. The cases they selected were all legacy cases, some over twenty years old. They then contacted the treating physician via a series of faxes, summarizing the current pharmacy regimen the patient was on and asking the doctor to sign and return an acknowledgment. From there their actions depended on the responses of the doctor, and included follow up with peer review support. After that point the company deployed what Tsourmas described as a carrot and stick approach. 

The carrot approach involved Tsourmas reaching out to these doctors, and Texas Mutual offering additional assistance with items like detox services, pain management programs, streamlined approvals and billing assistance. Each of those doctors were given Tsourmas' cell phone, providing them direct access to him for follow up and support. The stick approach involved using the power of a variety of medical licensing boards and various government agencies in the state who had a strong interest in controlling prescription drug abuse.

The company was clearly helped when the Texas Department of Insurance, with whom Texas Mutual works closely, proactively adopted ODG guidelines and established a drug formulary for the state. The results have been dramatic. Insurers in the state spent $5.5 million dollars on "N Class" drugs in 2009, prior to the adoption of the formulary. In 2011 that number dropped to $780,000. Opioid prescriptions have dropped from 11 -12% of annual pharmacy spend to 1.2%. The changes they made generated a significant difference.

While there were certainly more details in Tsourmas' presentation, what he really was describing was an actively engaged insurer partnering with treating physicians and state government to fix an area that was careening out of control. He indicated that they have seen improved pharmacy utilization from these doctors on new cases as well, and are on the path to avoid the mistakes that were plaguing the system prior. Motivated by 2 prescription related deaths, the company faced this demon, and not only significantly lowered their costs, but created a better environment for care out of their efforts. 

Everyone wins when a carrier pays attention and works to make a difference. The proof is here in Texas. Others would be wise to imitate their efforts.

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