Carriers face enormous challenges when attempting to settle cases with Workers’ Compensation Medicare Set-Aside (WCMSA) arrangements. Currently, one of these challenges is the appropriate use of prescription medications and their proper allocation. The Center for Medicare and Medicaid Services’ (CMS) operating memo of April 2009 changed the entire landscape as we know it, especially with regard to the management and allocation of prescription medications.
CMS Decisions Regarding Prescriptions Drug Therapy
I travel across the country educating carriers, attorneys, physicians, Workers’ Compensation judges, and even a state senator about these changes and how to best handle the ever-rising prescription drug costs and utilization in a WCMSA in the hope of a favorable decision by CMS.
A recent audit by Gould & Lamb has found that in a six month period, CMS has agreed to an alteration of prescription drug therapy that resulted in approval for nearly 51% of the submitted files. Considering how the April 2009 memo changed everything with Part-D allocations, this is very encouraging. Could it be the realization by CMS of inappropriate drug therapy, contraindications, or other factors which account for these approvals? Or, could it once again show the value of Pharmacists as a member of the multi-disciplinary approach to WCMSA?
Value-Added with Pharmacists Involvement
Some may say that use of a Pharmacist in WCMSA reviews is both useless and senseless. As the Senior Clinical Pharmacist for Gould & Lamb, I differ with this notion. Pharmacists bring a unique perspective and training that is a valuable asset to both carrier and organization alike. Who can best explain whether a medication can be identified as off-label, compensable, or contraindicated as part of a claimant’s long-term drug regimen? Who can best engage the prescribing physician in dialogue concerning the long-term impact of a claimant’s pharmacotherapy regimen?
For many Pharmacists, daily responsibilities center on both off-label review and Part-D allocations, while they spend hours reading medical journals, and presenting relevant pharmacy information to keep those involved with WCMSA educated and informed on the ever-changing Part-D rules.
As prescription utilization continues to escalate in the Workers’ Compensation industry, carriers will continue to rely on Pharmacists for guidance and recommendations on how to best handle rising costs and cost-containment strategies in order to settle claims.
Handling WCMSA Through Multi-Disciplinary Approach – Best Solution
As the favorable decisions from CMS continue, it is prudent for carriers to use a vendor with the proper professions on staff, including Pharmacists. WCMSA are best handled through a multi-disciplinary approach that involves input and skill from many different professions, not just pharmacy. Although Part-D represents a huge slice of the total MSA allocation, other disciplines are needed as well to ensure both the appropriateness and accuracy of them.
Don’t listen to the nay-sayers! Pharmacists will continue to play an important part in WCMSA reviews. As a licensed pharmacist for close to twenty years, I cannot give you legal advice, but I can give you pharmacy advice. You wouldn’t go to an accountant to fill a prescription, would you??
About the Author: William F. Bell, Jr. is the Senior Clinical Pharmacy Specialist for Gould & Lamb, LLC. His primary responsibility is the review of a claimant’s pharmacotherapy regimen and the identification of off-label medications in a Medicare Set Aside Allocation. He has given numerous presentations on the subject of medication management and how it relates to Workers’ Compensation and Medicare Set Aside Claims. Bill has also authored two continuing education articles for the Pharmacist’s Letter, a nationally known education resource for practicing pharmacists.