Putting Data and Automation to Task for Transformed Pharmacy Solutions 

Sarah Scott, Vice President, Network Services & Jill Falb, Vice President, Pharmacy Services, CorVel 

At the core of every injured worker’s care journey is a need for quick access to medications to aid in recovery. Conversely, employers want their employees to receive these necessary medications in a safe and cost-effective way, which may result in slight delays in access. These overlapping needs occasionally put the injured worker and employer at odds. However, the reality is that both entities desire the same outcome: timely access to affordable medications to aid in recovery and the return-to-work journey. 

To solve this imbalance and streamline medication access, pharmacy teams are leveraging data analytics and automation to promote safe and cost-effective prescriptions, identifying risk trends for early intervention, and mitigating waste and abuse. Ultimately, these teams are closing the gap between injured workers and employers to improve injured worker outcomes. Let’s explore these strategies in depth.  

Ensuring Safe and Cost-Effective Medications 

As financial headwinds continue to present challenges across the provider ecosystem, physician dispensing has risen as an alternate revenue stream for healthcare providers. For this profit-generating activity—often involving several entities (from third-party vendors to attorney teams)—providers may prescribe higher-cost name-brand drugs and expensive repackaged medications.  

Leveraging a tech-enabled pharmacy solution, employers can reduce costs brought on by physician dispensing to generate significant savings through conversion to lower-cost alternatives, generating savings of $350 on average.  

To further manage employer costs, pharmacy teams are utilizing automated systems to trigger engagement when medications do not meet price, regulatory, or formulary guidelines. This action is accomplished by first equipping injured workers with pharmacy ID cards linked to all major chains and most independent pharmacies. When the card is used to fill a prescription, all non-formulary medications or those not meeting specific drug utilization review (DUR) edits, plans, or state regulations will trigger a prior authorization at the point of sale. From here, claims teams approve, deny, or request additional documentation for the prior authorization request. 

Combining automation with clinical expertise, pharmacy teams may make additional cost interventions, such as converting brand-name drugs to generic substitutes, converting combination medications to generic components, and converting expensive topical medications to cost-effective alternatives, all at the point of sale. Through these interventions, pharmacy solutions ensure that medications are cost-effective for the employer and the safest and most appropriate for the injured worker. These automated tools and analytics employed for cost containment also have a place in flagging risk trends for intervention. Let’s explore that next.  

Risk Assessment & Intervention 

Every injured worker’s treatment journey is unique and highly personal. To ensure workers remain on track for a safe and timely recovery, it’s paramount to keep a close eye on potential risk trends. Given the variation in treatment, prescribing trends, and drug utilization monitoring, this process is extremely complex, but automation and data analytics can simplify it.  

Used effectively, risk monitoring generates positive outcomes. For example, due to successful  

interventions, workers’ compensation claims with opioids have declined from nearly 55% in 2012 to 32% in 2022. It is critical to have timely insight into drug utilization to sustain this reduction in prescription opioid use. Armed with insights, pharmacy clinicians can identify potential claims at risk and ensure safety with high-control drugs. Through the use of automated daily reporting and risk scoring, pharmacy clinicians can identify potential triggers for intervention, such as high morphine equivalency (MEQ) scores for non-acute claims, opioid weaning desired, and combined opioid use and high MEQ.  

In addition, pharmacy risk scores informed by advanced analytics equip pharmacy clinicians, employers, and additional stakeholders with a high-level overview of potential claims at risk. Under these systems, predetermined criteria, such as extended narcotic usage, multiple ER visits, or high drug spend, will mark at-risk claims for peer-to-peer medication review. These data-driven insights can inform clinical interventions to get the injured worker on a path to success and help determine, for example, whether opioid management is needed to address chronic pain with alternative solutions, including advocacy and physical therapy for injured workers. 

Finally, in addition to clinical risks, data, and automation can be used to identify trends suggesting waste and abuse.  

Preventing Waste & Abuse, Ensuring Compliance 

Nearly 25% of yearly U.S. healthcare spending constitutes waste, with 3% - 10% attributed to abusive billing practices. These costs introduce material losses to workers’ compensation programs, which ultimately contribute to rising drug prices and the cost of care. From the point of sale, advanced automation and analytics provide pharmacy teams with a birds-eye view of prescribing and usage activities potentially indicative of waste and abuse.  

With real-time data and reporting, pharmacy teams can access reports flagging anomalous prescribing trends or claims with unusual narcotics or drug combinations. These reports may then be escalated to adjusters for a full review of the claims profile. Teams can also look to dashboards, powered by advanced analytics, for a holistic look at pharmacy interactions to pinpoint year-over-year changes worthy of escalation. In addition, combining analytics capabilities with compliance requirements ensures pharmacy formulations meet state requirements and enforce limitations for states with limited oversight. 

To accelerate waste and abuse detection, leading pharmacy programs are also in the early stages of exploring use cases for generative AI, leveraging this technology’s predictive power to compare prescribing patterns to industry averages, reveal hidden interactions, and flag activities inconsistent with established rules.  

Looking to the Future 

The most anticipated GenAI use cases today include predicting physician prescribing outcomes before a pharmacy order is requested, identifying optimal medication dosage and type based on an injured worker’s genetic background, and using genetic insights to determine if injured workers are predisposed to adverse drug reactions. This accelerated technology enablement is expected to reduce communication silos, increase opportunities for collaboration between clinicians, claims teams, and employers, and accelerate recovery and return-to-work for injured workers. 

Advanced technology presents many opportunities to improve pharmacy outcomes for workers’ compensation programs, increase safety, and reduce overall costs. Indeed, in the next two to three years, generative AI will increase capabilities to manage claims risk and control medication costs. We are excited to see what’s next.  

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