This session at the 24th Annual National Workers’ Compensation & Disability Conference illustrated how Walmart analyzed its overall prescription cost drivers, found alternatives and reduced the prescribing of other pharmaceuticals threatening employee health within their organization.
- Mark Pew, Senior Vice President at PRIUM
- Janice Van Allen, Director of Workers’ Compensation at Walmart Stores, Inc.
Due to the rapidly-growing prescription misuse issues among Walmart’s associates in pain-management programs, the company decided to think differently about drug regimens used by their associates. Initially, the overall problem was anecdotal based on individual claim experience. This later became data driven when Walmart learned how to convert their data into Morphine Equivalent Dose (MED) values.
Walmart began by identifying concerning claims by assigning scores to them. What the data told them is that they needed help from an expert in this area, so they partnered with PRIUM, a vendor that provides managed care and medical intervention services.
Setting the Foundation
Walmart chose to start with the claims in which they felt the claimants were at the highest risk. They scored claims based on specific criteria using the following scale:
- High-Dose Opiate Therapy: MED is calculated and points are given starting at a daily MED of 100. Points increase as MED increases.
- Pharmacy Cost: Points are given for high monthly pharmacy cost, including any prescription drug. Points start at 1 point for between $300-500 up to 6 points for over $4000.
- Chronic Use of Acute Drugs: A point given is a patient receives an acute drug in five of the last six months. Drugs on the list include Actiq, Ambien, Hydrocodone, Tramadol, Nexium, Skelaxin, etc.
- Benzodiazepines: A claim receives a point for each Benzodiazepine prescription that is for more than 21 days. Drugs include Xanax, Valium, Klonopin, etc.
- Redundant Therapies: A claim receives a point for each drug in a repeated therapeutic class. Examples include receiving both Ambien and Lunesta of both Lexapro and Cymbalta.
- Multiple Prescribers: A claim receives a point for each prescriber beyond one.
- Dangerous Drug Combos: A point for each. Vegas Cocktail is Hydrocodone/APAP and Soma. Houston Cocktail is Hydrocodone, Xanax and Soma. Soma Coma is Codeine and Soma.
From there, Walmart decided to act as their own pharmacy benefit manager because it allowed them to choose the right provider for each service (pharmacy processor, network and utilization review services), have greater data visibility, have input into prescription edits, eliminate the conflict of interest prescribing certain drugs and maintain better communication between pharmacies and adjusters.
Creating the Plan
After laying the foundation, it was time to develop the actual plan. First, legacy claims were flagged weekly (as to not overwhelm their claims staff) for referral and given a score based on those flags to determine which claims to focus on. Walmart flagged for the following items:
- Dangerous drug combinations
- MED over 90
- Chronic use of acute medications
- Long-term use of benzodiazepines
- High-dollar prescription spends
- Redundant drug therapy
- Multiple prescribers
Next, their vendor reviews the prescriptions and medical history through the following steps:
- Managers review files before being sent to the vendor.
- The vendor reviews prescription and relevant medical history to determine appropriateness.
- A peer-to-peer discussion occurs to discuss any medical treatment not within guidelines and/or that may have room for improvement.
Finally, the vendor works with providers to adjust the drug treatment as appropriate through the following steps:
- The vendor works to achieve both written and verbal agreements from physicians
- Nurse case oversight is used when deemed necessary
Walmart also instituted proactive measures to prevent bad drug regimens from starting, including an informational mailer sent for first-fill opioids. They also established a “bell ringer” report for any month that a claimant fills over 90 MEDs. Finally, they created The Early Rx Intervention Program to identify claims that could potentially become problematic in the management of their medications to attempt to prevent the potential for creating addiction issues.
This program led to many successful interventions leading to an associate’s medical improvement. Overall, Walmart reports that they were able to lower average MEDs, had fewer problem claims, increased the amount of settled claims, had less disability and more return to work and, finally, has claimants requesting non-opioid drugs.