A Look at Drug Trend through Workers' Compensation

We discussed the highlights of Express Scripts’ Workers’ Compensation Report with Rochelle Henderson, director of health services research, research and new solutions, to learn more about how employees use prescription drugs through workers’ compensation.

In April 2013, Express Scripts released its newest offering, the 2012 Workers’ Compensation Drug Trend Report. This publication looks at cost and utilization trends in pharmacy under workers’ compensation, and provides suggestions to payers drawing on behavioral science research.

Specialty Pharmacy Times spoke to Rochelle Henderson, director of health services research, research and new solutions, Express Scripts, for some insight into why drug utilization increased 2.9% in 2012 under workers’ compensation.

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SPT: Overall trend increased 2.9% in 2012, and your report attributes this to increased use of antidepressants and dermatologicals for pain. What drove this trend?

RH: Antidepressants and topical dermatologicals are widely used for pain relief in work-related injuries. The increase in the trend for these 2 therapy classes was primarily from an increased cost per user for the year — up 9.1% for antidepressants and 9.3% for dermatologicals. The increase in per-user cost is from new product indicators in those classes, meaning existing products were utilized for more types of uses such as neuropathic pain. Use of brand-name medications in those classes also contributed to the high costs.

SPT: The report said, “For each dollar spent on potentially abused drugs, an additional $41 is spent on associated medical treatment.” How is this number calculated, and is it based primarily on the use of narcotic prescriptions billed through worker’s compensation?

RH: The estimate is based on a claims-based study conducted by WellPoint. The multiplier is not specific to workers’ comp but takes into effect the impact of prescription drug fraud and abuse on medical costs in general. Based on cases identified using our proprietary data analytics and investigated by Express Scripts, the impact is often significantly greater.

SPT: Do physicians who treat fewer injured workers per year know less about the dangers of narcotics?

RH: Physicians who do not routinely treat injured workers may be less familiar with the research associated with narcotic use among injured workers, as well as the clinical guidelines for the quantity and dose.

SPT: What is the driving force behind a patient’s choice of whether to use a third-party biller? Are these decisions usually based on the patient’s geographic location and the ease with which he or she can get to a pharmacy? What are some other reasons a patient may use a third-party biller, and would the “choice architecture” method work to drive patients on workers' compensation to preferred pharmacies?

RH: Injured workers do not have any out-of-pocket costs for their treatment and can typically use any pharmacy to obtain their medication. This means they may not be aware of the cost to their employer of using an out-of-network pharmacy. In some instances, they may not present their pharmacy/PBM ID card, which results in the pharmacy processing the prescription through a third-party biller, thus adding wasteful spending to the process.

We recently piloted a study that applied the behavioral science principle of social responsibility. Social responsibility means that people want to do the right thing and save money for their employer, even if there is no financial incentive. We applied this principle to the use of generic medications in workers’ compensation. There is no cost to injured workers for choosing a brand-name medication over a generic. Since there is no out-of-pocket cost to them, the common belief is that they would have no incentive to switch. We found, however, that injured workers who were sent a letter explaining how the choice of a brand-name medication added waste to the workers’ comp system were 60% more likely to choose a generic alternative. This demonstrates that there is potential to leverage the insights we have gained from behavioral science to workers’ compensation.

SPT: Antipsychotics had the highest average cost among the top 10 therapy classes for spend. Which brands in particular in this class are associated with the highest cost?

RH: At $628.55, Abilify (aripiprazole) had the highest average cost per prescriptions in this therapy class. Seroquel XR (quetiapine fumarate) had a cost per prescription of $460.13, and Seroquel (quetiapine), $390.65.

SPT: When Cymbalta (duloxetine HCl) loses patent protection in 2013, how much do you estimate costs for this class will decrease? Which drugs could potentially be prescribed in its place?

RH: We expect multiple manufacturers to launch generics to Cymbalta when the drug loses patent. It is the biggest drug in its therapy class and we expect the patent expiration and subsequent launch of generic medications to have a significant impact on the cost of treatment.

SPT: What drugs in development could serve as competition to Lidoderm (lidocaine topical) after its patent expires?

RH: The first generic option to Lidoderm is expected to be launched by Watson this September. However, Lidoderm has additional patents associated with the medication so we do not expect a significant number of generics on the market in the short term as you would with a typical oral medication. There are several others in development that could launch within the next year pending FDA approval.

There are a few topical products that could compete with Lidoderm. The most notable product is Eladur, which is currently in Phase II clinical trials and could reach the market as early as 2015. This product is applied once every 3 days versus 12 hours for the current Lidoderm formulation. However, Lidoderm/generics (when available) should still retain the lion’s share of this market.

SPT: The utilization of specialty medication within workers’ compensation is less than 1%, according to your report, but Enbrel (etanercept) is the most expensive drug on the list of the top 10 specialty medications. There are other options in this crowded therapeutic class — is Enbrel simply the least expensive choice in its class?

RH: Although the utilization of specialty medications within workers’ compensation is less than 1%, the costs of these medications are very high. Payers face increasingly significant challenges from high-cost biologics and other specialty medications. Enbrel, like Humira (adalimumab), Remicade (infliximab), and Orencia (abatacept), is a biologic medication with no cost-effective options available. Other drugs in this therapy class that have a high average cost per prescription include:

Humira: $2541.97

Remicade: $2444.46

Simponi: $2254.10

Increasing use of these medications, and their cost impact, further demonstrates the need to encourage use of generic medications to help lower costs for workers’ comp payers while ensuring healthier treatment outcomes for injured workers.