Through our partnership with Risk & Insurance magazine and other media opportunities, we have written the following informative article.

What's not so transparent about transparent pricing

June 5, 2020

The deal that wasn’t really a deal

As you plan a family vacation, you book your airline tickets and get a really great deal. The flight isn’t on your normal airline, but, you are saving money and you think, “How different can one airline be from another?” Right?

Then, you arrive at the airport and you quickly realize that the lower cost “deal” isn’t really a deal. There is an additional fee to check your bag. There are no assigned seats. You are slotted to board last. Drinks and snacks will cost extra in flight.

As you slog your way to the back of the plane, you start to realize that paying a little extra initially, may have been worth it for the services and conveniences you are looking for in an airline.

This is what third-party administrators (TPAs), self-insured employers, insurance carriers, and state funds are feeling after being sold ‘transparent pricing’ by a Pharmacy Benefit Manager (PBM). The “transparent” pricing pharmacy model includes the highly-publicized pass-through pricing and rebate sharing.

But are these models really transparent? We don’t think so.

The sparkle of a lower-cost transparent pricing model is often quickly dulled by the addition of administration fees and click fees to cover the workers’ compensation cost of services. Payers who only look at the bottom line of a transparent pricing model may miss the fact that they will pay extra for additional services or find that the services they need are just not available — even for an additional fee.

What does this mean for you? Services normally taken for granted, including a workers’ compensation-specific formulary, clinical oversight of claims, technology integration, public policy and regulatory affairs support, as well as data analytics and the interpretation of results are not automatically included in the lower price. It’s these types of services that contribute to significant success in managing workers’ compensation claims to help control utilization and costs and lead to a timely and adequate claim closure — whether that be a return to work for an injured person or settlement of that claim.

That’s why Optum is different.

Optum offers a Total Care Management approach to claims and services to help you manage them. Our solution includes clinical oversight across all phases of the claim lifecycle to:

Total Care Management also delivers data analysis and predictive modeling to proactively identify and address potential risks earlier in the claim lifecycle that can inflate costs and delay the care process. And because every situation is unique, we can flex and adapt our program to best fit your business needs and goals as we provide optimal care for injured persons and help to drive your internal operational efficiencies — all while reducing your bottom line.

The strength and value of Optum

With over 40 years in the workers’ comp and auto no-fault industry, our steep industry knowledge and long-standing client relationships are bolstered by the strength and support of our parent company, UnitedHealth Group. With the industry’s largest data set, we provide informative analysis of claim data and superior clinical care throughout the life of the claim to help clients make better decisions earlier in the claim.

Our clinical program is driven by our chief clinical officer, medical director, a team of clinical liaisons, a Pharmacy & Therapeutics committee and the largest clinical staff in the industry. This collaborative, values-based approach is resulting in greater savings, increased efficiencies, and safer, more appropriate clinical care for our clients and their injured persons across the globe.

The Optum Total Care Management solution and pricing model in action

Meet Olga. Olga is a 49-year-old female with a five-year-old injury whose services were originally managed using a minimal, ‘cost-effective’ PBM. Through this model, Olga received her medications but that was about it. Now, under the Optum Total Care Management solutions, Olga receives her medications AND the clinical oversight and care she needs for optimal results.

April 10, 2019, Olga had surgery and was treated at various clinics while seeing multiple physicians. Her medications included nine medications from four prescribers.

THROUGH THE OPTUM CLINICAL PROGRAM:

Clinical escalation alerts were triggered to our pharmacists for:

Polypharmacy (seven or more medications in 30 days)
Four prescribers
Duplication of therapy
Potential adverse drug reactions

Our Clinical Pharmacists made the following key observations:

A therapeutic overlap of Diclofenac gel, meloxicam and ketorolac)
Ondansetron, anti-nausea medication for cancer or following surgery was prescribed
Possible GI upset due to her multiple non-steroid anti-inflammatory drugs
Tramadol dosage exceeded the maximum
Duplication of therapy with multiple opioids prescribed

Our Clinical Pharmacists recommended a Pharmacy Review with Peer-to-Peer Outreach Review to launch a collegial discussion between Olga’s primary care physician and surgeon with the goal to agree upon a simplified medication regimen for improved patient, clinical and economic outcomes.

FOLLOWING THE PEER-TO-PEER OUTREACH REVIEW:

Through the Optum Total Care Management Solution — and all of the services it includes — we can help you better manage your claims from end to end. We will work with you to intervene and take action to change treatments for better outcomes as early as needed. Our pharmacy care services and superior clinical programs have proven to help clients lower cost and improve efficiency, eliminate waste, improve visibility, prompt action, reduce over-utilization, and promote a safe recovery. That’s a whole lot more than what a “transparent pricing” model PBM can offer.

Your business and your injured persons deserve more. You deserve First Class. You deserve the Optum Total Care Management Solution.

For more information on the Optum Total Care Management Solution and any of our products and services email us at ExpectMore@optum.com.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Optum Workers’ Compensation and Auto No-Fault. The editorial staff of Risk & Insurance had no role in its preparation.

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