Improving quality of life while optimizing Medicare Set-Aside exposure

the obstacle

In 2001 while working as a manager at Dave & Busters, Lori sustained an injury that caused ongoing cervical pain and chronic migraines leading to depression and anxiety. Despite the medication and years of treatment, Lori experienced increased pain and developed insomnia, constipation, and a decreased ability to function. Additionally, settling the medical portion of the claim was hindered by an overwhelmingly large Medicare Set-Aside (MSA). 

the opportunity

Lori was prescribed 11 medications every day, consisting primarily of high-cost brand-name formulations and “high-dose” opioids, which caused a high exposure on her MSA. Upon close review, we discovered that a number of her active medications had been prescribed to offset the side effects of earlier medications. Through our three-phase pharmacy intervention program, we worked with Lori’s treating providers to reassess her prescription regimen. 

the outcomes

After two successful face-to-face interventions—one with the family medicine doctor and one with the psychiatrist—Lori was able to be weaned from certain opioids and reduce the overall amount of medications she was taking. Not only did this reduce side effects but it also decreased pharmacy costs. PharmCompliance helped make changes stick over a long period of time, which ultimately reduced the Medicare Set-Aside exposure by over $500,000, contributing to what eventually was a successful settlement.