Reducing Medical Spend While Preserving Quality of Care

In this episode of MEC Connect Impact Stories, Jeff Pack Medical Management Consultant at MEC, shares two compelling cases that highlight how proactive clinical oversight and disciplined cost management can significantly reduce medical spend without impacting the quality of care for injured workers.

Jeff explores a rare and complex COVID‑19 vaccine–related claim involving immune thrombocytopenic purpura (ITP), where ongoing high‑cost specialty pharmacy treatments required close monitoring and strategic vendor negotiation. By collaborating with a preferred bill review vendor, MEC achieved meaningful cost reductions while maintaining treatment stability for the injured worker.

He then reviews a traumatic brain injury case where prescription refill patterns revealed an opportunity to adjust medication formulation — preserving therapeutic effectiveness while dramatically lowering long‑term pharmacy costs. By engaging defense counsel and the treating provider, the MEC team implemented a safe, physician‑approved change that resulted in substantial lifetime savings.

These Impact Stories demonstrate how MEC’s experienced people, proven processes, and trusted vendor relationships work together to deliver results that matter — protecting injured workers’ outcomes while responsibly managing catastrophic claim costs. 

Transcript

SPEAKER_00 0:02

Welcome to MEC Connect Impact Stories from Midwest Employers Casualty. I'm Sarah Hans. This season, our medical management consultants are sharing impact stories, real-world cases that demonstrate how strategic decision making, oversight, and collaboration can make a meaningful difference in complex claims. Today, Jeff Pack, a medical management consultant here at MEC, joins us to discuss reducing medical spend while preserving quality of care. Let's dive in.

Negotiating Nplate Costs Without Change

TBI Nausea Treatment As Cost Driver

Switching Formulations To Reduce Spend

SPEAKER_01 0:32

The first file I would like to talk about is a different type of COVID-19 case that involves a 30-year-old nurse who had a severe reaction to a then mandatory COVID-19 vaccine back in 2021. Little over a week after receiving the Johnson ⁇ Johnson vaccine, she broke out in a rash and made an appointment with her primary care physician. Her primary care physician did blood work and discovered her platelets were extremely low and admitted her to the hospital where she was ultimately diagnosed with idiopathic thrombocytopenic purpura, also referred to as acute immune thrombocytopenia or ITP for short. The term purpura refers to bruising and deposits of blood under the skin, which are commonly seen with platelet deficiencies, and was the rash that brought the injured worker to her PCP. So, what exactly is idiopathic thrombocytopenic purpura? It is a condition where the body's immune system mistakenly attacks the body's platelets, thinking they are a pathogen that has invaded the body. Platelets are one of the components that make up our blood and whose job it is to form clots and stop or prevent bleeding. The injured worker was treated with a combination of steroids and a bone marrow stimulant, L-Thrombopag. L-Thrombopag is also known by the brand name Promacta. This medication appeared to work initially, but her platelet count dropped extremely low again, and she needed emergent treatment of high doses of immunoglobulins and IV steroids. Her treating provider then tried Rituximab infusions. Rituximab is a monoclonal antibody known by the brand name Rituxin. Initially, her platelet count increased, but again dropped extremely low. She was switched to a different bone marrow stimulant called Romiplastin or N plate, which is a lot easier to say. The N plate injections stimulate the bone marrow to increase the number of platelets it can produce. She is now stable on a weekly N plate injection. Her weekly treatment protocol involves doing blood work to check her platelet levels, and then she will receive a sliding scale of N plate depending on how high or low her platelet levels are that week. These weekly treatments can cost anywhere between$12,000 and$25,000 per month at the state fee schedule, or about$222,000 per year. This is the major cost driver of this claim. We engaged one of our preferred vendors to work on bill negotiation, and through the partnership, they were able to negotiate an average reduction of about 23% below the state fee schedule, saving an additional$51,000 annually. They are continuing to negotiate with the facility and are striving to achieve a reduction of 25% below fee schedule for all future weekly treatments. This is just one way Midwest Employers Casualty was able to reduce the cost of a catastrophic claim without changing the level of service to the injured worker. The second case involves a utility worker who injured his head and neck when he fell into a trench, striking his head on a pipe at the bottom of the trench and was diagnosed with a traumatic brain injury and spinal fracture, for which he had a cervical fusion. He continues to suffer from post-traumatic headaches and associated nausea, and it is this treatment which is a cost driver on the claim. To treat his nausea, he was prescribed oncitron oral dissolving tablets as needed. The benefit of oral dissolving tablets is that the onset of effect is faster than the oral tablets, which would be important if the medication were to be taken as needed for a rescue type situation where the injured worker experienced a sudden wave of acute nausea. On Dancitron, oral dissolving tablets are also extremely expensive. The average wholesale price for the oral dissolving tablets is about$36.66 per pill. Multiply that price by the 30 pills per month and again by his life expectancy of 19 years, and this one medication would cost about$13,200 annually or$250,800 over the injured worker's life expectancy. However, while reviewing the claim and the prescription fill history, the Midwest team noticed that the injured worker was filling his prescriptions every month for more than two years. There could be many reasons why this was occurring. First, the injured worker was going to the pharmacy and requesting fills on all his medications that were available to be filled. Because it's easier to make one trip as opposed to multiple trips. Or he wanted to be sure he did not run out of medication later in the month. Or the injured worker was taking this medication in a scheduled fashion at the same time every day to prevent chronic nausea and not as a rescue medication for an acute onset of nausea. If the injured worker were taking his onansitron as a scheduled medication, there would not be a great need for a faster onset of effect from the oral dissolving tablets, and it might be possible to substitute the oral tablets of the same dosage without the injured worker experiencing any adverse effects associated with this change. The Midwest team worked with defense counsel who set up a conference with the treating provider. At the conference, the provider agreed that if in fact the injured worker were taking the undansitron as a scheduled medication, there would be no need for the oral dissolving tablets, and his prescription could be modified to the oral tablets of the same dose. At the next appointment, the treating provider confirmed that the injured worker was indeed taking his undansetron regularly at the same time every day and modified his prescription to the oral tablets. It has been five months since the treating provider made this change, and the injured worker has not noticed any adverse effects since switching from the oral dissolving tablets to the oral tablets. The average wholesale price of on Dancitron oral tablets is 63 cents per pill, or about$227 annually. If you recall, the annual cost of the oral dissolving tablets was about$13,200. By identifying this pattern and working with Defense Council, we were able to save about$12,975 annually, and if you extend that over the injured worker's estimated 19-year life expectancy, about$246,525. This is yet another of the many ways Midwest Employers Casualty works to mitigate prescription costs and medical spend without affecting the quality of care to the injured worker.

SPEAKER_00 8:43

Thank you for listening to MEC Connect. We hope today's impact story offered valuable insight into how thoughtful medical management can influence recovery, return to function, and long-term outcomes for injured workers. Be sure to follow MEC Connect for more impact stories throughout the season. Thanks for listening.