The Ontario Teachers Insurance Plan has added a lead pharmacy consultant to its group life and disability claims team to assist in managing both early intervention and ongoing disability claims.
The role, which was introduced in June 2021, creates a collaborative relationship between the pharmacist and the disability management team, providing further support for plan members. “We were looking for a clinical resource and thought this would be a great addition to our overall health-care strategy,” says Gail Enever (pictured left), vice-president of group life and disability claims at the OTIP. “We wanted to ensure plan members are receiving optimal pharmacological treatment and getting that treatment in a timely manner.”
Similar to most claims departments, the OTIP was using psychiatrists, physicians and other medical professionals in its ongoing disability claims management and adjudication process. However, it wanted to build on the strength of that team by adding the pharmacy component because it can have a significant impact on patient health outcomes, duration of claims and the overall member experience, says Enever.
The disability management team noticed a gap in services related to primary care through a general practitioner, as well as an increase in mental-health claims over the past couple of years, she adds. “[This role] will also allow our members in early-intervention rehabilitation programs who are receiving long-term disability benefits the opportunity to speak with a pharmacist and that helps to further destigmatize mental-health medications [and] understand the value of those medications and recommendations that are being made by their physician.”
Aimee Badali (pictured right), the OTIP’s manager of group life and disability claims and its early intervention program, agrees, noting the organization’s early-intervention rehabilitation program was seeing a huge rise in mental-health leaves from work. Bringing on a pharmacist adds another tool to help members navigate their mental-health journeys and assists in taking a holistic view, she adds.
“For our early-intervention rehab program, the pharmacist consulting service really aligns with the goal of the program, which is to shorten the duration of member leaves by ensuring they have access to treatment and resources that will have a positive impact on their medical condition. We’re also really hoping we’ll be able to prevent future leaves of absence from work so it’s not just a one-time [resource].”
The pharmacist’s role
In the new role, lead pharmacist of clinical and early intervention services, Faizan Baig’s (pictured centre) goal is to provide a clinical and drug therapy resource for plan members and for the disability claims team because he believes it’s important to have education on both sides.
“From the plan member side, they can often be overwhelmed with all the therapies they’re receiving and they don’t necessarily understand what different medications are for. When you provide that education, it helps them to be their own advocate in the health-care system, which is really important. And on the disability claims team, things are changing all the time. There are always new drugs and therapies coming through the gates.”
One of Baig’s main responsibilities is to gather important clinical information and conduct a comprehensive review. If he identifies a service or resource that can be implemented to help plan members, he drafts recommendations.
In a fair amount of cases, he has noticed people’s existing medications may not necessarily be optimized, which is why he believes it’s important to take a holistic approach. “We don’t want to just focus on the main reason why they’re leaving work, but also look at the whole picture and see if there’s anything else contributing because a lot of this stuff goes back and forth. So I look at cases holistically and identify drug therapy problems and treatment gaps.”
Another aspect of the pharmacist’s role is to be a middleperson between case managers, plan members and their physicians. Care instructions and other details are often lost in translation, so Baig helps to make the communications process more clear and efficient.
He’s also tasked with ensuring optimal patient health outcomes and facilitating a timely return to work. In terms of the early intervention aspect, Baig believes it’s a great opportunity to work with someone who’s eager to start treatment and is motivated to return to work. He conducts followups when necessary and ensures plan members know he’s available for any further discussions.
“When people end up waiting so long, it becomes frustrating for them and it creates a barrier to their recovery. My job is to bridge that gap, providing primary care support so people don’t have to wait. And what’s great about my role is I actually get to talk to members. It’s not necessarily just looking at the file — there needs to be a human point of contact [so I can get] their perspective of exactly what’s going on regarding their condition.”
Plan member feedback has been very positive since Baig’s role was added to the claims process, says Badali. Members have highlighted that he’s easy to talk to and his sessions have been helpful and informative. Some people even mentioned benefiting from his recommendations after bringing them to their physician or other specialist.
The OTIP is proud of the innovative initiative, which started as a pilot project, says Enever, noting the organization plans to continue developing it this year and expanding the capacity of the pharmacist’s role.
“We’ve fully integrated the services into our claims processes. Faizan’s role has actually evolved so he’s now reviewing every LTD claim that is approved and he looks for opportunities in the members’ treatment plans.”
Baig has also provided a few medical education sessions for staff, which were very well-received, so the organization is going to offer more sessions to cover a wider range of topics. He’s currently involved in a mental-health pilot program for the OTIP and will be involved in a new pharmacogenomics testing pilot as well, so the role is constantly expanding.
Moving forward, the claims team will continue to track Baig’s findings and outcomes so they can identify opportunities to build additional care initiatives and improve the plan member experience.
Sadie Janes is an associate editor at Benefits Canada.