WCRI Recap: Single Biggest Factor To Turn-Around Opioid Crisis

WCRI Recap – 3 Part Series

  1. WCRI Recap – Impact of Donald Trump and 2016 Election
  2. WCRI Recap: 3 Factors That Most Impact Worker Outcomes
  3. WCRI Recap: Single Biggest Factor To Turn-Around Opioid Crisis

 

It’s been two weeks since the WCRI Conference recently held in Boston. I’m Michael Stack with Amaxx. Today I want to give you some highlights and recap from that recent conference from the notes that I took and the perspective that I had on it.

 

The next session that I took some detailed notes on was how are states battling the opioid epidemic. I took a lot of different notes in this session, but Dwight Lovan who was formerly with the Kentucky Department of Workers Comp Claims made one statement that I think is the only statement that really needs to resonate with our industry and with state lawmakers.

 

 

 

Single Biggest Factor To Turn-Around Kentucky Opioid Crisis

 

We all know, or a lot of people know, that Kentucky was the epicenter of opioid overdose deaths and opioid drug problem, so they took this head on. He talked about really how they addressed it in Kentucky and the progress that they’ve made, which has been significant. He made one comment, and he said, and he kind of almost said it in passing, but I wrote it down and I highlighted it and I starred it and I bolded it, because he said, “The biggest impact and the one thing that they did that made the biggest difference was they required their physicians to check the PDMP data.” They made a mandate that required their physicians to check the PDMP data. If you’re not familiar with the prescription drug monitoring program it’s a database that basically doctors can check. It takes maybe 5-15 seconds to see what other drugs that injured worker is taking so they don’t overprescribe, so prevents doctor shopping. A lot of those biggest challenges that cause overdose deaths, so they made a mandate that required the physicians to check this PDMP data before they prescribe the drugs.

 

That made the biggest impact at the epicenter of opioid overdoes deaths and the significant progress that they have made. I checked this research. I researched it a little bit online. I’m not sure how accurate this data is, but it said 16 states have since implemented this mandate and it should be implemented in every single state, in all 50 states. If this made the biggest impact at the biggest problem area in our country, it’s an easy fix and it only takes five to 15 seconds to save a life, so hugely important point on this how states are combating opioids. If you have not implemented this in your state talk to our lawmakers. Let’s make this mandatory across the board.

 

 

Non-Pharmalogical Treatment of Pain

 

The last session was non-pharmacological treatment of pain as alternatives to opioids. This was a fantastic session. The information covered was very impactful and very moving for the results that it can give for each individual injured worker.

 

Dr. Dawn Ehde and I apologize because I’m probably pronouncing that wrong, from the state of Washington. She gave a tremendous presentation. Here’s the highlights of what she covered. She covered the idea that this medical model, or the currently medical model as far as the treatment of pain. It just doesn’t work. It doesn’t work because the biopsychosocial factors in all the different elements that go into how an individual perceives their own pain. This reinforces that idea of the do you think you’ll be back to work in four weeks. It reinforces that same idea, the perception of that individual person is such a huge factor on how well they’re going to do, and a huge predictive indicator of how well that claim’s going to go.

 

She talked about some of the current different options of what’s currently being used out there today. She talked about cognitive behavior therapy and she talked about mindfulness, so two different popular options which you may or may not be familiar with. What she went into a more detail, which I thought was extremely interesting and compelling was this idea of collaborative care. That’s what I want to cover here today.

 

 

Collaborative Care Model

 

It’s very much in sync with the best practice that I recommend, which is the weekly claims round table. It’s about looking at an individual claim, bringing in perspective some different experts to collaborate and come up with the best solution for that individual person because the solution for Tom’s going to be different than the solution for Sally is going to be different than the solution for Joe. Each individual person needs their own path and their own direction. You get the perspective from different experts to work together, collaborate for that outcome. That was really what she reinforced here.

 

She drew out this picture of the injured worker really being at the center of this model. You’ve got the providers up here. You have a care manager down here, and over here you have what she called consultants, and these consultants and everyone ties into here to service the injured worker. These consultants are psychiatrists, they’re different experts that can bring in and share some expertise with this care manager and with this provider to all work together to collaborate on the different elements that maybe needed to suit that person’s needs, to meet them where they are, to move them towards this positive outcome.

 

I’m oversimplifying this conversation, I’m oversimplifying this presentation, but you get the idea of what we’re trying to accomplish here and what she’s talking about and how they’re addressing this in the state of Washington to hopefully provide a model for the rest of the country to follow for these outcomes. The idea is to collaborate, connect with this injured worker regularly, have conversations with him, set those expectations. We talked about that in the worker outcome studies of how trust is such a huge factor so you build this huge level of trust with this care coordinator and they’re talking to them, that injured worker, about their expectations that do you think you’ll be back to work question is a huge factor in how they’re dealing with their pain, and how they’re going to recover.

 

They implemented, they haven’t done a ton of studies on this idea yet, but they implemented in a case of multiple sclerosis patients. There was 188 patients and it achieved what the medical community deems is the triple aim, which is better outcomes, lower cost, and higher satisfaction. That was the only study and they’re starting to roll this out in work comp, so very exciting for the solutions that can be brought to the table. Very impactful, very practical information as always from the WCRI Conference. I hope that you can take this information and put it into practice today.

 

 

Pick One Idea & Implement!

 

My recommendation is to start with one thing, start with one thing. What is it from that conference that you want to implement today and build that momentum, which is how significant change happens. Again, I’m Michael Stack with Amaxx, remember your success in Workers Comp is to defined your integrity, so be great!

 

 

 

4 Areas To Manage Workers’ Comp Medical Costs

Medical treatment has comprised the bulk of workers’ comp claim costs in recent years, and the trend seems to have no end in sight. Where indemnity used to be the main expense, medical now represents 60% or more.

 

There are a variety of tools to help manage medical costs; medical bill review, utilization review, provider networks, nurse case management, nurse triage, Medicare Set-asides, and the list goes on. While any of these tools can be effective, they might actually be costing you more than they are saving. You need to look at your return on investment and make sure the medical management services you are using are truly helping your organization save money on medical.

 

 

  1. The Doctors: Costs vs. Outcomes

 

Low-cost medical networks were all the rage in the workers’ comp system for a while. But in recent years, there’s been more and more evidence to show that going cheap on medical providers may come back to bite you.

 

The latest indication comes from a study in which a 63-year-old woman with low back pain was sent for MRIs at 10 facilities in the New York area to see what, if any differences there would be. Sure enough, not a single diagnostic finding out of 49 distinct findings reported was identified by all 10. The woman’s actual diagnosis was stenosis; she was given physical therapy and education and is said to be doing just fine. But had one of the 10 interpretations of her MRI been used, she might have been sent for unnecessary surgery and/or drugs — big expenses with a poor outcome.

 

The adage ‘you get what you pay for’ is as true of medical providers as it is for anything. Try to partner with area providers that A: understand the world of workers’ comp — and if there are none, start educating area physicians; and B: have low litigation rates and high return-to-work outcomes.

 

Likewise for other medical providers, such as physical therapists. Look at the number of treatments, their average cost, and the outcomes.

 

Once you’ve identified the best providers, partner with them and direct injured workers to them where possible. In states where the employer cannot direct care, you can still provide information that lets the injured worker know who the top providers are.

 

 

  1. Pharmacy Benefit Managers

 

Pharmacy benefit managers with good track records can be invaluable to a workers’ comp program. But again, you need to make sure you’re getting one that adds value to your company.

 

Where PBMs initially added value through lower prices, many have implemented clinical management programs to lower costs further and improve outcomes. It’s important to look at a PBM’s overall program to make sure you’re getting the best for your money.

 

Consider such things as pharmacy charges vs. pharmacy costs; the percentage reductions below the state’s fee schedule; the PBM penetration rate; cost per script; percentage of medications dispensed by pharmacies vs. physicians; and first fill rate.

 

 

  1. Involvement of Nurses

 

Nurses can be brought in to help with a claim — nurse case managers; or they can be the initial source to help determine medical treatment — nurse triage.

 

NCMs are the point person for the injured worker and medical providers. Those who do it in-office are telephonic case managers, whereas those who go out of the office are field case managers. Evaluating the effectiveness of NCMs is easiest with a large database, to compare things like the cost of claims and number of lost workdays with and without a NCM. Your insurer and/or third-party administrator may be able to help.

 

To find the value of nurse case triage, you can look at the number of calls divided by the number of claims actually reported for workers’ comp, to get the number of claims avoided by percentage.  It’s also important to look at the training and experience of the nurses involved. One thing to be aware of is how invested the triage nurse is involved in the claim. Triaging is at the initial stage of the claim, not manage the claim — which is the job of the NCM, if there is one.

 

 

  1. Bill Review

 

Medical Bill Review fees can be hidden and pricey, so it’s important to look for transparency from the claims administrator. There are many claim service providers now that have modified their BR fee structures so the costs are more obvious. Ideally you want a lower administrative cost for BR, combined with maximized savings.

 

You can find the net savings of your BR service by taking the gross savings (total charges minus total paid) and subtracting the BR service fees. Additional things you can measure to ensure you’re getting value are the percentage of net savings, the turnaround time, and the denied bill rate.

 

 

Conclusion

 

Price alone should not be the deciding factor for medical management tools; a holistic view of your services is best. However, you also want to make sure you aren’t shelling out more money than you are saving. Whether you are evaluating your current tools or looking for new ones, just make sure they lead to improved outcomes and lower costs, to get the best from your investment.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

4 Questions On Urine Drug Testing To Deliver Better Work Comp Outcomes

Urine drug testing (UDT) is one of the more controversial and misunderstood tools in the workers’ comp system. While medical guidelines support the tests for injured workers who are prescribed opioids, stories of over testing injured workers —and overcharging payers — abound. There are also questions about what type of testing to use, the frequency of the tests, and what to do with the results.

 

UDT used judiciously and paired with clinical expertise can be invaluable in ensuring injured workers get the right medications at the right time. Understanding some of the basics will help you get the best bang for your UDT buck.

 

Types of testing

 

  • Forensic. UDT has been around for decades, beginning with its use to identify illicit drug users in criminal and civil proceedings as well as the workplace. This forensic, or ‘gotcha!’ model is designed to determine yes or no that someone is taking certain, typically illegal drugs. An initial screening — presumptive — test is performed and any positive results are sent for confirmation. The types of tests include in-office point of care. Results from these tests can come in minutes. However, they are not necessarily designed to detect the use of medications at therapeutic doses, something critical in a clinical setting. Also, the tests are not available for all drugs, such as synthetic drugs of abuse. Since oxycodone is a semi-synthetic opioid, it may not always be detected in these tests.
  • Clinical. This model puts the focus on the patient-provider relationship and is used as part of patient care in various settings, including pain management. The idea here is to identify the presence of specific prescribed medications, non-prescribed medications and illicit substances to benefit the therapeutic goals of the patient. Definitive testing, typically used in this model, provides information about specific drugs and metabolites and can detect drugs at much lower concentrations, which presumptive tests do not. The results of these tests, however, may not be available for 24 hours or more.

 

The type of test used for an injured worker depends on a variety of factors, including the physician’s assessment of the patient’s risk. The types of medications also has a bearing on the most appropriate tests. If there are multiple opioids, for example, presumptive tests may not provide enough information to help the physician.

 

Why Test:

 

Guidelines published for prescribing opioids to injured workers support the use of UDT to help identify safe and effective treatment options.  Some of the reasons to undertake UDT include:

 

  • Risk assessment. Research shows many prescribing physicians are not aware of their patients’ past and current drug-taking behavior. Clinical UDT provides clear evidence of the patient’s drug taking behavior, which is vital to the provider’s treatment plan, risk assessment, and interaction with the patient.
  • Clarification. In addition, patients often do not know specifically which drugs they are taking. So the drug test can add to the provider’s understanding of the patient’s current medical treatment.
  • Data consistently shows about 18 percent of workers’ comp patient samples do not indicate they are taking the prescribed drug. Given the problems with diversion, misuse, and abuse, it is clear that workers’ comp patients may be complicit — wittingly or not — in the inappropriate consumption of prescription drugs.

 

How Often to Test

 

How often should an injured worker on opioids be monitored through UDT? This is one of the key questions and problems surrounding UDT. Too much testing is a waste of money, while too little testing may lead to missed opportunities for intervention and cause the claim to deteriorate.

 

Physicians can determine how often UDT should be conducted based on the injured workers’ risk of medication misuse, abuse or diversion; and the importance of adherence, such as if the injured worker is being weaned off certain drugs.

 

  • Low risk. Injured workers who have little to no risk should be tested annually.
  • Moderate risk. Injured workers who have some red flags indicating they are potentially at risk should be tested a few times per year.
  • High risk. Injured workers with a high propensity for medication abuse should be tested frequently, in some cases even monthly.

 

 

What to Do With The Results

 

One of the problems with UDT is the lack of follow through after an unexpected or inconsistent test result. Faced with evidence that the injured worker is not taking her medications as prescribed, and/or is taking medications that were not prescribed — including illegal substances — some intervention is necessary. The results may be a clue that the injured worker is getting medications from more than one provider. At the very least, the provider should discuss the results with the injured worker. Unexpected results occur on average more than half the time.

 

Once the test results are available there are several steps that may be beneficial.

 

  • Work with a PBM. A pharmacy benefit manager can help interpret the test results and provide guidance on what the next steps should be. An unexpected test result may be due to a variety of factors; such as drug-drug interaction, or a contaminated or diluted sample. The answer is not always black and white, and a PBM or other expert can help decipher what the results actually mean.
  • Additional clinical outreach.
  • Follow-up testing.
  • Peer-to-peer review.
  • Change in medication therapy.

 

Conclusion

 

UDT can provide much needed information to help guide a claim. However, it should be part of an overall strategy and not the only tool used. It’s important to know the benefits and limitations of UDT and use it to help understand the whole picture of the injured worker.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Opioid Addiction: The Painful Reality

For years, Express Scripts has been committed to managing concerns about long term opioid use, especially the risk for addiction.

 

new report from the U.S. Surgeon General highlights the rise of addiction to drugs and alcohol and calls for a deeper investment in pain management strategies. This first-ever report intended for health care providers, law enforcement, and policy makers focuses on numerous prevention and treatment methods available and the vision for a future with reduced stigma on alcohol, drugs and addiction.

 

The SAMHSA (Substance Abuse and Mental Health Services Administration), a federal agency charged with advancing the behavior health of the nation, contributed much of the data and analytics.

 

In 1964, a similar in-depth and prescient report regarding tobacco use is now considered to have been the catalyst for change in that industry, and many hope for a similar result from this Surgeon General report.

 

 

Express Scripts Commitment

 

For years, Express Scripts’ workers’ compensation team has been committed to managing both the clinical and cost concerns with long-term opioid use, especially the risk for addiction.

 

We have continued to build proactive solutions to address the issue from multiple angles. These solutions are focused on helping payers, physicians, risk managers and injured workers arm themselves with tools to ensure safe and cost-effective treatment.

 

Enhancements to the Express Scripts’ workers’ compensation program offering over the past year have focused on proactive intervention. New in 2016, ScriptAlert+SM, a bundle of point-of-sale edits can be used by workers’ compensation payers to review high-risk prescriptions before the injured worker leaves the pharmacy. This point-of-sale review is carried out in real-time, using OASIS – Express Scripts’ real-time connectivity platform, at the time that a prescription is submitted for filling at a pharmacy. In tandem with the Morphine Equivalent Dose program, Express Scripts proactive opioid programs attempt to tackle the potential of opioid addiction before it begins.

 

 

Looking Forward

 

Just as the Surgeon General calls for more advanced tactics to managing pain, we continue to evolve our solutions. We know that traditional opioid abuse programs identify suspicious activity that’s already happened – by which time behavior modification is extremely difficult. Looking forward, we’re leveraging our advanced analytics to identify and assign risk scores among patients, pharmacies, and even prescribers.

 

 

Author Brigette Nelson, MS, PharmD, BCNP, Senior Vice President of Workers’ Compensation Clinical Management, Express Scripts. In this role, Brigette provides strategic oversight for clinical programs for workers’ compensation PBM clients and leads a team of clinical pharmacists and technicians, with client-facing responsibilities for clinical program offerings. She also partners with the workers’ compensation product group in managing clinical programs and consults with clients regarding clinical outcome trend analysis to manage drug spend and appropriate therapy. http://lab.express-scripts.com/lab/insights/workers-compensation

America’s Pain Points

a-nation-in-pain-thumbnailExpress Scripts’ newest report, A Nation in Pain, provides a comprehensive examination of the trends in use of prescription opiates in the U.S.

 

America claims less than 5% of the world’s population, yet it consumes roughly 80% of the world’s opioid supply. Knowing the potential for misuse of these medications, and facing an increase in opioid-related deaths in this country, we wanted a deeper understanding of how patients in the U.S. are using these medications so we can identify additional ways to protect them from the risks associated with their use.

 

In A Nation in Pain, our research revealed a drop in short-term use of opioids, and stabilization in the number of patients using these medications longer term, which is in contrast to the increases seen in the past. Both trends indicate that doctors are being more cautious about prescribing these pain medications.

 

However, the research uncovered some concerning increases in the amount of prescription opioid medications Americans use, and the frequency in which these medications are used in dangerously high doses and in risky combinations with other medications.

 

 

Prescription Opiate Trends Increase Potential for Abuse

 

Nearly 60% of patients taking opioid pain treatments for long-term conditions were prescribed potentially dangerous mixtures of medications during the same time period. Two-thirds of patients using these medication mixtures were prescribed the drugs by two or more physicians, and nearly 40% filled their prescriptions at more than one pharmacy.

 

Among those taking dangerous drug mixtures last year:

 

  • 27% were taking multiple opiate pain treatments simultaneously.
  • Nearly 1 in 3 patients were on an opiate and benzodiazepine (an anti-anxiety medication), a combination that is the most common cause of multiple drug overdose deaths.
  • Approximately 28% took both a prescription opioid and a muscle relaxant, and 8% were combining an opioid, muscle relaxant and a benzodiazepine. Opioids, muscle relaxants and benzodiazepines all have sedating effects and can slow down the respiratory system. Taking these medications together could increase these reactions exponentially.
  • Women accounted for nearly two-thirds of those taking these potentially hazardous mixes of medications.

 

Although there could be instances in which prescribing an opioid in combination with these other medications is appropriate, evidence of this concurrent use at such a large scale – and involving multiple prescribers and pharmacies – indicates there could be a breakdown in communication among a patient’s care team or potential abuse.

 

Also concerning was the discovery that nearly half of patients who took opiate painkillers for more than 30 days in the first year continued to use them for three years or longer. In addition, almost half of chronic opioid users took only short-acting medications – rather than longer-acting formulations – thus increasing their risk for addiction.

 

 

Prescription Opiate Use Most Prevalent in Southeastern Small Cities

 

According to the report, the number of Americans using prescription opiates declined 9.2% in the past five years, yet both the number of opioid prescriptions filled and the number of days of medication per prescription rose more than 8% between 2009 and 2013.

 

 

PREVALENCE OF SHORT-TERM AND LONGER-TERM OPIATE PAIN MEDICATION UTILIZATION

prevalence-of-short-term-and-longer-term-opiate-pain-medication-utilization

Of the 25 cities with the highest prevalence of longer-term opioid use, 24 have populations fewer than 100,000. On average, 3.9% of Americans were using prescription opioids on a longer-term basis in 2013; in small cities, that average is significantly higher at 5.1%

.

Among small U.S. cities with fewer than 28,000 residents, the top five had between 12.3% and 18% of their population using prescription opioids and were located predominately in Alabama, Arkansas, Georgia and Kentucky.

 

 

STATES WITH THE HIGHEST AVERAGE PREVALENCE OF OPIOID USE

 

state-with-the-highest-average-prevalence-of-opioid-use

 

 

Express Scripts Protecting Patient Safety and Preventing Abuse 

 

Prescription opioids can provide patients with clinically safe and effective pain management. However, the potential for misuse and addiction requires vigilance and exemplary coordination of care.

 

When patients use home delivery to fill their prescriptions through the Express Scripts Pharmacy, they are cared for by specialist pharmacists with advanced training in pain treatments who can identify cases of suboptimal pain management and help patients use opioids safely and effectively. A subanalysis of the research shows that when compared to those who filled their prescriptions at a retail pharmacy, 23% fewer patients who filled their medication through the Express Scripts Pharmacy were using a potentially dangerous combination of medications, and 15% fewer patients were prescribed medications by multiple prescribers.

 

Express Scripts’ Fraud, Waste and Abuse program identifies potential cases of drug abuse, conducts extensive investigations and recommends interventions where necessary. The rate of concurrent use of potentially dangerous medications was 7.6% less in patients whose benefit plan was enrolled in the Express Scripts Fraud, Waste and Abuse program in 2013 compared to patients whose benefit plan was not enrolled in the program.

 

 

Research Methodology

 

For the report, Express Scripts examined 36 million de-identified pharmacy claims of 6.8 million commercially insured Americans of all ages who filled at least one prescription for an opioid to treat acute or longer-term (nonacute) pain from 2009 through 2013. Prevalence, use and costs were evaluated during the five-year study period, including assessments of trends according to age, gender and geography. The research also looked at users prescribed opioids in combination with other medications.

 

 

dr-nowakAuthor Lynne Nowak, MD, Express Scripts. Dr. Nowak is the Medical Director for the Express Scripts Lab, where she closely collaborates with the Express Scripts Personal Health Solutions team and Therapeutic Resource Center (TRC) specialist pharmacists, researchers and decision designers to implement programs and protocols to continually improve health outcomes for members. She received her internal medicine training at the Mayo Clinic and her medical degree at the University of Illinois. She practiced as a primary care general internist, an academic hospitalist, director of a hospitalist program and medical director of a nonprofit hospice organization. She sits on the Board of  Trustees of the Illinois State Medical Society and the Medical Services and Governmental Affairs Council.

You Win If Your IME Doctor Shows Up At The Comp Board

comp-board-imePicking the correct doctor for your Independent Medical Examination (IME) can determine whether you win or lose your workers’ compensation case.  This is based on a number of factors, which hinges on the ability of the examiner to prepare a persuasive report based on the facts provided to them.  Sadly, this is an area when claims management teams and other interested stakeholders defending workers’ compensation claims often cut corners.

 

Now is the time to change your thinking and be open to using the right medical examiner for the case. The IME is one of the few points where the outcome of the claim can be influenced, and you want to know that you have the right expert to WIN.

 

 

Preparing for the IME

 

In most jurisdictions, the employer and insurer get only one opportunity to have the employee seen and examined for purposes of the IME.  Due to the nature of the examination in the adversarial process, it is important to treat it with upmost importance.  A number of factors go in the examination, which often include:

 

  • The education and training of the expert. The practice of medicine is highly competitive.  Choosing a doctor with a reputable background is important.  It is also critical your expert has an updated Curriculum Vitae (CV) that includes information on their ongoing education training and reputation within the medical community.

 

  • Specialization is key. This is especially important in today’s cases where medicine is specialized and medical care and treatment is scrutinized by experienced compensation judges or members of the compensation board; and

 

  • Independence is essential. Your medical expert will be asked to give an opinion on issues regarding causation, the nature and extent of injuries, reasonableness and necessity of medical care and treatment, and need for future care.  The judge or hearing officer will view your expert as a more objective witness if he is truly independent and does not have any financial ties to the client/employer or vendor that is setting up the IME.

 

 

Show Up & WIN

 

In addition to the factors mentioned above, it is important to work with an independent medical examiner that adds value to the defense of the case.  This includes adding certain intangibles when the case boils down to a “battle of the experts.”

 

One such area an IME doctor adds value is the time they spend on a case.  IME physicians are paid a flat rate for their services.  A low fee paid to the provider means he will be unlikely to spend significant time reviewing the medical records and history, seeing and examining the employee, preparing their report, or being available to show up at a hearing to defend the case.

 

On the other hand, high quality IME service providers fairly compensate the right physicians to offer a meaningful opinion, and be available to show up at a hearing to defend their position. While this may increase the cost of the IME, the dividends can pay off significantly in future savings when settling cases.  Other benefits of working with service providers who provide a higher quality IME expert include:

 

  • A higher degree of accuracy and precision in the findings and opinions contained within the IME report;

 

  • Better familiarity with the file and its materials. This allows the doctor to develop their medical theory on direct examination and guard against losing credibility on cross examination; and

 

  • It avoids the wrongful perception the IME report is merely “bought and paid for” by the insurance carrier.

 

 

Conclusions

 

Workers’ compensation cases are often won or lost with an IME.  If service providers hinder the ability of their medical experts to do a complete job, the results may be disastrous to your file load.  When medical experts are fairly compensated for their time, they are able to reduce workers’ compensation costs and move your cases toward a reasonable settlement.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC.  . He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

Can You Authorize Up To $6,000 For A Winning IME?

doctor-imeThe cost of litigation in workers’ compensation is a driving factor that can impact a claim.  Most claim management teams require defense attorneys to submit detailed litigation budgets and hold their counsel to it.  While budgets are unavoidable in today’s marketplace, flexibility can be given in certain situations when it comes to costs associated with an Independent Medical Examination (IME).

 

 

Why Are IMEs Important?

 

The IME can make or break your case.  It can determine the direction of your claim and is used to defend issues concerning causation, the reasonableness/necessity of medical care, treatment parameters or other medical related issues.

 

Failing to use the right IME service provider will impact your claims based on a number of important issues.  These include:

 

  • Available panel selection of medical experts;

 

  • Quality control issues; and

 

  • Customer service issues, including the timeliness of IME reports.

 

 

Developing Trust with an IME Service Provider

 

When dealing with these matters, it is important to evaluate an IME service provider on how they perform in the following areas:

 

  • Service support during the examination process. This includes turning around reports in a timely manner and superior customer service;

 

  • Their panel selection and variety of medical experts. This is important in many instances where an area of specialization is vital to defending a claim; and

 

  • Other intangibles. This includes “best in class” service, the ability of medical experts to clarify issues and add value during all aspects of the examination process.

 

Having confidence in your IME service provider is paramount.  The IME service provider can assist attorneys, members of the claim management team and other interested stakeholders when it comes to evaluating their case and selecting a medical expert.  This is especially important in high exposure cases.

 

 

High Exposure Cases Require Trust & Flexibility

 

An IME cost will range between $500 – $1,800 depending on the provider and the state. This can include a review of all medical records and other documents pertinent to the employee’s background.  In most instances, this includes a summary of the employee’s deposition that has a description of their everyday work activities and specifics concerning the mechanism of injury.

 

Some cases, however, are not average cases and require more than the average IME, with potentially more than one expert opinion.  It is these situations where flexibility and a trusted IME provider relationship is paramount.

 

 

Can You Authorize Up To $6,000 To Get This Done?

 

The timing and execution of an IME requires a medically sensitive determination, and the selection of the right physician expert to make this determination is critical.  The best IME vendor relationships will be trusted and authorized to spend additional funds when necessary to select the right expert from their physician panel at the right time in a high exposure case. This expertise and specialized knowledge makes the IME vendor an invaluable partner to the claims management team.

 

This can be the case when you are dealing with the following issues:

 

  • Cases that include claims for mental/mental or physical/mental injuries. In cases involving a mental component, IME’s will often include multiple medical experts and an array of tests and procedures;

 

  • Instances where the employee has suffered significant physical injuires to multiple body parts. In other matters, future surgical procedures that are complex in nature often drive the cost of an IME; and

 

  • The prior claims history of the employee is also important to consider. When dealing with “experienced claimants,” it may be imperative to select an IME doctor who is not hindered by a budget and can go the extra mile to drive the matter toward settlement.

 

 

 

Conclusions

 

Litigation budgets are an important component of workers’ compensation cost containment.  When it comes to an IME, it can be an invaluable asset to allow for flexibility when defending a high exposure claim.  Develop a trusted relationship and leverage the expertise of your IME vendor as an invaluable partner to your claims management team.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Donald Trump, Hillary Clinton, and Workers Comp Medical Decisions

***Please note, the resources mentioned in this video are recommended to be used as a resource for when further intervention by a trained medical professional is required***

Hello, Michael Stack here with Amaxx. This past weekend was the second Presidential debate between candidates Donald Trump and Hillary Clinton. It was a 90-minute snapshot of information, with their policies, their views and unfortunately a lot of their personal indiscretions. It’s designed to give us information as the American public of who we want to decide individually who we want to be our next president.

 

There are individuals who have spent hours, weeks, months, years participating in the talk shows, reading the policies, learning every minute detail about their candidate in order to make their decision. There’s millions of Americans who don’t have the time or frankly the interest to study to that level of minute detail. They use the debates in order to make that decision, in order to get that information, to get that snapshot to make the extraordinarily important decision on Election Day for themselves.

 

It got me thinking of how this relates to Worker’s Compensation and the important decisions we make in a claims organization almost every day in regards to these medical decisions. There are doctors and people in the medical community who similarly will spend their entire career studying the biology to the minute detail in order to create determinations in regards to two specific points of injury duration and causation, of whether that injury is work related or not.

 

 

Work Comp Snapshot of Medical Information

 

What’s the snapshot? What’s that information that we can turn on for 90 minutes and hopefully get some information in order to help us make that decision? I’m going to give you two resources here in regards to injury duration and causation.

 

 

MD Guidelines / ODG Guidelines

 

Injury duration, the resource is MD Guidelines and ODG Guidelines. These are published by medical professionals and give you an idea of the expected duration of a particular injury, whether that’s 2 weeks, 5-10 weeks, 15+ weeks based on a various number of factors. You could look at a shoulder injury, a back injury, a wrist injury, a knee injury, whatever the case and get an idea of the expected duration of that injury. If it’s expected to be 5-10 weeks based on a certain number of factors for a shoulder injury and you’re getting a 9, 10, 11 weeks and that individual is not back to work, that’s cause to bring in some additional intervention strategies to get things going on the right track.

 

 

AMA Guide to Causation

 

Let’s talk about causation. I want to give you a resource here. The AMA Guide to Causation. In depth book. This is a book you can find on Amazon, will give you an understanding from the medical perspective and it’s really written and designed for the person that is not a medical expert but has some medical knowledge to understand the elements of causation.

 

Injury duration and causation, AMA Guide to Causation and the MDG and ODG Guidelines. Great resources in order to help you make that extraordinarily important decision.

 

Again, I’m Michael Stack with Amaxx, and remember, your success with Worker’s Compensation is defined by your integrity, so be great.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Know The Difference Between Sprain & Strain To Save Work Comp Dollars

sprainIn order to properly monitor and control workers compensation losses, it is necessary for the employer to have a working knowledge of traumatic injuries and occupational diseases.  For adjusters this knowledge is mandatory.

 

 

The Exposures:

 

The following sample questions demonstrate the need for medical fact information knowledge and understanding:

 

  • What are usual treatments for the injury or disease?
  • What are the normal recovery periods?
  • Will there be any residual disability?
  • What are the problems associated with improper treatment?
  • Did the mechanics of the loss or job exposures cause the injury claimed?
  • What underlying health conditions might be aggravated by this injury?
  • Is treatment in compliance with accepted medical practice?
  • Is there a prior record to demonstrate apportionment possibilities?
  • What apportionment ratios are possible?
  • What are indications that point to the need of an independent medical examination?
  • What questions and findings need to be presented to the examining medical practitioner?
  • Should the examination be done by a specialist, a general practitioner or physician’s assistant?
  • Are all facts of the occurrence and medical treatment available for presentation to the examining doctor?

 

 

Difference Between Sprains & Strains

 

The difference between sprains and strains is a classic example.  The terms are often used interchangeably, yet the actual injuries are quite different.  Their cause, severity, course of treatment, and residual possibilities vary greatly.

 

 

Sprains

 

Sprains are generally associated and limited to ligament stretching or tissue tearing.   Typically, they occur to knees, ankles, or wrists, and happen while walking, running, jumping, or falling.  The incident is usually abrupt or sudden and is prominent in sports or sports like activity.  Falling, while limbs are in out stretched position, or sliding, are ways sprains happen.

 

Symptoms are usually apparent almost immediately.   There is pain, swelling, bruising, loss of functional capacity, and weight bearing or applied pressure may be intolerable.  The patient may feel a pop or tearing sensation.  The symptoms can vary on intensity depending on the degree of severity.

 

Treatment generally consists of an x-ray or MRI, immobilization, pain medication, and applications of external heating or cooling devices, non-weight bearing, physio therapy, and possibly surgery. Use of crutches, slings, wheel chairs, walkers, and canes may also be necessary.

 

Recovery Disability can range from several days to twelve weeks without surgery. Hospitalization can range from several days to weeks depending on severity, and total disability can range from days to months.

 

 

Strains

 

Strains are caused by twisting, or pulling of the muscle or tendon.  They also occur from prolonged repetitive movement, and/or over use.

 

A strain is an acute situation brought about by trauma, blows to the body, improper lifting, and stressing.  The symptoms may be immediate or develop over a few days.  Strain symptoms are pain, localized swelling, cramps, muscle spasm, inflammation, loss of muscle function, general weakness of the muscles involved, and radiating symptoms following nerves.

 

Chronic strains develop over time as a result of repetitive motion or over use and symptom onset is delayed.  These cases may be accepted for other possible medical conditions.

 

The treatment and grades of strains are similar to strains, however full rupture of muscles often occurs and requires surgical repair.  Carpel Tunnel Syndrome is one of the chronic strain injuries and may need surgical intervention at the wrist level.

 

Recovery Disability parallels that of strains.

 

Learning and Reference Sources:

 

In addition to formal medical education courses, there are other places where medical knowledge can be obtained.  A few are:

  1. ACOEM and/or ODG Guidelines
  2. Local First aid and EMT classes
  3. Medical dictionaries
  4. Medical hand books designed for lay people and to be used in home or business
  5. Training sessions led by Medical Practitioners

 

Summary:

 

A strong medical knowledge of traumatic injury and occupation diseases is necessary.  This will allow for expected treatment, recovery periods, residual disability, and medical payments.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Chronic Pain: A Double Dose of Trouble

chronic-painDealing with “chronic pain” is an issue the workers’ compensation claims management team deals with on a daily basis.  This is highlighted by the daily dose of news about the prescription drug epidemic and the countless Americans who are either addicted to these legal medications, or become addicted to street drugs as the result of using them to deal with work-related injuries.  It is important to claim handlers to be proactive on this issue for the benefit of the injured employee and the bottom line.

 

 

What is Chronic Pain?

 

From a clinical standpoint, “chronic pain” is pain symptomology that lasts from three to six months following the onset of injury.  This can be the result of a specific incident such as a slip/fall injury, an aggravation or acceleration of an underlying condition or an injury resulting from workplace exposure or repetitive activity.

 

In most incidents, healthcare professionals in the United States deal with chronic pain by prescribing opioid-based pain medications.  These medications come in many forms and names people have come to know.  They include:

 

  • Codeine (available in generic form)
  • Fentanyl (Actiq, Duragesic, Fentora)
  • Hydrocodone (Hysingla ER, Zohydro ER)
  • Hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)

 

These prescriptions are useful as they relieve pain for a period and allow a person to recover from injury.  They are derived from opium, which is commonly processed into the street drug known as heroin.

 

 

Quick Facts on Opioid Addiction

 

  • From 2000 – 2013, the drug screening industry grew by $1.2 billion.

 

  • Workers’ compensation insurers in California alone spend about $100 million per year for opioid-based pain medications.

 

  • Prescriptions for buprenorphine and naltrexone—two drugs used to treat opioid addiction have risen to nearly 8 million in the last number of years.

 

  • At least 20 states allow doctors to both prescribe and sell drugs, often at dramatic markups.

 

  • Prescription drugs dramatically increase the cost of a WC claim:
    • $13,000: Average cost of a claim without opioids
    • $39,000: Average cost of a claim with Percocet
    • $117,000: Average cost of a claim with long-acting OxyContin

 

 

Issue Identification and Practical Solutions

 

Members of the claims management team are on the front lines of the battle against chronic pain and its “tax” on workers’ compensation programs.  Claim handlers can look for patterns and help identify issues early on before it becomes a larger problem.  This can especially be the case if a claimant overdoses as part of their medical care and treatment related to a work-injury.  If the death is related to the injury, the cost of the claim increases in the form of death benefits.  Fraud, waste and abuse are other drivers.  It is recommended to leverage a Pharmacy Benefit Manager relationship to help manage both cost and utilization of prescription drugs.

 

Key signs a claimant is abusing their prescription medications include:

 

  • Prescription medications that are often lost or stolen. In most instances, they are being sold to a third party or being given to family members.

 

  • Increasing use of pain medications without subjective reports of improvement. This information can be obtained from a claimant’s medical records and pharmacy receipts.  Information can also be gleaned when speaking to a claimant regarding issues concerning the injury.

 

  • Use of multiple doctors or pharmacies to obtain pain medications. While most states have pharmacy-reporting programs in place, it is still easy for people to game the system and obtain prescriptions from multiple sources.

 

  • Resistance to treatment agreements that include random urine samples or treatment plans.

 

 

Conclusions

 

Members of the claims management team play a necessary role when dealing with chronic pain.  This is an important function as monitoring this issue can help contain costs, while at the same time reduce unnecessary expenditures in any workers’ compensation program. A best in class Pharmacy Benefit Manager relationship should be leveraged to successfully manage chronic pain.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

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