Stopping Opioid Abuse Through Effective Communication

The main driver in the cost of workers’ compensation claims remains the medical aspects of the claim.  This is due in part to the use and overuse of prescription drugs—mainly opioid-based narcotics.  It is important for members of the claim management team to address this issue and adopt best practices to reduce their overall exposure.

 

 

How Bad is the Problem?

 

From 2000 to 2013, services used to screen for substance abuse in the United States grew by over $1.2 billion.  While some of this growth was the result of alcohol abuse, experts estimate a majority of it was due to the use and overuse of prescription drugs.  One significant source of abuse cited by claims and medical professionals was opioid-based prescription medications in workers’ compensation claims.

 

This overuse is taxing on the workers’ compensation system.  Insurers are spending an increasing amount of time and money to pay prescription drugs to stop this epidemic from spreading.  In the state of California alone, it is estimated that over $100 million per year is spent to fund the drug component portion of claims.  Workers’ compensation insurers are also spending scarce resources to pay for prescriptions for buprenorphine and naltrexone, which are two drugs used to wean an individual off these potent prescription drugs.

 

Prescription drug abuse is dramatically increasing the cost of workers’ compensation claims.  An example of this impact is as follows:

 

  • $13,000: Average cost of a claim without opioids;
  • $39,000: Average cost of a claim with a short-acting opioid, like Percocet; and
  • $117,000: Average cost of a claim with long-acting narcotic, like OxyContin

 

 

Combatting the Prescription Drug Epidemic

 

Members of the workers’ compensation claim management team are on the front lines fighting the prescription drug epidemic in the United States daily.  Failure to be effective in this battle can lead the following consequences:

 

  • Increased costs from prolonged disability and medical care and treatment;
  • Increased case valuation and settlements, which rapidly deplete reserves;
  • Increased possibility of claimant death and drug overdoses, including street-drugs.

 

The stakes are high. It is important for members of the claim management team to evaluate the following case characteristics:

 

  • Age of the claimant: Is tolerance going to be an issue?
  • Underlying pathology: Possible chronic pain with low pathology?
  • Chemical Dependency: Denial of some claims and urine screens are necessary.
  • Functional Ability: “Couch Potatoes” beware!
  • Other Long Term Goals: Brief use of opioids to facilitate rehabilitation and then tapered use; and
  • Other Issues: Personality disorders, psychological/psychiatric issues

 

 

Results Through Education & Communication

 

Effective claim management teams cannot win this battle alone.  In order to be effective and remain competitive, these teams should look to outside service providers for help in educating relevant stakeholders.

 

Best practices dictate partnering with a Pharmacy Benefits Management company that holds the proper expertise and authority to effect change.  The first step is education of relevant parties through communication.  This includes the following:

 

  • Educate and communicate directly with injured workers about the importance of safe treatment;
  • Communication and letters to doctors on behalf of the claim management team explaining legitimate concerns regarding opioid based prescription drugs; and
  • Bulletins regarding the dangers of physician dispensing.

 

 

Example – results of these systems of communication create staggering results:

 

Express Scripts saw a reduction of nearly 11% in utilization of opioids among their workers’ compensation clients in 2014. Additionally, the  percentage of injured workers using opioids for a longer term (i.e., more than a 30-day supply) decreased 2.6 percentage points in 2014, to 31.5% of opioid users.

 

Common belief has been that it would be hard to convince an injured worker to choose a lower-cost alternative because there is no financial incentive for them to do so, as injured workers have no out-of-pocket expense for the treatment related to their injuries. However, Express Scripts’ leveraged expertise in behavioral science to pilot a program that sent injured workers a “social responsibility” letter –  explaining how their prescription drug choices could help control the rising cost of healthcare. Injured workers who received the letter were 60% more likely to choose a generic equivalent.

 

 

Conclusions

 

The claims management team has an important role in stopping prescription drug abuse in the workers’ compensation system.  This includes being proactive and collaborating with representatives from the pharmacy industry to educate everyone.

 

 

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.

 

Reality Check on Generic Prescription Drug Costs

The use of generic drugs in workers’ compensation is an effective and efficient method for controlling workers’ compensation costs.  Notwithstanding recent headlines that suggest otherwise, this continues to be a successful tool in controlling the increase pressures place on programs seeking to remain competitive.

 

 

What are Generic Prescription Drugs?

 

The common perception of generic items being cheap or ineffective is simply not the case when it comes to pharmaceuticals.  When discussing the issue of drugs, it merely refers to a drug product that is comparable to a brand/reference listed drug product in dosage form, strength, quality and performance characteristics, and intended use.

 

For example, a common brand name drug used in workers’ compensation for pain relief is “Percocet.”  This is merely a combination of oxycodone and acetaminophen.  The generic of this prescription drug has the same molecular combinations, and is required by the U.S. Food and Drug Administration to have the same effectiveness and bioequivalent range.

 

 

Are Generic Drug Costs Rising?

 

Until recently, the conventional wisdom has been that generic drugs are less expensive than their name brand counterparts.  Some examples of this include the following headlines, which has sparked a media frenzy:

 

  • Why Are Generic Drug Prices Shooting Up?; Forbes, February 27, 2015
  • 5 Reasons Generic Drugs Cost so Much; ABC News, August 20, 2015
  • Rising Cost Of Drugs: Where Do We Go From Here?; Healthaffair.org, August 31, 2015

 

The issue of rising generic prices as reported in the media is due primarily to two main drivers: a consolidation of companies who manufacture these drugs and a short-lived shortage of active ingredients necessary to make the medications.  While it is true that the price of select generics has increased, the reality of the situation is not what one would think.  As a whole, the average price of generics continues to be significantly lower when compared to their name brand counterparts.

 

 

A Reality Check on Generic Prescription Drugs

 

According to a data published in the Express Scripts Drug Trend Report, since 2008, the average price of brand name drugs has almost doubled, while the average price of generic drugs has been cut roughly in half.  A clear illustration of this fact is found in their prescription drug price index, which graphs brand name prescriptions and generics in a similar way that the U.S. Consumer Price Index measures changes in the prices paid for a representative basket of goods and services.  At the beginning of 2008, starting from a baseline index of about $100, this survey noted an increase in the average brand name prescription medications cost to $227.39, compared to an increase in inflation to $111.24 in the baseline.  The average cost for generics has dropped from the $100 index in 2008 to $37.13 in 2015.

 

prescription index graph

 

Using Generics to Reduce Work Comp Costs

 

Notwithstanding the media hype and spin, generic prescription drugs remain and effective way to control costs in a workers’ compensation program.  The Drug Trend Report also determined it that for every 1% increase in generic fill rate, a payer can expect to reduce their overall prescription drug costs by as much as 2%.  This is welcome news for most workers’ compensation programs as even a small reduction in costs can free up settlement reserves.

 

 

Conclusions

 

Generic prescription drugs create a win-win in any workers’ compensation program.  In terms of serving injured workers, they provide effective pain relief and efficient medical care.  They also allow workers’ compensation programs to reduce costs and promote efficiency.

 

 

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.

 

Control Opioid Abuse With Morphine Equivalent Dose Program

The use and abuse of narcotics in workers’ compensation has exploded over the past decade, creating skyrocketing costs, along with sharp increases in hospitalizations and death from overdose. Best practices to control opioid overutilization require systems to identify the issues in real time, educate the parties, and have a proven plan to implement steps that will improve the claim outcome.

 

 

The Human Costs of Drug Addition in Work Comp

 

Conservative estimates state that nearly 3 million Americans will become addicted to prescription drugs every year.  The effects of addiction can often create devastating problems in personal relationships, employment difficulties, job loss, financial difficulties, legal issues, and psychological problems. Some of the mostly commonly abused prescription drugs include:

 

  • Central nervous system (CNS) depressants and anti-anxiety agents.  These are drugs used to treat psychological and psychiatric disorders;
  • The most common use of these prescriptions are used to treat attention deficit hyperactivity disorder (ADHD); and work shift-induced sleep disorder.
  • These are a classification of drug based from opium, which treat pain.  Common opioid-based medication used by workers’ compensation claimants include morphine, oxycodone, hydrocodone.

 

 

Using MED Management to Fight Morphine Abuse

 

One innovative concept to battle morphine abuse in workers’ compensation claims is Express Scripts’ Morphine Equivalent Dose (MED) Management program.  This unique idea  has shown demonstrable results.  As reported in the Express Scripts Drug Trend Report, the opioid utilization among injured workers decreased nearly 11% in 2014. It is also cutting costs in claim management programs and helping injured workers avoid problems related to prescription drug abuse.

 

 

What is MED Management?

 

The term MED is a calculation tool used to compare and contrast different pain medications to one another.  These calculations “level the playing field” so to speak when comparing OR converting from one narcotic to another. MED Management is a clinical program to calculate the  narcotic medication’s morphine-like potency, or MED, at the time it is being filled (before it has been dispensed).  This helps reduce the chances an injured worker will become addicted to prescription pain medication, and can be  particularly effective in  preventing overdose in those claimant’s consuming 100mg or more of narcotic pain medications. According to the Washington State Agency Medical Director’s Group (AMDG), patients receiving 100mg or more per day of MED had a nine-fold increase in overdose risk.

 

 

Best practices in MED Management dictate a continuous review of an injured worker’s use of prescription drugs.  When the prescription is presented at the pharmacy, there is an evaluation of the prescription medications a claimant is using.  Certain standards are set that the individual is not allowed to exceed in a given period of time.  If the individual exceeds the pre-authorized MED values, the prescription will not be filled, and will be submitted to the payer for review of appropriateness. The program also offers interested claim management stakeholders mechanisms to conduct ongoing utilization reviews of prescription drugs, which can also assist that person’s medical care management team to provide effective and efficient care.

 

 

The Benefits of MED Management

 

MED Management has countless benefits that provide a “win” for all interested stakeholders in a workers’ compensation claim:

 

  • Injured workers: They continue to receive the medical care and treatment they are entitled to under any workers’ compensation program.  They also receive attention to their needs and assistance in avoiding prescription drug addiction and overdose.

 

  • Insurance Carriers and Self-Insureds: Parties who use this system receive the benefit of a proven program that reduces cost and future exposure.

 

  • Claim Management Teams: Having an ally in managing a workers’ compensation claim is important.  This program provides expertise in a complicated area of the claims process.

 

 

Conclusions

 

The MED Management program can be an effective tool in the effective management of a workers’ compensation claim.  It also allows all parties to receive the benefit of a proven program by reducing the chances of the injured worker from becoming another statistic in the prescription drug epidemic.

 

 

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.

Use of Drug Formularies to Reduce Workers’ Compensation Costs

The California workers’ compensation system may soon see some relief from the rising costs of prescription drug use in workers’ compensation cases through the adoption of a drug formulary.  If successful, it may spark a nationwide trend that will allow insurance carriers in more states to push for similar cost saving measures.

 

 

What is a “Drug Formulary?”

 

A drug formulary is a list of prescription medications that practitioners use to identify drugs that provide the patient with the greatest benefit.  They also include a cost-saving element, which is important in the workers’ compensation system.  The medications on these lists are both name brand and generics.  A panel of medical professionals that include doctors, nurse practitioners and pharmacists selects the drugs for inclusion on the drug formulary.  In order to ensure patient satisfaction and cost-effectiveness, these lists are continually evaluated and updated as needed.

 

 

Use of Drug Formularies in Workers’ Compensation

 

Washington, Texas, Ohio and Oklahoma are the only states that currently employ a drug formulary in their workers’ compensation system.  The California legislature recently passed a law that allows for the formation of a drug formulary to be used in its workers’ compensation system by 2017.

 

There are some differences in how these states operate their formularies.  This includes two specific types of formularies.

 

  • Closed Formulary. This type of formulary will include all available FDA prescription and non-prescription drugs.  These drugs are dispensed on an outpatient basis and identifies specific drugs, or drug classifications that required a pre-authorization process or are not covered.

 

  • Open Formulary. This will include all FDA approved prescription and non-prescription drugs with no pre-authorization or coverage barriers.

 

When a drug formulary is developed, it is includes a Preferred Drug List (PDL).  A PDL is a list of drugs included in the formulary that is “preferred” for coverage purposes.

 

Drug formularies typically exclude investigational or experimental drugs and “N” listed drugs, which are not recommended for use.  Like drug formularies for private health insurance plans, the injured worker is required to use medications on the formulary.  If a treating doctor prescribes a medication not on the approved list, exceptions can be made by following specified procedures.

 

 

Benefits to of a Drug Formulary

 

The use of drug formularies in workers’ compensation is a rather new concept so the exact impacts and long-term benefits are unknown.  Drug formularies are common in individual and group health plans, which have proven to be successful in reducing cost to the insurance carrier, yet at the same time making sure the patient receives the quality of care they deserve.  Other benefits include:

 

  • Provide patients with evidence-based outcomes and better results in prescription drug management;
  • Create a consensus on prescription medication treatment and care for patients;
  • Ensure a consistency of medical care and treatment; and
  • Involve a dispute resolution process and expedited appeals.

 

 

Additional Workers’ Compensation Applications

 

The use of a drug formulary can also be used to monitor the usage habits of a workers’ compensation claimant an identify areas of concern.  This can include malingering and use or abuse of opioid-based medications.  Another practical application is the prevention of fraud, waste and abuse in the system.

 

 

Conclusions

 

More states are adopting a drug formulary in their workers’ compensation system.  When used correctly, a formulary can ensure that injured workers receive the medical care and treatment they are entitled to and provide insurance carriers with cost savings.  However, while a formulary does carry many benefits, it is important to recognize it is not a ‘quick fix.’ Employers are encourage to remain actively involved in the process, including the management of a proactive pharmacy benefits management vendor relationship.

 

 

 

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 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 monthly basis 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.

 

 

©2015 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.

The Face and Cost of Opioid Addiction

The face of addiction is often perceived as not a pretty sight. The "normal" people of the world stand in judgment scoffing at what "those" people are doing.  In reality, the face of opioid addiction in workers’ compensation can look just like you, your neighbor, your best friend, or any average employee that had an accident at work. 

 

This honest, “average Joe” employee has never had a major injury, and has never been prescribed narcotics. 

 

 

Just Make the Pain Go Away

 

The pain from the injury is severe, so the treating physician prescribes a powerful opioid.  What the physician doesn’t know is that this injured worker is also facing a number of personal problems above and beyond his injury and has been looking for a magic bullet to make those go away.  Instead of using the opioid as prescribed, he starts to take more of it and more often, sometimes in combination with other medications or alcohol. 

 

When the magic bullet doesn’t work, the patient may tell stories of increased pain to convince the doctor, in good faith, to increase the strength of the pills or to prescribe more of them.  He may start seeing different doctors to obtain more drugs or even get drugs from friends and family.    His focus of recovery from the injury is replaced with a focus on obtaining more of the opioid, even though his problems continue to mount.   If his primary doctor does not continue to prescribe opioids as he requests, he may keep searching for a new doctor until he finds one that does.  This approach will only work for so long, as the injured worker continuously has to increase either the frequency of consumption or increase the potency of the opioid to find that euphoria. His craving intensifies and his motivation changes to seek the drug, even as his life spins out of control. He has become addicted to opioids.

 

 

Average Lost Time Claim with Long Acting Opioid 900% Higher than Without

 

This unfortunate story has become all too common in recent years.  The New York Times published an article on the subject titled “The Soaring Cost of the Opioid Economy.”  While the article does not address the cost within any particular company, the information gives us a scope of the opioid problem.

 

The cost of workers' compensation claims skyrockets when injured employees start using opioids.  The average workers’ comp claim with lost time costs $13,000 when no opioids are used.  When an employee is prescribed a short-acting opioid like Percocet® (oxycodone and acetaminophen), the average lost time claim cost triples to $39,000.  When an employee is prescribed a long-acting opioid like Oxycontin, the average lost time claim costs explodes to $117,000, an increase of 900% over the average lost time claim without the use of any opioids.

 

If an injured worker progresses from patterns of misuse to addiction, the treatment for addiction adds to the overall cost of the worker’s compensation claim.  The opioid addiction may be treated with…additional drugs, buprenorphine and naltrexone, as well as a comprehensive behavioral health and psychosocial model.  The use of buprenorphine and naltrexone has risen from near zero prescriptions in 2002 to nearly 8 million prescriptions in 2012.

 

Overall overdose deaths where prescription opioids were involved have also risen sharply along with the cost.  In 1999, there were 4,030 deaths due to opioid overdose.  By 2010, that number had more than quadrupled to 16,651.

 

 

Real Time Intervention Can Prevent Addiction and Decrease Costs

 

Whether an employer is self-insured for workers’ compensation, or has a work comp insurance company, the numbers clearly show how the cost of opioids can have a significant impact on the employer’s overall workers’ compensation costs.  To avoid the cost and employee health concerns of inappropriate opioid use, the employer or insurance company should utilize a comprehensive set of tools from their PBM to screen for patterns of misuse).  PBM best practices for early intervention screening for opioid utilization patterns should include: 

 

  • Implement real time flagging of inappropriately high doses of opioids with tools like a Morphine Equivalent Dose management program
  • Screen for early refill patterns to identify patients who may be taking medications more frequently or at higher doses than prescribed
  • Limit the number of doctors who can prescribe narcotics for an injured worker
  • Screen for opioid prescriptions from multiple pharmacies

 

 

Summary

 

NCCI research shows that while the number of workers' compensation claims has decreased, costs associated with these injuries continue to increase- especially for those on chronic opioids.  This cost is magnified if the injured worker misuses the medication or becomes addicted.  Aside from the huge cost to payers, addiction is very difficult to treat which negatively impacts the life of the worker.  Best practices to control opioid overutilization require systems to identify the issues in real time, educate the parties, and have a proven plan to implement steps that will improve the claim outcome.

 

 

Author Michael B. Stack, Principal, COMPClub, Amaxx Work Comp Solutions. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com, and Founder of the interactive Workers’ Comp Training platform COMPClub. Contact: mstack@reduceyourworkerscomp.com

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

WORKERS’ COMP TRAINING: https://workerscompclub.com

 

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

 

 

 

 

 

Understanding “Medical Marijuana” in Workers’ Compensation

Over the last several years, more states have adopted laws that govern the use of marijuana for medicinal purposes.  While marijuana remains a Schedule I controlled substance under federal law, more states are considering it for legal use to treat work injuries.

 

 

What Do State Laws Permit

 

There are roughly 23 states that allow the use of marijuana for medicinal purposes.  The laws in these states vary on how they can be used.  In Minnesota, the use of this drug is limited to liquid, pill or vaporized forms.  The smoking of marijuana remains illegal.  In other states such as California, possession of marijuana is limited to a specific number of plants a person may cultivate and otherwise possess, and allows for state issued cardholders to smoke marijuana to treat a medical condition.

 

The conditions for which marijuana can be used also vary from state to state.  Most states allow for it to be used for the following conditions:

 

  • Most forms of cancer;
  • Glaucoma;
  • HIV/AIDS;
  • Tourette’s Syndrome;
  • Amyotrophic lateral sclerosis/Lou Gehrig’s Disease (ALS);
  • Seizures and epilepsy;
  • Severe and persistent muscle spasms;
  • Crohn’s Disease;
  • Terminal illness with a life expectancy of less than a year; and
  • Chronic pain conditions.

 

The use of medical marijuana for “chronic pain conditions” is a contentious issue as definitions or pain varies in each jurisdiction.  The required levels of pain to qualify are often subjective in nature, which can lead to abuse or de facto legalization for recreational use.

 

 

Conflict with Federal Law

 

States that currently allow the use of marijuana for medical (and recreational use) are in conflict with federal law and the Controlled Substances Act, which is found under Title 21 of the United States Code.  Federal law enforcement has not taken dramatic steps for force compliance with federal law.  Under a 2015 federal budget act, the U.S. Department of Justice is specifically prohibited from using appropriations to shutdown state-legal medical marijuana programs.  Notwithstanding this capitulation by federal law enforcement, it is unclear how employers can comply with federal and state workplace safety laws if an employee has marijuana present in their system; even if they are not under the influence of the drug.

 

 

Implications in Workers’ Compensation

 

Most states with legalized medical marijuana are struggling to reconcile these laws with workers’ compensation program stakeholders seeking to promote “drug free” workplaces and other barriers imposed by federal laws and regulations.  One example of this conflict was in New Mexico.

 

In Vialpando v. Ben’s Auto. Services, 331 P.3d 975 (NM Ct. App. 2014), an employer was ordered to reimburse an injured employee for payments made to receive medical marijuana.  According to the court, the Lynn and Erin Compassionate Use Act, in conjunction with the New Mexico Workers’ Compensation Act required employers/insurers to provide “a worker [to] receive through employer reasonable and necessary health care services, which the regulations define to include drugs….”  In this instance, because marijuana was legal for medical use, it was compensable for purposes of workers’ compensation and “reasonable and necessary” medical care.

 

In approving the reimbursement for medical marijuana, the Court also examined a number of public policy concerns raised by the employer/insurer, which included:

 

  • A conflict in federal law regarding marijuana and state legalization for medical purposes; and
  • Workplace safety and concerns regarding employee’s using/being under the influence of controlled substances.

 

Both arguments were rejected by the courts.

 

 

Addressing Concerns Regarding Medical Marijuana

 

The legalization of marijuana presents a number of issues for program managers and other stakeholders in the area of workers’ compensation.  It is important for these parties to remain engaged on this issue and address it within their programs.  It also serves as an opportunity for people to be in contact with the state agencies who administer the workers’ compensation laws and regulations.

 

 

Author Michael B. Stack, Principal, COMPClub, Amaxx Work Comp Solutions. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com, and Founder of the interactive Workers’ Comp Training platform COMPClub. Contact: mstack@reduceyourworkerscomp.com.

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

WORKERS’ COMP TRAINING: https://workerscompclub.com

 

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

 

Overall Drug Trend For Workers’ Compensation Increased 1.9%

Webb StevenSteven Webb, President, Workers’ Compensation, Express Scripts

 

…on the need for a team approach to opioid management

 

There’s no silver bullet to manage the safety and cost concerns associated with opioid use. At Express Scripts, we help payers fire on all cylinders.

 

For example, our Morphine Equivalent Dose Management Program is a real-time safety check to prevent abuse or misuse of opioids before medication is dispensed.

 

We also have a program in place to communicate directly with the injured worker upon their first opioid fill.

 

And we collaborate with claims staff and prescribing physicians through various tools and communications to ensure comprehensive visibility into the injured workers’ prescription histories.

 

When payers proactively arm themselves with tools that hit every touch point, they help ensure safe and cost-effective treatment for their injured workers.

 

Upcoming Webinar: Insights from the 2014 Workers’ Compensation Drug Trend Report from Express Scripts Experts: May 21, 2015 at 11:00 CDT.

 

___________________________________________________________________________________________

 

Workers’ Compensation Rx Spend Increased 1.9% in 2014

 

While rising costs per prescription is still a concern, Express Scripts’ effective utilization management programs helped to stabilize the increase in drug trend.

 

Overall drug trend for workers’ compensation increased 1.9%, according to the 9th Annual Express Scripts Workers’ Compensation Drug Trend Report.

 

A 5.4% decrease in utilization helped offset a 7% increase in the cost per prescription.

 

TOP 10 WORKERS’ COMPENSATION THERAPY CLASSES

 TOP 10 WORKERS' COMPENSATION THERAPY CLASSES

 

 

Opioid Management Mitigates Spend Increases

 

The modest increase in overall pharmacy spend demonstrates the effectiveness of Express Scripts utilization management programs. In fact, opioid utilization among injured workers decreased nearly 11% in 2014.

 

As drug prices continue to increase, payers – now more than ever – are looking to contain costs by implementing effective programs that ensure safe and appropriate use of opioids.

 

Our data-driven solutions help payers meet this goal. For example, the Express Scripts Morphine Equivalent Dose (MED) Management program allows our clients to set maximum threshold levels for the amount of opioid medications an injured worker can fill. Amounts exceeding MED program levels undergo a review process by the client before the medication is dispensed.

 

According to the Washington State Agency Medical Directors’ Group (AMDG), patients receiving an MED of 100mg or more per day had a nine-fold increase in overdose risk. Our research found that more than one fifth of patients with work-related injuries longer than 15 years exceeded the MED of 120mg per day on more than half of the days for which opioid medications were being filled.

 

 

INJURED WORKERS PRESCRIBED OPIOID THERAPY WITH MED ≥ 120 MG

 

INJURED WORKERS PRESCRIBED OPIOID THERAPY WITH MED ≥ 120 MG

 

Although older injuries may require higher doses of opioids because the patient has become tolerant to previous doses, patients receiving an MED of 100mg or more raises serious concerns about the potential of addiction and abuse. Better management of opioid use among injured workers helps to reduce abuse, limit addiction and control costs.

 

 

Combatting Rising Compounded Medication Costs

 

For the second year in a row, compounded medications were one of the top 10 costliest therapy classes for workers’ compensation payers.

 

Unsustainable pricing greatly impacted the overall trend, and the average cost of compounds per prescription in 2014 was $1,696.99.

 

Our research found that pharmacies who compound more than two-thirds of their total prescriptions increased their prices 51.5% in 2014. Low-compounding pharmacies – or those than compounded less than 67% of their total prescriptions – averaged only a 9.7% price increase.

 

 

MEDIAN COSTS OF COMPOUNDED PRESCRIPTIONS FILLED

 

MEDIAN COSTS OF COMPOUNDED PRESCRIPTIONS FILLED

 

Our research also found that 10% of compound utilizers did not receive a traditional prescription before receiving their compounded medication – that is, they used a compounded medication as the first prescription for their injury.

 

This raises the question of why first-line therapies were not tried first. While accommodating needs for a patient who cannot ingest or is allergic to available alternatives is appropriate, there is no clinical evidence that compounded medications are more effective than FDA-approved, commercially available drugs.

 

 

Compound Management Solution

 

At the point of sale, Express Scripts workers’ compensation clients have the option of reviewing all compounds for authorization. Retrospectively, we communicate to physicians and injured workers encouraging the use of commercially available, cost-effective alternatives where appropriate.

 

When payers implement the physician communications program, 46.6% of their injured workers discontinued filling unnecessary compounded medications.

 

 

Reining in the Cost of Physician Dispensing

 

Medication dispensed through a physician’s office not only has a higher cost than if dispensed through a retail pharmacy, it also lacks a comprehensive view of a patient’s prescription history and profile. Without the checks and balances between prescriptions and pharmacists, injured workers are at risk for medication errors, drug interactions and duplicate dosing.

 

Our research found that the average cost of a physician-dispensed medication in 2014 was $173.75, compared to $111.68 for a pharmacy-dispensed medication.

 

This means that clients paid an average premium of about $62 per prescription for physician-dispensed medications.

 

Express Scripts’ Physician Dispensed Medication Solution helps to tackle the cost and utilization of physician dispensing.

 

 

The Reality Behind Generic Drug Inflation

 

Although price inflation for a few generic drugs has captured media attention recently, it is not a new phenomenon. There are two primary drivers of the inflation in generic drug pricing: manufacturer consolidation and temporary shortages of active ingredients.

 

While it’s true that the price for some generics have increased, on the whole, generic medications continue to deliver significant cost savings by providing cost-effective alternatives to brand name medications. Consider that since 2008, the average price of brand drugs has almost doubled, while the average price of generic drugs has been cut roughly in half.

 

 

THE EXPRESS SCRIPTS PRESCRIPTION PRICE INDEX

THE EXPRESS SCRIPTS PRESCRIPTION PRICE INDEX

 

Express Scripts helps lower drug costs by driving competition in the market and by leveraging our scale to drive the best prices for payers. In general, encouraging use of generics over more expensive brand alternatives, when clinically appropriate, is still an effective way for payers to keep costs down.

 

Express Scripts research found that for every 1% increase in the generic fill rate, a payer can expect to reduce prescription drug costs by as much as 2%.

 

 

Understanding Specialty Trend

 

Specialty medications treat relatively small groups of patients with complex, chronic conditions. These drugs are typically are very expensive and most have special-handling requirements. In addition, patients taking specialty medications may need ongoing clinical monitoring and more-intensive assistance and guidance from pharmacists or other caregivers.

 

Many occupations have specific risks such as HIV, hepatitis C, or other blood-borne pathogens resulting from needle sticks or other exposures (healthcare providers and first responders), black lung disease (coal miners), and Lyme disease (outdoor workers/landscapers or park employees). Additionally, some consequential conditions, including post-operative blood clots, osteoarthritis knee pain and even organ failure, are treated with specialty medications.

 

Although specialty medications represent less than 1% of all medications used by injured workers, they have the potential to increase drug spend significantly because their costs are rising rapidly. Between 2013 and 2014, spend on specialty medications increased 30.4%. New specialty medications offer clinical options for the treatment of occupational injuries and the hope of improved medical outcomes, but the cost pressures they present prove challenging to payers in the management of these medications.

 

For example, drugs to treat hepatitis C, Sovaldi® (sofosbuvir) and Olysio® (simeprevir), had the highest cost per prescription, with average cost upwards of $20,000 per 28-day prescription. Sovaldi alone accounted for more than 57% of the new-drug contribution to 2014 PUPY specialty spend.

 

 

Author: 

 

Rochelle Henderson, PhD, is Senior Director of Research for Express Scripts, Inc. In this capacity, she supervises a team of Ph. D. heath policy researchers and works with schools of pharmacy and medical schools in the greater St. Louis area. She serves on a number of health related research teams with institutions across the St. Louis region: Washington University School of Medicine with Barnes Hospital, the Veteran’s Administration Regional Hospital, and with the School of Nursing from Southern Illinois University at Edwardsville (SIUE). Dr. Henderson holds an adjunct faculty position at SIUE, teaching courses in epidemiology and quantitative analysis. She has 20 years of experience in pharmacoepidemiologic and pharmacoeconomic research. Dr. Henderson also has extensive publishing credits, including numerous peer-reviewed articles in American Journal of Managed Care, Journal of Managed Care Pharmacy, Annals of Pharmocotherapy, Clinical Therapeutics, and other prestigious journals. Dr. Henderson received her Doctorate from the University of Missouri – St. Louis.

 

Workers’ Compensation Prescription Drug Spend Increased 1.9 Percent in 2014, Stabilized by Effective Utilization Management Programs

Rising Prescription Prices for Compounded Medications Still a Concern

 

St. Louis, /PRNewswire/ — Workers’ compensation pharmacy spending increased 1.9 percent in 2014, as a 5.4 percent decrease in utilization helped offset a 7 percent increase in the cost per prescription, according to new data released today by Express Scripts (NASDAQ: ESRX).

 

The 2014 Express Scripts Workers’ Compensation Drug Trend Report discusses the overall pharmacy trend as well as in-depth research on opioid use among injured workers.

 

 

Opioid Management Mitigates Spend Increases

 

The modest increase in overall pharmacy spend demonstrates the effectiveness of utilization management programs, such as those which drove down injured workers’ opioid utilization nearly 11 percent in 2014.

 

This decrease in utilization balanced an 11.5 percent increase in the average cost per prescription. As a result, total spending on workers’ compensation opioids remained flat (-0.5 percent) in 2014, at a per-user-per-year cost of $487.59.

 

“As drug prices continue to increase, payers now more than ever are looking to contain costs by implementing effective programs that ensure safe and appropriate use of opioids,” said Jennifer Kaburick, RN, senior vice president, Workers’ Compensation Product, Compliance and Strategic Initiatives.

 

Express Scripts leverages data to develop innovative solutions to meet these needs. For example, the Express Scripts Morphine Equivalent Dose (MED) Management program allows clients to set maximum threshold levels for the amount of opioid medications an injured worker can fill. Amounts exceeding MED program levels undergo a review process by the client before the medication is dispensed.

 

Patients receiving an MED of 100 milligrams or more per day had a nine-fold increase in overdose risk.Express Scripts’ research found that patients with work-related injuries longer than 15 years exceeded the MED of 120 milligrams per day on more than half of the days for which opioid medications were being filled.

 

“Although older injuries may require higher doses of opioids because the patient has become tolerant to previous doses, patients receiving an MED of 100 milligrams or more raises serious concerns about the potential of addiction and abuse,” said Brigette Nelson, MS, PharmD, BCNP, senior vice president, Workers’ Compensation Clinical Management at Express Scripts. “Better management of opioid use among injured workers helps to reduce abuse, limit addiction and control costs.”

 

 

Combating Rising Compounded Medication Costs

 

For the second year in a row, compounded products were one of the top 10 costliest therapy classes for workers’ compensation payers.

 

Unsustainable pricing greatly impacted the overall trend, and the average cost of compounds per workers’ compensation prescription in 2014 was $1,696.99.

 

According to Express Scripts’ research, pharmacies that compound more than two-thirds of their total prescriptions increased their prices 51.5 percent in 2014. Low-compounding pharmacies — or those than compounded less than 67 percent of their total prescriptions — averaged only a 9.7 percent price increase.

 

At the point of sale, payers have the option of reviewing all compounds for authorization. Retrospectively, Express Scripts communicates to physicians and injured workers encouraging the use of commercially available, cost-effective alternatives where appropriate.

 

Express Scripts research found that 10 percent of compound utilizers did not receive a traditional prescription before receiving their compounded medication — that is, they used a compounded medication as the first prescription for their injury.

 

“This raises the question of why first-line therapies were not tried,” Nelson said. “While accommodating needs for a patient who cannot ingest or is allergic to available alternatives is appropriate, there is no clinical evidence that compounded medications are more effective than FDA-approved, commercially available drugs.”

 

When payers implement the physician communications program, 46.6 percent of their injured workers discontinued filling unnecessary compounded medications.

 

  • Other key findings of the Workers’ Compensation Drug Trend Report include:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), used in treating pain and inflammation, increased 13.4 percent to reach $158.33 per user per year.
  • Antidepressants and dermatologicals decreased 19.6 percent and 10.9 percent, respectively.

 

While specialty medications represent less than 1 percent of all medications used by injured workers, spending on these drugs increased 30.4 percent between 2013 and 2014, largely driven by expensive medications to treat hepatitis C.

 

The Express Scripts 2014 Workers’ Compensation Drug Trend Report is available at http://Lab.Express-Scripts.com.

 

 

About Express Scripts

 

Express Scripts (NASDAQ: ESRX) manages more than a billion prescriptions each year for tens of millions of patients. On behalf of our clients — employers, health plans, unions and government health programs — we make the use of prescription drugs safer and more affordable. Express Scripts uniquely combines three capabilities — behavioral sciences, clinical specialization and actionable data — to create Health Decision Science(SM), our innovative approach to help individuals make the best drug choices, pharmacy choices and health choices. Better decisions mean healthier outcomes.

 

Headquartered in St. Louis, Express Scripts provides integrated pharmacy-benefit management services, including network-pharmacy claims processing, home delivery, specialty benefit management, benefit-design consultation, drug-utilization review, formulary management, and medical and drug data analysis services. The company also distributes a full range of biopharmaceutical products and provides extensive cost-management and patient-care services.

 

For more information, visit Lab.Express-Scripts.com or follow @ExpressScripts on Twitter.

 

MEDIA CONTACT:
Ellen Drazen

Office: 314-684-5355
evdrazen@express-scripts.com

 

Logo – http://photos.prnewswire.com/prnh/20080827/EXPRESSSCRIPTSLOGO

 

To view the original version on PR Newswire, visit:http://www.prnewswire.com/news-releases/workers-compensation-prescription-drug-spend-increased-19-percent-in-2014-stabilized-by-effective-utilization-management-programs-300068465.html

 

SOURCE Express Scripts

Convincing Data Shows Physician’s Writing Scripts For Profit

A new study from Cambridge-based Workers Compensation Research Institute (WCRI) entitled “Physician Dispensing Associated With Unnecessary Prescribing Of Opioids,” found evidence that physician dispensing encouraged some physicians to unnecessarily prescribe strong opioids. The study analyzed the prescribing behavior after Florida banned physician dispensing of strong opioids.

 

 

Physician Prescribing Practices Consistent With What Benefits Their Pocketbook, Rather Than Patient Health

 

The authors of the study, The Impact of Physician Dispensing on Opioid Use, expected little change in the percentage of patients getting strong opioids—only a change from physician-dispensed to pharmacy-dispensed. Instead of finding an increase in pharmacy-dispensed strong opioids, the study found no material change. Rather, there was an increase in the percentage of patients receiving physician-dispensed weaker pain medications—specifically, nonsteroidal anti-inflammatory medications (e.g., ibuprofen)—from 24.1 percent to 25.8 percent, and the percentage receiving weaker (not banned) opioids increased from 9.1 percent to 10.1 percent.

 

The study found there was a high level of compliance with the ban by physician-dispensers. Prior to the reforms, 3.9 percent of injured workers received strong opioids dispensed by physicians during the first six months after their injuries. After the ban, only 0.5 percent of patients with new injuries received physician-dispensed strong opioids. If the pre-ban strong opioids were necessary, researchers would expect that workers who received weaker physician-dispensed pain medications after the ban would later need strong opioids (that can be dispensed only at a pharmacy). But only 2 percent of those with weaker physician-dispensed pain medications in the first six months after the ban received strong opioids at a pharmacy in the next six months.

 

 

Policymakers Should Consider Reforms That Limit Physician Dispensing

 

According to the study, the policy debate in a growing number of states has been focused on the much higher prices charged by physician-dispensers than pharmacies for the same medications. The debate has recently begun to focus on whether the economic incentives attendant to physician dispensing (like any form of physician self-referral) lead to prescribing and dispensing of unnecessary medications. Over the past 10 years, 18 states have modified reimbursement rules to reduce the prices paid for physician-dispensed drugs. Until recently, few of these states also limited the use of physician dispensing. The findings of this study raise the question of whether policymakers should consider reforms that limit the use of physician dispensing of certain medications in addition to reforms aimed at limiting the prices of physician-dispensed drugs.

 

“When we compare pre- and post-reform prescribing practices, it appears that physician-dispensers not only reduced their dispensing of strong opioids, but also reduced prescribing of strong opioids. This raises concerns that a significant proportion of pre-reform physician-dispensed strong opioids were not necessary, which means injured workers in Florida were put at greater risk for addiction, disability or work loss, and even death,” said Richard Victor, WCRI’s executive director. “Since Florida has banned physician dispensing of strong opioids, the lessons of this study are relevant for the other states concerned about eliminating unnecessary costs in their system while protecting injured workers from unnecessary medical care.”

 

This study analyzed data on the medications dispensed for injured workers covered by the Florida workers’ compensation program. It included both open and closed Florida claims. The claims were divided into two groups: pre-reform, with dates of injury from January 1, 2010, to June 30, 2010 (prior to the July 1, 2011, effective date of the ban) and post-reform, with dates of injury from July 1, 2011, to December 30, 2011 (immediately after the ban). The data included 24,567 claims with 59,564 prescriptions in the pre-reform group and 21,625 claims with 52,747 prescriptions in the post-reform group.

 

For more information about this study or to purchase a copy, visit http://www.wcrinet.org/result/PD_opioid_result.html.

 

 

ABOUT WCRI:

 

The Workers Compensation Research Institute (WCRI) is an independent, not-for-profit research organization based in Cambridge, MA. Founded in 1983, the WCRI is recognized as a leader in providing high-quality, credible, and objective information about public policy issues involving workers’ compensation systems. WCRI’s diverse membership includes employers; insurers; governmental entities; managed care companies; health care providers; insurance regulators; state labor organizations; and state administrative agencies in the U.S., Canada, Australia, and New Zealand. For more information, visit: http://www.wcrinet.org.

 

 

 

Author Michael Stack, Principal of Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  As the senior editor of Amaxx’s publishing division, Michael is on the cutting edge of innovation and thought leadership in workers compensation cost containment. http://reduceyourworkerscomp.com/about/.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

Physician Dispensing Associated With Unnecessary Prescribing Of Opioids

 

Cambridge, MA, Dec. 16, 2014―A new study from the Workers Compensation Research Institute (WCRI) found evidence that physician dispensing encouraged some physicians to unnecessarily prescribe strong opioids. The study analyzed the prescribing behavior after Florida banned physician dispensing of strong opioids.

 

 

The authors of the study, The Impact of Physician Dispensing on Opioid Use, expected little change in the percentage of patients getting strong opioids—only a change from physician-dispensed to pharmacy-dispensed. Instead of finding an increase in pharmacy-dispensed strong opioids, the study found no material change. Rather, there was an increase in the percentage of patients receiving physician-dispensed weaker pain medications—specifically, nonsteroidal anti-inflammatory medications (e.g., ibuprofen)—from 24.1 percent to 25.8 percent, and the percentage receiving weaker (not banned) opioids increased from 9.1 percent to 10.1 percent.

 

The study found there was a high level of compliance with the ban by physician-dispensers. Prior to the reforms, 3.9 percent of injured workers received strong opioids dispensed by physicians during the first six months after their injuries. After the ban, only 0.5 percent of patients with new injuries received physician-dispensed strong opioids. If the pre-ban strong opioids were necessary, researchers would expect that workers who received weaker physician-dispensed pain medications after the ban would later need strong opioids (that can be dispensed only at a pharmacy). But only 2 percent of those with weaker physician-dispensed pain medications in the first six months after the ban received strong opioids at a pharmacy in the next six months.

 

According to the study, the policy debate in a growing number of states has been focused on the much higher prices charged by physician-dispensers than pharmacies for the same medications. The debate has recently begun to focus on whether the economic incentives attendant to physician dispensing (like any form of physician self-referral) lead to prescribing and dispensing of unnecessary medications. Over the past 10 years, 18 states have modified reimbursement rules to reduce the prices paid for physician-dispensed drugs. Until recently, few of these states also limited the use of physician dispensing. The findings of this study raise the question of whether policymakers should consider reforms that limit the use of physician dispensing of certain medications in addition to reforms aimed at limiting the prices of physician-dispensed drugs.

 

“When we compare pre- and post-reform prescribing practices, it appears that physician-dispensers not only reduced their dispensing of strong opioids, but also reduced prescribing of strong opioids. This raises concerns that a significant proportion of pre-reform physician-dispensed strong opioids were not necessary, which means injured workers in Florida were put at greater risk for addiction, disability or work loss, and even death,” said Richard Victor, WCRI’s executive director. “Since Florida has banned physician dispensing of strong opioids, the lessons of this study are relevant for the other states concerned about eliminating unnecessary costs in their system while protecting injured workers from unnecessary medical care.”

 

This study analyzed data on the medications dispensed for injured workers covered by the Florida workers’ compensation program. It included both open and closed Florida claims. The claims were divided into two groups: pre-reform, with dates of injury from January 1, 2010, to June 30, 2010 (prior to the July 1, 2011, effective date of the ban) and post-reform, with dates of injury from July 1, 2011, to December 30, 2011 (immediately after the ban). The data included 24,567 claims with 59,564 prescriptions in the pre-reform group and 21,625 claims with 52,747 prescriptions in the post-reform group.

 

For more information about this study or to purchase a copy, visit http://www.wcrinet.org/result/PD_opioid_result.html.

 

 

ABOUT WCRI:

 

The Workers Compensation Research Institute (WCRI) is an independent, not-for-profit research organization based in Cambridge, MA. Founded in 1983, the WCRI is recognized as a leader in providing high-quality, credible, and objective information about public policy issues involving workers’ compensation systems. WCRI’s diverse membership includes employers; insurers; governmental entities; managed care companies; health care providers; insurance regulators; state labor organizations; and state administrative agencies in the U.S., Canada, Australia, and New Zealand. For more information, visit: http://www.wcrinet.org.

 

 

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