Eliminate Physician Dispensing To Reduce Prescription Drug Costs

One of the driving factors in workers’ compensation cost containment is pharmaceutical waste.  This waste is having a significant impact on the medical costs associated with claims.  Seeking partners that have solutions to reduce waste can lead to a more effective program and benefit all interested stakeholders.



Waste in Pharmacy Benefits Defined


The concept of “waste” can be defined as the extra amount of money spent with no incremental gain in health outcomes.  In the area of pharmacy benefits, this most often takes place when prescription medications are dispensed through more expensive methods of delivery to the injured worker, for example through the physician’s office directly. It can also be the result of inexperienced healthcare consumers—the injured worker—making misinformed decisions on where to receive their prescription medications.



Trends in Work Comp Pharmacy Benefits Costs


According to Express Script’s Workers’ Compensation Drug Trend Report, payers spend 58% more for physician-dispensed medications than for pharmacy-dispensed medications. Also, medications dispensed via home delivery will often realize a greater discount than pharmacy-dispensed medications.


The 2016 NCCI Workers’ Compensation and Prescription Drugs Research Brief states “recent Rx findings include the countrywide 2014 physician‐dispensed share of prescription drug costs was 10%…in highly regulated states the physician‐dispensed share of prescription drug costs was less than 2%…if not highly regulated…costs exceeded 20%.”



Convenience and Safety


The most attractive feature of physician dispensing for the injured worker is convenience.  However, it is important to recognize that medications dispensed from a physician’s office are not subject to the same safety controls and oversight as in retail or home delivery pharmacy.



Do Not Allow Physician Dispensing


If the employee’s medical provider has been dispensing medication to the injured employee from the provider’s office, send a letter to the employee, employee’s attorney, and the doctor advising that the PBM should provide all medications through the pharmacy benefit card provided to the employee. The letter to the employee should detail the safety concerns, as well as highlight the benefits and potential to eliminate waste. In addition, encourage PPOs to create policy forbidding network physicians to dispense drugs.


Reasons to avoid physician dispensing:


  • Cost of drugs is significantly higher
  • Dispensing from physicians office bypasses all of the safety measures of prospective and retrospective review by the PBM.
  • Misaligned financial incentives for prescribing physician



Consider Home Delivery For Long-Term Medications


Home delivery is the most convenient, safe, and cost-effective delivery channel when an injured worker is taking long-term medications for their injuries. The use of home delivery a successful model that can meet the needs of all interested stakeholders in a workers’ compensation program.


  • Insurance Carriers and TPAs: Home delivery meets the needs of this stakeholder by reducing costs associated with pharmacy claims and reducing waste.  It allows for the easy monitoring of what prescription medications are being ordered to avoid issues associated with addiction.  It can also reduce dispensing costs and streamlines billing purposes.  This is especially the case of self-insured employers or those who use TPAs to administer their workers’ compensation programs; and


  • Injured workers: Home delivery is the most convenient mechanism for an injured worker to receive their long-term prescription medication.  It is predictable, reduces waste, and utilizes state-of-the-art technology, checkpoints, and automation to virtually eliminate errors that error retail pharmacy.




Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center.


Contact: mstack@reduceyourworkerscomp.com.

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


©2018 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.


WCRI Conference to Highlight Trends, Solutions to Opioid Dependence in WC

“We find extensive opioid prescribing leads to longer duration of temporary disability. When we compare the effect of longer-term opioid prescriptions with no opioid prescriptions, the effect is to triple the duration of temporary disability benefits.”


That finding from the Workers Compensation Research Institute highlights the latest trends in the opioid epidemic as it relates to the workers’ compensation industry. It represents the first evidence of a causal relationship between long-term opioid use and disability duration. The authors will be on hand to delve into the research and the topic during WCRI’s Annual Issues and Research Conference in Boston this month.



Latest Evidence


The WCRI researchers looked at data from 28 states for low back pain injuries between 2008 and 2013 where workers had more than 7 days of lost work time. Additional findings were:


  1. Local prescribing patterns play a significant role in whether injured workers receive opioid prescriptions. In certain states and particular areas within states, injured workers are more likely to receive opioid prescriptions than in other areas. When they compared injured workers with the same injuries in different areas, they found that a 10 percentage point increase in the local rate of longer-term opioid prescribing was associated with a 2.6 percentage point higher likelihood that a similarly injured worker would receive longer-term opioid prescriptions.


  1. Opioid prescriptions persist, despite recommendations against them. While most medical guidelines do not typically recommend prescribing of long-term opioids for low back pain, about 12 percent of WCRI’s sample had them prescribed, and about 39 percent of workers had at least three opioid prescriptions.



Experts Weigh In


In addition to reviewing the most up to date trends, conference attendees will also hear about successful solutions employers are undertaking. The session “Saving Lives—Building a Modern Pharmacy Program amid a Deadly Epidemic” will feature the medical director of the Ohio Bureau of Workers’ Compensation discussing interventions that have had notable results:


  • 2011 — more than 8,000 injured workers in Ohio were opioid dependent; meaning they were taking the equivalent of at least 60 mg a day of morphine for at least 60 days.
  • 2017 — by the end of the year, the number was reduced to 3,315.


Dr. Terrence Welsh will outline the steps the Bureau took to reduce by 4,714 the number of injured workers at risk for opioid addiction.


United Airlines has undertaken various initiatives to curb the misuse of opioids among its injured workers, which will be outlined in a separate session. Joan Vincenz joins a representative from the National Safety Council and another from WCRI to discuss how opioids are impacting the workplace and steps employers can take to mitigate them.


A growing interest in medical marijuana and its potential effect on opioid prescribing for chronic pain patients is the focus of a discussion in another session. Dr. David Bradford of the University of Georgia will share results of a new study on drugs used to treat clinical conditions for which marijuana might be a potential alternative treatment.



The Evolution of WC


In addition to the opioid epidemic, the conference also focuses on how the work world is changing and the potential impact on workers’ compensation.


  • Will robots take our jobs?
  • Will the workplace be safer with automation or less safe with undertrained independent contractors?
  • How will we insure the new workplace?
  • Will new legal cases arise around independent contractors and on-the-job injuries?


Those are among the questions a distinguished panel of workers’ compensation thought leaders will attempt to answer. A representative each from a large employer, carrier, judicial sector, and labor will make their predictions.


A longer-term forecast is expected in the session, “Scenarios: Workers’ Compensation 2030.” Former WCRI President and CEO Richard Victor will examine external forces shaping the world and the challenges they pose to the industry.


The conference, with the theme “Work and the Comp System: Evolution, Disruption, and the Future,” takes place March 22 and 23 in Boston.



Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center .


Contact: mstack@reduceyourworkerscomp.com.

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


©2018 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.


How Prescription Drugs Impact Your Company and What You Can Do About It

How Drugs Impact Your Company and What You Can Do About ItMore than 70 percent of employers say they have felt the impact of prescription drug usage. That sobering statistic from the National Safety Council highlights the fact that, despite successful efforts by some employers and Pharmacy Benefit Managers to stem the abuse and misuse of opioids and other legal drugs among injured workers, the workplace continues reeling from the effects of legal medications.


The NSC’s survey of employers shows there are many areas where employers can take action to address the issue, and for each employee helped, employers can save more than $3,200 annually. Representatives of the NSC, United Airlines, and the Workers Compensation Research Institute will unveil the latest research on how opioids are impacting employers, and the duration of disability for injured workers, during WCRI’s upcoming annual conference.



Substance Use Disorder


‘Substance use disorder’ is the current term to describe the recurrent use of alcohol and drugs that cause clinically and functionally significant impairment, including health problems, disability and a failure to meet major responsibilities at work, school or home. The terms substance abuse and substance dependence are no longer used, according to the latest version of the Diagnostic and Statistical Manual of Mental Disorders.


In 2014, there were an estimated 1.9 million people with opioid use disorder related to prescription pain relievers and an estimated 586,000 with an opioid use disorder related to heroin use. There are a variety of symptoms, such as an inability to control or reduce use, continued use despite interference with major obligations or social functioning, use of larger amounts over time, development of tolerance, spending a great deal of time to obtain and use opioids, and withdrawal symptoms that occur after stopping or reducing use, such as negative mood, nausea or vomiting, muscle aches, diarrhea, fever, and insomnia.



Impact on Employers


Absenteeism is cited as the #1 impact of prescription drugs in the workplace, according to the NSC survey. Workers who have substance use disorders miss almost 50 percent more work days than their peers — up to six weeks annually.


Using pain relievers at work, having a positive drug test and being impaired or having decreased job performance were also included on the list of ways prescription drugs have impacted companies.


‘Near miss or injury’ was named by 15 percent of the respondents as a problem among prescription drug abusers. 84 percent of the employers cited concern over the costs of workers’ compensation because of prescription drug use.


Here are some additional findings from the survey:


  • 76 percent are not offering training on how to identify signs of misuse.
  • 81 percent lack a comprehensive drug-free workplace policy. Of those that do a drug test, 41 percent don’t test for synthetic opioids.
  • 19 percent feel ‘extremely prepared’ to deal with prescription drug misuse.
  • 70 percent would like to help employees return to work following appropriate treatment.
  • 88 percent are interested in insurance coverage for alternative pain treatments


The NSC conducted the survey of more than 500 HR decision makers for companies with at least 50 employees. Looking at specific industries and demographics, the Council said construction, entertainment, recreation and food service sectors have twice the national average of employees with substance use disorders.


Industries dominated by women or older adults had a two-thirds lower rate of substance abuse, and industries that have higher numbers of workers with alcohol use disorders also had more illicit drug, pain medication and marijuana use disorders


Employers were most concerned about the costs of benefits associated with substance use disorders, and their ability to hire qualified workers. They were less concerned about drug misuse and illegal drug sales or use.


The NSC also said that workers who are in recovery have lower turnover rates and are less likely to miss workdays, less likely to be hospitalized and have fewer doctor visits.


While 71 percent of employers say prescription drug misuse is a disease that requires treatment, 65 also feel it is a justifiable reason to fire an employee.



Action Steps


Healthcare costs for employees who misuse or abuse prescription drugs are three times higher than for other employees. And the annual cost of untreated substance use disorder ranges from $2,600 to as high as more than $13,000 per employee.


The good news is employers can take steps to protect their companies and employees. They include:


  1. Recognize prescription drugs impact the bottom line
  2. Enact strong company drug policies
  3. Expand drug panel testing to include opioids
  4. Train supervisors and employees to spot the first signs of drug misuse
  5. Treat substance abuse as a disease
  6. Leverage a best-in-class Pharmacy Benefits Management provider relationship




Nearly 21 million are living with substance use disorders of one type or another; more than the entire population of the state of New York. Most of those people are employed.
The problem costs the U.S. economy more than $400 billion per year. Employers can play a significant role in reducing this epidemic. In fact, employer-supported and monitored treatment yields better-sustained recovery rates than treatment initiated at the request of friends and family members.



Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center.


Contact: mstack@reduceyourworkerscomp.com.

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


©2018 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.

Arm Injured Workers with Information to Prevent Opioid Abuse

Arm Injured Workers with Information to Prevent Opioid AbuseThey say the best consumer is an informed consumer. This statement is certainly true for injured workers being prescribed opioids.


Among the steps that will help curb the opioid epidemic in this country is educating patients. Most people are not fully aware of the effects of these drugs or that they are not the only option for treating pain.


“I’ve always felt that if patients knew all the risks, beyond those of addiction, many of them would opt for one of the other therapies,” said Phil Walls, Chief Clinical Officer of myMatrixx. In his webinar series on patient advocacy and opioid therapy, Walls stresses the idea of arming injured workers with full knowledge of the side effects and warnings before starting them on opioids. He suggests providers use information available on the internet from the federal government to begin a dialogue with injured workers.



Many Risks of Opioids


While the risks of addiction, overdose, and death have been well publicized with prolonged use of opioids, there is also the danger of tolerance. Tolerance means the person will need to take more of the medicine to get the same pain relief; and a higher risk of physical dependence, along with withdrawal symptoms is present if the drugs are stopped.


There are many other, less publicized risks from opioids. The Centers for Disease Control and Prevention outlines several of them in its Prescription Opioid Factsheet for Providers:


  • Increased sensitivity to pain
  • Constipation
  • Nausea, vomiting, and dry mouth
  • Sleepiness and dizziness
  • Confusion
  • Depression
  • Low levels of testosterone that can result in lower sex drive, energy, and strength
  • Itching and sweating


The risks are even higher when certain other conditions are present. Sleep apnea, for example, heightens the risk of side effects, as does pregnancy, depression, and being 65 years of age or older.


Mixing opioids with other medications can be dangerous or even fatal. A cocktail of benzodiazepines — Xanax or valium — and muscle relaxants should be avoided “unless specifically advised by your health care provider,” according to the CDC.





“Opioids are not the first line or routine therapy for chronic pain,” the CDC explains. Research shows that other medications with far fewer side effects can be as, or more effective for pain relief if taken as prescribed. These alternatives include acetaminophen, ibuprofen, and naproxen.


Other non-medicinal treatments for chronic pain include physical therapy, and cognitive behavioral therapy (CBT). CBT is a short-term, goal-directed approach that teaches patients how to modify their thinking and behaviors to manage pain.


For injured workers who fail to get pain relief from any other measures and are prescribed opioids, nonpharmacologic therapy, and nonopioid pharmacologic therapy should be combined with them, the CDC advises. Opioid therapy should be considered “only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.”



Discussion Starters


In addition to the CDC, other government entities also have valuable information available on the web. One is the Food and Drug Administration.

“How does the FDA approach patient advocacy with regard to opioids? They arm the patient with questions to ask their provider,” Walls explains. “This is a very interesting approach because the FDA is empowering patients to take charge of their own care.”


The FDA document, What to Ask Your Doctor Before Taking Opioids, can be a great way to open the dialogue about opioids and their alternatives. Among the FDA’s suggested questions are:


  1. Why do I need this medication — is it right for me? Topics under this general heading that should be addressed between the provider and injured worker are:
    1. How long do you expect it to last?
    2. What medication are you giving me?
    3. If it’s an opioid, are there non-opioid options that could help with pain relief while I recover?”


  1. How long should I take this medication? The FDA suggests patients ask their providers to prescribe the lowest dose and the smallest quantity for the average patient. Walls says providers should be even more vigilant, realizing that many patients are not ‘average.’ “If the patient isn’t average, that average low dose may actually be an overdose,” he says. “The only way to find the lowest possible dose is to start with one less.”


  1. Can I have a Rx for naloxone? This medication can reverse the effects of an opioid overdose. Walls points out that only high-risk patients should need this, in which case the provider should consider something besides opioids. Also, the injured worker’s caregiver needs to understand that naloxone takes the patient into an immediate withdrawal situation, which requires emergency care.





In addition to educating workers’ compensation stakeholders about the risks of opioids, injured workers themselves should be made aware of the facts. Information available on some government websites can help providers be prepared to have honest discussions with their patients.




Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center.


Contact: mstack@reduceyourworkerscomp.com.

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


©2018 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.

Leverage Specialty Pharmacy Services in Complex Workers’ Comp Claims

Leverage Specialty Pharmacy Services in Complex Workers’ Comp Claims The increasing use of prescription medications places unique challenges on workers’ compensation programs.  Part of the problem is the complex nature of these issues.  This includes the use of “specialty pharmacy” to address the needs of complex matters.



What is Specialty Pharmacy?


The pharmaceutical business is always changing.  One of those changes is the rise in “specialty pharmacy,” which fills specialized prescription drugs, or those that are needed for small groups of patients with complex, chronic conditions. These prescriptions require additional care in their dispensing, handling, and delivery including patient education and training on side effects and self-administration of drugs beyond what is available at a typical retail pharmacy.


Specialty Pharmacy staff including nurses and pharmacists will be trained in complex conditions and treatments to offer patients additional education and resources.



Specialty Pharmacy and Its Impact on Work Comp


According to the latest Express Script’s Workers’ Compensation Drug Trend Report, specialty drugs account for 5.9% of total pharmacy costs, yet account for less than 1% of drugs used by injured workers’.


Specialty pharmacies focus on prescription medications that are not commonly used and dispensed.  These medications usually affect high-risk occupations that have unique challenges.


Some examples of conditions where specialty pharmacy come into play include:


  • Hepatitis C infections;
  • HIV/AID treatment;
  • Various cancers; and
  • High blood cholesterol­­­.



Common specialty prescription medications used include:


  • Harvoni® (ledipasvir/sofosbuvir): Antivirals (hepatitis C)
  • Enoxaparin sodium: Anticoagulants
  • Enbrel® (etanercept): Anti-inflammatories
  • Truvada® (emtricitabine/tenofovir): Antivirals (HIV)
  • Gleevec® (imatinib): Oncology drugs
  • Isentress® (raltegravir): Antivirals (HIV)
  • Xolair® (omalizumab): Asthma and allergy drugs



Implementing Specialty Pharmacy to Reduce Program Costs


Using a specialty pharmacy as part of your workers’ compensation program is essential for any workers’ compensation program administrator who seeks a competitive advantage in complex cases.  Use of this program can drive down costs and maintain a high standard of care for injured workers with the most complex and chronic conditions.


In the area of specialty pharmacy, the increasing cost associated with lifesaving prescription medications is primarily driven by two factors: an increase in the average cost per prescription, and increased utilization costs associated with specialty pharmacy medications.


Implementation of a specialty pharmacy program should be part of working pharmacy benefits manager relationship with expertise in this area.  Run a pilot program for 60-90 days to evaluate and compare your results to industry benchmarks.





To be successful with complex and chronic conditions, workers’ compensation program administrators and members of the claim management team should be aware of and utilize specialty pharmacies.  This will allow them to properly manage and reduce costs for specialized prescriptions that can cure and relieve the effects of uncommon workers’ compensation injuries.




Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center.


Contact: mstack@reduceyourworkerscomp.com.

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


©2018 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 Significance of Maximum Medical Improvement in Worker’s Comp

The Significance of Maximum Medical Improvement in Worker’s CompThe concept of “maximum medical improvement” (MMI) is an important notion in workers’ compensation claims.  This concept is based on the fact that it often triggers the discontinuance of various wage loss benefits.  In other instances, once an employee reaches MMI, cases are prime for settlement.  Failure to identify this status promptly can add unnecessary costs to claims and the bottom line of a workers’ compensation program.



What is MMI?


Maximum medical improvement (in some instances referred to “end of healing period”) is a legal concept where no further significant recovery from or lasting improvement to a personal injury can be reasonably anticipated, regardless of subjective complaints from the employee.  In essence, additional medical care and treatment may still be required to keep the employee in a stable condition, but no noticeable improvement will take place in that medical care.


Each jurisdiction has a legally defined standard for MMI.  This standard is defined in statute or rule and interpreted via case law.  Any doctor or health care provider can usually declare an injured employee to be at MMI if they have an adequate foundation to issue their findings and opinions within a reasonable degree of medical certainty.



Significance of MMI in Your Claim


Placing an employee suffering the effects of a work injury at MMI has a significant impact on the employee’s ability to receive future workers’ compensation benefits including entitlement to wage loss.  In some jurisdictions, it can reduce or limit the employee’s ability to receive future medical care via a workers’ compensation program.


Regarding wage loss benefits, many jurisdictions allow the employer and insurer to discontinue wage loss benefits once a medical opinion of MMI has been given and notice given to the employee.  This primarily includes the discontinuance of temporary total disability benefits and in other cases temporary partial disability benefits.  Once this occurs, a workers’ compensation claim can take several directions:


  • The employee can challenge the MMI determination and seek to have temporary total or temporary partial disability benefits reinstated;


  • Forces the employee to return to work in some capacity; or


  • Encourages the employee to be open to settling their workers’ compensation claim.


In many jurisdictions, wage loss benefits such as temporary total or temporary partial disability benefits can be reinstated should the employee’s condition worsen.  If a medical opinion is given regarding MMI from an independent medical examiner, it is important to receive that medical expert’s opinions on the following issues:


  • Additional medical care and treatment the employee may require;


  • Restrictions and limitations on the employee’s condition; and


  • Applicable permanent partial disability ratings. This rating should also include a detailed description as to why it is appropriate per the applicable guidelines.



Using MMI to Settle Your Claim


Once an employee reaches MMI, it is important to move a workers’ compensation claim toward settlement.  This is important for several reasons:


  • Once the employee reaches MMI, there will typically be a finding regarding additional future medical care and treatment. This allows for the preparation of a Medicare Set-aside allocation, if appropriate;


  • Allows for the defense interests to evaluate future indemnity exposures better. This also allows for reserves to be more accurately set and also to receive settlement authority; and


  • Facilities a better transition for the employee to return to work, even in a restricted capacity. This is based on the establishment of permanent work restrictions.


Interested stakeholders should never wait for the employee to make the first move when it comes to settling a workers’ compensation claim.  Be proactive and contact the employee or their attorney regarding this matter.





MMI is an important legal concept for members of the claims management team to understand.  They should also view it as an important milestone in their case and an opportunity to settle a workers’ compensation claim.  By taking these steps, interested stakeholders can reduce costs in their workers’ compensation programs.



Michael Stack - AmaxxAuthor Michael Stack, CEO 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 & lead trainer of Amaxx Workers’ Comp Training Center. .


Contact: mstack@reduceyourworkerscomp.com.

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


©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.

Gene Therapy Holds Great Promise, But Big Price

Putting new lifesaving medicines within reach requires novel collaboration.


In approving America’s first commercial gene therapy – an extremely expensive, but highly effective treatment for the most common type of childhood cancer – the U.S. Food and Drug Administration (FDA) ushered in a “new frontier in medical innovation,” according to a statement by FDA Commissioner Scott Gottlieb.


But paying for this treatment, and other groundbreaking gene therapies that will follow, requires new models for collaboration among payers, pharma companies, and pharmacy benefit managers like Express Scripts. We are committed to put these medications within reach of the patients who need them.



Dramatically Higher Price


The newly approved drug, KymriahTM (tisagenlecleucel)‎, manufactured by Novartis, brings hope to the 3,100 people under the age of 20 in the United States who are diagnosed each year with acute lymphoblastic leukemia. The medicine is customized for each individual, using genetically modified versions of the patient’s own immune cells to target and kill leukemia cells. The price is $475,000 – lower than the $600,000 to $750,000 that some analysts expected, but still dramatically higher than other specialty drugs.Gene therapies introduce genetic material into a person’s DNA to replace faulty or missing genetic material that leads to disease. These therapies are administered once, unlike nearly all other medications that are repeatedly taken over time. And therein lies the challenge.


Pharmaceutical companies have a single opportunity per patient to get paid. And many gene therapies target extremely rare diseases, so there aren’t many patients to share the cost drug makers require to justify the expense of research, development and commercialization. The result is very high price tags: the first two commercial gene therapies, approved for use in Europe, cost $1.4 million and $665,000. Despite promising clinical results, one failed and the other is struggling to find a market.


The health care system isn’t set up for this type of economic model.



We Need a New Payment Model


Express Scripts is working with drug makers, policymakers, patient groups and payers on innovative approaches to make gene therapies accessible for patients. Value-based contracting can ensure that payers and patients aren’t on the hook when a treatment isn’t effective. Consultations involving pharma companies and payers can help set appropriate prices. Discussions with policymakers can help set an appropriate regulatory framework.


Ultimately, Express Scripts believes gene therapies will require payment and patient care systems which are as novel as the medications themselves. Ideas on the table include paying for a treatment over time, establishing insurer risk pools and financing one-time payments. A successful model must address patients who change insurers or employers, and tracking their health outcomes over time to ensure payments aren’t being made if the treatment stops being effective.



Putting Medicine Within Reach


The promise of gene therapy is great: Approximately 4,000 diseases are linked to gene disorders, and many lack any effective treatment. More than 1,500 potential treatments are in research and development by dozens of pharmaceutical companies; including nearly 600 targeting cancers and 500 for rare and debilitating or deadly conditions.


As these life-saving and revolutionary treatments continue to be developed, it is up to payers, pharma companies and policymakers to unite and ensure they reach patients. Express Scripts stands ready to do its part.



Author. Steve Miller, MD – Chief Medical Officer, Express Scripts. Dr. Steve Miller’s expertise represents years as a medical researcher, clinician and administrator, and spans numerous healthcare subjects. Since joining the company in 2005, he has represented Express Scripts as a presenter at nationwide conferences. Dr. Miller is currently the company’s chief medical officer and is actively involved in developing our clinical programs and advancing the use of generic pharmaceuticals and specialty medications. He is a leader in the promotion of legislation to create a pathway at the U.S. Food and Drug Administration for the regulation of biogenerics and biosimilars. Prior to joining Express Scripts, Dr. Miller was the vice president and chief medical officer at Barnes-Jewish Hospital, Washington University School of Medicine in St. Louis. He has an MBA from the Olin School of Business at Washington University in St. Louis and a medical doctorate from the University of Missouri-Kansas City.


7 Ways to Reduce Your Workers’ Comp Prescription Drug Spend

Focusing on generics instead of brand name drugs, and in-network pharmacies instead of third-party billers are among the ways payers can help reduce their workers’ compensation costs while still ensuring quality care. Taking a deeper look into where and how the industry spends money on pharmaceuticals reveals many additional things organizations can do to eliminate unnecessary expenses for medications.


A recent report on drug trends within the workers’ compensation system shows, for example, that brand name abuse-deterrent formulations for opioids cost on average $520.85 more per prescription than non-brand abuse deterrent formulations (ADFs). Even though these medications are not typically included in workers’ compensation formularies (unless by client request), they are having an impact, according to the Drug Trends Report from Express Scripts.


Steps to eliminate wasteful Rx spending include:


  1. Educate providers and patients about the risks and benefits of opioids, and consider alternatives for chronic pain by using evidence-based guidelines.
  2. If an ADF is requested, consider whether the patient is at risk of abuse when considering whether to approve the medication and if they can use a more traditional opioid. Likewise, if  an overdose antidote is requested because of overdose risk, consider less expensive alternatives to Evzio where possible, such as narcan, naltrexone or naloxone.
  3. Look closely at dermatologicals that are prescribed; consider lidocaine rather than the more expensive Lidoderm.
  4. Closely review prescriptions for compound medications to see if they are truly needed for the patient. Likewise, for physician-dispensed drugs.
  5. Educate and encourage providers to use of generics rather than brand name drugs, where possible.
  6. Avoid third-party billers if possible.
  7. Closely review and watch prescriptions of specialty medications.


Below is a look at several categories of medications prevalent in the workers’ compensation system and where payers can reduce their costs.





These remain the most expensive and most utilized class of drugs in workers’ compensation, despite industry and governmental efforts to stem their abuse. Express Scripts said they accounted for 26.6 percent of per-user-per-year (PUPY) spend and 24.3 percent of PUPY utilization among its clients. The good news is that spending on opioids decreased last year.


Still, more than half of injured workers — 50.9 percent had an opioid prescription last year, and 25 percent of injured workers used them for at least 30 days.


Patient and provider education is key to reducing utilization and prescribing of these drugs so that they are used according to evidence-based guidelines in the more acute phases of pain, rather than injured workers with chronic pain.


The use of ADFs among injured workers increased by 50 percent from 2015 to 2016. Typically, a payer must approve the medication prior to dispensing due to the cost of the drug and the need to assure that it’s appropriate for the injured worker.


If you receive a request for an   opioid overdose antidote, look at the specific drug noted. Several versions are on the market, including naloxone; Narcan®, (naloxone); naltrexone; and Evzio, as self-injectable form of naloxone. It is important to note however, “the average cost per prescription for Evzio was $3,380.69 higher than for Narcan, naltrexone and naloxone combined,” according to the Express Scripts report.





Of the top 10 drug therapy classes, the total spend per class decreased on 7 of the 10 classes between 2015 and 2016. Among those with an increase were dermatologicals, which had a spending increase of 1.3 percent. The 10 percent increase in the average cost per prescription was moderated by a 9.5 percent decrease in utilization, according to the 2016 Drug Trend Report.


Generic versions of Voltaren® gel helped decrease utilization of the brand name drug, and should be considered by payers.


Prescriptions of lidocaine decreased, and the average cost per prescription is almost half that of Lidoderm — a lidocaine patch. Even though Lidoderm only had 4.2 percent of market share in 2016, the cost increased nearly 28 percent from the previous year.



Compounded Medications


Spending on these has decreased considerably in recent years, mainly due to a decrease in utilization. However, these are still seen as a significant cost driver in the workers’ compensation system. Medical treatment guidelines generally do not consider these a first line therapy for conditions typical of injured workers. They are excluded from most formularies and require prior authorization.


The cost of compounded drugs “averaged $1,966.92 per prescription in 2016 compared to $1,558.14 in 2015,” according to Express Scripts.



Physician Dispensing


These cost “$109.19 more than drugs dispensed by pharmacies,” the Drug Trend Report said. More than 38 percent of physician dispensed drugs are for pain or pain/inflammation.


The top physician dispensed drugs in 2016 according to Express Scripts were meloxicam, cyclobenzaprine, gabapentin, tramadol and Mapap® (acetaminophen).





Generics are identical in effectiveness to brand name drugs. Nevertheless, prescribers may turn to brand name drugs due to “habit, lack of awareness of available alternatives or patient request,” according to Express Scripts. “Injured workers create waste by requesting brand-name drugs instead of generics. Workers’ compensation payers can create unintentional waste when, to limit potential disruption, they fail to adopt programs that encourage the use of equally effective, lower cost options.”



Network Pharmacies


Prescriptions that are filled through third-party billers or out of network pharmacies “incur additional costs, with no additional value,” according to Express Scripts. The company noted that payers using its network pharmacy system spent 15 percent less than through third-party billers.



Specialty Drugs


These account for less than 1 percent of drugs used by injured workers, however the costs for them can add up. Spending on them increased 3.2 percent in 2016 and represented 5.9 percent of total spending, among Express Scripts’ clients.


There was a 46.9 percent increase in spending for the HIV drug Truvada® prescribed for pre-exposure prophylaxis; spending on Xyrem® (sodium oxybate) in the therapy class of psychotherapeutic and neurological agents (anticataplectic agents) increased 68.6 percent; and Xolair® (omalizumab), an asthma medication saw a 64.3 percent increase in spending. Client spend on specialty medications varies, largely dependent on the injured worker population covered by the client.




Ensuring injured workers get the best medical care for optimal outcomes should not be contingent on spending on unnecessary medications. Payers can control their costs for medications and still provide quality care.




Michael Stack - AmaxxAuthor Michael Stack, CEO 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 & lead trainer of Amaxx Workers’ Comp Training Center. .


Contact: mstack@reduceyourworkerscomp.com.

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


©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.

Increase Generic Fill Rate to Eliminate Wasteful Pharmacy Spend…Brand Name Drugs Increased 208% Since 2008

generic fill rate workers compHere’s a sobering statistic: “the average price for the most commonly used brand-name drugs has increased 208 percent since 2008, while generic drug prices overall have declined.” That revelation from the Express Scripts Prescription Price Index should cause workers’ compensation payers to take a close look at their generic/brand mix.


Overall, generic drugs still offer the best cost savings for payers while ensuring injured workers get the medications they need. Surprisingly, not everyone is as focused on generic fills as you might think.


For reference, the average generic fill rate among Express Scripts’ workers’ comp payers in 2016 was 84.4 percent. But that average is not necessarily true for all payers. Brand name drugs are commonly prescribed for many reasons including habit, lack of awareness of available alternatives, or patient request.


Clearly there are instances when a brand-name drug is more appropriate for a particular injured worker. But by and large generics offer the same outcomes and at lower costs.


“From the base price of $100.00 set in January 2008, in December 2016, prices for the most commonly used generic medications decreased to $26.27 (74% decrease),” the Index explained, “and prices for the most commonly used brand medications increased to $307.86 (208% increase).”


The news begs the question, are you doing all you can to ramp up your generic fill rate? If not, it may be time to turn to your pharmacy benefit manager for help.



PBM Advantage


A good PBM has an inherent advantage over individual payers in getting the best quality for the lowest costs. They typically have large client bases, giving them better leverage to negotiate for reduced generic prescription drug prices. That creates competition and pressure among manufacturers of generic drugs to provider better pricing.


Work with your PBM to get a higher generic fill rate with the following:


  1. Educate providers. Prescribers may choose a brand name over the generic drug out of habit. Or they may be unaware of an available generic. You need to inform providers about the generics that are available, especially for the most commonly used medications.
  2. Inform employees. Injured workers may believe they need a brand-name drug — even if they have never tried the generic version. Employees need to understand more about the workers’ compensation process than they typically do. They should understand, for example, how unnecessary costs impact the entire organization, including for pay raises and/or additional help. Informed employees who become injured are more engaged in their own recoveries if they have a good understanding of the system.
  3. Praise & reward. Generic medications have the same clinical outcomes as their more expense brand name counterparts. Providers that turn first to generics over brand-name drugs should be praised and rewarded.
  4. Create programs. Work with your PBM to develop strategies that will improve the generic fill rate, while still ensuring injured workers get the most appropriate medications and treatments.





If your medical spend seems higher than it should, it’s time to find out why and what you can do about it. Pharmaceuticals are among the biggest cost drivers in the workers’ compensation system. By working with a PBM, you can cut wasteful spending while still ensuring your injured workers get the very best medical care.



Michael Stack - AmaxxAuthor Michael Stack, CEO 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 & lead trainer of Amaxx Workers’ Comp Training Center. .


Contact: mstack@reduceyourworkerscomp.com.

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


©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.

Safe Patient Handling and Mobility Claims Coding: A Pragmatic and Functional Approach

Authors: Vicki J. Missar, Michael Fray, Candy Raphan, Mary Matz, Wendy Weaver


Whitepaper originally published by The Association of Safe Patient Handling Professionals (ASPHP). All of the authors of this white paper are members in good standing with ASPHP and serve as Board members.  


Reference: https://www.choosebroadspire.com/media/11899/safe-patient-handling-white-paper.pdf





Healthcare organizations are now engaged in Delivery System Transformation (DST), whereby performance-based incentive payment programs are used to support and reward hospitals for investing in projects that advance care and population health while lowering costs. In these efforts, it becomes critical to understand causes of patient handling and mobility workers’ compensation injury claims. Until now, programs that are self-administered or utilize a Third Party Administrator (TPA) have differing, if any, codes to determine employee injury trends. Unfortunately, these coding structures, particularly when it comes to causes, lack any real, actionable data to establish investment needs for safe patient handling interventions. Healthcare organizations are left to drill down to the accident-description level and extract key causes of the patient handling injury, a time-consuming and unrealistic option given the human resources demand within healthcare. This paper proposes a condensed, yet powerful, sub-level coding structure for safe patient handling claims that any claims reporting system can easily adopt. As a result, this coding structure will eliminate the need to manually sort through lines and lines of data for relevant trends. Adopting this proposed coding structure nationally will reward the safe patient handling community with a consistent and transparent approach to claims. As a result, it will enable facility-level comparison of key functions and tasks associated with patient handling claims, peer-to-peer benchmarking of these causes and return on investment calculations at the fingertips of the end user.





Healthcare companies in today’s business environment experience an unprecedented amount of change in terms of change drivers and pace of change: technology, shifting workforce demographics, global opportunity and competition, new sources of competitive advantage and rapidly evolving risk and regulatory requirements. Healthcare is an industry in the midst of fundamental transformation across the entire value chain and to all sectors, including physician groups, individual hospitals, senior care facilities, managed care organizations, insurance companies, wellness organizations, and integrated healthcare systems. As organizations address new business realities driven by healthcare reform and DST, they must reassess their data-mining capabilities around leading loss drivers that impact employee health and safety. With the right data and trending capabilities, safe patient handling claims can be easily dissected and solutions funded.


An apparent need exists to develop a standardized coding method focusing on the sub-category of activity type associated with patient handling injuries. So far, no national standard addresses the way these claims are coded in a Risk Management Information System (RMIS). This lack of uniformity leads to time-consuming efforts to extract key trending and cause analysis for meaningful solutions.


Standardization is applicable to overall workers’ compensation management, as well as risk managers, safety practitioners and occupational health professionals concerned with preventing safe patient handling and mobility (SPHM) injuries. The current mechanism to track injury types and occurrences proves neither healthcare specific nor customized by individual stakeholders. In addition, there’s a lack of detail-level standardization to provide easily identifiable and actionable data. Table 1 shows a snapshot of a healthcare organization RMIS loss run. The vague nature of the injury and cause descriptions provide little intelligence on the tasks (e.g. transfer type, toileting, bathing, etc.) performed at the time of injury. Therefore, a significant blind spot remains for safe patient handling professionals, and need for improvement on a national level is evident.



Table 1: Snapshot of a RMIS Loss Run for a Healthcare Organization



Current State: The Era of Big Data


Claims administrators require the ability to pare down injuries to focus on cost and frequency. Data available through loss run or other high-level data output provide only a general understanding of cause (See Table 1). The table does not provide sufficient detail to describe how the action being performed caused the injury. Technology is available via RMIS to affect change, but it cannot be used productively without changing and improving the information captured. A small addition to the current coding will make patient handling claims/injuries more transparent and actionable, create a best practice in the industry and produce long-lasting benefits.


Multiple methods are used in an attempt to address the need for this transparency which will bring patient handling claim trends forward. The following are examples:


  • Manually reviewing narrative reports to ascertain cause, associated circumstances and activities performed at the time of injury
  • Creating manual methods to map injuries with specific sites within a facility
  • Manually creating and using customized codes specific for a healthcare system or facility
  • Benchmarking national research reports that take years to publish
  • Using the National Institute for Occupational Safety and Health (NIOSH) Occupational Health Safety Network (OSHN) coding system (NIOSH, 2015)


Manual attempts at transparency are generally labor-intensive and may be highly burdensome. In an environment where human resources are stretched and patient and staff safety have become national priorities, the current state requires change.



Patient Handling Claims


Frequent injuries to patients and residents—regardless of the healthcare setting—have created a national call for action as demonstrated by several laws passed over the past few years. In addition, the American Nursing Association has issued an interprofessional national standard with the goal to put an end to these life-altering and career-ending injuries. The Occupational Safety and Health Administration (OSHA) points to manual patient handling as the cause of the high incidence, and severity, of injuries in the healthcare industry (OSHA, 2003). In 2013, the most frequent national, nonfatal occupational injury and illness, as well as injury and illness requiring days away from work, transfer, or light duty, were within healthcare and social assistance categories (Bureau of Labor Statistics (BLS), 2014). BLS data for 2013 demonstrate this impact  on caregivers. As seen in Figure 1, nursing assistants and orderlies accounted for some of the highest rates of nonfatal injuries and illnesses resulting in lost work days. These rates are approximately three times that of construction laborers and similar to that of firefighters. Compounding the personal and organizational impacts of such severe injuries, the financial cost of these injuries is profound (Institute of Medicine, 2011).



Figure 1: BLS Musculoskeletal Injury Rates for 2013 (per 10,000 work hours)



As illustrated above, injuries to caregivers, who are providing essential services for the infirm, are clearly significant. A typical certified nursing assistant, one who provides the majority of direct patient care, averages 4.5 injuries per year, according to a study by Khatutsky et.al (2012). However, while the study listed patient handling as a key loss driver, the study did not define the cause or activity (toileting, repositioning, etc.) involved in the injuries. Lack of easily accessed injury details on a sub-category level is a significant disadvantage for many SPHM professionals. Without that detail, there is no mechanism to facilitate implementation of effective Safe Patient Handling and Mobility Programs using RMIS data. Practitioners are left with manual, time- consuming data-crunching processes.



Reaffirming the Core Problem


There is a significant lack of easily accessible, detailed causative factors related to patient handling and mobility incidents available to healthcare sectors and stakeholders on a cumulative level. Patient handling and mobility incident causality data is generally a labor-intensive extraction effort using manual processes Without key elements, justification for the financial support of development, implementation and maintenance of SPHM programs may not be attained.


Collection and reporting of patient handling and mobility injuries must be easily implemented, concise and user-friendly to be sustainable. Above all, this proposed standard collection and reporting of more detailed data elements associated with patient handling and mobility injuries must also address the realities of the normal working environment and the various documentation requirements posed to the practitioner on a daily basis. In the era of big data, we must simplify the approach.



Future State:  Keep it Simple and Transparent


Figure 2 provides a basic workflow for any healthcare system to investigate and adjudicate claims. The current U.S. workers’ compensation structure lacks uniformity across casualty claim service organizations related to patient handling and mobility injury identifiers. This inconsistency prohibits the ability to affect change through benchmarking or modeling at the local, regional and national levels. These critical data elements promote effective resource allocation, pre- and post-loss program development and implementation. Some of the key data elements not currently documented range from the most obvious, such as making an occupied bed, to other notable elements such as managing aggressive behavior. These causes provide the information to propel effective change and mitigate costs of these pervasive and many times debilitating injuries.


Other categories used to define specific types of movement and activities will create consistency across claims platforms as well as the much needed transparency for better injury cause identification and implementation of relevant, impactful solutions tied to the visible trends. This provides a mechanism to quickly and credibly identify a host of benefits:


  • Trend injuries by patient handling task/activity (e.g. repositioning up in bed, limb holding, toileting, vehicle transfers)
  • Identify predictive causes of injury
  • Track frequency of specific injury types
  • Effectively simplify big data into actionable elements
  • Measure return on investment with SPHM programs
  • Identify impact of patient handling and mobility equipment and programs
  • Add additional dimension to the description of injuries
  • Provide a method to benchmark outcomes
  • Develop a sustainable best practice


Clearly the benefits demonstrate the need for moving forward with a simplified method. This approach will have a broad appeal as it closes a significant gap in the scope of the data being collected and allows SPHM professionals to compare data across peer groups in a consistent manner. Collecting more detailed information regarding the injury will also streamline RMIS coding constructs and allow providers to set up identical coding for all healthcare-related clients.



Figure 2:  Current and Proposed Claim and Reporting Processes


The detailed injury information proposed to be added to the intake process and RMIS systems will have a profound impact on the ability to extract actionable data elements. By instituting standard coding for the type of “Patient/Resident Handling and Mobility Activity” and “Patient/Resident Handling and Mobility Equipment Use” as shown in Table 2, risk managers or consultants to healthcare companies can retrieve actionable data from their claims administrators or internal systems.


Table 2 also shows the proposed national standard for additional elements, and it comprises a simple, yet easily implemented coding structure to add increased value to the claims intake and reporting process. By adding these critical categories, the benign loss run categories of “patient handling” or “strain—pushing/pulling” for example, bear more meaning and record vital information. (‘Patient’ is used in this paper to include all healthcare recipients; patients, residents, clients, etc.)



Table 2:  Proposed Patient Handling and Mobility Injury Codes



It is accepted that some patient handling injuries are difficult to classify and fall into the “no defined/listed cause (21)” category because they are cumulative in nature and may not have a specific cause. It is not uncommon to hear a caregiver say she has been lifting patients all day and now experiencing back pain. No specific task is identified as the cause nor can the caregiver suggest what caused the pain or injury other than, “lifting patients all day.” Such cumulative injuries are included in the “no defined/listed cause” sub-code. Additionally, RMIS includes cumulative trauma as a cause, so that code was not included in the proposed structure. Importantly, although cumulative trauma codes do not provide a clear understanding of what activity led to caregiver discomfort or pain, knowledge of trends in cumulative trauma provides actionable data in and of itself.Table 2 shows the codes defining patient handling, which will provide a clearer picture of the injury the caregiver experienced while performing a specific patient handling and mobility task. These definitions are supported by other incident reporting systems (e.g. NIOSH, Veterans Health Administration (VHA), etc.). Only a single code is required from each column. Ultimately, the data will provide information that may point to a single causative factor for that injury, such as the use or non-use of a SPHM assistive device.


Some workers’ compensation personnel may not be entirely familiar with the range of equipment used to support SPHM including ceiling and floor-based lifts, air-assisted lifting and lateral transfer devices, slippery sheets, friction reducing devices, roller boards, powered wheelchair/bed movers, powered toilet lift seats and more. Some beds, stretchers and gurneys are also included as SPHM equipment when they perform functions to help move and handle patients. However, walking aids such as walkers, canes, and crutches, as well as push wheelchairs and fixed or manually adjusted beds/trolleys/gurneys are NOT considered SPHM equipment. Slings (Table 2, Item 12) are used with patient lifting equipment to move and/or lift a patient or body part.



Stakeholder Value


Evidence-based information clearly demonstrates that certain categories of the data are linked to cost drivers. It is important to effectively utilize that information to more globally understand the overall results. Understanding the collection, reporting and data available to SPHM injury stakeholders and the impact that this information will have is imperative. The information in Table 3 will guide the improvement of the SPHM program functioning overall and reduce the negative effects of unnecessary patient handling and mobility injuries.



Table 3: List of Stakeholder Benefits and Corresponding Details


When Table 3 was developed, each of the named stakeholders’ perspectives was assessed through its own respective lens. For the reader to clearly understand how standardization of coding will impact each of the named stakeholders, a brief description and situational illustration is offered for each label in Impact of Coding Improvements.



Impact of Coding Improvements


Data Integrity and Consistency – Accurate, complete and concise capture and report of all requested data elements. Without standard data elements that are practical to obtain and easily recorded, the risk of incomplete and inaccurate information increases, reducing the possibility of any analysis or conclusions to be drawn organizationally or nationally.


Benchmarking – Comparing one’s SPHM program and performance metrics to industry bests or best practices. Comparative analysis provides a point of reference to internal and/or global results that may be either compared or assessed. Benchmarking provides a method through which each organization/facility may measure its SPHM program success against that of others; providing information to facilitate change.


Predictive Analytics – Extracting information from existing data sets to determine patterns and predict future outcomes and trends. Through the use of a set of standardized data elements, these trends may be used to draw sound conclusions and provide direction for future program decisions, such as determining SPHM program and equipment needs.


Claims Management – Advice or services related to claims for compensation, restitution for loss or damage due to injury or illness incurred in the practice and performance of patient handling and mobility activities. Standardized data elements provide claim managers valuable information to complete a thorough investigation and adjudication of each claim.


Capital Equipment Purchase Justification – Typically capital equipment is defined as items of considerable value that have durability and that are used to provide a service or increase revenue over the lifetime of the item. This may also be considered a tangible corporate asset. For the subject at hand, the justification of capital equipment purchases may be considered the more significant obstacle to development of a SPHM program. Data collected as a result of customized coding identifies cost drivers that in turn provide justification and validation for SPHM program capital expenditures.


SPHM Program Operating Cost Justification – Operating costs are expenses related to the operation of a business, or to the operation of a device, piece of equipment, or facility. They are the cost of resources used by an organization to maintain its existence. SPHM Program and equipment costs are considered operating costs. In healthcare, there is much competition for these funds. For this reason, there must be iron-clad justification/s for SPHM program and equipment costs. SPHM justification must include direct and indirect SPHM operational costs including equipment, staff training, staffing, and others. As well, benefits and cost savings for both patients and staff must be included. Staff cost savings relate to decreases in the rate of injuries, lost time, and modified duty injuries. Decreases in patient adverse events result in huge cost savings for an organization when there is an effective program.


Direct and Indirect Operational Costs – Direct costs of medical care (including rehab), indemnity (lost wages) and legal services are only several line item expenses to consider when assessing the fiscal impact of a musculoskeletal workers’ comp injury incurred due to SPHM activities. To be included with these obvious core costs are other expenses that must be accounted for when evaluating at the entire monetary effect of these injuries. Professionals also acknowledge injury indirect costs which include wages paid to injured workers for absences not covered by workers’ compensation insurance; administrative time to investigate the incident and perform other related supervisory duties; employee training and costs for replacing the injured workers; and lost productivity and accommodation of injured workers. While specific stakeholders are able to use data on certain line items to provide financial and other useful information, all stakeholders need to see the full picture of how SPHM injuries can affect the facility’s fiscal health and overall employee satisfaction.


Identification of Specific Cost Drivers – Specific activities or actions that have been identified to have costs associated to them. Customized coding will provide detailed activity descriptions to allow quantification of data and associated costs resulting from injuries.


Labor Retention and Recruitment Efforts – Data supports the fact that successfully competing for educated, trained and experienced healthcare workers in today’s market does not just depend upon wages, salaries, benefits, work shifts or available days off. Musculoskeletal injuries, cumulative or traumatic, have a significant effect on the professional and personal lives of the injured. Some injuries can disable and/or destroy a career. Competent caregivers also acknowledge that their safety and health closely relates to the welfare of their patients/residents. Having a SPHM program in place within a culture of safety demonstrates to recruits and affirms to current employees that the facility supports and protects them.


Patient Safety and Quality of Care – Currently, organizations must pay for negative patient outcomes related to hospital stays. Increasing evidence points to the importance of mobilization of all patients in the recovery process, which patient handling equipment facilitates. Falls, skin breakdown, UTIs, pneumonia, and other hospital-acquired injuries/illnesses are positively impacted when SPHM programs foster equipment use.


Utilization of Best Practices – There are tried and true processes for SPHM program development, implementation and maintenance. The ANA Safe Patient Handling and Mobility Interprofessional National Standards relay those national experts agree upon. The Veteran’s Health Association has the largest and most successful SPHM program in the United States, incorporating best practices found to be valuable in other organizations as well. When these best practices are supported, patient and staff injuries are impacted positively.


Quality Improvement Programs – These specific and defined process-based, data-driven approaches to improving the quality of a product or service are significant in all modes of healthcare provision. In the context of this paper, patient handling injuries drive many of the quality improvement programs’ focus. Customized coding will provide a consistent method from which data may be obtained and analyzed in the context of performance-based measurements.


Caregiver Safety – Occupational health and safety programs continue to identify risk factors and specific interventions to mitigate injuries due to patient handling. Rates of musculoskeletal injuries from overexertion in healthcare are among the highest when compared with other industries. A primary focus of this paper is to identify those data elements, which will provide sound and reproducible data to drive the continued development and improvement of SPHM programs.


Public Relations and Brand Protection – Communication systems provide immediate and up-to-date information to the consumer seeking products or services. These channels, whether newswires or social networking sites, provide the conduit for widespread public relations and positive branding. Public acknowledgment and reporting of a SPHM program developed, installed and maintained in the facility bespeaks the culture of safety that has been promoted and secured by administration. Knowledge that the facility cares not just for the patients/residents but also for the employees focuses on the humanity of the healthcare entity and instills consumer trust.



Engagement Blueprint


To gain consensus and buy-in for consistent coding, first think and act locally, then move to global applications. Figure 3 shows a simple process for adopting the proposed category in a gradual yet meaningful way. Step 1 involves adding proposed codes to the incident reports and other data capture processes to get consistent points adopted on the front end. As with any change, stakeholder education is critical. Steps 2 and 3 are at the administrator level, whereby stakeholders gain approval to institute the new coding in RMIS or other data capture systems. For example, adjustments to intake scripts would need to include the new coding, ensuring these questions are answered at the claim-reporting level. Because the new coding is simple in nature, there should be minimal impact to a data warehouse/RMIS system.



A Call to Action


Early adopters of more detailed coding practices have clearly demonstrated a positive impact on overall loss costs when compared to those that have yet to embrace this practice. These organizations are likely to garner peripheral and significant benefits such as staff retention, attraction of clinical talent in an environment with skilled nursing and medical professional shortages and productivity drains to name a few. However, administrators require tangible metrics to support the business case for development and maintenance of robust SPHM programs.



Ongoing state legislative activities are gaining momentum to encourage development, adoption and standardization of programs. This movement will likely continue. Federal adoption and support of SPHM standards and practices have yet to be enacted. However, without a standard from which to measure outcomes, comparison and trending, enumerable losses will continue. Moving forward, stakeholders will need to take a pragmatic and incremental approach to engage all participants in the process. As engagement increases and results are measured, further expansion of codes may be introduced as practically appropriate.





Fundamentally, caregiving is a humanitarian effort based on respect and concern for others. As science and the ability to treat and cure has progressed through the years, longer lives lived with chronic, debilitating and frail conditions and the needs for more challenging rehabilitation efforts have resulted.


The caregiving workforce and the patients/residents are all aging. And more than ever, the condition of the financial bottom line is tenuous and difficult to control.


It can easily be acknowledged that the implementation of a successful SPHM program, led by an expert in the field and supported by others who are educated and experienced in the scope and practices of the program, makes a significant difference in the health and welfare of the caregivers, the cared-for and the service-providing entity.


Be reminded of Table 3, illustrating the value of this proposition, and all the ways that patient handling and mobility injuries can negatively affect lives, jobs and the bottom line. The proposal for standardized coding herein is simple and easy to implement so that healthcare organizations can maintain the practice and contribute meaningfully to decreasing staff injuries, improving patient/resident care and prolonging solid careers.


With inclusion of the proposed categories, improved data and its analysis will become consistent and available to all; providing the information necessary to improve safety programs. Assistive patient handling and mobility equipment is available and will continue to improve when the exact needs for the implicated tasks are consistently coded and brought to light.





  • American Nurses Association (ANA). (2013). SPHM Interprofessional National Standards Across the Continuum. Publisher: Nursebooks.org. Silver Springs,
  • National Institute for Occupational Safety and Health coding system [Occupational Health Safety Network (OHSN) (2015) http://www.cdc.gov/niosh/topics/ohsn/injury.html
  • Bureau of Labor Statistics 2014 BLS Newsletter 2014. http://www.bls.gov/news.release/archives/osh2_12162014.pdf
  • S. Department of Labor, Occupational Safety and Health Administration. (2013). Hospital eTool: Healthcare Wide Hazards – Ergonomics. Available at: https://www.osha.gov/SLTC/etools/hospital/hazards/ergo/ergo.html. Accessibility verified 1/29/2016.
  • Institute of Medicine (IOM) (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies
  • National Institute for Occupational Safety and Health (NIOSH). NIOSH Standard Occupational Data Architecture (SODA 2.0) Draft document dated June 24,
  • Khatutsky, G., Wiener, J. M., Anderson, W. L., & Porell, F.W. (2012). Work-related injuries among certified nursing assistants working in US nursing homes. RTI Press publication No. RR-0017-1204. Research Triangle Park, NC: RTI Press. Retrieved from rti.org/rtipress.



Disclosure Statement


The Association of Safe Patient Handling Professionals (ASPHP) does not endorse one particular company or organization. Reference within this paper to any specific commercial or non-commercial product, process, or service by trade name, trademark, manufacturer or otherwise does not constitute or imply an endorsement, recommendation, or favoring by the ASPHP.


The views and opinions of the authors of content provided in this paper do not necessarily state or reflect the opinion of the ASPHP and cannot be used for advertising or product endorsement purposes.





All of the authors of this white paper are members in good standing with ASPHP and serve as Board members.  Wendy Weaver is the past Executive Director of the organization.





Mike Fray PhD, BSc(Hons), BHSc, MCSP, FHEA Senior Lecturer

HEPSU, Design School, Loughborough University UK


Vicki  Missar,  MS, CPE, SSBB, CSPHP, CHSP

Associate Director, Global Risk Consulting Aon 


Candy Raphan, RN, BSN, ARNP-C, MAOM Regional Vice President

Client Services Medical Management Broadspire®



Patient Care Ergonomics Consultant President, Patient Care Ergonomic Solutions


Wendy Weaver, MEd

Gateway Coaching & Consulting, LLC

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