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

Why “Abuse Deterrent” Is A Misnomer

Instead of mandating first-line coverage for ADF opioids, we must remain committed to reducing opioid misuse through a comprehensive, well-coordinated solution that includes law enforcement, providers, plan sponsors and patients.

According to the U.S. Food & Drug Administration (FDA), opioid formulations with abuse-deterrent properties are meant to target expected routes of abuse, such as crushing in order to snort or dissolving in order to inject. However, the FDA fully acknowledges that these products are not abuse proof.


Over the last two years, approximately 50 pieces of legislation requiring coverage of Abuse-Deterrent Formulations (ADF) of opioid products have been introduced in more than 30 different states.


Although the bills around ADF varied, the legislation generally seeks to address common objectives:


  • Mandate preferential formulary placement for ADF products, and/or
  • Prohibit utilization management tools like step therapy and prior authorization for ADF products.


The proffered goal of these bills – to reduced opioid abuse – is laudable in light of our nation’s crisis of opioid misuse and abuse. However, this type of legislation presents several problems:


  • The FDA fully acknowledges that these products are not abuse proof. Last week, the agency held a public workshop to gather data and methods for evaluating the impact of ADF.
  • A legitimate worry is that ADF opioids will lead prescribers into thinking the products are less addictive and overprescribing patterns will continue.
  • While ADF opioids make tampering more difficult, these products cost a lot more than their non-ADF counterparts. Required ADF legislation has been estimated to cost the state of California $4.5 million, with another $3.2 million borne by plans sponsors and patients in the state. By enacting these bills, states deprive plan sponsors from exercising some of their control over formulary design.


Instead of mandating first-line coverage for ADF opioids, we must remain committed to reducing opioid misuse through comprehensive, well-coordinated efforts among providers, payers, state and federal governments and law enforcement – with an emphasis on drug safety, counseling and patient support.



Author: Express Scripts Lab team—a diverse group of dedicated and passionate healthcare professionals. Some of us are behavioral scientists, some pharmacists, some statisticians, and some doctors. Together, we’re committed to the Express Scripts mission to make the use of prescription drugs safer and more affordable for the tens of millions of patients who rely on us.


About: Express Scripts Advanced Opioid ManagementSM solution works across the care continuum from safe disposal, to tools for physicians at the point of care and safety checks for dispensing pharmacies. This solution helps to significantly reduce unnecessary prescribing, dispensing and use to help avoid unnecessary hospitalization, ER and drug treatment costs, while ensuring access to medication patients need.

Leverage Pharmacy Controls to Reduce Opioid Spending 13.4%

The workers’ compensation industry has been a leader in addressing the national opioid epidemic. Nevertheless, medical providers continue to prescribe these drugs for chronic pain, despite research and recommendations that caution against using them as a first line of treatment.


The good news is that payers can take steps to reduce the unnecessary use of opioids. In its latest Drug Trend Report, Express Scripts said its clients saw an average 13.4 percent decrease in spending for opioids — even though the drugs continue to be the most expensive and highly utilized class for work-related injuries.


Armed with more evidence of the dangers and with increased persistence, payers can further reduce the prescribing of opioids for injured workers.



The Problem


The Centers for Disease Control and Prevention ( CDC)  released a new study that shows the more days for which opioids are prescribed, the more likely a person would become a chronic opioid user. The risks for chronic opioid use increases with each additional day of prescription. The days most associated with chronic use of the drugs were the 3rd, 5th and 31st days of the prescriptions.


Starting a patient on a long-acting opioid showed the highest probability of continued opioid use at 1 and 3 years. Patients who were started on the drug tramadol were the second most likely to have continued opioid use.


Additional potential triggers for abusing the drugs were:


  • A second prescription or a refill. Authorizing a second opioid prescription was shown to double the risk for opioid use one year later.
  • A morphine equivalent cumulative dose of at least 700 milligrams.
  • An initial supply of 10 or 30 days.


Opioids cause changes to a person’s brain. They have a chemical structure similar to a natural substance in the body. The drugs go to the pleasure center of the brain and release dopamine, a neurotransmitter that can cause depressed breathing, blood pressure and alertness, as well as decreased pain and a euphoric effect. Eventually, the drugs can result in a compromised ability to regulate unsafe or risky behaviors.


Over time, the body can become tolerant and dependent on the drug, meaning the patient must take more of the drug to achieve the same pain relief results.  Some people then become addicted to the drugs.


Opioids can be life threatening, even for a first time user, due to depressed breathing. Other side effects associated with opioids include depression, constipation, confusion, insomnia, and sexual dysfunction.



What to Do


Adoption of strategies addressing morphine equivalent dose (MED) led to significant decreases for Express Scripts’ clients, the company said. “Payers who adopted the MED program had a 32.7% reduction in cumulative MED >100 and a 24.7% overall decrease in cumulative MED,” according to the Drug Trend Report.


The company also uses a proprietary “point-of-sale and concurrent drug utilization review (DUR) edits to identify dangerous drug combinations (such as benzodiazepines and/or skeletal muscle relaxants with opioids) or other therapy concerns (duplication, use of long-acting opioids as a first choice and more).” Benzodiazepines in combination with opioids “should be avoided whenever possible due to respiratory depression and greater risk for potentially fatal overdose.”


Additional best practices to control over use and abuse of opioids are the following:


  • Real-time monitoring of MED and payer notification prior to any opioid fill that exceeds predefined MED thresholds.
  • Patient education and prescriber outreach for certain prescribing patterns, dangerous combinations and MED thresholds.
  • Leveraging opioid prescriber and patient trends with sophisticated reporting and analytics to identify fraud, waste and abuse and other risky behavior.
  • Coordinating efforts among providers, governments and law enforcement.
  • Ensuring providers prescribe opioids for the shortest duration possible when used to treat acute pain. Three days or less is ideal, while more than 7 is rarely needed.
  • Inform providers and discourage them from unnecessarily prescribing tramadol for chronic pain.





Opioids have a place in the nation’s healthcare system. However, their use for chronic pain has clearly been exceeded in recent years.


Payers that stay abreast of the latest research findings and establish protocols based on the information can go a long way to help prevent an injured worker from developing chronic opioid abuse, and save significant dollars.




Michael Stack - AmaxxAuthor Michael Stack, Principal, 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.

Use A Medical Advisor To Maximize Value of Independent Medical Exam

Use A Medical Advisor To Maximize Value of Independent Medical Exam A company medical advisor can be one of the most effective tools for reducing workers’ compensation costs as there is often a need to address specific health issues in regard to an injured employee’s case.



Leverage Medical Advisor for Independent Medical Exams (IME)


An example is leveraging your company’s medical advisor regarding an Independent Medical Exam (IME). Follow these steps:


  1. Accompany your adjuster’s letter with a signed cover letter from the medical advisor or director. Doing so results in more comprehensive and conclusive independent medical evaluation and examination (IMEs) reports.
  2. Be sure to include claim number and all relevant addresses and contact information on the letter.
  3. Welcome the physician to ask questions.



Be sure to ask the independent medical evaluation physician (IME) to answer the following questions or types of example questions:


  1. What is the patient’s present diagnosis and work status since it is X months since the original injury?
  2. Has s/he achieved maximal result?
  3. Can s/he perform the job as a painter (or whatever is the usual work task)?
  4. Specifically, please address whether s/he would have difficulty simply walking on a flat surface and going up and down a ladder?
  5. Since the latter involves flexion and extension of the ankle, would the lateral sprain affecting primarily pronation and supination really interfere with performance?
  6. If the worker uses an ankle support, would it be sufficient to allow work performed as a painter?


For example, this may be necessary when documentation states:  “Patient may have trouble walking.”  and your company needs to know how long the worker can walk for, at what inclination and duration.  These specifics can be determined by the independent medical examiner but may require some slight prodding to get documented.



Medical Advisor Often Overlooked


As part of an overall workers’ compensation cost-control program, hiring a medical advisor to work proactively on claims is an important, but often overlooked step.




Author Michael Stack, Principal, 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.

Express Scripts & myMatrixx Combine to Offer Best In Class Pharmacy Services

ST. LOUIS, May 17, 2017 /PRNewswire/ — Express Scripts (NASDAQ: ESRX) today announced it is taking an important step in expanding its customized workers’ compensation pharmacy solutions by acquiring myMatrixx, a pharmacy benefit solutions provider for the workers’ compensation industry. The companies will merge core capabilities to deliver best-in-class clinical expertise, advanced analytics, and customized client experiences to serve workers’ compensation clients and injured patients.


Express Scripts, St. Louis, Missouri. (PRNewsFoto/Express Scripts)


Terms of the transaction were not disclosed. Bryan Cave LLP and Skadden, Arps, Slate, Meagher & Flom LLP served as legal counsel to Express Scripts. SunTrust Robinson Humphrey acted as myMatrixx’s exclusive financial advisor and Akerman LLP served as myMatrixx’s legal counsel.


The combination of Express Scripts and myMatrixx will make enhanced pharmacy services offerings available to current and prospective workers’ compensation clients. The combined workers’ compensation team will be led by Artemis Emslie, currently Chief Executive Officer of myMatrixx.


“We are proud to create best-in-class pharmacy services for workers’ compensation programs by combining our deep expertise with the market-leading myMatrixx customer experience and technology,” said Express Scripts President & CEO Tim Wentworth. “We are well-equipped to address our clients’ evolving needs. Our unique combination of scale, technology, and a customized client experience sets the standard for workers’ compensation programs.”


“myMatrixx’s industry knowledge, technology and client experience have put us at the forefront of pharmacy services for workers’ compensation programs,” said Ms. Emslie, myMatrixx CEO. “With the demand for customized pharmacy solutions only growing, now is the right time to partner with Express Scripts and leverage the size and scale of the nation’s largest PBM to benefit our clients.”


With more than 83 million members, Express Scripts brings an ability to invest resources into advanced analytics. Express Scripts will leverage its clinical expertise innovation, client services, and strong marketplace footprint on behalf of its workers’ compensation program. myMatrixx’s strong reputation in the market for client services and agility will generate new growth opportunities and the combination will create more customer value.


Underlining the growing need for novel workers’ compensation solutions, earlier this month, Express Scripts released new data finding that the company’s innovative solutions lowered prescription drug spending for workers’ compensation payers overall by 7.6 percent in 2016. Much of this reduction can be ascribed to a sixth consecutive year of decline in overall opioid trend. In 2016, opioid trend decreased 13.4 percent due to a combination of Express Scripts’ clinical solutions, aggressive client management, and state and federal opioid regulatory trends.



About Express Scripts


Express Scripts puts medicine within reach of tens of millions of people by aligning with plan sponsors, taking bold action and delivering patient-centered care to make better health more affordable and accessible.


Headquartered in St. Louis, Express Scripts provides integrated pharmacy benefit management services, including network-pharmacy claims processing, home delivery pharmacy care, specialty pharmacy care, specialty benefit management, benefit-design consultation, drug utilization review, formulary management, and medical and drug data analysis services. Express Scripts 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.


About myMatrixx


myMatrixx® is a full-service workers compensation pharmacy benefit management company focused on patient advocacy. By combining agile technology, clinical expertise, and advanced business analytics, myMatrixx simplifies workers’ compensation claims management while providing safer medication therapy management. Located in Tampa, Florida, myMatrixx has positioned itself as a thought leader in the workers’ compensation industry.


Media Contact:

Ellen Drazen

(314) 684-5355



To view the original version on PR Newswire, visit:http://www.prnewswire.com/news-releases/express-scripts-and-mymatrixx-combine-to-offer-best-in-class-pharmacy-services-for-workers-compensation-programs-300459277.html – See more at: http://phx.corporate-ir.net/phoenix.zhtml?c=69641&p=irol-newsArticle&ID=2273690#sthash.1V3b2ynl.dpuf

Kicking the Opioid Problem: 5 Steps to Keep the Train Moving

There’s been some good news about opioid challenges in the workers’ compensation system lately. The percentage of new claims receiving opioids has decreased in recent years, as has the number of opioid scripts per claim. Several pharmacy benefit management companies have recently reported decreases in opioid use.


While the news signifies we are on the right track, now is hardly the time to turn a blind eye to the issue. Additional facts are that more than half of injured workers got an opioid script last year and of those, about half used them for at least 30 days, driving up costs for payers and leaving still scores of injured workers in states of extended disability or worse.


In order to keep heading in the right direction, the industry needs to stay up to date on the latest happenings and be vigilant in doing all we can to prevent opioid abuse, misuse and diversion.



The Latest


In terms of new regulations, the feds have joined the anti-opioid movement, with the Centers for Disease Control and prevention’s Guideline for Prescribing Opioids for Chronic Pain and a report by the Surgeon General, Facing Addition in America. States are implementing a variety of measures to try and limit opioid use for those truly in need; including formularies, prescribing limits, and other guidelines.


Sone of the latest developments in the opioid epidemic include the following:


Drug interactions.  In addition to the problems associated with opioids themselves, combining them with other medications can be fatal. Benzodiazepines taken with opioids can create a cocaine-like high for the user; however, they can lead to respiratory depression and heighten the risk of a fatal overdose. Also, some benzodiazepines are being used as muscle relaxers to treat spasms.


Long- vs. short- acting. Medical treatment guidelines, such as those from the American College of Occupational and Environmental Medicine and the Official Disability Guidelines do not recommend opioids as a first line of treatment for chronic pain. In those circumstances where opioids might be the best option, short-acting meds should be the way to go. Where a typical workers’ compensation claim might cost $16,000, short-acting opioids can increase that to $47,742, while long-acting opioids increase the average claim cost to more than $156,000, due to extended disability.


Abuse deterrent drugs. There are several medications approved as emergency treatment for opioid overdoses. Narcan, sold as naloxone is one of the main ones available. Three years ago, the government approved a self-injectable form, and in 2015 a nasal spray form hit the market. Called Evzio, the average cost is $3,380.69 higher than for the original Narcan products. The laws on the products vary among the states, with some allowing them without a prescription. While these medications are not typically part of a workers’ compensation formulary, use of them increased among injured workers by 50 percent from 2015 to 2016.



Prescription Drug Management


As an employer/payer, there are things you can do to maximize safe and appropriate opioid use and prevent abuse/misuse. Working with various partners, you can develop a narcotics management plan. Pharmacy benefit managers, insurers, third-party administrators, nurse case managers, providers and others should be involved. The plan should include several factors.


Provider outreach. Treating physicians need to understand and be on board with your plan. Those who are not may prescribe unnecessary opioids and should be excluded from your network in states with directed-care. The physician should use evidence based medicine as the standard of care. Providers, as well as pharmacies should be instructed to monitor the prescription drug monitoring program, depending on the jurisdiction. Opioids that are prescribed should be short-acting, for a limited time period and at a low morphine equivalency dose; the provider should conduct urine drug monitoring at an appropriate frequency; and should set up a ‘contract’ with the injured worker to identify rules related to opioid prescribing. Consistent and frequent communication with the treating physician is necessary to provide your support and ensure appropriate prescribing patterns are followed.


Patient education. Injured workers who may be prescribed opioids should be thoroughly informed about the risks vs. benefits. They should be made fully aware of the problems of long-term use of opioids, the risks from combing opioids with other medications, and the potential results of overuse.


Functional restoration. This should be the goal on which all decisions are based, to get the injured worker back to function and work.


Nurse Case Managers. Nurse case managers can be an invaluable resource to assess and intervene in certain claims. For example, they can assess the original diagnosis compared to the current diagnosis, check prescriber credentials, and make sure UDT and patient contracts are being used. They can do pain perceptions as well as psychological and functional assessments with the patient; create a functional outcome plan; and communicate consistently with the treating physician.


POS monitoring. Medications should be monitored at the point of sale and alerts sent when appropriate; for example, if a benzodiazepine is being purchased with an opioid.





Opioids are still the most commonly abused prescription drugs, as well as the most expensive and most often used therapy class. The workers’ compensation industry has made great strides in reversing the trend. But that will only continue if employers and payers are adamant in their efforts.



Author Michael Stack, Principal, 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/

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


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


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

Workers’ Compensation Prescription Drug Spending Decreased 7.6% in 2016

St. LOUIS, Apr. 4, 2017 – Express Scripts (NASDAQ: ESRX) lowered prescription drug spending for workers’ compensation payers by 7.6 percent in 2016, according to the 11th edition of its Workers’ Compensation Drug Trend Report.


“In a year when many payers wrestled with drug price increases that dominated the news, Express Scripts protected clients from this impact,” said Dr. Brigette Nelson, senior vice president of workers’ compensation clinical management at Express Scripts. “By practicing pharmacy smarter, we helped clients balance appropriate care for injured workers while keeping costs down.”



Decrease in Opioid Use Drives Down Trend


In 2016, opioids remained the most expensive therapy class at $391.35 per user per year (PUPY). Thirteen of the top 25 workers’ compensation medications were opioids.


However, for the sixth year, overall opioid trend decreased. In 2016, trend decreased 13.4 percent due to a combination of Express Scripts’ clinical solutions, aggressive client management, and state and federal opioid regulatory trends.


This stark decrease in overall pharmacy trend — heavily driven by decreased opioid utilization — proves key stakeholders are taking action to combat the epidemic of opioid abuse and misuse:


  • Payers: Through point-of-sale programs, physician outreach, patient education and advanced analytics, Express Scripts’ solutions enable payers to combat the safety and cost concerns associated with opioid use from every
  • Prescribers: Scrutiny of opioid prescribing patterns drove the creation of new guidelines from the Centers for Disease Control and Prevention (CDC), as well as the Surgeon General’s Report on Facing Addiction in America.
  • Regulatory: Many states have adopted or are considering formularies, opioid prescribing limits or other medical treatment



Bending the Curve on Compound Spending 


For the third year in a row, spending on compounded medications decreased. In 2016, trend was -28.6 percent. These drugs still remain very costly, yet with a 31 percent decrease in utilization, it is clear that effective management strategies can reduce unnecessary costs and waste associated with more than 1,000 clinically unproven ingredients.



Optimizing the Dispensing Channel


Medication dispensed directly to injured workers by prescribers may result in additional costs as the drugs are typically repackaged or relabeled and often are not subject to the same pricing regulations as those dispensed by a pharmacy. Injured worker safety is also a concern.


“Physician-dispensed medications lack the point-of-sale safety edits which occur at a retail or home delivery pharmacy,” Nelson said. “This puts injured workers at risk for potential drug interactions or duplication of therapy.”


According to 2016 data, the average cost of a physician-dispensed medication was $219.25, compared to $110.16 for a pharmacy-dispensed medication. Express Scripts Workers’ Compensation clients therefore paid an average premium of about $109 for physician-dispensed medications and bypassed pharmacist review at the point of sale.


When prescriptions are filled through more costly channels, such as an out-of-network pharmacy or third-party biller, payers incur additional cost, with no additional value. This results in waste in the healthcare system.


For long-term medication needs, drugs delivered directly to an injured worker’s home cost payers 15 percent less than those purchased from a retail pharmacy, while adding convenience for the injured worker.



Continued Vigilance for Specialty Medication Trends


Spending on specialty medications to treat conditions such as hepatitis C and HIV stabilized in 2016. While these drugs represent less than 1 percent of all medications used by injured workers, the extreme high cost per prescription requires payers to stay vigilant.


“Managing specialty spend requires clinical expertise and strategic guidance,” Nelson said. “Clinicians at Express Scripts and our specialty pharmacy Accredo® have disease-specific experience to ensure safety, promote adherence and provide individualized clinical counseling for injured workers with the most complex conditions.”


The comprehensive review of trends in prescription drug spending for workers’ compensation plans is available at express-scripts.com/corporate.



About Express Scripts


Express Scripts puts medicine within reach of tens of millions of people by aligning with plan sponsors, taking bold action and delivering patient-centered care to make better health more affordable and accessible.


Headquartered in St. Louis, Express Scripts provides integrated pharmacy benefit management services, including network-pharmacy claims processing, home delivery pharmacy care, specialty pharmacy care, specialty benefit management, benefit-design consultation, drug utilization review, formulary management, and medical and drug data analysis services. Express Scripts 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, Express Scripts 314-684-5355


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

WCRI Recap – 3 Part Series

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


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


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




Single Biggest Factor To Turn-Around Kentucky Opioid Crisis


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


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



Non-Pharmalogical Treatment of Pain


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


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


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



Collaborative Care Model


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


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


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


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



Pick One Idea & Implement!


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




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