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.

 

 

Conclusions

 

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.

 

 

Conclusions

 

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.

 

 

Opioids

 

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.

 

 

Dermatologicals

 

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

 

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.

 

Conclusion

 

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.

 

 

Conclusion

 

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

 

 

Abstract

 

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.

 

 

Introduction

 

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.

 

 

Conclusion

 

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.

 

 

References

 

  • 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.

 

 

Acknowledgments

 

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®

 

Mary Matz, MSPH, CPE, CSPHP

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.

 

 

Summary

 

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

evdrazen@express-scripts.com

 

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

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