Dealing with “chronic pain” is an issue the workers’ compensation claims management team deals with on a daily basis. This is highlighted by the daily dose of news about the prescription drug epidemic and the countless Americans who are either addicted to these legal medications, or become addicted to street drugs as the result of using them to deal with work-related injuries. It is important to claim handlers to be proactive on this issue for the benefit of the injured employee and the bottom line.
What is Chronic Pain?
From a clinical standpoint, “chronic pain” is pain symptomology that lasts from three to six months following the onset of injury. This can be the result of a specific incident such as a slip/fall injury, an aggravation or acceleration of an underlying condition or an injury resulting from workplace exposure or repetitive activity.
In most incidents, healthcare professionals in the United States deal with chronic pain by prescribing opioid-based pain medications. These medications come in many forms and names people have come to know. They include:
- Codeine (available in generic form)
- Fentanyl (Actiq, Duragesic, Fentora)
- Hydrocodone (Hysingla ER, Zohydro ER)
- Hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)
These prescriptions are useful as they relieve pain for a period and allow a person to recover from injury. They are derived from opium, which is commonly processed into the street drug known as heroin.
Quick Facts on Opioid Addiction
- From 2000 – 2013, the drug screening industry grew by $1.2 billion.
- Workers’ compensation insurers in California alone spend about $100 million per year for opioid-based pain medications.
- Prescriptions for buprenorphine and naltrexone—two drugs used to treat opioid addiction have risen to nearly 8 million in the last number of years.
- At least 20 states allow doctors to both prescribe and sell drugs, often at dramatic markups.
- Prescription drugs dramatically increase the cost of a WC claim:
- $13,000: Average cost of a claim without opioids
- $39,000: Average cost of a claim with Percocet
- $117,000: Average cost of a claim with long-acting OxyContin
Issue Identification and Practical Solutions
Members of the claims management team are on the front lines of the battle against chronic pain and its “tax” on workers’ compensation programs. Claim handlers can look for patterns and help identify issues early on before it becomes a larger problem. This can especially be the case if a claimant overdoses as part of their medical care and treatment related to a work-injury. If the death is related to the injury, the cost of the claim increases in the form of death benefits. Fraud, waste and abuse are other drivers. It is recommended to leverage a Pharmacy Benefit Manager relationship to help manage both cost and utilization of prescription drugs.
Key signs a claimant is abusing their prescription medications include:
- Prescription medications that are often lost or stolen. In most instances, they are being sold to a third party or being given to family members.
- Increasing use of pain medications without subjective reports of improvement. This information can be obtained from a claimant’s medical records and pharmacy receipts. Information can also be gleaned when speaking to a claimant regarding issues concerning the injury.
- Use of multiple doctors or pharmacies to obtain pain medications. While most states have pharmacy-reporting programs in place, it is still easy for people to game the system and obtain prescriptions from multiple sources.
- Resistance to treatment agreements that include random urine samples or treatment plans.
Members of the claims management team play a necessary role when dealing with chronic pain. This is an important function as monitoring this issue can help contain costs, while at the same time reduce unnecessary expenditures in any workers’ compensation program. A best in class Pharmacy Benefit Manager relationship should be leveraged to successfully manage chronic pain.
Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: firstname.lastname@example.org.
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