Keeping Up With Clinical Trends – Use Of Hepatitis C Medications In Workers’ Compensation

Kathy-Tiemeier myMatrixxHepatitis C, a viral infection of the liver caused by the hepatitis C virus (HCV), can be spread through contaminated blood and other body fluids. The infection can range in duration from a few weeks (acute) to a life-long illness (chronic). Between 75% and 85% of the people who become infected with hepatitis C will develop the chronic form1, CHC, which now affects more than 3 million people in the U.S.2 CHC may lead to chronic liver diseases, including cirrhosis and liver cancer. With the 2011 arrival of newer therapies to treat HCV (specifically direct-acting antiviral therapies, or DAAs), alcohol-related liver disease now has surpassed HCV as the leading cause of liver transplantation in the U.S., and HCV as an indication for liver transplantation is expected to continue its decline.3

 

 

I have received a request for a medication to treat hepatitis C. Will you please tell me why hepatitis C drugs might be needed to treat an occupational injury?

 

While we don’t see a lot of hepatitis C patients in workers’ compensation, it may be appropriate for claims under certain situations. Occupational exposure to hepatitis C could result from needlesticks in some injured worker populations, such as healthcare personnel, first responders and other municipal workers. The risk of HCV infection following a needlestick or sharps exposure to HCV positive blood is approximately 0.1%.1Injured patients who received blood or organs from an HCV-positive donor also could be infected.

 

Unlike for hepatitis A and hepatitis B, no vaccine currently is available for hepatitis C.1 Further, not enough evidence is available to support the effectiveness of post exposure prophylaxis, or PEP, after potentially being exposed to HCV.4

 

 

Recommendations from the Centers for Disease Control and Prevention (CDC)5:

 

  • PEP is not recommended for hepatitis C.
  • PEP following an occupational needlestick does include antiviral drugs for human immunodeficiency virus (HIV) and vaccination for hepatitis B, however.
  • Pre-existing chronic infection:
    • The occupationally exposed worker should be tested within 48 hours of exposure to determine the presence of antibodies to the hepatitis C virus (anti-HCV).
    • Anti-HCV will be present if the exposed worker has previously been infected with hepatitis C. If positive, further testing and referral to care for pre-existing CHC infection may be needed.
  • Infection as a result of the occupational exposure:
    • Those who test negative within the first 48 hours should be tested for HCV RNA three or more weeks after exposure to determine whether HCV then exists in the exposed worker’s bloodstream, with referral for care for a positive test as a result of the occupational exposure.6
    • Patients may spontaneously clear an acute infection up to six months after exposure. Therefore, all exposed workers who test positive in less than six months should be tested again at least six months after exposure to determine existing infection status.

 

 

Are the newer hepatitis C drugs much different from the older ones and why are they so expensive?

 

In addition to the cost of treatment, the choice of medication treatment protocol should take into account the genetic makeup, which is known as the “genotype”, of the virus. Hepatitis C has seven recognized viral genotypes1. Knowing the genotype is important to determine the most appropriate medications once a person has been diagnosed with CHC. In the U.S., about 70% of CHC cases are genotype 11, which has a lower response rate to older hepatitis drugs like ribavirin and injectable pegylated interferon, than other genotypes.7

 

DAAs, the newer treatment options for CHC, are available in oral form, so they are more convenient to use. They are much more expensive than earlier drugs; but they produce substantially higher cure rates than the older medications, more than 90% for many patients in as little as eight weeks. Before DAAs were introduced, the success rate for previous HCV therapies was only about 41% and severe side effects often were associated with using them.8

 

Curing an exposed worker of the HCV infection prevents chronic liver disease and possible liver cancer or transplantation. In addition, DAA medications are effective for most patients without requiring multiple courses of therapy. Even at their high initial cost compared to other drugs, they typically cost much less than managing liver cancer or undergoing a transplant along with their corresponding follow-up treatments.

 

 

I have heard some of the newer hepatitis C drugs have generics. Can you provide details?

 

Yes. Authorized generics to Harvoni® (ledipasvir 90mg/sofosbuvir 400mg tablets) and Epclusa® (sofosbuvir 400mg/velpatasvir 100mg tablets) became available early 2019. Gilead Sciences, Inc., the manufacturer of both medications, made them accessible through a newly created subsidiary, Asegua Therapeutics LLC. The Average Wholesale Prices (AWP) for the generics are significantly less than the brand name medications.

 

 

Do DAAs have any drawbacks?

 

Treatment for CHC is evolving quickly, and so are treatment guidelines. The promising news is the DAAs that cure hepatitis C offer hope of eliminating it in the near future. Unfortunately, however, data from the CDC indicate the number of new HCV infections is on the rise. From 2010 to 2015 the number of acute hepatitis C cases reported to the CDC nearly tripled – mainly from increased injection-drug abuse. Improved case detection contributed to this increase as well, but to a much lesser degree. 9 Symptoms are often mild and vague in acute cases, making diagnoses difficult.

 

Not every patient is cured after one course of DAA treatment. A small percentage fail the initial therapy and need another round, usually with a different set of drugs. Hepatitis C will recur for some treated patients and others may be re-infected after CHC has been cured.

 

Another major concern related to the development of new HCV therapies is the emergence of resistance to DAA drugs. Drug resistance occurs when the hepatitis C virus no longer responds to treatment. This challenge to chronic HCV treatment is developing rapidly and it already has shown clinical impact on available DAA regimens. Drug-resistant viruses most frequently develop when drug doses are below therapeutic levels. However, they can also emerge when DAA therapy fails.10,11

 

 

CONCLUSION

 

As stated previously, within workers’ compensation, the prevalence of hepatitis C is rare. However, the higher cost of new drug therapies can make a significant impact on workers’ compensation payers even if only used by a small portion of their injured worker population. Curing the infection is important, though, to prevent progressive liver damage that can result in debilitating and costly outcomes.

 

 

  1. Centers for Disease Control and Prevention. Hepatitis C questions and answers for health professionals. https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#section1. Last updated April 30, 2018. Accessed Dec. 7, 2018.
  2. U.S. Department of Health and Human Services. Office of Population Affairs. Hepatitis C. https://www.hhs.gov/opa/reproductive-health/fact-sheets/sexually-transmitted-diseases/hepatitis-c/index.html. Last reviewed April 10, 2018. Accessed Dec. 7, 2018.
  3. Cholankeril G, Ahmed A. Alcoholic liver disease replaces hepatitis C virus infection as the leading indication for liver transplantation in the United States. Clin Gastroenterol Hepatol. 2018;16(8):1356-1358. doi: 10.1016/j.cgh.2017.11.045.
  4. Hughes HY, Henderson DK. Postexposure prophylaxis after hepatitis C occupational exposure in the interferon-free era. Curr Opin Infect Dis. 2016;29(4):373-380. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5527758/. Accessed Dec. 7, 2018.
  5. Centers for Disease Control and Prevention. Information for healthcare personnel potentially exposed to hepatitis C virus (HCV). https://www.cdc.gov/hepatitis/pdfs/testing-followup-exposed-hc-personnel.pdf. April 2018. Accessed Dec.7, 2018.
  6. American Association for the Study of Liver Diseases and Infectious Diseases Society of America. HCV testing and linkage to care. https://www.hcvguidelines.org/evaluate/testing-and-linkage. Last updated May 24, 2018. Accessed Dec. 7, 2018.
  7. NIH Consensus Statement on Management of Hepatitis C: 2002. NIH Consens State Sci Statements. 2002;19(3):1-46. https://consensus.nih.gov/2002/2002HepatitisC2002116html.htm. Archived. Accessed Dec. 7, 2018.
  8. Pharmaceutical Research and Manufacturers of America. Twenty-five years of progress against hepatitis C: setbacks and stepping stones. http://phrma-docs.phrma.org/sites/default/files/pdf/Hep-C-Report-2014-Stepping-Stones.pdf. December 2014. Accessed Dec. 7, 2018.
  9. Centers for Disease Control and Prevention. Viral hepatitis. https://www.cdc.gov/hepatitis/statistics/2015surveillance/commentary.htm. Last updated June 19, 2017. Accessed Dec. 7, 2018.
  10. American Association for the Study of Liver Diseases and Infectious Diseases Society of America. HCV resistance primer. https://www.hcvguidelines.org/evaluate/resistance. Last updated May 24, 2018. Accessed Dec. 7, 2018.
  11. Downward E. Drug resistance. HepatitisC.net. https://hepatitisc.net/treatment/drug-resistance/. Last reviewed March 2018. Accessed Dec. 7, 2018.

 

Kathy-Tiemeier myMatrixxAuthor Kathy Tiemeier, RPh, DAIPM, myMatrixx, Senior Clinical Account Executive. myMatrixx, an Express Scripts company, offers best-in-class pharmacy services for workers’ compensation programs that include: formulary and network management, utilization management, claims processing, home deliver and specialty pharmacy care and physician outreach programs. Working with the financial and risk management leaders of organizations, myMatrixx helps reduce the pharmacy cost associated with injured workers through innovative programs, business analytics and robust clinical protocols and expertise.

 

To learn more about our Clinical programs, email Clinical@myMatrixx.com.

Fentanyl in Workers’ Compensation – 4 Ways to Keep Injured Workers’ Safe

Fentanyl in Workers' CompensationFentanyl is 100x stronger than morphine. Carfentanil is 100x stronger than fentanyl. For injured workers who become addicted to prescribed opioids, that can be a death sentence.

 

Armed with information about the latest illicit drugs and a willingness to adopt certain strategies, payers can ensure their injured workers get the most appropriate treatment and avoid becoming victims of the latest drug nightmare.

 

 

Heroin, Fentanyl, and Analogues

 

The dangers of unnecessary opioid use have been well documented and publicized for several years. To its credit, the workers’ compensation has been at the forefront of efforts to stem what has become a national crisis. But often overlooked are injured workers who already are, or become addicted to these prescription drugs and turn to the illicit drug market for relief.

 

Opioid prescribing dropped by nearly 9 percent in 2017, according to some accounts. However, some injured workers who were already addicted turned to heroin, leading to fatal overdoses from that drug. More recently, additional drugs have taken over the market, many of which are far more potent than opioids.

 

As described in It’s Not Just Heroin Anymore, a white paper from myMatrixx, synthetic opioids such as fentanyl have risen on the black market, mainly due to economics. Where heroine requires growing the opium poppy plant, harvesting the resin and processing it into the final product, fentanyl is purely synthetic, meaning it can be made easily and cheaply.

 

“Fentanyl is 50 times more potent than heroin and 100 times more potent than morphine,” according to the research paper. “Even more alarming, however, is the fact that there are compounds with molecular structures closely similar to fentanyl (analogues) that are drastically more potent and these are now making their way into the hands of drug addicts.”

 

Illicit makers of fentanyl have found in analogues a way to circumvent the regulations of the Controlled Substances Act. The CSA classifies substances based on their chemical identity. Since the fentanyl analogues are not on the list as identified controlled substances, they, technically, are not illegal substances.

 

There are 4 fentanyl analogues that are legal for medical use, including:

  • Carfentanil, only for veterinary use, it is normally dispensed as an elephant tranquilizer. It is 100 x stronger than fentanyl. myMatrixx notes it has been linked to increases in overdoses in the Midwest in particular.
  • Sufentanil
  • Alfentanil

 

 

Other analogues of fentanyl are Schedule I under the Controlled Substances Act.

 

 

What to Do

 

Most people prescribed opioids do not become addicts; however, anyone can develop an addiction. That is why it is imperative for workers’ compensation stakeholders to take every precaution to prevent addiction and address it appropriately in injured workers affected.

 

Here are ways payers can keep their injured workers safe:

 

  1. Educate providers. Despite their good intentions, some treating physicians are not trained in dealing with pain and/or opioid prescribing. They may also not follow evidence-based guidelines. Payers who develop solid relationships with network and/or area physicians can work with them and make sure they understand how to mitigate the risks.

 

For example, providers should know to:

 

  • Avoid prescribing opioids as a first line therapy
  • Screen patients for addiction before starting opioid therapy and continuously throughout treatment
  • Conduct urine drug screenings to monitor compliance
  • Be aware of, and adhere to formulary restrictions
  • Watch for, and address aberrant behavior
  • De-escalate or discontinue opioid therapy when necessary

 

  1. Provide strong clinical oversight, of physicians and pharmacies. Working with a pharmacy benefit manager and/or carrier is a place to start.
  2. Ensure providers are aware of alternative therapies to opioids and encouraged using them
  3. Intervene when there are concerns of opioid overprescribing. Having another physician talk with the provider can be effective. Insurers and/or third-party administrators often have medical personnel available to help.

 

 

Summary

 

The opioid crisis within the workers’ compensation system has improved in recent years. However, it is far from over. Stakeholders should stay up-to-date on the latest issues surrounding the problem and take steps to protect their injured workers.

 

 

 

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: https://blog.reduceyourworkerscomp.com/

 

©2019 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.

6 Triggers for When, And When NOT to Use Nurse Case Managers

when to use nurse case managementNurse case managers are a hot topic in workers’ compensation, and with good reason. Used properly, they can generate great results for organizations in getting injured workers back to work as soon as possible and saving precious dollars for organizations. But there is often misunderstanding about how and when to use Nurse Case Managers. For example:

 

  • Should you use a Nurse Case Manager on every workers’ compensation claim?
    • No
  • If a Nurse Case Manager is used, should it be for the entire duration of the claims process?
    • No
  • Is there a difference in telephonic vs. field Nurse Case Managers?
    • Yes

 

Nurse Case Managers can reduce litigation rates, foster patient engagement in the recovery process, and provide vital communication among all stakeholders. They can also be a waste of money and add little value.

 

Understanding when and how to use Nurse Case Managers is key to getting the best bang for the buck.

 

 

What They Can Do

 

Research showing the potential value of Nurse Case Managers has resulted in some companies using them on every single claim from beginning to end. Many of these companies then wonder why they are spending so much money without seeing a return on investment, so they discontinue using Nurse Case Managers altogether. Both are a mistake.

 

Here are some of the many ways Nurse Case Managers can help on a workers’ compensation claim:

 

  • Advocate and educate. The best reason to use a NCM is to help an injured worker who is frightened, confused and angry — often a recipe for litigation. The NCM can educate and advocate for the injured worker and guide him through the entire process, so he knows what to expect. The NCM can also inform employers on how the injured worker is progressing, and work with the treating physician to make sure the worker is getting appropriate care.

 

  • Flag potential problems. If the injured worker has psychosocial or pain management issues or needs durable medical equipment, the NCM can spot that early in the claims process and help coordinate the necessary treatment.

 

  • Communicate with all stakeholders. The NCM can keep everyone in the loop, so necessary details don’t fall through the cracks.

 

 

When to Use Nurse Case Managers

 

Simple, medical-only, and claims where the injured worker is highly engaged and anxious to return to full duty as quickly as possible do not signal the need for a NCM. On these and other cases the addition of a case manager is unnecessary and a waste of money.

 

More complex claims are where Nurse Case Managers can have a significant impact. Certain claims should trigger involvement from a NCM, including:

 

  1. Lost time. Workers who are off the job for more than a couple of days can benefit from extra involvement. A NCM can answer the injured worker’s questions and ensure he is complying with the treatment plan.

 

  1. Surgery is needed. Even if it is a medical-only claim, the need for surgery should be a red flag to get a NCM on the claim. There will be many things going on, such as preparing at home, the need for and type of pain medications after, and any DME that might be temporarily needed. The NCM can coordinate the various moving parts.

 

  1. Failing to attend scheduled medical appointments. Whether the worker is off the job or working in some capacity, failing to see treating physicians, physical therapists and other providers is a sign there may be a problem. A NCM can contact the injured worker and either get the person to comply or find out if there is an underlying problem that should be addressed.

 

  1. Comorbid Conditions. An injured worker with diabetes, obesity, hypertension or other comorbid conditions is prime for a more complicated claim. A NCM can help keep the claim on track.

 

  1. Uncooperative treating physician. If the injured worker’s primary physician continues to say the patient needs to stay out of work entirely, a NCM can intervene, find out why the person is not recovering, and explain return-to-work principles — such as light duty and employer accommodations.

 

  1. Catastrophic and/or multiple injuries. These claims involve many people and moving parts. A NCM can be the go-to person for all parties involved, including the injured worker and his family. The NCM can also make any arrangements needed, and keep costs down by selecting the most appropriate equipment.

 

 

When to End NCM Involvement

 

Putting a NCM on a claim doesn’t need to be a long-term prospect. These can be short assignments — even just one or two visits or calls. Depending on the complexity of the claim and ongoing issues, the NCM may need to contact the injured one time to keep him on track and in compliance with medical appointments; or may need to reach out to the treating physician for something simple; or discuss accommodation possibilities with the employer. The earlier a NCM intervenes in a claim, the shorter the assignment typically is.

 

You can gauge when the NCM is no longer needed, for example:

 

  • The injured worker is back to work in at least a light duty capacity
  • Stakeholders are communicating well with one another
  • Restrictions are decreased, and the worker is progressing well

 

 

Conclusion

 

Nurse Case Managers can add tremendous value to a claim, generating optimal outcomes for injured workers and lower costs for payers. But it is not a black and white issue; meaning they don’t need to intervene in every single case, and they don’t need to be involved indefinitely. Thinking through a strategy for using Nurse Case Managers can have a significant impact on claims.

 

 

 

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: https://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.

 

Compounded Medications — 6 Solutions to Address a Nagging Issue for WC

Compounded Medications — 6 Solutions to Address a Nagging Issue for WC“There is no such thing as an FDA-approved compound medication.” That statement from myMatrixx Chief Clinical Officer Phil Walls underscores one of the main criticisms of these medications; while the drugs within the mixtures may all be FDA-approved, the specific combinations have not been tested and verified.

 

Safety is just one concern, however. The other is cost; they generally are priced significantly higher than similar, FDA-approved drugs or the sum of their underlying medications.

 

Both the utilization and the average cost of compounded medications in the workers’ compensation system has decreased in recent years. However, there are still pockets of excessive use. Stakeholders need to maintain a steady and continued focus on efforts to curb the unnecessary use of these pharmaceuticals.

 

 

Problems Cited

 

Compounds are a mixture of drugs intended for a specific patient’s use. According to an FDA report, they are beneficial only in limited circumstances; such as when other medications have failed, a patient is allergic to some of the inactive ingredients or has difficulty swallowing.

 

The federal agency inspected compounding facilities and noted the following “troubling conditions” that could lead to widespread harm of patients:

 

  1. Toaster ovens used for sterilization.
  2. Pet beds near sterile compounding areas.
  3. Operators are handling sterile drug products with exposed skin, which sheds particles and bacteria, among many others.

 

 

Latest Stats

 

Compounded medications are not considered first-line therapy for pain or other common conditions of injured workers according to industry guidelines, such as evidence-based medicine guidelines from Work Loss Data Institute, American College of Occupational and Environmental Medicine, and many other state-specific guidelines.

 

Compounds are available in many applications but are used in workers’ compensation most often as topical products for pain management. Usually, compounded medications are excluded from workers’ compensation formularies, and require prior authorization before they are dispensed to an injured worker.

 

State legislatures and organizations within the workers’ compensation system have taken steps in recent years to reduce the overuse of compounds, and they have been largely effective, according to the most recent Drug Trend Report in the workers’ compensation system from myMatrixx:

 

  • Spending on compounded medications declined 37.1 percent in 2017
  • It was the third year in a row that payer spending on compounded drugs has decreased
  • Compounds fell from the top 10 therapy classes
  • Utilization decreased 21.2 percent
  • The average cost of compounded medications decreased 15.9 percent

 

Along with the good news, however, are some disturbing reports.

 

Recent Problems

 

  • Pennsylvania. A recent report found that legislative reforms in the state resulted in cost savings on physician-dispensed drugs; however, they were offset by an increase in pharmacy dispensing of expensive compound drugs.

 

The legislation that took effect in December 2014 capped prices paid for physician-dispensed drugs and restricted physician’s ability to dispense opioids and other drugs to limited timeframes. The Workers Compensation Research Institute found there was an associated decrease in the number of injured workers who received physician-dispensed drugs. But they also found there was a “dramatic” increase in the prescription payments for compound drugs in the same years, which it attributed to the emergence of new pharmacies dispensing expensive drug products, especially compound drug prescriptions.

 

  • Texas. A loophole in the state’s drug formulary allowed compound prescriptions to be filled without obtaining preauthorization to confirm medical necessity. Regulators said the workers’ compensation system saw a 46.4 percent increase in compound prescriptions from 2010 to 2014, with the total cost of an average prescription more than doubling from $356 to $829.

 

 

Solutions

 

A new rule amended the Texas formulary to exclude any prescription drug created through compounding and required preauthorization for all compounded medications. That rule took effect July 1. Several additional states have adopted similar measures, including Arkansas, Oklahoma, Florida, Nevada and Tennessee, and the idea is being considered in other jurisdictions.

 

The National Conference of Insurance Legislators is considering model legislation with clearly established guidelines for the reimbursement of pharmaceutical products in the workers’ compensation system. It includes language that would limit compound medications and require a critical evaluation with a physician documented statement of medical necessity or a utilization review of the compounded pharmaceutical products.

 

Stakeholders can work closely with state regulators and legislators. Additional ways to address the issue of excessive use of compound medications include:

 

  1. Working closely with a pharmacy benefit manager to ensure compounds are used judiciously and only when preauthorized
  2. Payment limits. Placing reimbursement limits per each script or per each ingredient in a compound medication
  3. Limiting the number of ingredients or the total cost per script
  4. Retrospective review. Allowing employers the option to deny coverage for a compound medication that has not been preauthorized
  5. Network pharmacies. Allowing employers to direct injured workers to specific pharmacies
  6. Including compound medications in the list of medications allowed only with preauthorization

 

 

Conclusion

 

The overuse of compound medications has been a troubling area for workers’ compensation stakeholders for several years. Strategies to address the issue are effective but must be continually employed and updated to ensure the problem is appropriately managed.

 

 

 

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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

How to Use HIPAA to Obtain Timely Medical Records

Members of the claims management team obtain medical records on a frequent basis when investigating workers’ compensation claims.  It is important they do this promptly given the many constraints of workers’ compensation laws.  Given the nature of these requests, state and federal privacy laws come into play.  Failure to understand these laws and their requirements can lead to delay and problems down the road.  Now is the time to better understand these laws and how to incorporate them into your team’s best practices.

 

 

It All Starts with HIPAA

 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) serves as the basis for healthcare privacy and the dissemination of medical records in the United States.  The law was enacted in 1996 to address the many issues medical providers were facing and to protect the privacy of all individuals.  In essence, it serves as the baseline for standards enacted at the state level for all covered entities.

 

 

Understanding the Basics of HIPAA

 

To understand the law, it is important to understand when it applies and whom it protects.  HIPAA applies to all “covered entities,” which are defined under 45 C.F.R. §160.103, as:

 

  • Health care providers who transmit “protected health information;”

 

  • Entities that process personal health information (healthcare clearinghouses);

 

  • Health plans such as Group Health Plans; and

 

  • Any business partner of a “covered entity.”

 

It is also important to note that the federal law applies to “protected health information,” otherwise known as PHI.  This is information defined under 45 C.F.R. §164.501, which is individually identifiable health information maintained or transmitted in any form, whether electronically, on paper or orally.

 

 

Exceptions to HIPAA in Work Comp

 

Employees at healthcare providers are required to know and understand HIPAA and have a duty to protect a patient’s PHI.  Training is required for these entities as part of their ability to do business.  Problems arise when employees at these facilities do not understand the nuances of HIPAA and how a state workers’ compensation act allows members of the claims management team to obtain PHI without properly executed authorizations.  One such exemption is found under 45 C.F.R. §164.512(l), which states, “A covered entity may disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.”

 

 

Effectively Using the “Work Comp” Exception

 

Although this exception to HIPAA allows for easier access to a patient’s PHI, there are important limitations and requirements one must first understand.  Failure to understand these issues can result is frustration, delay, and sanction.

 

  • The permissible release of PHI is limited to only medical records directly related to the work injury in question. It does not provide for the cart blanche release of “any and all medical records;”

 

  • State workers’ compensation and other privacy laws often require the requesting party to notify the injured worker in writing they are making a request. Additional requirements sometimes require the requesting party also to disclose the medical records obtained from a provider to the injured party; and

 

  • Failure to make the necessary request disclosures may result in a sanction against the requesting entity.

 

It is also important to note that medical providers releasing documents under this exception may charge the requestor reasonable copy and retrieval fees.

 

 

Conclusions

 

It is important for members of the claims management team to obtain medical records in a timely manner.  Part of this can include the request of medical records related to a workers’ compensation claim under HIPAA without obtaining written authorization.  Before making these requests, it is important for claim handlers to know the necessary rules and follow them to avoid problems down the road.

 

 

 

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: https://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.

4 Ways to Stay Vigilant On Specialty Medication Costs

The latest trend in medications for injured workers is good news indeed — for the most part. But one tiny area can add up to major dollars. Spending on specialty medications increased 3.8 percent in 2017, according to the latest Drug Trend Report from myMatrixx, an Express Scripts company.

 

The fact that these drugs represent less than 1 percent of all medications used by injured workers is by no means a reason to overlook them. Because of the high costs associated with specialty medications, payers need to stay vigilant in understanding and addressing this small but growing segment of pharmacy spend.

 

 

The Issue

 

HIV, osteoarthritis, high cholesterol, and hepatitis C are among the comorbidities that require prescriptions for specialty medications. Just over 2 percent of injured workers used one of these drugs last year, accounting for 0.6 percent of all prescriptions filled and 6.3 percent of total pharmacy spend.

 

The most used specialty drug for injured workers in 2017 based on per-user-per-year spend according to myMatrixx, was Truvada®, used to treat pre-exposure to HIV. The cost per Rx was $1,019.11. The overall use of medications to treat HIV increased by 17.6 percent — not too surprising considering the need for them to treat workers with occupational exposure to needle sticks.

 

However, the use of medications to treat osteoarthritis rose 21.6 percent, while the cost per prescription increased 1.1 percent. The medication Synvisc had increased utilization of more than 58 percent. Driving the increase was likely the fact that workers may use the drug for repetitive stress injuries caused by activities that stress the knee joint — squatting, kneeling or lifting heavy objects.

 

The most expensive medication on the top 10 list is Epclusa®, with a price tag per Rx of $24,510. However, the drug has been hailed as curing the disease.

 

 

Affected Workers

 

Workers in a variety of occupations may need specialty drugs.

 

  • Medical workers may contract HIV and hepatitis C from blood-borne pathogens due to exposures to needlesticks.
  • Coal miners are at risk of black lung disease
  • Outdoor workers are vulnerable to Lyme disease.

 

Other reasons workers may need specialty drugs include postoperative blood clots and organ failure.

 

 

The Drugs

 

The top 10 specialty medications for 2017 according to myMatrixx were:

 

Drug                           Therapy Class

Truvada®                    HIV

Isentress®                   HIV

Synvisc-One®            Osteoarthritis

Xolair®                       Asthma

Enbrel SureClick®     Inflammatory conditions

Enoxaparin                  Anticoagulant

Repatha SureClick®   High cholesterol

Enbrel ®                     Inflammatory conditions

Xyrem®                      Anti-cataplectic agents

Epclusa®                    Hepatitis C

 

 

What to Do

 

It’s important for claims handlers and injured workers to have a clear understanding of how and why they are using these medications. They often require special handling instructions, for example. While denying a specialty medication to an injured worker in need would not be prudent, organizations can rein in costs and prevent overutilization by ensuring the drugs are used appropriately and judiciously.

 

  1. Train. Injured workers and those involved with the claim should know what side effects may be present with each specialty medication. Injured workers should be well informed about self-administering the medications.

 

  1. Monitor. These injured workers often need ongoing clinical monitoring and more intensive help from pharmacists and other caregivers to ensure they are taking the medications as prescribed, as patient adherence is crucial.

 

  1. Use specialists. Specialty pharmacies are better equipped and should be utilized for handling these medications, as they typically offer services not available at retail pharmacies. For example, on-staff nurses and physicians who are experts in the conditions and treatment are likely to be available only in specialty pharmacies.

 

  1. Engage physicians. Nurse case managers and other caregivers should work with treating physicians to make sure the injured worker is getting the proper medications and treatment. Some medications, including Repatha for high cholesterol, are appropriate only for a small number of patients and must be appropriately managed for patient safety and costs. Cancer medications are not usually included in workers’ compensation formularies and therefore may require prior authorization.

 

 

Conclusion

 

Specialty medications represent just a fractional component of prescriptions filled by injured workers, yet their costs can be nearly prohibitive. Since they offer an important lifeline for injured workers who truly need them, it’s important to see they are prescribed only where appropriate and are taken as prescribed.

 

 

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: https://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.

Education is Key to Prevent Dangerous Opioid Drug Combinations

There is good news on the opioid front in the workers’ compensation system. According to the latest Workers’ Compensation Drug Trend Report from myMatrixx, an Express Scripts company,

 

  • Average spending on the drugs declined 11.9 percent
  • The percentage of injured workers using opioids for at least 30 days decreased by a couple of percentage points
  • The morphine-equivalent dose (MED) declined — with a 33.7 percent reduction in cumulative MED greater-than 100 and a 26.9 percent decrease in cumulative MED overall.

 

But the good news is tempered by the persistent problem of opioids prescribed in conjunction with other medications that together form a dangerous interaction. While the numbers were somewhat better in 2017 than the previous year, there are still too many injured workers being put at risk for overdoses and death. Education and outreach are needed to address the problem.

 

 

The Facts

 

According to the Drug Trend report, 74.2 percent of payers spent less on opioids in 2017 than in 2016. The average amount per claim declined to $342.57, compared to $388.80 in 2016. Opioids continued to be the most expensive and highly used class of drugs among injured workers and accounted for 24.1 percent of total pharmacy spend in 2017.

 

“While a decrease in the utilization of opioids is a positive sign for the workers’ compensation industry, there is still work to be done,” according to the report. “Nearly 40 percent of injured workers took an opioid along with a muscle relaxant, while 9 percent took an opioid and benzodiazepine. Taking these medications together can increase the risk of side effects and death from respiratory depression.”

 

The report showed that in 2017

 

  • 7 percent of injured workers took an opioid and a muscle relaxant, compared to 31.1 percent in 2016.
  • 3 percent took an opioid and a benzodiazepine last year, compared to 7.3 percent the previous year.
  • 5 percent took an opioid, a muscle relaxant and a benzodiazepine in 2016, compared to 3.1 percent in 2016.
  • Among injured workers using opioids for a short-term (less than a 30 days’ supply), 79.6 percent used opioids only, and4 percent used an opioid and a muscle relaxant.
  • For injured workers using opioids for more than 30 days, 36.1 percent filled both an opioid and a muscle relaxant.

 

Despite the slightly better news, there is still much to be done to curb the problem of combining opioids with certain other drugs. The federal government reports more than 30 percent of overdoses involving opioids also involve benzodiazepines or ‘benzos.’ These drugs are used to help anxiety, insomnia, muscle tension, seizures, and alcohol withdrawal. Both benzos and opioids suppress breathing, sedate users and impair cognitive functions.

 

Benzos are commonly sold under the names Valium, Xanax, and Klonopin. Additionally, some benzos, have muscle relaxant properties and are often prescribed for injured workers with muscle spasms.

 

The Centers for Disease Control and Prevention issued new guidelines in 2016 that recommend clinicians avoid prescribing benzos concurrently with opioids whenever possible. Both opioids and benzo medications now carry warnings from the Food and Drug Administration (FDA) highlighting the dangers of using the drugs together.

 

Research clearly shows the dangers of combining opioids with benzos. In a North Carolina study, for example, researchers found the overdose death rate among patients receiving both types of medications was 10 times higher than among those who only received opioids.

 

Part of the problem is that physicians may prescribe opioids on a long-term basis to treat acute or chronic pain, along with Valium to treat muscle spasms. Injured workers may also receive a Xanax prescription from a therapist if they suffer from anxiety.

 

 

Additional Medication Dangers

 

In addition to muscle relaxants and benzos, many other medications can be harmful when taken in combination with opioids. The FDA has issued warnings for physicians to limit their prescribing of the following for patients on opioids:

 

  • Antidepressants
  • Migraine medications
  • Antipsychotic drugs
  • Sleep medications
  • Serotonergic drugs, such as St. John’s wort.

 

There’s also evidence that antihistamines, which can cause drowsiness and sedation, may be problematic when combined with opioids. Finally, mixing alcohol with opioids can be deadly.

 

 

Risks

 

Over sedation and depressed breathing are two of the biggest problems resulting from a mix of opioids with other medications. Over sedation renders the person unable to wake up or respond to stimuli, creating risks for falling or slipping into a coma. Depressed breathing leads to a lack of oxygen to the brain and eventually shuts down vital organ systems, causing brain damage or death.

 

There are additional risks as well.

 

  • Serotonin Syndrome, a serious central nervous system reaction occurs when high levels of the chemical serotonin build up in the brain and cause toxicity. Symptoms may include agitation, hallucinations, rapid heart rate, excessive sweating, shivering, muscle twitching and trouble with coordination.

 

  • Adrenal insufficiency is a rare but serious condition in which adequate amounts of the hormone cortisol cannot be produced. Cortisol helps the body respond to stress. Symptoms of adrenal insufficiency include nausea, vomiting, loss of appetite, fatigue, weakness, dizziness or low blood pressure.

 

  • Decreased sex hormone levels are associated with long-term use of opioids and can reduce the person’s interest in sex, or lead to impotence or infertility.

 

Knowing the symptoms of an overdose is important, and may include

 

  • Pinpoint pupils
  • Unconsciousness
  • Dizziness or lightheadedness
  • Extreme sleepiness
  • Slowed, irregular breathing
  • Confusion
  • Unresponsiveness
  • Blue lips
  • Snoring or gurgling sound in the throat

 

Educating patients and physicians about the dangers of combining opioids with many other medications is the first step to reduce the problem. Those managing claims should reach out to prescribers to ensure they understand the risks of interaction.

 

Conclusion

 

The combination of opioids with other medications should only be prescribed to patients who do not respond adequately to other treatments. If they do, the dosages and duration of each medication should be the lowest amount possible.

 

 

 

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: https://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.

Practical Tips for Implementing Urine Drug Testing

Identifying and intervening with at-risk injured workers can save payers a bundle. These are the so-called “creeping catastrophic’ claims; the seemingly minor injuries expected to resolve within weeks that go south and before you know it, have been on the books for months or longer. They typically involve a variety of expensive medical procedures and medications, all of which are unsuccessful in alleviating the person’s pain.

 

This small fraction of workers’ compensation claims encompasses a majority of costs for payers. In recent years, the industry has done a better job of red-flagging these claimants earlier in the process. But an oft-overlooked tool to help is urine drug testing.

 

Urine Drug Testing helps physicians whether the patient is compliant with prescribed medications and/or using non-prescriber or illicit drugs.

 

But UDT has been ignored in many cases or overused in others. Using UDT judiciously can be a tremendous help.

 

 

The Stats

 

Recent research shows fewer than half the injured workers prescribed opioids received UDT – 17 percent to 50 percent. However, it also showed that of the top 5 percent of claims, UDT was conducted in 7 out of 10 physician visits.

 

Guidelines from the American College of Occupational and Environmental Medicine, the Official Disability Guidelines and the Washington State Interagency vary regarding UDT frequency recommendation. But they all call for UDT at baseline when opioids are initially prescribed, then at various times throughout the year based on the injured worker’s risk stratification. Those at low risk may only need UDT every six months to annually; while high-risk claimants might need to be tested monthly.

 

The testing provides objective information to support improved clinical decision making, and helps medical providers:

 

  • Monitor and support their decisions about medications.
  • Identify recent use of prescription and illicit substances.
  • Detect medications that may negatively interact with other drugs.
  • Better communicate with their patients about their treatment plan.
  • Identify possible medication abuse and misuse.

 

A recent national sampling of more than 11,000 testing specimens revealed that fewer than half – 47 percent – adhered to their treatment regimens. That means more than half were not taking their medications as prescribed, taking other medications that were not prescribed, or used illicit substances. It is, therefore, incumbent on organizations to include UDT as part of their treatment plans for injured workers prescribed opioids – especially those at higher risk.

 

 

Whom to Test

 

Testing all injured workers might not be feasible or practical. However, there are certain injured workers who should undergo UDT. Identifying those at risk for delayed recovery can involve several steps. One is risk factors for substance abuse disorders, such as:

 

  • History of substance abuse disorder.
  • Family history of substance abuse.
  • Major psychiatric disorder.
  • Cigarette smoking.
  • Preadolescent sexual behavior.
  • Poor family support.

 

Injured workers with no history of substance abuse – their own or their families, and no psychiatric history or other risk factors would be considered at low risk for substance abuse disorders. They should undergo UDT when opioids are initially prescribed, then yearly. It should be noted, however, that a person’s risk level can change. Medical providers should be instructed to watch for aberrant behavior or any signs of a problem.

 

Injured workers with substance abuse histories of non-opioids, and/or factors such as family history of substance abuse or psychiatric histories would be considered at moderate to high risk and should be tested two to four times per year, as well as when they initially prescribed opioids.

 

 

Patients Found Abusing

 

Those who are currently abusing or addicted to substances and/or have psychiatric histories or other factors present would be considered high-risk patients. These patients should no longer receive opioids from their primary physician and be referred for addiction therapy.    These injured workers should be tested at least three times a year and possibly as much as monthly, according to the guidelines.

 

Data from pharmacies can also be helpful in identifying injured workers at higher risk. Pharmacy benefit managers can help identify at-risk claimants based on their patterns of medication use, for example.

 

Once an injured worker has undergone testing, it’s important to have an expert interpret the results and help determine whether and what type of intervention may be necessary. Expert interpretation is generally provided by the testing lab. An employer may also consider consulting with a medical advisor.

 

 

Practical Tips for Employers / Payers Implementing UDT

  • Avoid poor quality and abuse by not letting doctors complete their own testing.
  • Contract for a panel of tests with a reputable lab.
  • Direct testing from physicians to the preferred lab.

 

Conclusion

 

There are a variety of tools that can help early identification of injured workers at risk of poor outcomes. UDT can be valuable when it is done with the proper frequency, and when the results are accurately understood and acted upon.

 

 

 

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: https://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.

5 Ways to Relieve and Prevent Chronic Low Back Pain

5 Ways to Relieve and Prevent Chronic Low Back PainExperiencing low back pain is common among adults. And as one of the most pervasive and expensive causes of workers’ compensation claims, it makes sense do everything possible to prevent LBP.

 

Our industry could prevent needless disabilities and save employers and payer’s a significant amount of money if armed with the latest research and some simple exercises.

 

About LBP

 

The biggest risk factor for a second episode of LBP is having a first episode. New research out of Australia shows that more than any other risk factor – whether it is obesity, smoking, or some other comorbidity – a single occurrence of LBP is the main commonality among those who have a second occurrence.

 

Specifically, one-third of people who have LBP will have a second episode within a year, and the chance of another recurrence triples after that. The researchers were surprised, given that preventing a recurrence of LBP is fairly easy.

 

Studies indicate that doing exercise can reduce the risk of a LBP episode by 35 percent, and combined with education about LBP, the risk drops by 45 percent.

 

That said, treatment for acute back pain is different from chronic LBP.

 

Acute LBP. This is short-term, generally lasting no more than six weeks.

 

  • The best treatment is to stay active, but avoid overdoing it. Keeping up with activities such as work is advised, and no bedrest!
  • Almost all episodes of acute back pain will resolve spontaneously, even when there is evidence of disc herniation and sciatica. So conservative measures are called for and appropriate.
  • An MRI prior to 6 weeks of persistent pain is not recommended unless various red flags are present suggesting a serious or progressive condition. Premature MRIs have a high likelihood of showing incidental chronic changes which are common in adults and are not related to the patient’s complaints.
  • Psychosocial factors play a major role in LBP and should be addressed, g., stress, job dissatisfaction and sleep disturbances.

 

Chronic LBP.  LBP is label as chronic when it persists for at least three months and is a major cost driver in workers’ compensation.

 

  • One in four injured workers with chronic LBP is out of work for up to six months, increasing the chances of permanent disability.
  • The estimated direct costs exceed $14 billion annually.

 

 

Treatment

 

While most episodes of LBP resolve themselves within a few weeks, there is no quick fix for chronic cases. The best advice is to do exercises that target specific areas, although no one exercise is ‘best.’ The best exercise is the one the injured worker does consistently.

 

Ideally, the injured worker should do movements that increase mobility and range of motion, since that will reduce their pain. Tight, weak muscles don’t allow the joints to move properly.

 

Pilates and Yoga are great ways to reduce pain and prevent LBP. Here are additional exercises that can help LBP

 

  1. Strengthening. Exercises that help strengthen muscles in the front and back of the spine are best. They should focus on the deeper, transverse abdominis that support the spine. Planks are a good example. They also help the intrinsic, tiny muscles that attach to each vertebra and provide postural support, which is important.

 

  1. Practicing good posture is key to improving stability. The goal is to have a neutral spine. Workers who sit all day put increased pressure on the spine.

 

  1. Body mechanics. Proper lifting techniques, for example, help protect the spine and prevent recurrences of LBP.

 

  1. Flexibility. Exercises that target the lower extremities are important. The hip rotators, hamstrings, and hip flexors can tighten up and cause pain. Movements that increase flexibility can relieve chronic LBP.

 

  1. Stretching. Taking the stress off the lower back can greatly relieve LBP. Gentle stretches can provide the fastest relief for LBP. The ‘cat/cow stretch’ is especially effective and easy to do. The worker is on the floor on his hands and knees, with hands under the shoulders and knees under the hips. He rounds the back, stretching the mid-back between the shoulder blades, similar to how a cat stretches. After 5 seconds, he relaxes and then arches his lower back and holds for another 5 seconds. Another is the ‘knee to chest stretch.’ In this one, the worker lies on his back with knees bent and feet flat on the floor, with his hands behind the knees or just below the kneecaps. He then gently brings both knees toward the chest, using the hands to pull them; and holds for 20 to 30 seconds.

 

 

Conclusion

 

Any worker of any age can experience LBP. Older workers typically have degenerative changes, while younger employees tend to experience soft tissue problems. Treatment will vary depending on the specific pain generator and be customized according to specific evidence-based medicine guidelines. The key is to make a correct diagnosis, and then target the best therapy beginning with conservative measures.

 

 

 

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: https://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.

U.S. Workers’ Compensation Prescription Drug Spending Decreased 3.3 Percent in 2017

ST. LOUIS /PRNewswire/ — Workers’ compensation pharmacy spending decreased 3.3 percent in 2017, according to new data released by myMatrixx, an Express Scripts (NASDAQ: ESRX) company.

“By merging the core capabilities of Express Scripts and myMatrixx to deliver superior clinical expertise, market-leading client experiences and innovative technology-based solutions, myMatrixx is now uniquely positioned to serve workers’ compensation clients and injured workers,” said Phil Walls, RPh, Chief Clinical Officer for myMatrixx. “We’re doing more to help clients balance appropriate care for injured workers while keeping costs down.”

 

More than half of myMatrixx Workers’ Compensation plans reduced drug spending last year.

 

 

Curtailing the Opioid Epidemic

 

Spending on opioids declined 11.9 percent for workers’ compensation payers in 2017.

 

For decades, myMatrixx has championed safe and appropriate use of opioids through solutions that leverage data, educate those at risk for adverse events and ensure connectivity across the care continuum. In addition, many states have taken action to address the opioid crisis through a multifaceted approach involving state-specific formularies, opioid guidelines and limits on initial opioid dispensing days’ supply and/or morphine equivalent dose.

 

These factors resulted in 74.2 percent of workers’ compensation payers spending less on opioids in 2017 than in 2016.

 

“While a decrease in the utilization of opioids is a positive sign for the workers’ compensation industry, there is still work to be done,” said Brigette Nelson, senior vice president of workers’ compensation clinical management at myMatrixx.

 

myMatrixx research found dangerous drug combinations and long-term use of opioids still pose care and cost concerns. Nearly 40 percent of injured workers took an opioid along with a muscle relaxant, while nine percent took an opioid and benzodiazepine. Taking these medications together can increase the risk of side effects and death from respiratory depression.

 

By deploying a holistic approach to manage opioid use, myMatrixx works with physicians, pharmacists and injured workers to mitigate the concerns of drug interactions or overuse.

 

Additionally, myMatrixx noted by the eleventh year of injury, the cost per injured worker reached $3,402.07, with $1,862.36 spent on opioid medications. Among those with age of injury of 10 years or more, more than half filled an opioid medication in 2017.

 

 

Compounded Medications Decline Further

 

For the third year in a row, spending on compounded medications decreased – a decline of 37.9 percent in 2017, falling out of the top 10 therapy classes.

 

While compounded medications continue to be a focus because of their high cost, it is clear that effective management strategies can reduce unnecessary costs and waste associated with clinically unproven ingredients.

 

 

Specialty Medication Utilization Remains Low, but Growing

 

Spending on specialty medications to treat conditions such as HIV and osteoarthritis increased 3.8 percent in 2017. 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.

 

“Payers who have injured workers with occupational exposure to needle-sticks often include HIV medications on their formulary to ensure quick access to work-related HIV prophylaxis therapy,” Nelson said. “This therapy class saw the highest spending among specialty medications.”

 

 

Other Key Findings of the Workers’ Compensation Drug Trend Report include:

 

  • Generic fill rate increased to 85.6 percent across our workers’ compensation payers in 2017. Yet, payers could have saved $80.8 million through an optimal mix of clinically appropriate generic options.

 

  • The average cost of a physician-dispensed medication was $270.70, compared to $108.49 for a pharmacy-dispensed medication. This means plans paid a $162 premium for physician-dispensed medications which bypass pharmacist review at the point of sale. Of the medications dispensed by physicians, nearly half are used to treat pain.

 

  • On average, payers spent $1421.36 per injured worker for prescription medications in 2017.

 

 

About the 2017 myMatrixx Drug Trend Report

 

The 2017 myMatrixx Workers’ Compensation Drug Trend Report is among the industry’s most comprehensive analyses of workers’ compensation drug spending in the U.S. In its 12th edition, the research examines de-identified prescription drug use data of injured workers with a pharmacy benefit plan administered by myMatrixx. The report also includes analysis of state and federal government regulations and their impact on pharmacy-related challenges in workers’ compensation.

 

In calculating trend, prescription drug use was considered for legacy Express Scripts clients with a stable injured-worker base, defined as having a change in user volume of less than 50 percent from 2016 to 2017.

 

The comprehensive review of trends in prescription drug spending for workers’ compensation plans is available at myMatrixx.com

 

 

About myMatrixx, an Express Scripts company

 

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. Located in Tampa, Florida, myMatrixx has positioned itself as a thought leader in the workers’ compensation industry.

 

For more information, visit myMatrixx.com

 

Media Contacts:
Phil Blando
202-258-4978
PJBlando@express-scripts.com

 

Ellen Drazen
314-684-5355
EVDrazen@express-scripts.com

 

 

SOURCE myMatrixx

Related Links

http://www.mymatrixx.com

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