Medical & Pharmacy Management Archives

Vocational Rehabilitation Qualified Rehabilitation Consultant Misconduct

October 30, 2019 by Michael B. Stack

Vocational rehabilitation and working with a Qualified Rehabilitation Consultation (QRC) can reduce workers’ compensation costs and get an injured employee back to work in a timely manner. Problems can arise when the QRC starts acting like an advocate for the injured employee. Members of the claim management team and other interested stakeholders need to be on the look-out for QRCs gone wild – and ensure they are working for the rehabilitation plan, and not the employee.

What are QRCs?

QRCs are trained vocational rehabilitation consultants than assist employees in post-injury return-to-work and medical management activities. Requirements for QRC registration are typically governed by administrative rules established by an industrial commission. They are appointed following a work injury where the employee’s injury is severe enough to require extended time off work. They should have a solid medical background, and understanding of the labor market and empowering employees to return to suitable gainful employment.

Acting in the Best Interests of the Rehabilitation Plan

QRCs will meet with an injured employee at appointed times set forth in statute or rule and determine the vocational goals. This includes an assessment of various factors, which can include:

The nature and extent of the employee’s injury;

Restrictions and other limitations placed on the employee post-injury;

Transferable job skills and ability of the employee to return to work;

Ability of the date of injury employer in returning the employee to work, including in a light-duty capacity.

QRCs are required to be neutral parties and not an advocate for the employee. The best interests of all parties need to be carefully balanced and taken into consideration.

Qualified Rehab Consultant Misconduct

QRC misconduct is defined by statute or rule in each jurisdiction. There are general principles that govern the conduct of a QRC. Proactive members of the claim management team need to be on the look-out for these factors and take appropriate action against a QRC that steps outside their role.

Failure to perform rehabilitation services with reasonable skill because of negligence, habits, or other cause. This can include a number of different factors and behaviors. It can be something as basic as missing meetings or appointments, and consistently not returning telephone calls in a timely manner. It can also include failing to properly supervise QRC interns and support staff;

Engaging in conduct that is likely to deceive, defraud, or harm the public;

Fraudulent billing practices, or failing to properly bill for vocational rehabilitation services; and

Engaging in adversarial communication or activity. This can include behaviors such as offering opinions on the facts of the case, litigation strategy, requesting information not related to the rehabilitation plan, failing to report all relevant information, and not complying with authorized requests for information.

QRCs need to take their responsibilities seriously. Let the attorneys advocate for their client(s).

Removing a QRC From the Rehabilitation Plan

Each jurisdiction has the mechanisms and standards for removing a QRC from the rehabilitation plan and installing a difference vocational assistant. Most states look at the “best interests of the parties” when making such changes. Factors for consideration include the following:

Loss of trust of the QRC. Claim handlers making this argument should provide concrete evidence on how the QRC has “picked sides” in a dispute – become an advocate for the inquired employee;

Duplicative time and costs that may be incurred as the result of the removal/change in QRC. This is an argument that can be made when the claim management team opposes the change in QRC;

Reputation and years of experience and complexity of assignments by the individual; and

Geographic location of the QRC. In some instances, one QRC may be better than another if the employee relocates.

Conclusions

QRCs play an essential role in vocational rehabilitation and getting an injured employee back to work. Claim handlers need to be diligent in making sure the QRC is doing their job and being an advocate for the rehabilitation plan, and not a party. Failure to do so will result in an employee being off work for a longer time, and more money spent on vocational rehabilitation costs.

Author 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/

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

Filed Under: Medical & Pharmacy Management

Closing Down Vocational Rehabilitation Workers’ Comp Cases

October 29, 2019 by Michael B. Stack

Vocational rehabilitation is an essential workers’ compensation benefit for employees suffering from the effects of a work injury. It not only helps the employee understand their medical care and treatment, but provides them with assistance in getting back to work. This reduces the money spent on a workers’ compensation claim and improves program efficiency. Members of the claim management team need to examine their files to ensure this benefit is being provided in a responsible manner. When there is no longer a benefit to the employee, steps must be taken to discontinue services.

When is Vocational Rehabilitation Appropriate?

Vocational rehabilitation services are provided to employees who are qualified under a workers’ compensation law. This is a benefit that did not come into acceptance in most jurisdictions until the 1970s. It is generally not available to an employee unless they have been off work for an extended period of time.

In order to qualify, a consultation is usually performed by a Qualified Rehabilitation Consultant (QRC), and a recommendation is made regarding the employee’s status. Factors generally considered include:

Whether the employee is permanently precluded or is likely to be permanently precluded from engaging in their usual and customary occupation or from engaging in their pre-injury job;

Whether the employee is reasonably expected to return to suitable gainful employment with the date of injury employer; and

Whether the employee can reasonably be expected to return to suitable gainful employment through vocational rehabilitation services by taking into consideration the treating physician’s opinion regarding the employee’s ability to work.

Vocational Rehabilitation is Being Provided – Now What?

During vocational rehabilitation, the QRC will issue regular progress reports. It is essential that the claim handler monitors vocational rehabilitation once it has been approved. These reports outline the services being provided and the progress the employee is making in recovering from the work injury. Important issues to consider when reviewing periodic reports are as follows:

New or continuing physical limitation that significantly interferes with the completion of the rehabilitation plan;

Whether the employee is participating fully with the plan; and

Whether the goals of the plan should change, or be modified.

Steps should be taken to termination vocational rehabilitation services if it appears the employee will not benefit from ongoing assistance from the QRC.

Do Not Pass Go: Shutting Down Vocational Rehabilitation Services

Each jurisdiction has the prescribed method one must follow in order to terminate the rehabilitation plan, and discontinue ongoing services from the QRC. While the process may differ, there are general requirements that are considered when putting an end to vocational rehabilitation serves.

A new or ongoing physical disability that significantly interferes with the completion of the rehabilitation plan. This is sometimes the case when the employee has a significant setback in their medical care or new injury or disability that is not related to their work injury;

The employee is not cooperating with the vocational rehabilitation being provided by the employee. Common examples include missing medical and physical therapy appointments, or failing to keep in contact with the employer and/or QRC; and

The employee is not participating effectively in the implementation of the rehabilitation plan.

The focus of the arguments made to terminate ongoing vocational rehabilitation services is whether the employee would benefit from additional vocational rehabilitation assistance. The party seeking to cease these services has the ultimate burden of proof. Grounds for stopping these services that are absolute usually include:

An employee who has returned to work with a negligible wage loss, or without a wage loss. Expectations of near-term future earnings can also be taken into consideration;

Settlement of a workers’ compensation case, which closes out future vocational rehabilitation services;

The employee is no longer making themselves available for services;

Death of the employee.

The closure of a rehabilitation plan generally requires a form to be filed with the industrial commission.

Conclusions

Members of the claim management team must closely monitor every workers’ compensation benefit being received by an employee. This includes keeping abreast of the employee’s status and cooperation with vocational rehabilitation benefits. While this is a useful benefit, steps should be taken to terminate it if evidence supports the conclusion the employee would not likely benefits from ongoing vocational rehabilitation services.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Medical & Pharmacy Management

Brand Name and Specialty Drugs Drive Up Workers’ Comp Pharmacy Costs

October 2, 2019 by Michael B. Stack

There’s a lot of good news in the latest pharmaceutical reports for the workers’ compensation industry. Prescribing and spending on opioids is down, and compound medications are much less of a factor than they have been in the past.

Stakeholders that want to continue seeing positive trends need to keep their eyes on the ball with trends affecting the industry. Many are wondering what’s next? What will be the next development that could unexpectedly drive up pharmaceutical costs among injured workers?

“There’s significant concern over the rising cost of prescription drugs,” according to the Drug Trend Report released by myMatrixx earlier this year. And “there is a lack of understanding about the impact specialty medications may have on workers’ compensation insurance.”

Stakeholders who are aware of, and take steps to address these two issues will be ahead of the game in holding down pharmaceutical costs.

Brands vs. Generics

Substituting generics for brand-name drugs where possible is one of the most effective and easiest ways to reduce drug costs in the workers’ compensation system. And yet, there are still many providers who prescribe brand name drugs unnecessarily. These prescribers and their injured-worker patients may be unaware of the cost differences involved.

“Over the past five years, the most commonly used brand-name traditional drugs among injured workers experienced list price inflation of 65.5%, but prices for the most commonly used generic medications declined 35.0%,” according to the myMatrixx report. “In contrast, a market basket of commonly used goods (e.g., milk, bread, etc.) rose only 7.4%.”

As Phil Walls, chief Clinical Office of myMatrixx explained, a generic version of a drug may cost 20 percent of the price of the brand name drug, on average. Spending $100 for a drug that could be purchased for $20 can have a significant impact on costs. But cost is not the only issue.

Many providers and injured workers believe brand name drugs are inherently of better quality than the generic versions. However, they have the same active ingredients and work the same way as brand name drugs.

“A generic medicine is the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and should be used,” per the Food and Drug Administration.

To gain FDA approval, a generic medication must be ‘bioequivalent’ to the brand name version. That means they are chemically nearly the same, although generic drug makers are allowed 20 percent variation in the active ingredient from the original formula. But according to Harvard researchers, “while the FDA does allow for up to 20 percent wiggle room, in reality, the observed variation is much smaller, 4 percent.”

Several brand name drugs that are widely used among injured workers have patents that have recently expired, such as Lyrica. That’s good news, in that less expensive generic versions will likely come on the market soon. However, stakeholders are advised to ask their pharmacists if the generic may be substituted for the form of a drug that their injured worker is receiving.

For example, some drug makers issue a long-acting version of a medication that is set to expire and set the cost at a lower amount than it would be for 2x the original drug. Providers and patients would be inclined to seek the long-acting version since it would essentially cost less than taking two pills of the original version. However, once the patent expires, patients who are taking the long-acting version won’t be eligible to receive the generic version, which would only be a substitute for the original version.

Some additional drugs with patents expiring this year are Amrix®, Fentora®, Flector®, and Vivlodex®.

Specialty Meds

The vast majority of workers’ compensation payers will likely never encounter a claim that involves specialty drugs. But for those that do, it can be a shock. These drugs comprise just 1.7 percent of claims, yet they drive 7.1 percent of spend. That number represents an increase of 18.5 percent over the prior year.

“On average, payers spent $5,130.57 per injured worker on a specialty medication,” according to the myMatrixx report. “Specialty medications cost four times as much, or more, as traditional medications for payers.”

While those numbers might cause payers to shy away from footing the bill for these medications, that strategy will drive up costs even more. “The maxim that the most expensive specialty drug is the one not taken means that poor adherence on the part of the patient may render even the best therapy ineffective,” the report said. “Compliance is vital; if the patient is not compliant, the course of therapy has to be repeated,” Walls added.

Paying for, and ensuring that injured workers take specialty medications when warranted is, therefore, imperative to achieving the best outcomes and containing costs.

Specialty medications are used for conditions that have not traditionally been associated with injured workers. However, that is changing.

The proliferation of new cancer-presumption laws for firefighters means more cancer drugs will be seen in workers’ compensation claims. Needlestick injuries to healthcare workers and first responders may warrant specialty drugs for HIV and Hepatitis. Specialty drugs for hepatitis C can cost $100,000 for a 90-day supply.

Workers most likely to receive a specialty drug include:

Emergency first responders
Public safety personnel
Law enforcement officers
Correctional officers
Healthcare workers
Certain defined workers in states with cancer presumption laws

Conclusion

Drug spend in the workers’ compensation system can be astronomical, but the costs can be controlled. Staying on top of issues such as generic vs. brand name drugs, and the increased use of specialty medications will help. Working closely with providers, pharmacists, and PBMs is the best way to ensure injured workers get the medications they need without payers spending unnecessarily.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Prescription Drug Use & Abuse

Spot Over-Treatment from Medical Providers

September 9, 2019 by Michael B. Stack

Members of the claim management team need to take control of their files to reduce workers’ compensation costs by spot unscrupulous practices by medical providers. While a vast majority of providers are ethical, never let down your guard, and be proactive in identifying red flags when it comes to over-treatment by medical providers.

The medical records are “template” style or barely exist at all.

A careful review is required when medical records all look the same. It is important to note “template” style records that repeat does not mean you are dealing with a shady doctor. It could just be that the doctor is very poor at note-taking. Great doctors do great analysis and back up opinions with objective medical facts. They arrive at this point by walking through the medical records and creating a great conclusive medical report.

Missing dates of service, or no date labels on the medical notes

Missing dates of services are often paired with “template “style medical records. The doctor uses a fill-in-the-blank system. Typical examples include: Patient came in with complaints of _______ which they attribute to work causing them _____ pain out of 10, with 10 being the worst pain imaginable.

Pay attention to medical records generated by health care providers. If anyone is watching, a physician will not get far by doing this. On the other hand, if nobody is paying attention, thousands of dollars could be paid for unnecessary medical care and treatment. Make sure the notes are clearly labeled, dated, and legible. If not, you need to contact that physician’s office immediately.

Different handwriting or inks on the same dates of service.

Some medical providers are not fully digital when it comes to the preparation of medical records. A nurse or the medical assistant may make notes in a medical record before the doctor attends to the injured employee. However, in some instances, this could mean notes are being manufactured. Carefully review these records.

The medical provider will not send medical records or state that they do not keep medical “records.”

All legitimate medical providers should keep records of patient interactions, including telephone calls and messages. Even the most trivial of companies store records of some sort. As a matter of best practice, refuse to pay any bill ever without a medical record.

The medical notes showed continued high levels of pain.

All legitimate medical care and treatment should provide some relief to an injured employee. If it is two months post-injury and the employee reports a pain level of “10 out of 10,” questions need to be raised as to what care is being provided, and why the injured employee is still suffering from the effects of the injury. If the physician is not doing anything about it, or the person is no better, then you must find out what is going on medically and get that person to a specialist or set up an Independent Medical Exam(IME) to address these ongoing complaints.

Conflicting medical reports or conflicting subjective complaints.

Take the following example: You are reviewing a stack of medical records on a claim. The injured employee states they are in very bad pain, 8/10. It is hard to bend and walk. The next day they show up for therapy, and they tell the therapist they are doing great, and they think treatment is really helping them. Two days later they go back to the doctor and say they feel the same, about 7-8/10 pain. Then the same day they have therapy and tell the therapist they feel great, and are looking back to getting back to work.

Therapy can flare pain up a bit, but over a few weeks, the pain should be gradually lessened. If you start to notice inconsistent pain complaints, and pain out of proportion to the injury, think about getting an IME to better understand what is going on.

Conclusions

All health care providers should have consistent billing practices. They should be using standard billing forms such as a CMS/HCFA-1500 form so the bill can be processed and paid in a timely manner. All medical bills should conform to the medical record that is often required to be attached to the bill. If not, ask immediate questions. It is also important to ask questions if red flags are raised when reviewing medical records. Failure to do so can result in excessive money being spent.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Medical & Pharmacy Management

Reducing Work Comp Costs With Field Nurse Case Managers

August 27, 2019 by Michael B. Stack

Interested stakeholders in the workers’ compensation claims process should seek creative methods to reduce workers’ compensation program costs without cutting corners. When looking for ways to reduce costs, the well being of the injured employee is paramount. One step that can be taken is to use field nurse case managers to better direct care, and do so in a cost-effective manner.

It All Starts with the Claim Handler

When a claim handler is faced with a new and severe claim, it requires immediate attention. The injured worker may have a life-altering injury at work requiring emergency surgery before the adjuster even sees the claim. These injuries are crush injuries, severe fractures, spinal injuries, or closed-head injuries. The claim handler should also ask the following questions:

Does the injured employee require an extended hospital stay?

Does the injured employee have adequate in-home medical care or is an outside service provider recommended?

Will the injured employee require more surgery?

These are questions that must be answered, and if the claim handler is unavailable, a Field Nurse Case Manager can be very useful.

What is a Field Nurse Case Manager?

Field Nurse Case Managers are typically a registered nurse who specializes in the coordination of medical care of injured employees in workers compensation cases. They are aware of a variety of resources that manage the claim and bring a high level of medical care to the employee and ensure the proper utilization of services and resources. They can serve as a “go-between” for the various other interested stakeholders – multiple medical facilities, doctors and other specialists, and vocational rehabilitation consultants. They can also serve as a resource for friends and family members of the injured employee by ensuring the injured party receives a high quality of medical care when they are off work for an extended period.

Benefits of Field Nurse Case Managers

There are many benefits to using a Field Nurse Case Manager. Here are some examples of how an employee can receive best in class service, while not requiring the insurance carrier to spend significant amounts of money on a claim.

Help ease the transition from hospital to home and beyond.

Insurance carriers sometimes look at short-term costs, but forget the long-term risks. It can be easily forgotten that employees who sustain serious trauma have virtually every aspect of their life impacted. A Field Nurse Case Manager can assist in the transition by monitoring medical care and educating family members on the needs of the injured employee.

Secure medical records faster than the claim handler.

A claim handler is often burdened with several important tasks that are time-sensitive, and requesting medical records is often a low priority that causes delays. An experienced Field Nurse Case Manager will know where to go in the hospital, and who to speak with to get this much needed information.

Help make a discharge from hospital to home easier.

Employees with severe injuries can receive medical care and treatment in-home. By using a Field Nurse Case Manager, this care can be coordinated to take place by ensuring it is provided correctly, and assist with issues concerning transportation to/from appointments.

Will stay on the case until the injured worker is stabilized.

The Field Nurse Case Manager assists the injured employee’s initial needs of moving from the hospital to home, ongoing medical care, and other issues. They also serve as a point of contact regarding pressing medical concerns and can attend medical appointments with the employee. There is also a benefit to working with a FNCM when it comes to chronic pain or mental health concerns.

Provides the injured worker resources of care.

The Field Nurse Case Manager provides the injured employee a resource with all interested stakeholders. By assigning a FCNM, the employee can better understand what care is best, provide answers to questions, durable medical equipment assistance, arrange in-home medical care, and seek to improve the employee’s daily life.

Conclusions

Field Nurse Case Manager workers have a special job coming to a severely injured worker needing help. They aid in many areas, not only to the injured party but also to the family. The Field Nurse Case Manager helps the carrier by obtaining much needed information about the injury, while at the same time assist the employer by providing updates on the injured employee’s status. Most importantly, the worker gets help to focus on healing with quality service that only a nurse can provide.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Medical & Pharmacy Management

Weeding Out The Truth About Medical Marijuana

August 14, 2019 by Michael B. Stack

Marijuana is illegal under federal law. But workers’ compensation stakeholders who think that gives them license to ignore the issue are making a huge mistake, according to experts.

The cannabis industry is growing by leaps and bounds and shows no signs of slowing. Most states now allow the drug in some form. Judges are increasingly siding with injured workers who want to be reimbursed for the drug.

Employers, especially those who do business in multiple states, need to know how to ensure a safe workplace, be fair to all employees and protect themselves from litigation. Staying abreast of the latest developments is key.

Some Basics

Terminology. Keeping up with the lingo can be exhausting, but payers who do have an edge when it comes to addressing the issue. Some important terms include:

THC: A cannabinoid that produces the ‘high’ that users experience
CBD: A molecule touted as having potential medical benefits without the psychoactive properties of THC.
Hemp: A strain derived from the species cannabis sativa, as is marijuana, but with lower concentrations of THC and more CBD. The Agricultural Improvement Act signed into law recently removed hemp from the list of Schedule I controlled substances and made it an ordinary agricultural commodity. CBD derived from hemp has recently become widely available.
Strains: There are hundreds of combinations, mainly from three strains:

Indica — produces a more relaxing effect
Sativa — is more energizing
Ruderalis — has low levels of both THC and CBD.

Budtender: The person at a ‘dispensary’ who gives advice about which varieties may be more helpful to the user

Physical Effects

Whether and to what extent marijuana helps with various physical or mental conditions is a matter of debate, since the federal prohibition of the drug stymies research on it. But there is some evidence it may help alleviate chronic and neuropathic pain, cancer pain, and spasticity. Some people claim it can also help with anxiety, post-traumatic stress disorder, traumatic brain injury, depression or acute pain. There are conflicting studies about whether marijuana can serve as a viable substitute for opioids, but the most recent study suggests it does not.

High doses of marijuana, especially when it’s ingested as an edible, can have serious repercussions. Some users have gone to emergency rooms believing they are having a heart attack. In addition to the potentially positive impacts, the drug can also cause a variety of unpleasant symptoms, including:

Rapid, irregular heart rate
Anxiety
Lung irritation
Coughing, wheezing
Nausea, vomiting
Various exacerbations of serious psychiatric conditions such as depressions, bipolar illness, schizophrenia and other psychotic disorders.

Problems for Employers, Payers

Drug testing to identify marijuana users high on the job may be counterproductive. Since the drug stays in the body long after its effects have worn off, the tests can’t really determine if a person is impaired. Workers in safety-sensitive jobs are another story, as they are prohibited from performing their jobs if there is any sign of drug use identified.

However, for other workers, employers may notice certain signs that could indicate an employee is under the effects of marijuana:

Slowed responses and reflexes
Lethargy, drowsiness
Slowed perception of time; appearing in an almost dreamlike state
Unfocused
Impaired memory function
Red eyes or dilated pupils

Employers who suspect their workers of being high on the job must be careful about how they respond. Unless they have clear-cut policies that allow for drug testing when they suspect impairment, organizations can be accused of discriminating against certain employees. Working with an attorney and developing a solid policy that is communicated to all employees is imperative.

Another major concern for payers concerns the logistics for reimbursement. It’s not like other, FDA-approved drugs, where a physician prescribes a certain dose, number of pills per day and timeframe for use. Physicians in medical marijuana states can only recommend using the drug. It’s then up to the user, working with the budtender, to determine what might help.

The many different strains mean one purchase may be different from another. There are many inconsistencies in terms of the quality and purity as well as labeling — within states and even within communities.

However, as the pharmaceutical companies begin to derive purer and more targeted compounds from marijuana, we will likely see more employees using prescribed, rather than marijuana dispensary, formats which will reduce the rationale for using the latter, and will provide safer, efficacious and accurately dosed drugs.

The best advice from experts is to work closely with all stakeholders involved, including the injured worker. Working with the physician, for example, might persuade her to prescribe a treatment or medication other than marijuana. At the very least, it could help determine how much and for how long the drug will be used. Having more and better communication with the injured worker can provide insight into whether and why he believes marijuana is the best option and help determine the anticipated expense.

Conclusion

The issue of medical marijuana is not an easy one for workers’ compensation stakeholders right now, but it should not be ignored. Regardless of personal feelings about the issue, organizations are increasingly being forced to deal with it. Those who understand their states’ laws and the various nuances involved, and work with other stakeholders will be best prepared when it arises.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Prescription Drug Use & Abuse

NCCI Report Highlights Early Identification of Prescription Drug Abuse

May 21, 2019 by Michael B. Stack

Prescription drugs continue to contribute to a significant portion of medical costs in workers’ compensation claims nationwide. This is due in part to opioid addiction and its negative impact. Gains are being made, which means proactive members of the claim management team need to be continually engaged and implement best practices to avoid addiction and reduce the portion of claims consumed literally by prescription drugs.

NCCI Report Highlights the Problem

The National Council on Compensation Insurance (NCCI) recently released a report regarding prescription drug costs in workers’ compensation case. The report sets forth the following encouraging conclusions:

Physician dispensing and use of more expensive brand name prescription medications are declining;

While the prescription drug share of medical costs in workers’ compensation cases is at 13.7%, this amount declined by 2% in 2015, and 4% in 2016; and

Main drivers in prescription drug usage include Lyrica, OxyContin, and Gabapentin, which account for more than 15% of prescription drug costs in 2016.

While some of these trends are positive, it should still be understood that more can be done by proactive claim handlers to control the costs of prescription drugs in workers’ compensation claims and run a more effective program.

Early Identification of Prescription Drug Abuse

All interested stakeholders should be on the look-out of for overuse and abuse of prescription drugs. Signs of misuse include the following:

Identification of injured employee’s with risk factors that include past/present history of substance abuse, family history of substance abuse, and various psychological and/or psychiatric conditions;

Injured employees that specifically request prescription medications by their name brand and refuse to accept generics; and

Instances where someone regularly claims to lose their prescription drugs and is requesting a refill.

The existence of a pain management agreement is a common feature in most workers’ compensation laws in instances where an employee is using opioid-based drugs. This agreement should be strictly followed. There should also be a renewed effort on the part of everyone to direct an injured employee back to work, even if it is in a light-duty/sedentary capacity. Studies suggest strong return-to-work efforts significantly reduce the medical spend on any type of personal injury claim.

Multi-Faceted Approach to Reducing Prescription Medical Expenses

Proactive stakeholders in the workers’ compensation system can advocate for change to reduce the cost and human toll prescription drugs – mainly opioid-based – take on injured employees. This includes an effective three-pronged approach.

Prevent new cases of opioid-based prescription medication abuse from occurring: This all starts with the use of a pain management agreement – and making sure it is strictly enforced. This zero-tolerance approach will ensure powerful pain medications are not misused or abused. Terms within the agreement should include exactly how the medications are to be used, random drug testing and consequences for false/positives, failed tests and missed testing, how replacement medications are to be dispensed and where all prescriptions are to be filled – avoiding physician dispensing protocols.

Treat people who are addicted with compassion: No process is foolproof, and anyone can become addicted. It is important to treat individuals who suffer from this consequence are treated with respect and dignity. All reasonable and necessary forms of treatment should be made available; and

Use drug utilization measures to better target prevention and treatment: This is one of the most effective tools available to members of the claim management team in combating the abuse and overuse of opioid-based prescription medications. Drug utilization review (DUR) is the process of reviewing all aspects of prescription drug usage – prescribing, dispensing, and use of medication. It examines the individual usage of someone against predetermined criteria based on evidence-based medicine to ensure an effective and efficient result. The recent NCCI report also credited the effective use of DUR in driving down the amount of money spent on prescription drugs in workers’ compensation claims.

Conclusions

There are many negative consequences of prescription drug abuse and misuse in workers’ compensation cases. Steps are being taken to hold these adverse effects in check and also reducing workers’ compensation program costs. This can be accomplished by implementing an effective approach that includes drug utilization review in your program.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Prescription Drug Use & Abuse

11 Tips for Safe Use of NSAIDS to Treat Pain in Workers’ Compensation

May 14, 2019 by Michael B. Stack

There’s good news about the latest drug usage in the workers’ compensation, although it comes with a word of caution. The good news, according to the latest Drug Trend Report from myMatrixx is that the use and spend on opioids have once against decreased. Alternative medications treatments are being used more often to treat pain. While that’s good in the effort to prevent unnecessary use of opioids, one class of medications need to be taken with caution.

NSAIDs — nonsteroidal anti-inflammatory drugs— have become one of the medications of choice to treat pain. These can be very effective and don’t carry the risks of addiction or dependence of opioids. However, the problem is the potential negative effects on the cardiovascular system. Care needs to be taken when prescribing them, especially to older workers.

The situation is something of a Catch-22; older injured workers often have pain, but they are typically more vulnerable to problems of the cardiovascular system. Payers can help protect injured workers who are prescribed these medications by understanding the risks, educating patients and exercising caution.

NSAIDs and Cardiovascular Issues

NSAIDs are often used to treat mild to moderate pain. They are especially helpful for pain caused by inflammation, such as arthritis or a sports-type injury.

NSAIDs are drugs with analgesic, anti-inflammatory, and antipyretic activity. Some of the commonly used over-the-counter varieties are ibuprofen, such as Motrin and Advil; and naproxen sodium, or Aleve and Anaprox. Prescription NSAIDs include Celecoxib, or Celebrex; and diclofenac, known as Cataflam and Voltaren. Aspirin, which is an NSAID, does not pose a risk of heart attack or stroke and is commonly used to prevent those conditions.

Gastrointestinal problems associated with NSAIDs are well known. But researchers have also found that these medications can increase blood pressure and lead to congestive heart failure, as well as acute myocardial infarction.

The Food and Drug Administration warned of the potential risks of heart attack or stroke from NSAIDs in 2005. Ten years later the agency strengthened its warning, based on the advice of an expert panel that had reviewed additional information.

The risk was especially noted when the drug rofecoxib, or Vioxx, was on the market. It was removed in 2004, after being associated with as many as 140,000 heart attacks in the U.S. during the five years it was sold. It prompted further research about the risks of heart attack and stroke from NSAIDs in general.

According to the FDA:

The risks of heart attacks and strokes increase even with short-term use of NSAIDs and may begin within a few weeks of taking the medications.
The higher the dose of NSAID, the higher the risk. Also increasing the risk is the length of time the medications are taken.
People most at risk are those who already have heart disease, although others can also be at risk.

Patients taking diuretics may be at the highest risk of heart attack or stroke, especially during the first few weeks of taking NSAIDs.

Preventing NSAID Risks

Taking NSAIDs for a few days to relieve pain generally carries just a small risk, for most people. Employers and payers can help ensure injured workers are less at risk of developing heart attacks or strokes from the medications through the following strategies:

Monitor for signs and symptoms of adverse effects.
Educate injured workers and family members on the risks, especially those more at risk.
Prescribe the lowest dosage possible.
Prescribing taking the drugs for only a limited period of time.
Try alternative remedies for people who have heart disease, if at all possible.
Do not take more than one type of NSAID at a time.
Try alternative medications, such as acetaminophen. Be aware, however, that this drug can cause liver damage if the daily limit exceeds 4,000 milligrams or if the person drinks more than three alcoholic beverages a day.
Suggest week-long NSAID ‘holidays’ on occasion.
Advise the injured worker to get medical attention immediately if he experiences chest pain, shortness of breath or sudden weakness or difficulty speaking.
For muscle or joint pain, suggest hot or cold packs or physical therapy before NSAIDS, for those more at risk.
Injured workers already taking aspirin to prevent a heart attack should talk with their physician first, as some NSAIDs may hamper the aspirin’s effectiveness.

Conclusion

The workers’ compensation industry has made inroads in curbing the unnecessary use of opioids. However, care needs to be exercised before giving an injured worker a blanket recommendation or prescription for NSAIDS, especially for people who have pre-existing heart-related conditions. As with all medications, moderation is key.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Prescription Drug Use & Abuse

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

April 8, 2019 by Kathy Tiemeier

Hepatitis 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.

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Downward E. Drug resistance. HepatitisC.net. https://hepatitisc.net/treatment/drug-resistance/. Last reviewed March 2018. Accessed Dec. 7, 2018.

Author 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.

Filed Under: Prescription Drug Use & Abuse

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

February 26, 2019 by Michael B. Stack

Fentanyl 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:

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

Provide strong clinical oversight, of physicians and pharmacies. Working with a pharmacy benefit manager and/or carrier is a place to start.
Ensure providers are aware of alternative therapies to opioids and encouraged using them
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.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Prescription Drug Use & Abuse

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

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

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