The Best Tidbits of News from the Workers Comp Community

 

For 20 years, the National Workers' Compensation and Disability Conference® & Expo has been the industry's leading training event. It offers cutting-edge, yet practical solutions for your workers' comp, disability management and RTW programs. This year's event is promised to take it to the next level – see the agenda posted here.

 

 

A "permanently disabled" person finds his way back to ability

Watch this inspirational video posted to the Workers Comp Roundtable by Dr. Marianne Cloeren, Medical Director at Managed Care Advisors. She states "This video is worth the time to watch. The transformation of this disabled vet is inspirational. Here is our challenge: how can we help the clients/claimants/ patients/injured workers (people) we work with grasp that the power to change rests within them?"[WCx]

 

 

VIDEO: Never Give Up 

 

Lexis Nexis Communities Top Stories:

 

Posted by
The AMA Guides generally disfavors grip loss as a measurement for rating a whole person impairment (WPI). (See AMA Guides Fifth Edition, page 508.) However, a series of recent WCAB panel decisions indicate that there may be circumstances when the grip loss metric is the most accurate tool for assessing an injured worker’s (WPI). Use of the grip loss measurement generally results in a much higher permanent disability (PD) rating for the injured worker.  Read More…

 

 

Larson’s Spotlight on Recent Cases: Civil Action Against Supervisor Moves Forward

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Larson's Spotlight

Larson's Spotlight on Civil Action Against Co-Employee, Exclusive Remedy, Volunteer Status, and Causation Involving Fatal Overdose. Larson's surveys the latest case developments that you need to know about. Thomas A. Robinson, the staff writer forLarson's Workers' Compensation Law, has compiled the list below.  Read More…

 

 
Posted by
The Social Madness corporate challenge has kicked off, and LexisNexis is one of 60 Dayton-area companies selected to compete in this social media competition hosted by the Dayton Business Journal and its parent, American City Business Journals.
The three national winners of the challenge will be able to designate a favorite charity to receive a $10,000 donation.  Read More…

 

Posted by
The most disturbing conclusion that the Workers’ Compensation Research Institute (WCRI) presented in a webinar entitled “Use of Narcotics and Compliance with Guidelines” was that many workers’ compensation claimants (claimants) who were prescribed narcotics were not provided recommended services for monitoring and managing long-term use of those drugs. These services included overseeing that use and treating its ill effects.
Other major findings were:
1) Most claimants who were prescribed pain medication for compensable harm were prescribed narcotics; and
2) Massachusetts, Pennsylvania, Louisiana, and New York had particularly high usages of narcotics.


Workers' Compensation Roundtable Passes 5,000 Member Mark

We reached an important milestone this week, and we want to once again thank you for your continued efforts in building what we believe to be an excellent group. We passed the 5,000 member mark this week, only the 2nd workers' comp group ever to do so on LinkedIn. 

In fact, we've added 4,500 members in just the last 18 months, and if you search Groups here on LinkedIn for "workers' compensation", you will find we are the #1 result they return. The Group Search page was "recently updated to make it easier for you to find the most valuable places to network", and at the time of the upgrade they announced that they made these determinations on the "relevance and quality" of the discussions in the groups. Showing up first in that search result is a huge compliment for our community! Read More…[WCx]


Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 

 


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©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Pill Mills are a Cost Driver in Workers Compensation Claims

The fastest growing area of workers compensation fraud is narcotics abuse. The fake workers comp claim for the purpose of feeding a drug addiction, or for the purpose of obtaining narcotics for resale, is a fast growing problem.  Employers and claim adjusters should proceed with caution when an employee has been given a narcotic prescription, especially when there has not been a recent surgery.

 
The term “pill mills” has been used by law enforcement to describe medical facilities where the primary purpose of the medical facility is to write prescriptions for painkillers.  The U.S. Drug Enforcement Administration (DEA) has been raiding medical facilities in Florida, Georgia, Ohio and other states with mixed results. They close down one pill mill only to have another one pop up. (WCxKit)
 
 
Pill mills often try to camouflage the activity as pain management clinics. There is however some red flags that distinguish a pill mill operation from a legitimate pain management clinic.  Included below are some characteristics of pill mills.
 
-The physician(s) have little training / background in pain management.
-The facility sees a high volume of patients daily.
-The facility provides scant patient examinations before prescribing narcotics.
-The facility both writes the prescription and fills the prescription.
-The facility writes prescriptions for amounts that exceed the manufacturer’s recommendation for maximum usage.
-The price of the prescription is inflated over what the same dosage would cost at a chain drug store.
-The facility operates on a cash-only basis.
-The patients often travel long distances to the facility, even from out of state.
-The facility is often located near an interstate highway for convenience of patients traveling long distances.
-The facility advertises its “services” on Craigslist or other similar Internet sites.
 
 
The abuse of narcotics has gotten so bad that, per the Associated Press, drug overdose deaths have surpassed traffic accidents as the top cause of accidental death in Ohio, Colorado, Massachusetts, New York, Oregon and 11 other states.  According to the Center for Disease Control, 20,000 people a year die from prescription drug overdose.
 
 
Pill mills like the Greater Medical Advance Clinic in Wheelersburg, Ohio are at the center of this epidemic.  According to the arrest documents, the clinic owner, George Marshall Adkins, wore a handgun in the clinic while dispensing tens of thousands of painkillers at inflated prices.
 
 
Employers in Florida should be especially cautious of prescription drug abuse on the workers compensation claims.  According to Florida state officials, 85% of all oxycodone pills sold in the United States come from Florida, with the top 50 medical prescribers of such drugs being located in Florida.
 
Carlos Gonzales in South Florida was arrested for his black market business of selling narcotics.  Gonzales was not an ordinary street level drug dealer.  He was a doctor operating a “pain management center” with numerous workers compensation patients. He lived in a multi-million dollar home with a Mercedes, a Bentley and a Lamborghini parked in the driveway.  The DEA estimated he was making from $13,000 to $20,000 a week writing thousands of prescriptions.
 
 
There are steps an employer can take to stop workers comp fraud / drug abuse through pill mills.  Among the ways the employer can fight workers comp fraud / drug abuse include
 
 
-Operate a drug free workplace – if the employees knows that drug testing for hiring and random drug testing is performed, the employees inclined to abuse drugs (and to file bogus workers comp claims to obtain drugs) will go somewhere else to work until they pull the workers comp fraud.
 
-Drug screen after each injury – a drug screen on the day of the injury should be a part of the immediate medical treatment.  In many states a failed drug screen can be grounds for the denial of the workers comp claim.  In the states where the workers comp claim cannot be denied due to the failed drug screen, the employer will at least know what the employee’s drugs of choice are.
 
-In the states where the employer is allowed to select the medical provider, be sure to do so.  Check the reputation of the medical provider with local defense counsel to eliminate doctors known for over prescribing medications or known for referring employees to questionable pain management clinics.
 
 
-Whenever pain becomes a significant part of the employee’s complaints following an injury, especially pain without visible trauma, a nurse case manager should be assigned to the claim to prevent narcotics abuse.
 
 
-All prescriptions for the injured employee should be filled through a pharmacy benefit manager (PBM).  Any time the employee is exceeding the manufacturer’s recommended maximum dosage, the PBM can review the requested dosage with the medical provider. (WCxKit)
 
 
By taking the above steps, the employer can significantly reduce the number of bogus workers comp claims for the purpose of obtaining narcotics, either for drug abuse or for resale. 
 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
 
 
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

WCRI Provides Unbiased Research to Industry

Few people realize the workers’ compensation industry is actually 100 years old. It’s one of the most-successful public-private partnerships in U.S. history.
 
 
Since 1983, the Workers Compensation Research Institute (WCRI) has been providing the public with research on WC public policy issues. Based in Cambridge, Mass., the organization includes among its members employers, labor organizers, public and private insurers, health care providers, managed care companies, and state government representatives from the U.S., Canada, New Zealand, and Australia.
 
 
Dr. Richard Victor, WCRI executive director, oversees the institute’s studies and analysis that has added ammunition for the reforms to various aspects of the workers' comp system. Prior to working at the institute, he spent seven years conducting research at The Rand Corporation in Washington , D.C., and Santa Monica , Calif. His law degree and Ph.D. in economics is from the University of Michigan.
 
 
LowerWC recently asked Victor for his impressions of the industry. What follows are some of his comments:
 
 
“One of the most important, and troubling, areas for workers’ compensation systems is to find the appropriate ways to use narcotics – and to discourage abuse and diversion. A second critical issue is to find new and innovative ways for help workers return to productive employment,” Victor says.
 
 
To this end, WCRI is conducting several research phases to help find answers for WC narcotic use and return-to-work issues, he says.
 
 
Victor says the latest trends in workers’ compensation also include medical cost management. “Medical costs now represent more than half of workers’ compensation costs in most states. There is increasing focus on pharmaceutical costs and utilization and the payments made to hospitals and ambulatory surgery centers,” he says.
 
 
Further, everyone wants to know how to save the employers money. Victor says, “Most large employers are focused on three legs of the four-legged cost containment table – risk financing, injury prevention, and claim management. The fourth leg is a large opportunity because employers have underinvested in it – improving the ‘rules of the game’ to make the system more effective for workers and more cost effective for employers.”
 
 
He continues, “This requires that employers join together to formulate political positions and strategies and gather available evidence about how a given state system is performing, how it might be improved, and what lessons can be learned from other states.”
 
 
California and Texas are good examples of where employers have taken collective action and costs have fallen significantly, Victor says. One of the chief objectives of the WCRI CompScope benchmarking studies is to help stakeholders and public officials set priorities and debunk myths.
 
 
One important part of this research is an upcoming conference. The WCRI Annual Issues and Research Conference will be Nov. 16-17 in Boston with keynote speaker Peter Barth, professor of economics emeritus at the University of Connecticut. This will be its 28th year.
 
 
The goal there to present new ideas and alternative views, Victor says. “Whether you are managing workers’ compensation claims, involved in strategic planning, concerned with medical costs and utilization, or just looking for a better understanding of workers' compensation – this is the conference for you.”
 
 
All of the sessions highlight the first presentations of the latest research findings from WCRI while drawing upon the diverse perspectives of highly-respected workers’ compensation experts and policymakers from across the country, he says. “Attendees tell us that they value the large attendance because it allows them to leverage their time while at the conference. There are also opportunities to meet and interact with WCRI researchers.”
 
 
“The most important advice I can give remains a secret until the WCRI conference, when I (present) ‘The Elephant in the Room.’ It will highlight some things that are underappreciated, but are likely to shape workers’ compensation systems for the next decade. The future is not always like the past,” Victor says. “Of course, I would like to see your readers attend to stretch their thinking, gain a competitive edge, and network with peers.”
 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of  Manage Your Workers Compensation: Reduce Costs 20-50% on cost containment techniques.  www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

Workplace Precautions for Handling Hazardous Drugs to Healthcare Workers

Hospital and health care employers were reminded recently that hazardous drugs such as antineoplastic drugs could pose serious job-related health risks to workers if proper precautions are not used in handling the drugs.
 
 
The National Institute for Occupational Safety and Health (NIOSH), the Occupational Safety and Health Administration (OSHA), and The Joint Commission highlighted the need for safe practices in a letter to hospitals in the U.S. (WCxKit)
 
 
Drugs used for chemotherapy, antiviral treatments, hormone regimens, and other applications have potential for serious adverse occupational health effects, the agencies said. Irreversible effects from work-related exposures even at low levels, without taking appropriate precautions, can include cancer, reproductive and developmental problems, allergic reactions, and others.
 
 
"Potent therapy drugs can have great benefit for patients when used in proper regimens, where doses are controlled and risks are minimized. But they can also have serious consequences to the workers who handle, dispense, mix, apply, and dispose of them without proper controls and training," said NIOSH Director John Howard, M.D. "We are pleased to join with our partners to remind hospital employers that protecting the health of their employees is vitally important."
 
 
Substances that present a potential health hazard to workers must be included in an employer's hazard communication program, and it should be readily available and accessible to all including temporary workers, contractors, and trainees, added David Michaels, Assistant Secretary of Labor for OSHA. “We encourage employers to address safe drug handling by committing their management staff to taking a leadership role identifying and remediating hazards, offering employee training, and evaluating workplace injury and illness prevention programs for continuous improvement.”
 
 
In their letter to hospital employers, NIOSH, OSHA, and The Joint Commission encouraged employers to:
 
 
  1. Commit their management staffs to taking a leadership role in worker safety and health.
  2. Offer opportunities for meaningful employee participation in efforts to identify and remediate hazards, develop and offer training, and evaluate the hospital's injury and illness program for continuous improvement.
 
 
A list of hazardous drugs can be found in a NIOSH document, "NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2010" (www.cdc.gov/niosh/docs/2010-167/) . The list was updated as part of an earlier document, "NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Healthcare Settings," which provides guidance on protecting healthcare employees from hazardous exposures (www.cdc.gov/niosh/docs/2004-165/).
 
More information on identifying hazards, determining appropriate controls, and applying safe practices can be found in a NIOSH webpage on hazardous drug exposures in healthcare (www.cdc.gov/niosh/topics/hazdrug/) and an OSHA webpage on hazardous drug safety and health at www.osha.gov/SLTC/hazardousdrugs
 
Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact:Info@ReduceYourWorkersComp.com .

 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

WCRI Report Says Narcotics Use Varies by State

 
A study from the  Workers Compensation Research Institute’s  (WCRI) report cites narcotic overuse as a major national public health problem. WCRI reports, “Medical treatment guidelines recommend that patients who receive ongoing narcotics prescriptions be actively monitored by the physician using urine tests and given psychological evaluations.”
 
 
According to WCRI study, Interstate Variations in Use of Narcotics, narcotic-prescribing physicians are not monitoring use, abuse, and diversion. The study is based on nonsurgical workers compensation claims with more than seven days missed work and prescribed pain medications.(WCxKit)
 
 
In some states, WCRI found prescribed narcotic use was more likely to turn into a long-term habit. These states are: California, Louisiana, Massachusetts, New York, North Carolina, Pennsylvania, and Texas. WCRI looked at 2006 injuries and the subsequent prescriptions through spring of 2008.
 
 
According to the abstract, other findings include:
1.      The amount of narcotics per claim was the highest in Louisiana, Massachusetts, New York, and Pennsylvania among the 17 states studied.

2.     
In the other 13 states, there were large differences in the amount of narcotics received by injured workers.

3.     
A higher than typical percentage of claims that received narcotics may signal overuse of narcotics for some states.

4.     
The proportion of nonsurgical cases with narcotics that were identified as longer-term users of narcotics was substantially higher than typical in California, Louisiana, Massachusetts, New York, North Carolina, Pennsylvania, and Texas. (WCxKit)

5.     
Few longer-term users of narcotics received the recommended services for monitoring, contrary to medical guideline recommendations.
 
 
For more information, the complete report is available for purchase here.

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
 
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

Using Pharmacy Benefits Management to Control Narcotic Use in Workers Compensation

Since narcotics play an active role in the treatment of chronic non-malignant pain (including workers compensation injuries), it is essential for payors to take proactive measures in monitoring for opportunities or instances of misuse. An effective means to do this is to partner with a pharmacy benefits manager (PBM) experienced in the workers compensation industry. The remainder of this paper explores that role of the PBM. It also will provide insight on what to look for to ensure your organization reduces fiscal, legal and personal risk resulting from narcotics abuse.

 

 

The Role of a Pharmacy Benefits Manager (PBM)

Forming a partnership with a PBM can provide workers compensation payors a valuable resource in controlling narcotics use and thereby reducing risk for all stakeholders. There are eight key best practices PBMs can deploy to assist payors. We discuss the first four here.

 

Key Best Practices One through Four

(Key Best Practices 5 to 8 Discussed in Future Blog)

 

#1: Defining a Strategy

Getting control of narcotics usage requires a well-defined strategy. The first step in this process is for the PBM to review prescription history. Once the history is reviewed, it should be used to develop a customized narcotics strategy for each medication plan. These plans identify which medications are appropriate for the injury type and body part. They also account for proper duration of use and quantity limits. By defining a narcotics strategy, the workers compensation payor will have put into place the proper mechanisms to begin controlling narcotic use. (WCxKit)

 

 

#2: Capturing Prescriptions at First Fill

When new claims are filed, it is important to capture when and what type of medication is filled at the onset of injury. PBMs should have in place a mechanism to capture this prescription information. Often these early prescriptions begin telling the story of the medication history and medication therapy to come. One method to capturing this data is through First Fill cards. These cards are typically distributed by the employer to the injured worker at the point of accident or injury. To ensure both employers and injured workers use the program, PBMs should offer training programs on their use.

 

 

#3: Offering Home Delivery Programs and Retail Drug Cards

Both retail and home delivery programs provide the workers compensation payor an effective means to monitor and control an injured worker’s medication utilization. They also provide payors an opportunity to fully leverage pharmacy network participation and discounts, thereby reducing medication expenses.

 

 

Retail drug cards: When an injured worker requires additional medications, a retail drug card program will give the payor control over what, when and where the prescriptions can be filled. The injured worker should be able to use the retail drug card at the PBM’s retail network pharmacies. Not unlike a first fill prescription card, the retail drug card should contain injured worker-specific drug utilization review information to ensure only appropriate medications are filled.

 

 

Home delivery programs: A home delivery program offers the injured worker the convenience of ordering prescriptions either online or on the phone while providing the workers compensation payor the ability to engage in proactive utilization review programs. In addition, they also give the payor a mechanism to educate injured workers on the risks associated with narcotics through direct interaction with the pharmacist dispensing the injured worker’s prescriptions. Physician contact is often easier as well since the prescriptions are being managed directly through the mail order facility.

 

 

#4: Reduce Out-of-Network Bills

A high number of out-of-network bills can lead to issues with managing utilization of narcotics. Not only are individual out-of-network bills typically higher than those in-network, they are often not included in the utilization process. It is vital for payors to have a process in place for properly driving those bills back into the network. This can be done by working with a PBM offering both paper and electronic out-of-network bill solutions. This will ensure critical injured worker data on number of prescriptions, duration of therapy, doctor information and other related factors are captured to better monitor utilization.

 

 

However, the best method for controlling out-of-network bills is to make it easier for the injured worker to go in-network as early in the life of the claim as possible. One method for doing this is through First Fill cards, which are distributed by the employer at the onset of the injury. Two other strategies for reducing out-of-network bills are home delivery and retail drug card programs. (WCxKit)

 

Summary

It is expected narcotics will continue to play a role in treating pain in workers compensation. While greater oversight of narcotics use is already underway by the FDA through its REMS requirement, workers compensation payors must take proactive measures to reduce misuse and abuse. By doing so, payors decrease risk for litigation, improve injured worker safety and obtain more control over medication expenses.

 

Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.

About Progressive Medical
Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.  http://www.workcomptransformation.com/narcotics-quandary/

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Reducing Narcotics Abuse in Workers Compensation

On-the-job injuries often involve chronic pain and long-term liability for workers compensation payors. Many times, pain from a chronic injury is treated with narcotics. According to the 2010 Progressive Medical Drug Spend Analysis, narcotic spending accounts for 34 percent of workers compensation medication expenses.1 While narcotics can be beneficial in the treatment plan for a patient in pain, there are serious risks involved when they are not used properly.
The Centers for Disease Control (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) both indicate increasing misuse and abuse of narcotics over the past decade. SAMHSA data shows there was a significant increase from 2000 to 2006 in the treatment of substance abuse cases related to abuse of opioid analgesics.2 In addition, another study co-released by CDC and SAMHSA found emergency room visits linked to nonmedical use of narcotics rose 111 percent between 2004 and 2008.3
As the cost of prescriptions, including narcotic medications, directly impacts the cost of a workers compensation claim, insurers are looking for ways to quickly get control of cases of misuse and abuse. One of the most efficient ways to manage narcotic use in a claimant population is to partner with a pharmacy benefit manager (PBM). A PBM can clearly define a strategy for proactively and effectively monitoring narcotics. These plans and strategies help payors ensure injured worker safety and reduce expenses. (WCxKit)
 
The Workers Compensation Narcotics Quandary
Narcotics, also referenced as opioids or opiates, have a long history of being used to therapeutically treat pain resulting from on-the-job injuries. They are often prescribed to alleviate pain after an injury first occurs, when other drugs are ineffective for acute pain and in chronic pain cases.
And, while narcotics are considered safe and effective if used properly, they have the potential for leading to addiction and abuse if not monitored and controlled. Misuse and abuse of narcotics represent three areas of particular concern for workers compensation insurers including:
1.      Potential for serious health risks.
2.      Higher percentage of medical expenses as claims age.
3.      Risk of litigation.
Potential for Serious Health Risks
The United States Food and Drug Administration (FDA) has recognized serious risks associated with narcotics use including respiratory depression, central nervous system depression, addiction, and death. Some of these risks are associated with improper dosing, indication, patient selection, abuse, and addiction. As a result of these adverse events, the FDA has begun to take serious steps to monitor whether the benefits of narcotic medications outweigh the risks associated with short- and long-term usage.4
These steps include an FDA-led panel developing Risk Evaluation and Mitigation Strategy (REMS) for long-acting narcotics. The purpose of REMS is to ensure that prescribers are educated regarding the proper use of narcotics and that benefits outweigh risks associated with:
1.      Abuse.
2.      Misuse.
3.      Overdose, both accidental and intentional.
Narcotics, including methadone tablets, fentanyl patches and extended-release medications containing morphine, oxymorphone, and oxycodone are among the medications effected by the REMS requirement. Narcotics on the FDA’s list are provided in a table at the end of this article.5
Recently, the FDA proposed plans to further address the increasing misuse and abuse of narcotics specifically related to extended-release (ER) and immediate-release (IR) opioid analgesics. While a panel committee agreed the goals of the REMS are appropriate, the individual components of the REMS are insufficient to address the misuse and abuse of ER opioid analgesics. It was agreed that these particular REMS plans be tabled until there is a stronger proposal in place.6
Higher Percentage of Medical Expenses as Claims Age
While narcotics account for more than a quarter of workers compensation medication spending, even more troubling is the allocation of that spending. In a recent study released by the National Council on Compensation Insurance, narcotics’ total share of medication expenses increases as claims age – from 15 percent in year one to as much as 35 percent in the fifth year of service.7
The role narcotics play in total workers compensation claims expenses has not gone unnoticed by state workers compensation funds. For example, the Arizona State Compensation Fund noted they were easily able to pinpoint over-prescribing of narcotics as a key source of inflated medical costs.8
What’s more, the longer an injured worker is on narcotics, the longer the delay in the injured worker’s ability to return to work in a timely fashion. There is also an increased likelihood the payor will need to pay for rehabilitation programs for addiction.
 
 
Risk of Litigation
Narcotic abuse poses serious legal risks for workers compensation payors. While much of the litigation to date has been targeted against physicians and pharmacies, there are many experts who believe workers compensation payors will be next. This is because payors have access to data showing patterns of abuse and misuse and may have the duty to warn injured workers and prescribers in cases involving potential misuse.9
Workers compensation payors who choose not to take proactive measures to monitor utilization or communicate with physicians could face lawsuits for negligence. This is especially critical in cases where one or more narcotics are prescribed for more than six months at a time. (WCxKit)
With respect to paying questionable claims, many payors have done so rather than face the expense and time of litigation. Morally, this poses a key question for insurers. Is it acceptable for insurers to settle fraudulent claims or does it position them as aiding and abetting the perpetrator? This could change if payors become defendants in lawsuits related to narcotic abuse.
References
1. “2010 Workers Compensation Drug Spend Analysis.” Progressive Medical, April 2010.
2. “Risk Evaluation and Mitigation Strategies for Certain Opioid Drugs; Notice of Public Meeting,” Federal Register, Volume 74, Number 74; Notices, Pages 17967-17970, Department of Health & Human Services, Food and Drug Administration, Docket No: FDA-2—0-N-0143.
3. “Trends in Emergency Department Visits Involving Nonmedical Use of Narcotic Pain Relievers,” Substance Abuse and Mental Health Services Administration and Centers for Disease Control, http://www.cdc.gov/mmwr(/mmwr/).
4. Gardiner Harris, “FDA to Place New Limits on Prescriptions of Narcotics,” New York Times, February 9, 2009.
5. “Opioids Products Chart,” U.S. Food and Drug Administration, http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163654.htm.
6. “Opioid Drugs and Risk Evaluation and Mitigation Strategies (REMS),” U.S. Food and Drug Administration, http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163647.htm.
7. Barry Lipton, Chris Laws and Linda Li, “Narcotics in Workers Compensation,” NCCI Research Brief, December 2009 p.5.
8. “Sky High Out of Control Drug Costs A Threat,” State Compensation Fund of Arizona.
9. “Prescription for Peril,” December 2007, Coalition Against Insurance Fraud, p. 43.

Brand Name Opioid Products
Generic Name
Trade Name
Applicant/Sponsors
Fentanyl
Duragesic Extended Release Transdermal System
Ortho McNeil Janssen
Hydromorphone
*Palladone Extended Release Capsules
Purdue Pharma
 
Methadone
Dolophine Tablets
Roxanne
Morphine
Avinza® Extended Release Capsules
King Pharms
 
Morphine
Kadian® Extended Release Capsules
Actavis
 
Morphine
MS Contin Extended Release Tablets
Purdue Pharma
 
Morphine
Oramorph Extended Release Tablets
Xanodyne Pharms
 
Oxycodone
OxyContin Extended Release Tablets
Purdue Pharma
 
Oxymorphone
Opana® Extended Release Tablets
Endo Pharma
 
*No longer being marketed, but is still approved.
 
Generic Opioid Products
Generic Name
Drug Name
Applicant/Sponsors
Fentanyl
Fentanyl Extended Release Transdermal System
Actavis
 
Fentanyl
Fentanyl Extended Release Transdermal System
Lavipharm Labs
 
Fentanyl
Fentanyl Extended Release Transdermal System
Mylan Technologies
 
Fentanyl
Fentanyl Extended Release Transdermal System
Teva Pharms
 
Fentanyl
Fentanyl Extended Release Transdermal System
Watson
 
Methadone
Methadose[O1]  Tablets
Mallinckrodt
Methadone
Methadone HCL Tablets
Mallinckrodt
Methadone
Methadone HCL Tablets
Sandoz
Morphine
Morphine Sulfate Extended Release Tablets
Endo
 
Morphine
Morphine Sulfate Extended Release Tablets
KV Pharmaceuticals
 
Morphine
Morphine Sulfate Extended Release Tablets
Mallinckrodt
 
Morphine
Morphine Sulfate Extended Release Tablets
Watson Labs
 
Oxycodone
Oxycodone Extended Release Tablets
Mallinckrodt
 
Oxycodone
**Oxycodone Extended Release Tablets
Impax Labs
 
Oxycodone
**Oxycodone Extended Release Tablets
Teva
 
** Discontinued products.

Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.

About Progressive Medical
Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.      http://www.workcomptransformation.com/narcotics-quandary/

Book: Manage Your Workers Compensation Program: Reduce Your Costs 20-50%

http://corner.advisen.com/partners_wctoolkit_book.html

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

Using Utilization Review Programs to Control Narcotic Use in Workers Compensation

Utilization Review: Role of a Pharmacy Benefits Manager (PBM)

As discussed previously, forming a partnership with a PBM can provide workers compensation payors a valuable resource in controlling narcotics use and thereby reducing risk for all stakeholders. There are eight key best practices PBMs can deploy to assist payors. We discuss key best practices five through eight here. See previous discussion for best practices one through four.

 

 

Key Bests Practices Five through Eight

#5: Managing Prospective and Concurrent Narcotics Utilization Review Programs

The PBM should have a clinical management process to govern narcotics utilization managed by clinical pharmacists. The clinical drug utilization review (DUR) program should use a combination of evidence-based guidelines, peer review journals and recommendations provided by government organizations. Both prospective and concurrent review processes are essential to a successful program. (WCxKit)

 

 

Prospective utilization reviews: A prospective program allows all involved parties to plan for future outcomes with up-front information. Historical data and practices guide future decisions at the establishment of the PBM relationship. This prospective process allows for the achievement of cost control and utilization control.

 

 

Concurrent utilization reviews: The PBM triggers concurrent alerts to inform the dispensing pharmacist about possible reasons a prescription should be questioned further prior to filling. These point-of-sale alerts may establish behaviors that could indicate abuse involving the use of multiple pharmacies and physicians for different narcotics or excessive early refill attempts. The messaging from the PBM ensures that prescriptions for narcotics will not be fulfilled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the payor.

 

 

#6: Conducting Retrospective Drug Utilization Reviews and Clinical Intervention Programs

Retrospective reviews: After a prescription is fulfilled, a PBM’s clinical pharmacist team should audit these prescriptions for indicators of inappropriate use. Indicators often include:

  •  Sole use of narcotics as treatment.
  •  Multiple physicians.
  •  Use of multiple short or long acting narcotics.
  •  Excessive duration and use.

 

These types of utilization review programs are essential to maximize the effectiveness of a narcotics usage strategy and are most effective when leveraged in conjunction with prospective and concurrent drug utilization reviews. PBM programs should be flexible enough to allow for customization of review requirements for clients, as client goals and objectives often vary even within organizations.

 

 

Physician monitoring: A PBM should continually monitor the use of multiple physicians by one injured worker.

 

The physician monitoring program should be based on established best practices and contain multiple components including:

  • Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines.
  • Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA-approved generic equivalent exists.
  • Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns.

 

Clinical intervention programs: The PBM should have a range of clinical intervention programs to assist a client with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions to more detailed evaluations including peer reviews and direct consultation with prescribing physicians. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation through the use of the information gathered in prospective, concurrent and retrospective review processes.

 

 

One example of these recommendations is physician letters of medical necessity. The use of the letter of medical necessity helps to substantiate the treatment of an illness or injury with particular narcotic or adjunctive medication.

 

 

If further analysis is required, the PBM should have other program options available. Program options could include a detailed review that contains a summary of the injured worker’s medication history through more in-depth medication evaluation referencing the entire clinical record.

 

 

#7: Providing Ongoing Consultation

A quality narcotics utilization program is an essential component of controlling narcotics use. To ensure the utilization program is effective, the pharmacists managing the programs should take proactive measures to continually expand utilization review programs as the workers compensation industry evolves. As changes occur, they should also be available to consult with clients on how to adapt their DUR programs accordingly.

 

 

When first released, several powerful narcotics such as Actiq® and Fentora® were developed and prescribed to treat terminal cancer pain. Recently these two narcotics, along with others, have been widely prescribed for lower back pain. An effective PBM should continually expand its DUR auditing capabilities to meet this type of changing prescribing pattern. In addition, the PBM should have the capability to audit prescribers for questionable prescribing patterns.

#8: Validating Narcotics Use through Reporting

If a DUR program is successful, there will be a reduction in unnecessary medication usage, including narcotic use. A PBM should easily be able to validate those reductions through a wide range of real-time and ad-hoc reports.

 

 

User-run reports: The PBM should offer a tool that gives a client an option to run a wide range of reports to gain an in-depth understanding of all activity. To maximize the effectiveness and ease of use of the reports, the PBM should ensure the reports are categorized into varying levels depending on how the reports will be used. For example, while all user levels will be able to access savings data, the claims professional should be able to access detailed claims information to help maximize savings opportunities such as individual reports that identify home delivery conversion opportunities, details on narcotics use and details on each injured worker.

 

 

Management level users should be able to run reports to assist with managing the claims professional, such as a report providing exception or override information as well as a report providing details on actions sent to the PBM.

 

 

Other available reports should include: savings reports that can be sorted by a range of time periods, jurisdictions, groups and/or branches, pharmacy network utilization and savings reports, generic efficiency and opportunity, as well as a wide range of trending reports including top prescribing physicians, top therapeutic classifications, top pharmacy medications, top ICD-9, top injury type and reports detailing prescribing physician habits.

 

Drug utilization review report:  To provide information on savings achieved as a result of the program, the PBM should have a detailed DUR report.  This report should provide information on savings achieved as a result of the program and should document savings in distinct areas rather than broad categories in order to provide the complete picture of DUR activity.(WCxKit)

Ad-hoc reporting: In addition to user-run reports and reports detailing DUR activity and savings, the PBM should have the ability to supply ad-hoc reports to assist with narcotic utilization management. If the PBM captures the data, then the PBM should be able to provide reports based on those data elements.

 

 

Summary

By partnering with a PBM, workers compensation payors can put an effective narcotics utilization strategy into place. A relationship with a strong PBM partner experienced in workers compensation will enable the payor to not only monitor utilization but stop point-of-sale fulfillment of unnecessary narcotics.

 

 

Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.

Get more information here: http://www.workcomptransformation.com/narcotics-quandary/

About Progressive Medical
Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.

Manage Your Workers Compensation Program:

Reduce Your Costs 20-50%

http://corner.advisen.com/partners_wctoolkit_book.html


WORK COMP CALCULATOR: 
http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

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