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Payers start early to curb opioid abuse

Posted On: Jun. 5, 2017 12:00 AM CST

Early intervention is the latest trend in opioid prescription management for injured workers’ claims, according to experts.

Getting in front of the opioid issue is the best way to curb the abuse and dependence, and other issues, they say.

“The industry knows the longer you wait … the future is very bleak,” said Silvia Sacalis, Tampa, Florida-based vice president of clinical services for Healthesystems L.L.C. “That’s why early intervention is crucial.”

Nearly every workers comp insurer, third-party administrator and pharmacy benefits manager has a claims management program in place to avoid problems like Atlanta-based Delta Airlines Inc. found when it began combing through older claims two years ago in an effort to rein in the problem.

For them, the tally of older opioid-related claims was 60, according to Susan Emerson, general manager of claims management, disability leave and workers compensation for Delta.

Delta’s older claims were mired in some form of opioid dependence, essentially stalling claim closure or return to work — for years, in some cases, Ms. Emerson said during a May 10 Marsh L.L.C. Workers Compensation Center of Excellence webcast on prescription trends and costs. Today, 40 claims have been resolved with weaning programs or other interventions that put people back to work or closed the claim, she said.

Diving into the older claims and looking for solutions as Delta did isn’t easy — injured workers on opioids tend to suffer a host of side effects from the medication, comorbidities are a typical issue, and psychosocial problems such as depression and anxiety complicate matters, experts say.

And then there’s drug dependency: Someone who has been taking medication such as Vicodin or OxyContin cannot stop cold turkey without experiencing painful withdrawal symptoms. That in itself leads to more complications and sometimes litigation, experts say.

Ms. Emerson’s advice to workers comp claim handlers? “Focus on the front end of the claim,” she told those listening in.

Myriad approaches

For stakeholders that means everything from flagging a claim early — as Delta now does working with Sedgwick Claims Management Services Inc., an example of just one of several companies now looking at opioid prescribing from the first fill; to nurses who do nothing but look at prescribing behavior and initiate contact with doctors — as Coventry Health Care Inc. does for its clients; to using predictive modeling and risk-score modeling to examine whether a claim has the potential to be problematic — as Travelers Cos. Inc. and third-party administrator ESIS Inc., a subsidiary of Chubb Ltd., now do (see related story).

The common denominator is that none of these claims managers is ignoring opioids, and no industry stakeholder is waiting on regulation and legislation to introduce prescribing limits and formularies, Ms. Sacalis said.

“Laws are behind the curb,” she said. “States are moving toward making better decisions (on access to opioids) but they are really slow in getting there.”

“We have lots of eyes on this,” said Dr. Craig Ross, Bala Cynwyd, Pennsylvania-based regional medical director for Liberty Mutual Insurance Co. “We are identifying cases that are going off the rails and intervening.”

The process starts the first time a prescription is written, most experts say.

Picking up where doctors fail

The first person to decide whether an injured worker needs an opioid prescription is the doctor, most experts agree.

“We are not against opioids,” said Rich Ives, Hartford, Connecticut-based vice president of claims for workers compensation at Travelers. “There are good, effective reasons to use opioids when the injured worker is in the acute pain phase.”

The issue becomes complicated when the second or third prescription is filled, he said, adding that more prescriptions lead to a secondary issue.

“The issue at hand is rising frequency of chronic pain,” he said.

It’s usually the doctor’s job to weigh whether an injured worker is on path to becoming drug-dependent and isn’t getting better, said Dr. Teresa Bartlett, Troy, Michigan-based vice president of medical quality at Sedgwick.

“We only see that 30% of physicians do that screening,” she said. “Most doctors will just say, ‘We know our patients.’ They have a trust and belief that they know their patients. Don’t forget that doctors are in a business as well, and if they alienate their patients then they don’t have a business.”

At Delta, one of the first steps in early intervention was finding “top-tier providers,” said Ms. Emerson. “We find those (who) tend to treat conservatively,” she added.

Claims handlers are the next intervenors in the process, said Dr. Bartlett.

“These programs target opioids when they are first used,” she said. “We work … to identify medications that need to be reviewed and discussed with the treating physician prior to dispensing to the injured worker … The prescriptions are stopped at the point of sale and routed to nurses who look at all the medical notes and reach out to the doctor to determine if the medication is appropriate.”