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ARC: HOW EMPLOYERS CAN BETTER MANAGE THE PHARMACEUTICAL PORTION OF THEIR WORKERS COMPENSATION PROGRA

Doctor dispensing curbs lead to increase in physician-conducted urine tests

Costs grow as physician-conducted urine tests increase dramatically

Limits On Doctor Dispensing of Drugs

When states began placing limits on physician dispensing of drugs to injured workers in 2007, that squeezed the health care balloon, creating another problem: More physicians are conducting urine tests, primarily for opioids, in their offices rather than using accredited labs, which is driving up the volume of tests and their cost, industry sources say.

A California Workers Compensation Research Institute study released in May 2012 “confirms a viral-like growth rate in the volume of drug testing and in the amounts billed and paid for these services.” The study showed a 315% increase in the average cost of a test from 2004 to 2011.

“Our data shows that physician billing varies from $17 a test to $2,000 a test, which is a 125% increase, on average, in the past year,” said Kimberly George, senior vice president of managed care and client services at Sedgwick Claims Management Services Inc. in Chicago.

“It's a lot like physician dispensing was five years ago,” said Dan Gifford, executive vice president of product development at Progressive Medical Inc., a workers comp pharmacy benefit manager in Westerville, Ohio. “I think we're on the tip of the iceberg,” he said, noting that testing companies are advertising to install testing equipment in physician offices to generate revenue. The CWCRI report is “a cry for regulation around” urine testing, said Mr. Gifford.

Only Colorado and Washington state have stringent urine testing guidelines, sources said. Delaware has proposed legislation that limits the number of tests but contains “nothing in the line of medical management,” said Tron Emptage, chief clinical officer at Progressive Medical.

The CWCRI study also shows that the cost increases “coincide with the dramatic growth in the use of opioids to treat work injuries.”

Workers comp experts have long held that overprescription and inappropriate prescription of opioids are a significant factor in driving up workers comp costs. Workers can quickly develop a dependence on the powerful narcotics, which leads to other medical conditions and prolongs their absence from work.

Progressive Medical has created a network of labs on behalf of their clients and payers to address inappropriate testing and combat “egregious billing,” Mr. Gifford said.

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In the process Progressive Medical has developed with payers, the physician usually has a conversation with the patient stressing that opioids won't be prescribed if the urine test is not compliant. The first baseline sample is collected at the doctor's office and sent to a network lab with Clinical Laboratory Improvement Amendments certification and College of American Pathologists accreditation. Urine is then collected at the doctor's office at random in six months.

The labs send test results to the physician and to Progressive, which routes it to the insurer or the third-party administrator. If compliant with the prescribed drug regimen, the test is generally done at least twice a year. If noncompliant, it's done every 30 days until compliance is achieved.

“We pass the lab reports electronically to the carrier so they have the injured worker's information quickly and can use it as a tool to reach out to the physician,” said Mr. Emptage.

“It depends on the doctor and how they want to influence the patient. There's no regulation, there's guidelines — that's the challenge,” Mr. Gifford said.

“We designed our program to look for criteria that could suggest high narcotic use and claimants that are potentially at risk for long-term use,” Mr. Emptage said. “The doctor should be looking for triggers. Are (patients) asking for early refills? Are they getting prescriptions filled at multiple pharmacies, and is there a pattern that can indicate diversion” of the drug for sale? Mr. Gifford said.

“It's not "let's test everybody' as often as possible, but test those at the trigger points,” said Mr. Emptage.

Sedgwick has developed an opioid risk assessment that “evaluates substance abuse history and tendencies with predictive analytics that score an injured worker's risk. Based on the risk score, we determine if the patient has a low, moderate or high risk and is appropriate for testing,” Ms. George said.

Sedgwick “partners with the physician regarding the appropriate testing to be conducted, how to address testing results and next steps,” she said.

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