BI’s Article search uses Boolean search capabilities. If you are not familiar with these principles, here are some quick tips.
To search specifically for more than one word, put the search term in quotation marks. For example, “workers compensation”. This will limit your search to that combination of words.
To search for a combination of terms, use quotations and the & symbol. For example, “hurricane” & “loss”.
The workers compensation industry is focused on preventing the overutilization of opioid painkillers, but sources said payers also should monitor underutilization of medication and other types of nonadherence, such as stopping physical therapy, that can delay an injured worker's return to the job and increase costs.
Nonadherence occurs when patients don't take medications or participate in therapies as prescribed. It can be monitored for group health coverage by taking vital signs, such as blood pressure or blood glucose levels, but can be difficult to measure for workers comp coverage, since most therapies prescribed are to treat pain, sources said.
“In the pain arena,” there's the potential for overutilization and underutilization, “which doesn't get publicized a lot but it does happen, particularly in people who are fearful of addiction or don't like the side effects,” said Steven Passik, Indianapolis-based vice president of clinical research and advocacy at medication monitoring service Millennium Health L.L.C.
Medication nonadherence in the United States costs up to $290 billion annually, according to the U.S. Centers for Disease Control and Prevention.
While opioid overutilization is a big concern for the industry, “oftentimes a bigger problem is the underutilization of medication,” said Leanne Bronold, Mobile, Alabama-based clinical writer and case management product manager Genex Services L.L.C.
“But nonadherence is rarely something that our clients bring to us and say, 'Help us manage this,'” said Jennifer Kaburick, St. Louis-based vice president of workers compensation product management and strategic initiatives at Express Scripts Inc.
When injured workers stop taking their pain medicine, it also can signal that they're recovering and the drugs are no longer needed, she said.
However, it's important that injured workers properly manage their pain so they can avoid being “noncompliant with other recommended treatments,” such as physical therapy and exercise that often are part of treating work-related injuries, Ms. Kaburick said.
In the short term, a claim may be less expensive if the injured worker isn't filling his or her prescriptions, Ms. Bronold said. “But if they quit taking the anti-inflammatory and they're pushing themselves at therapy, the next thing you know, they're having a tough time ... and they're going to slide back as far as improving their conditioning and getting back to their normal activities.”
Sources said pharmacy benefit managers and nurse case managers can work with claims adjusters and employers to identify and correct problems with adherence.
“We set up programs with our clients, and they tell us what types of things they want to be informed about,” said Dr. Robert Hall, Westerville, Ohio-based medical director at PBM Helios.
Common payer concerns include not filling prescriptions at all, getting refills too soon, changes in prescriptions that affect morphine equivalence and going to multiple prescribers or pharmacies, Dr. Hall said.
PBMs can also help identify possible drug interactions, which might cause side effects and make injured workers less likely to take their medications, Dr. Hall said.
Sources said in-person or telephonic case management also promotes medication adherence among injured workers.
Nurse case managers learn a lot through building relationships with injured workers, said Tammy Bradly, Birmingham, Alabama-based vice president of clinical product development at Coventry Workers' Comp Services.
For example, Ms. Bradly said, an injured worker might not be “compliant with (physical therapy) because they don't have transportation, or they lost their child care and they have no one to watch their children … There are a lot of things that go on in a person's life that may not always be evident on the surface, but if a nurse uses her coaching skills, it sometimes helps her to uncover those things.”
For cost reasons, case management usually is reserved for catastrophic claims or claims where an adjuster has identified some type of nonadherence within a treatment plan, Ms. Bronold said.
Injured workers might be more likely to take medications or participate in active therapy as prescribed if they understand how it will help them recover and return to work, sources said.
While concerns about opioid use and dependence have raised alarms in workers compensation claims, medical experts say insurers and payers also should be wary of not providing enough treatment to injured workers suffering chronic pain.