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Pain medication problems addressed by workers comp programs

Pain medication problems addressed by workers comp programs

Workers compensation programs are springing up to help steer injured employees away from prescription opioid pain medications that are blamed for addictions and overdose deaths, yet experts say more work needs to be done.

While there is plenty of discussion within the workers comp industry about the negative consequences of opioids that are prescribed inappropriately for claimants, experts say more insurers and other providers must get involved.

“I think there is very good discussion and I think there is really good perspective (on opioid-related problems),” said Patrick J. Walsh, vp and chief claims officer for Lansing, Mich.-based Accident Fund Holdings Inc., “I don't think people are overreacting to what clearly is a problem, but candidly, I am not seeing a lot of action yet.”

Accident Fund's discussions with pharmacy benefit managers during 2011, for example, revealed that while PBMs monitor opioid prescribing, several still lack specific “actionable initiatives or processes that would then help make a difference” by reducing such prescriptions and their impact, Mr. Walsh said.

While other industry sources say more can be done, efforts have increased to address questionable narcotics prescribing for workplace injuries. Overall, opioid prescriptions have risen steadily (see chart).

“There have been a lot of actions and efforts in the last couple of years to try to better monitor, control and assure the appropriate use of opioids, both in workers comp and in other medical systems,” said a spokesman for the California Workers' Compensation Institute in Oakland.

Examples include a requirement implemented last year by the California State Compensation Insurance Fund that its network doctors obtain authorization before prescribing an extended regimen of opioids, the spokesman said.

Earlier this month, Accident Fund launched a program that includes “real-time” detection of opioids prescribed to injured workers. The insurer's claims managers, nurse case managers and other personnel are then alerted to develop intervention strategies on a case-by-case basis, Mr. Walsh said.

The intervention could be as simple as an adjuster calling the prescribing doctor, Mr. Walsh said.

“Or because of the complexity of the case,” Mr. Walsh said, “do we want to get another physician involved or a vendor involved who specializes in pharmaceuticals to talk to that (treating) physician or even to start thinking of a (detoxification) program to get somebody weaned off of a narcotic?”

Among other measures, Chartis Inc. utilizes a “formulary approach” that relies on its PBM system to flag new prescriptions for “long-lasting” opioids, said Don Hurter, senior vp of medical management services in Maitland, Fla.

Flagged claims then are screened using medical guidelines and, when necessary, channeled to a Chartis medical director for peer-to-peer discussions with prescribing doctors.


Those discussions may involve whether the patient is an appropriate candidate for narcotics and potential alternative treatments.

The early intervention strategy has resulted in the denial or revision of claimants' prescriptions in 80% of such cases, Mr. Hurter said.

Compared with even a year or two ago, there are more workers comp industry programs to address overprescribing opioids, said Kevin T. Glennon, vp of clinical services for MSC Complex Care (formerly TMS), a division of MSC Care Management, a workers comp company based in Jacksonville, Fla.

Yet more insurers, PBMs, third-party administrators and other providers need encouragement to engage their medical resources to develop “cohesive, comprehensive programs,” according to Mr. Glennon.

Such programs must go beyond merely monitoring opioid prescriptions to providing services such as non-narcotic options for managing chronic pain, he added.

“I think what we will see happen more and more is that (insurer) medical directors are going to be speaking with the primary physicians and questioning their prescribing patterns,” he said.

One improvement applies pharmaceutical tracking systems to red flag opioid prescribing earlier than the more established retrospective practice of identifying claims needing attention after opioid prescriptions have been filled, sources said.

“The challenge with that (approach) is the cow may already be outside the barn,” said Jeffrey D. Miller, chief operating officer at Santa Ana, Calif.-based Paladin Managed Care Services Inc.

Paladin soon will launch a program that reaches out to treating doctors at “the front end of the (treatment) process” to learn about narcotics prescriptions before they are filled, Mr. Miller said.

“You really have to get to as close to when it's prescribed as possible,” Mr. Miller said.

For in-depth coverage of this topic and related issues, visit our Solution Arc on Opioid Abuse and Workers Compensation: Tackling a Growing Problem.