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While the overall use of opioids among injured workers is trending downward due to the combined efforts of doctors, insurers, pharmacy benefit managers and regulators, older claims remain troublesome, experts say.
These “legacy claims” include opioid prescriptions that are several years old and may include other drugs aimed at addressing the side effects of opioids, ranging from constipation to insomnia. The claims represent a disconnect between prescribing physicians, claims handlers, nurse case managers and oftentimes lawyers because of the lack of weaning protocols to address longtime opioid use.
“We’ve created a very desperate situation here,” said Chris Hart, a former pharmacist and recovering opioid addict in Findlay, Ohio, who now teaches courses on dependency and withdrawal.
“People who are injured have been on these medications for a long time, and if they go off, withdrawal symptoms kick in,” he said.
Withdrawal can happen on the first day of weaning and can trigger symptoms such as heart palpitations, cramping, tremors and more pain, he said.
“I have people who have not been able” to navigate the complicated health scenarios involved in weaning, said Mike Pringle, Manchester, New Hampshire-based medical case manager who oversees chronic pain services for the Windham Group Inc.
Heart conditions and fear of pain are among the biggest hurdles, he said.
A challenge in addressing legacy claims is that most stakeholders do not know how many active claims fit into the category.
California, for example, in its formulary for injured workers that requires utilization reviews for all opioid prescriptions, mandated that doctors create weaning programs for long-term opioid patients by April 2018. A spokesman with the Department of Industrial Relations told Business Insurance in an email that it is not tracking patients who are under weaning programs and did not respond to follow-up questions on why.
“The problem with (California’s guidelines) is they didn’t put any teeth in it,” said Dr. Michael Coupland, West Palm Beach, Florida-based network medical director for IMCS Group Inc., a national network of clinicians who focus on opioid treatment disorder among injured workers.
A doctor he works with in California, for example, oversees 13 clinics with an estimated 7,000 comp patients. As many as 5,000 of them would require a weaning program created by a doctor, under the state formulary rules, he said.
“That was untenable,” Dr. Coupland added. “The goal is philosophically aligned, but the scope of the problem is just too large.”
Ohio is another state that has made headlines in its tackling of the opioid epidemic in workers compensation. A spokeswoman with the Ohio Bureau of Workers’ Compensation reported that the number of opioid doses prescribed in the system fell 66% in seven years.
But the state does not carve out older claims from its data, so it’s unclear whether the drop represents fewer opioids in newer claims or the older ones where an injured worker might have been prescribed opioids for several years, according to the spokeswoman.
Several insurers and pharmacy benefits managers also said they did not have this type of data.
AmTrust Financial Services Inc. in May reported that it saw the percentage of claims with opioids decrease to 25% in 2018 from 60% in 2017, partly due to improved monitoring of all claimants prescribed opioids.
The New York-based insurer intends to look into how many of the older claims specifically are seeing reductions, Melissa Burke, Southington, Connecticut-based head of managed care and clinical for AmTrust, told Business Insurance.
Tracking such legacy claims is not simple, other experts say.
“There are no easy ways of finding who these claimants are,” said Marcos Iglesias, Sunrise, Florida-based chief medical officer for Broadspire Services Inc., the third-party administrator unit of claims manager Crawford & Co.
“Legacy claims have been open for years, and many of them predate our success in reducing opioids,” he said.
Doctor coding may have something to do with it, according to Dr. Iglesias. Doctors are not putting in their charts or coding for payers key words or phrases such as “opioid use disorder” or “dependence,” he said. Doctors are mostly billing for a primary diagnosis, with little to no details on opioid dependency, which in most cases would trigger the necessity to wean, he said.
Dr. Iglesias estimated that one in four older workers comp claims with opioids attached would fall under opioid dependency or opioid use disorder.
“We have no reason to think we are immune to this,” he added. “To me, that is frustrating that we can’t pinpoint them that easily.” Gathering data on the claims is further complicated by patients who use a primary care
physician under their group health program to access opioids, which is common, said Dr. Teresa Bartlett, Troy, Michigan-based senior medical officer for Sedgwick Claims Management Services Inc. “There are so many variables we don’t know,” she said.
Another problem is that in some older claims indemnity has settled and it is just the medical component remaining, according to Dr. Bartlett. In some scenarios a longtime doctor “pushes back” on reducing opioids for the patient, whom the doctor considers “stable,” she said.
Until recently, “nobody has been paying attention to” legacy claims, she said.
Injured workers who lose their opioid prescriptions are engaging attorneys to try to maintain access to the drugs, according to legal experts.