Rx Abuse in Workers’ CompensationSTATISTICS AND METHODS FOR COMBATING THE PROBLEM

PATRICK CRONIN, CPCU, AIC, AIM, AAI, ARM, CWCP

BRANCH AND CLAIMS MANAGER – CORVEL HEALTHCARE CORPORATION

Discussion Points

Federal Classification of Controlled Substances

Statistics

Rx Impact on WC Expenditures

Problems Compounding the Problem (no pun intended)

Adverse Effects of Opioid Abuse

Potential Tools in the Battle (Cost Savings)

Potential Tools in the Battle (Preventing the Adverse Health Effects)

Federal Classification of Controlled Substances

Statistics

Prescription abuse is the fastest growing drug issue in America

In terms of controlling the cost of indemnity claims, prescription opioids are the number one problem

Nationally, 55% to 86% of all claimants are receiving opioids for chronic pain relief

Evidence based medicine only supports its long term use in very specific cases, most of which involve end-stage cancer treatment

Overdose deaths (involving opioids) have increased 300% since 1999

The misuse of prescription pain-killers was responsible for 475,000 ER visits in 2009

Rx Impact on WC Expenditures

1990 – Rx accounted for approximately 2% of medical expenditures

2001 – Impact increased by 400% (from 1990)

Today – WC Rx accounts for approximately 19% of total medical expenditures

Opioids account for approximately 25% of the current Rx spend

Opioids account for approximately 35% (or greater) of Rx spend in claims open for three (3) or more years

Based on projected Rx utilization (and, specifically, opioids), the cost of MSA calculations are increasing exponentially

Rx Impact on WC Expenditures (continued)

Less than proactive pharmacy management increases TTD

Less than proactive pharmacy management results in greater PPI ratings

The treatment of comorbidities (when coupled to opioid abuse) results in 20-30% of workers’ compensation’s ultimate developed cost

Bottom line – the ship has sailed on Rx’s relatively minor impact on workers’ compensation claim costs

In general, employers are unaware of the sizable impact of Rx on their workers’ compensation costs

Injured workers prescribed even one (1) opioid had total claim costs 4-5 times greater than claimants with similar claims who didn’t get opioids

Problems Compounding the Situation

Some PBMs (pharmacy benefits management) protocols do not capture leakage of prescriptions written and dispensed by doctors (40%-50%)

Some PBM stewardship reports only speak of discounts achieved through network utilization

Some PBMs lack aggressive protocols for intervention into potential opioid abuse

Some PBMs do not measure (via bill review protocols) the potential interventions associated with doctor prescribed/dispensed Rx

Adverse Affects of Opioid Abuse

Increased frequency of emergency room visits from overdose

Death

Addition treatment

Comorbidities

Abuse and misuse of prescription drugs

Estimates show that approximately 35% of patients receiving long-term opioid treatment protocols may be addicted

Since opioids reduce a patient’s pain by 30%-40%, it is common for opioids to be combined with other, non-opioid analgesics

Potential Tools in the Battle

Cost saving measures Generic equivalents PBM penetrationNetwork steerage Mail order protocol for long term Rx treatment

Potential Tools in the Battle (details to follow)

Methods to help avoid the adverse health effects of Rx (and, specifically, opioid) abuse Aggressive tier based formulary (established in concert with your PBM)

Ensure that all opioid prescribed claimants are routinely drug tested

Link Rx trends to your bill review provider (captures and measures drugs prescribed AND dispensed out of network)

Don’t over-ride formulary denials without specific justification and medical guidance

Review PBM reports (both monthly and claim specific)

Look for opportunities to engage the treating physician in intervention

Risk Assessment Tools (clinical modeling, clinical modeling and medication reviews

Aggressive Tier Based Formulary

PBMs can provide valuable assistance in the process

Restrict first fills and non-approval required medications to minor pain medications and anti-inflammatories

Limit the type and duration of potentially addictive pain-killers and muscle relaxants to a prior approval protocol

Set a protocol with your PBM and TPA for dealing with potentially problematic, long-term cases Rx Review

EME

Nurse case management intervention

Ensure Routine Drug-Testing for Opioid Prescribed Claimants Injured workers’ may not be taking the correct amounts, as

prescribe, which could lead to addiction problems and comorbidities

Lack of evidence in testing can ascertain ulterior motives for seeking and obtaining opioids (they may be selling the discussed medications)

Certain outcomes can lead the adjuster to make recommendations for alternative methods of containment (surveillance and activity checks)

If the claimant is not taking the medications, why should you pay for them? (most doctors will suspend, or even terminate, the prescribing of certain opioids if there’s evidence of lack of use)

Link Rx Trends to Bill Review Provider

Doctor prescribed/dispensed medications can be measured and certain cost saving methods can be utilized

Doctor prescribed/dispensed medications can be entered into clinical modeling analytics for future treatment management protocols

Your PBM can sometimes re-direct these types of prescribing patterns into your network

Don’t Over-Ride Formulary Denials Without Specific Justification and Medical Guidance

You set up the formulary to prevent abuse – don’t disregard it’s efficacy

Know when to get aggressive, based on the circumstances surrounding the injury

Obtain nurse case management intervention, when circumstances warrant it

Obtain independent medical interventions, when warranted (pharmacy review and employer medical evaluations)

Utilize treatment guidelines, when warranted

Review PBM reports (Both Monthly and Claim Specific)

Look for trends in prescribing patterns, across the board

Look for outliers – claim specificDevelop plans for interventionReview of opportunities for formulary

adjustment, when necessaryReview of geographical trends – adjust for

them, going forward

Look for Opportunities to Engage the Treating Physician(s)Reach out to the medical provider to

discuss possible changes Nurse Case Management interventionPharmacy reviews – peer to peerEmployer Medical Evaluations – utilize

when necessary

Risk Assessment Tools – Clinical Modeling

Risk Assessment Tools – Clinical Modeling

Risk Assessment Tools – Clinical Modeling