How to Stop Opioid Use in Workers’ Compensation, a White Paper

Rather than trying to rescue drowning victims, we should find out who is pushing them in the water upstream—and stop them!

It’s no secret opioid use in Workers’ Compensation has reached the critical level, having escalated over the past ten years. The issue is serious, not only because of the cost in dollars, but it also has a human toll. Productivity in the workplace is jeopardized, the risk for new injuries is exacerbated, and claimants’ lives are devastated by addiction. Much has been written and important studies have been conducted on the topic.

Recent studies illuminate the problem
A central location that links to recent studies and articles on the topic along with serious discussion is found on Linkedin, the Work Comp Analysis Group. The studies by NCCI and CWCI are convincing. The only reasonable conclusion is that the problem is real, it is serious and it is growing. Specifically, the increase in drugs as a percentage of claim costs is disturbing. Moreover, the studies also show overutilization is the cost driver, not increases in drug costs. This article is offered by way of contributing a tool to the solution side of the problem.

The solution side of the issue
To address the solution side of the issue, it seems only logical that efforts are directed to the upstream source, those who prescribe the drugs. That narrows the scope considerably since only specially-licensed MD’s can prescribe DEA (Drug Enforcement Administration) controlled drugs. Moreover, only those drugs that have been prescribed and billed through the Workers’ Comp system are causing huge increases in claim costs. Consequently, the spotlight of prevention should focus on the prescribing doctors.

Of course, illicit drugs and drug trafficking exist everywhere. While these drugs may contribute to reduction in employee productivity and risk of new injuries, illicit drugs will not impact pharmacy costs in Workers’ Compensation claims. Only prescribed drugs can do that.

Using analytics to nab the perpetrators
As a Workers’ Compensation analytics company, MedMetrics analyzes and quantifies physician performance based on the data. Networks, insurers, TPA’s, and self-insured employers are increasingly using this information to create outcome-based, quality medical provider networks. MedMetrics includes prescribing behavior along with multiple other performance indicators analyzed for individual providers.

Not as easy as it would seem
Identifying physicians who overprescribe Schedule II drugs should be easy. According to the studies they comprise only a very small percentage of treating physicians. However, analyzing physician performance in Workers’ Comp requires collecting data from multiple sources. Billing data is needed for diagnostic and treatment information, though billing for drugs is typically not found there. Yet, some is, particularly when physician dispense the drugs themselves.

Additionally, claims data is needed to evaluate outcomes of the treatment such as lost time, actual paid amounts, and disability ratings. Yet another data set is needed, that of prescribed drugs found in Pharmacy Benefit Management (PBM) data.

Adding to the complexity of what would otherwise seem simple is the proliferation of drugs in this category. Many of the drugs are opioids, meaning they are artificial versions of the real thing—morphine. As new iterations of these drugs emerge, so do new drug names and NDC’s (National Drug Code) that is supposed to identify them. The DEA (Drug Enforcement Agency) classifies the drugs with still another set of codes.

Overall provider performance analysis
Once collected from the various sources, the data must be integrated, validated and analyzed. Comprehensive data analysis that is very simply described here provides a complete picture of provider performance in context with conditions in the entire claim. When provider performance is evaluated using all the key factors, a fair determination can be made about providers’ practices.

Link analytics to action
Those charged with carving out quality networks can make use of this information about individual physician performance, including prescribing behavior on an ongoing and current basis. Moreover, they also have in hand the objective and tangible rationale for removing poorly performing physicians from their networks.

MedMetrics takes this process a step further. User organizations can elect to be notified when a low-ranking physician, including those who have been identified as over-prescribers of Schedule II drugs submit a bill. This “head-up“ approach allows organizations to proactively intervene, thereby linking analytics to action.