Welcome to the MedMetrics Blog

The MedMetrics blog provides comments and insights regarding the world of Workers’ Compensation, principally, issues that are medically-related. The blog offers viewpoints regarding issues affecting the industry written by persons who have long experience in the industry. Our intent is to offer additional fabric, perspective, and hopefully, inspiration to our readers.

Search The MedMetrics Blog

Thursday, August 22, 2013

How to Tap the Power of Rx Monitoring for Opioids

by Karen Wolfe

In a nutshell
Much has been said about the cost of Schedule II pain medications in Workers’ Compensation. Rebecca Shafer, JD recently summarized the stunning financial impact in this way: “The average lost time work comp claim in the U.S. without the use of opioids cost $13,000. When an employee is prescribed a short-acting opioid like Percocet, the average lost time claim cost triples to $39,000. When an employee is prescribed a long-acting opioid like oxycontin, the average lost time claim costs explodes to $117,000, an increase of 900% over the average lost time work comp claim without the use of any opioids.”[1]

Do nothing
Obviously, doing nothing about this problem is not an option. Moreover, cost is not the only issue. The lives of injured workers, their families, and fellow workers are affected by long term use of Opioids used in the treatment of pain. The probability of return to pre-injury status after long term treatment with Opioids is meager. 

Analyze prescription practices
The first step in solving or mitigating the problem is to analyze the data to profile medical doctor prescribing history. Those who continually prescribe Opioids of any type, and particularly those who prescribe long acting Opioids should not be a part of any medical provider network. A proactive strategy should be used to eliminate such doctors from the network and direct injured workers to best practice doctors.

The best doctor solution
Direct injured workers to best practice providers. Avoiding  over-prescribing doctors will solve the problem. Pretty simple.

Automatic trigger
Nevertheless, in situations where avoiding the perpetrators is impossible or they are unknown, another approach is available. Ms. Shafer recommends, “If you do not have a nurse case manager assigned to all of your lost time claims, the issuance of a prescription to the injured employee for any narcotic should be an automatic trigger to assign the nurse case manager.”[2]

The catch
The catch is, what is an automatic trigger or how is the information about prescriptions conveyed to nurse case managers?

The most expedient way to spot Opioid prescriptions and impending disaster is through concurrent electronic data monitoring.

Proactive medical management
The trick is to always know when a narcotic is ordered and to monitor the type and subsequent prescriptions. Manual monitoring is time consuming and costly. It is also inaccurate as important information is easily missed. Instead, apply the power of technology through concurrent electronic data monitoring. Deliver automatic alerts to nurse case managers. The nurse will take it from there to discuss the treatment plan with the doctor, provide the doctor with evidence of poor results with continued Opioid use, and refer to peer review when the doctor is resistant.

Responsible Opioid use
The question might be posed, “Should Opioids ever be prescribed for pain?” The answer is yes. Opioids, can be very effective pain relievers and injured workers deserve relief from acute pain. However, responsible prescribing and monitoring prescriptions is essential to avoiding the disaster of addiction.

Data made a work-in-progress information tool
Systems designed and to monitor prescriptions and automatically alert the appropriate person when Opioids are prescribed are available. Alerts can be adjusted to the number and type of prescriptions, thereby establishing consistent standards of care. Read more about how to make data a work-in-progress information tool for proactive computer-intensified medical management How to Optimizethe Nurse Case Management Advantage.

Karen Wolfe is President and CEO of MedMetrics®, LLC, an online Workers’ Compensation analytics company. MedMetrics analyzes data to score provider medical performance and provides “apps” for quick look-up of best practice providers by medical specialty and geo-zip,. MedMetrics also monitors concurrent integrated data to detect potentially high risk or high cost events in claims and automatically alert the appropriate persons.

[1] Shafer, R. Workers Compensation Claim Costs Skyrocket with Use of Opioids ©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.
[2] Ibid.

Thursday, August 8, 2013

Part III California SB 863, a Guide to Building and Monitoring Networks with Intelligence

by Margaret Wagner and Karen Wolfe

California has defined how medical networks in Workers’ Compensation should be structured and managed. Part I and Part II of this series described how California’s SB 863 LC 4616 (b) (2) and LC 4616 (b)(3) takes medical provider network directives to a new level. The key imperative is, “Every MPN must establish and follow procedures continuously to review the quality of care, performance of medical personnel, utilization of services, facilities, and costs. However, a few additional key points should be considered when selecting and monitoring medical providers for the California MPN or any network.

Beyond legislation
Escalating problems in the industry with Opioid overuse and abuse, as well as physicians who are dispensing medications from their offices are additional factors that must be considered. While the California SB 863 legislation does not address these issues, the data should be scrutinized to identify physicians who demonstrate unfavorable prescriptive practices. Analyzing the data to evaluate physician performance in that regard is essential to vetting physicians for membership in a network. It is also crucial to monitoring networks going forward.

Opioid over-prescribers
Workers’ Compensation literature is replete with information about Opioid overuse and abuse with its disastrous human and resource waste. Unfortunately, measures taken to curb inappropriate prescribing behavior are few and vary widely across the country.

Simply stated, the best way to reduce Opioid abuse is to avoid Opioid over-prescribers. Analysis of the data will identify the perpetrators. They should never be a part of a Workers’ Compensation medical network.

Back to California - CURES
California has a program that approaches the problem by monitoring patient utilization of prescribed Schedule II drugs and making that information available to authorized prescribers and distributors (pharmacies) of controlled drugs.

California’s program is called CURES (Controlled Substance Utilization Review and Evaluation System, and PDMP (California Prescription Drug Monitoring Program). [1] The California Department of Justice, has a Prescription Drug Monitoring Program (PDMP) system which “allows pre-registered users including licensed healthcare prescribers eligible to prescribe controlled substances, pharmacists authorized to dispense controlled substances, law enforcement, and regulatory boards to access timely patient controlled substance history.

The California Attorney General's Office said that if doctors and pharmacies have access to controlled substance history information at the point of care it will help them make better prescribing decisions and cut down on prescription drug abuse in California. The role of the CURES/PDMP entrusts that well informed prescribers and pharmacists can and will use their professional expertise to evaluate their patients’ care and assist those patients who may be abusing controlled substances.

The state’s database known as the Controlled Substance Utilization Review and Evaluation System (C.U.R.E.S) contains over 100 million entries of controlled substance drugs that were dispensed in California. Each year the CURES program responds to more that 60,000 requests from practitioners and pharmacists. The online CURES/PDMP system will make it much easier for authorized prescribers and pharmacists to quickly review controlled substance information via the automated Patient Activity Report (PAR) in an effort to identify and deter drug abuse and diversion through accurate and rapid tracking of Schedule II through IV controlled substances.”
Submission of Controlled Substance Data
Pursuant to Health & Safety Code Section 11190, and Business & Professions Code Section 1170, all licensees who dispense Schedule II through IV controlled substances must provide the dispensing information to the Department of Justice on a weekly basis in a format approved and accepted by the Atlantic Associates Inc.(AAI),and the DOJ. Similarly, pursuant to California Health and Safety Code Section 11165(d), dispensing pharmacies and clinics must provide weekly dispensing reports to the DOJ on Schedule II, III, and IV prescription drugs.

For purposes of creating an intelligent MPN, insure any physician under consideration for an MPN in California is a member of CURES/PDMP. That notwithstanding, the data should be monitored continuously to determine actual performance.

Physician-dispensed medications
Another prescription abuse issue not addressed by the California legislation is physician-dispensed medications. While it is portrayed as a patient convenience, and probably is, the medications are prepackaged and extraordinarily costly. Once again, this practice can be monitored in the data. Bills reflecting drugs dispensed by the treating doctor are not monitored by Pharmacy Benefits Managers (PBM), rather, they appear in normal provider billing.

Networks with Intelligence
All medical provider networks serving any jurisdiction should analyze integrated data, meaning all data associated with claims. Integrated data is sourced from claims level systems, bill review systems, PBM systems, and other such as utilization review to understand the broad spectrum of claims and all individuals, organizations, and events touching them. The goal is to select best-in-class doctors by objectively identifying excellent provider performance.

Margaret Wagner is President and CEO of Signature Networks Plus, Networks with Intelligence™. She is considered an expert in network selection, monitoring and management, thereby creating Networks with Intelligence for clients. MWagner@signaturenetworksplus.com

Karen Wolfe is President and CEO of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics scrubs and enhances provider data in systems, integrates the data from organizations’ disperse systems, then analyzes, scores, and monitors medical provider performance. MedMetrics also offers online “apps” that link medical analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org