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.

Tips for Building a Medical Provider “A” Team

by Karen Wolfe

The “noise” in the Workers’ Comp industry about increasing medical costs is not subsiding. If anything, the chatter is swelling into a crescendo and much of it is relevant and important. Recent conferences such as the Workers’ Compensation Research Institute (WCRI) underscored the continuing problem of Opioids. Also of concern at the conference was physician-dispensed drugs.

Studies show when Opioids are prescribed inappropriately and when physicians sell patients medications directly from their offices, claim costs increase and outcomes deteriorate. However, while discussion of the topic increases, new initiatives in the industry designed to target the problem are scarce.

Source of the problem

The source of these two major cost problems is certain treating doctors. Doctors are the ones licensed to prescribe drugs and some are abusive. Probably only a few of the doctors are perpetrators, but the trick is to know in advance which doctors they are. Particularly for organizations that have employees geographically spread, this is a continuing challenge.

Networks are not a safe haven

Payer organizations have been lead to believe their networks are their safe haven. If an injured worker is sent to a network provider, a discount on medical services can be assured. Unfortunately, networks are known to contract with every physician and ancillary provider alive, without consideration of the provider’s Workers’ Comp knowledge, interest, or medical integrity. Nor are quality, overall cost, and outcomes considered.

Networks do not vet physician performance. They allege savings based on discounts off medical bills, but the number of bills is not measured. Most networks have not stepped up to apply analytics to provider performance so payers must look elsewhere.

Networks lack necessary data

The only practical way to evaluate provider performance in order to select the best is to analyze the data. The problem for networks is they do not have the scope of data necessary to fairly evaluate performance. They receive medical bills, discount them, take a cut, and pass them back to the payer. But medical bills alone are not adequate for evaluating provider performance.

Data from multiple sources is needed

To understand a provider’s performance, claims level data is also essential. It is needed to evaluate the uniquely Workers’ Comp nuances of return to work, indemnity costs, legal involvement, claim duration, timing, and other key factors.

Opioid data, another source

In the case of Opioids, the best source of data for evaluation is from the Pharmacy Benefit Management program (PBM). The PBM data set contains the detail of what drug was prescribed and when, who prescribed the drug, and where it was filled. However, Indicators of physician dispensing will not be found in PBM data.

Physician dispensing data

Physician dispensing will appear as an item on a normal bill from the treating doctor. The degree to which it is camouflaged will vary and it may or may not be noted by the bill review system. Many bills are summarized by the time they reach the claims adjuster, so adjusters cannot discern which bills are physician-dispensed drugs. Analysis of the data is the best approach, not with the goal of avoiding payment, but to avoid the physician altogether.

Networks are a platform for analysis

Payer organizations should use their network providers as a platform for selecting their A Team. By analyzing the data, the best practice providers will surface and injured workers can be directed to them. Unfortunately, most organizations do not have the necessary resources to accomplish that task.

The solution

The best solution is to invite a third party that specializes in analyzing Workers’ Comp data and identifying the best practice medical providers in your data. Avoiding doctors that prescribe Opioids and those that dispense medications from their offices will save thousands of dollars on any given claim—more than enough for ROI on the third party service. Savings can be measured in reduced claim costs and far better outcomes compared to claims where the perpetrators of these abuses were involved. Identifying the best medical providers and directing injured workers to them are powerfully effective cost containment initiatives.

Karen Wolfe is president of MedMetrics which specializes in medical provider performance analytics with easy user search tools. We analyze your data for you to score providers based on multiple indicators. Visit MedMetrics to learn about MedMetrics Provider Performance Suite of information services, including detailed Provider Performance Analysis and Master Provider Index, a quick search for best practice providers by specialty and geo-zip. For questions, contact karenwolfe@medmetrics.org.

 

 

Teach Your Data to Fight Opioid Abuse

By Karen Wolfe

Workers’ Compensation research, networking communities, and press are overflowing with information about Opioid overuse and how it is negatively impacting claim costs and outcomes. Information about the problem abounds. Opioid abuse is clearly recognized as a serious problem in the industry, clearly evidenced by recent research.

Industry research
An example of recent research on the topic is from Alex Swedlow at the California Workers Compensation Institute (CWCI), “An association was found between greater use of Opioids and delayed recovery from workplace injuries.” Swedlow says it’s not so much that the drugs themselves are costly, rather, it is the collateral damage that accompanies their use.

A recent study from NCCI (National Council on Compensation Insurance, Inc.) is entitled, “Early Narcotic Use Is Indicative of Prolonged Use.” Findings showed that high use of narcotics in the first quarter following injury indicates a higher than average probability of narcotic use in subsequent periods.

The list of studies and articles is long. In fact, a Google search for “Opioid abuse in Workers’ Compensation” draws nearly 100,000 results. Now that the problem is well-defined, the focus shifts to correcting it.

Fixing the problem
MedMetrics recently conducted a small study for EK Health and their Next Step program. The Next Step program leverages EK Health’s many professional medical resources to address complex claims where the injured worker is addicted to prescription medications. They effectively apply expert peer to peer consulting to assist treating physicians in weaning claimants from their prescribed drugs. The EK Health Next Step program is uniquely effective in bringing those old and very complicated claims to closure.

While the EK Health Next Step program is a powerful tool, it could have even greater impact on costs and outcomes if implemented earlier in the course of the claim, well before so much damage and costs have played out. Early awareness and intervention by referral to the experts could have exponentially positive effects.

Identifying risky claims early
Busy claims adjustors are not accustomed to identifying early Opioid use in claims. In fact, hey often do not have the means because many claims systems do not capture prescription detail. Moreover, Pharmacy Benefit Management data, another source of critical information, is usually a separate system and is not readily available to claims adjustors. Consequently, they are unaware of narcotic prescriptions. However, they and others who might intervene could be made aware through computer-aided medical management, by teaching the data to find the problem.

Computer-aided management tools
Industry research and data studies serve to define and clarify the problem, but they can also illuminate a very practical means to resolution. The research contains tips and actual predictors of risky claims. A derivative of research is the knowledge of what to look for in the data.

For instance, the NCCI study identifies a predictor that when narcotics are used for pain early in the course of the claim, it can be indicative of impending trouble. Armed with this well-founded intelligence, the problem can be proactively addressed from the beginning of a claim by continually searching for the prescriptive indicators in the data.

Monitor current data
Concurrent data monitoring is a powerful cost control methodology to identify early Opioid use. By monitoring current data for Schedule II drugs prescribed, claims can be automatically flagged and referred for more intense scrutiny. Claims with this critical information will not be overlooked when using computerized data monitoring.

Likewise, providers who prescribe the drugs outside the accepted medical guidelines such as ACOEM (American College of Occupational and Environmental Medicine) can be monitored electronically. The system can identify providers known for higher Opioid prescription rates. When those physicians are involved in a claim, the system sends an alert to the claims adjustor, medical case manager or other key persons. The system can also send a notification to the prescribing physician.

Notifying the prescribing physician in near real time can serve as a potent preventive tool. It puts physicians on notice to let them know they are being observed.

IT resources
Creating vigorous computerized medical management tools such as these is an IT function. Technicians are required to develop the programs under the guidance of the business leaders who understand medical indicators. Unfortunately, many organizations suffer from scarce IT resources and such initiatives are not implemented. Therefore, outsourcing to a company that specializes in developing computerized medical management tools is the right answer.

To learn about MedMetrics medical management data monitoring, contact Karen Wolfe at 541-390-1680 or karenwolfe@medmetrics.org.