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Raising the Bar to Lower Opioid Risk

Opioid medications pose risks to patients even at low doses, and require more aggressive management.
By: | November 2, 2015 • 5 min read

The last couple of years have seen a decline in the number of opioids being prescribed, but evidence still shows that a significant portion of patients are receiving chronic treatment with opioids longer than 90 days. According to a recent study conducted in Rochester, New York, 1 in 4 patients receiving a new opioid prescription progressed to chronic use.1 Further, patients receiving long-term opioid treatment were more likely to have a past or current history of substance abuse, even though treatment guidelines specifically recommend that these patients should not receive opioid therapy. And while prescribing habits and rates vary by state, it remains that millions of Americans are receiving long-term opioid treatment.

While strides are being made against the pervasiveness of opioid overprescribing in workers’ compensation, there remains room for improvement, and recent guideline updates are taking a strong stand to make this happen.

Lower Dosing Thresholds

Daily morphine equivalent dose (MED) of opioid medications directly correlate with negative outcomes ranging from abuse and overdose to increased risk of depression and other serious side effects. Increased risk for overdose has been documented at MED as low as 20mg, with significant risk occurring at MED 100mg or higher.2 The American College of Occupational and Environmental Medicine (ACOEM) updated their Practice Guidelines at the end of 2014 with the goal of providing more detailed guidance for all phases of opioid treatment.3 The organization sets the bar for recommended daily MED thresholds at 50mg based on their analysis of studies that indicate a sharp increase in risk for overdose death at levels above 50mg.4,5 This is an aggressive target compared with other evidence-based or state-specific guidelines, which set the maximum recommended daily MED between 80-120mg.

Although the recommended MED thresholds vary depending upon the guidelines followed, the approach to prescribing remains the same: when dealing with a medication with so much potential for risk, it is always best to err on the conservative side. Care management strategies should emphasize alternative pharmacological and non-pharmacological treatment whenever possible. When opioid treatment is clinically appropriate, opioid treatment duration should be minimized, and tools that enable close monitoring and ongoing clinical assessment are critical.

Healthesystems, in concert with its customers, takes a proactive and aggressive approach to opioid risk management. Among claims managed by Healthesystems, more than 80% of injured worker claimants receiving opioid therapy fall below the ACOEM maximum recommended daily MED of 50mg, the most stringent threshold set in the industry.6

Preventing Chronic Use

Keeping MED levels low is a positive sign that opioids are being managed appropriately. However the ultimate goal is to achieve an MED level of zero – whether that means seeking alternative treatment in patients upfront, or tapering them off opioids as needed following acute treatment in favor of a more appropriate long-term treatment strategy.

The state of Washington has taken a strong stance on this approach with their recently updated opioid prescribing guidelines. The 2015 Interagency Guideline on Prescribing Opioids for Pain places a greater emphasis on decision-making in the acute stage of treatment, as well as preventing transition to chronic opioid use.7 It also includes expanded recommendations for non-opioid pain management options and stresses the importance of tracking clinically meaningful improvements in function as well as pain management to make decisions regarding opioid treatment. The previous 2010 guidelines had primarily focused on chronic non-cancer pain, and the new update represents a dramatic shift towards early intervention opportunities. And while the most recent Washington guidelines have kept the official recommended maximum daily MED at 120mg, they do acknowledge the potential risks associated with MED higher than 100mg/day. They also emphasize that there really is no “safe” opioid dose, and therefore chronic use should be avoided altogether, wherever possible.

The California Division of Workers’ Compensation (DWC) has also initiated a process to update the chronic pain section of its Medical Treatment Utilization Schedule. The updates include a new, standalone chapter for opioid guidelines that stress the exploration of alternative treatments such as physical activity, yoga and acupuncture, as well as non-opioid medications. For patients in whom opioids are appropriate, California guidelines recommend a maximum daily MED of 80mg.8

Guidelines As A Tool For Payers, PBMs

Guidelines serve not only as recommendations for prescribers in making appropriate treatment decisions; they also serve as a powerful tool for payers and PBMs to enforce clinically sound decisions. State-implemented guidelines can support claims professionals in making decisions regarding high-risk, high-cost medications such as opioid analgesics.

The application of evidence-based guidelines in treatment of the injured worker has a proven impact on both clinical and cost-related outcomes. This extends to pharmacologic and non-pharmacologic treatment – from recommendations for appropriate opioid prescribing to guidance on when physical therapy is preferred over surgery or imaging services.

This article appears in the Fall 2015 issue of RxInformer, an industry journal published by Healthesystems. For more articles on current and emerging topics that impact workers’ compensation, visit

1 Hooten WM, St Sauver JL, McGree ME, et al. Incidence and risk factors for progression from short-term to episodic or long-term opioid prescribing: a population-based study. Mayo Clin Proc. 2015;90:850-6.

2 Zedler B, Xie L, Wang L, et al. Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Med. 2014;15:1911-29.

3 Hegmann KT, Weiss MS, Bowden K, et al. ACOEM Practice Guidelines: Opioids for treatment of acute, subacute, chronic, and postoperative pain. J Occup Environ Med. 2014;56:e143-e159.

4 Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305:1315-21.

5 Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152:85-92.

6 Healthesystems data.

7 Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Prescribing Opioids for Pain, 3rd Edition. June 2015.

8 California Division of Workers’ Compensation (DWC). Draft Medical Treatment Utilization Schedule (MTUS) Chronic Pain Medical Treatment Guidelines and Opioids Treatment Guidelines. July 2015.

Healthesystems is a leading provider of Pharmacy Benefit Management (PBM) & Ancillary Benefits Management programs for the workers' compensation industry.
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3 Elements That Optimize Physical Medicine Management

Effective application of physical medicine services can reduce utilization and costs while promoting functional improvement.
By: | November 2, 2015 • 4 min read

It is well-supported within worker’s compensation that non-pharmacologic methods of treatment, such as physical medicine, are a valuable component of the overall treatment plan. However, less supported is the ability for payers to evaluate and manage the quality of physical medicine services. Although evidence-based guidelines exist as a framework for treatment decisions, payers traditionally have had limited means to objectively measure the impact of services on patient recovery. Without objective measures, it is impossible to assess the clinical value, as well as the cost-effectiveness, of treatment.

Physical medicine encompasses a range of non-pharmacologic services that include physical (PT), occupational (OT), aquatic and massage therapies, chiropractic, acupuncture, and work hardening. When not managed optimally, physical medicine services can contribute significantly to the costs of a claim without facilitating earlier return to work. However, effective application of physical medicine services has been shown to reduce utilization and costs. There are several elements that must be part of a physical medicine program in order to best manage not only the cost, but more importantly, the quality of physical medicine services provided to the injured worker patient:

Clinical decision support
A program that supports outcomes-based care decisions vs traditional utilization-based models

Outcomes-based performance assessment
Objective measures and criteria to accurately assess quality and effectiveness of service

A bigger-picture perspective
A comprehensive platform that considers costs and utilization of physical medicine services within the greater context of the claim

Clinical Decision Support

The process of ensuring quality care begins early in the claim, where evidence-based guidelines should drive clinical decision-making in regard to how physical medicine services are best implemented into the treatment plan. Quality in this case refers not to price, but rather, adherence to evidence-based and outcomes-focused treatment. Studies demonstrate that clinically appropriate application of PT contributes to reduced utilization and overall spend within a claim. In this sense, quality of service becomes the driver for containment of cost and utilization.

It is this focus on quality, asserts the chief medical officer at Healthesystems, Robert Goldberg, MD, FACOEM, that marks a significant departure from how physical medicine has traditionally been managed. “Right now, claims professionals are often making decisions solely based on utilization. We need to change the conversation from how many visits are acceptable, and instead ask the question, what level of functional improvement was accomplished during those visits?”
In order to shift the model from one that is largely utilization-based to one that is outcomes-based, claims professionals must have access to a platform that provides them with the support they need to make clinically sound decisions. This is where physical medicine programs within workers’ comp have a significant area of opportunity.

Outcomes-Based Performance Assessment

Evidence-based medicine is only as valuable as the outcomes it manifests; and true outcomes evaluation can only be achieved with objective measures of clinical progress. In simpler terms, to accurately assess a provider’s quality of services, one must use the right yardstick. Comprehensive data should include measures that are overlooked by conventional physical medicine programs, including specific measures of:

  • Clinical outcomes (e.g., range of motion, strength)
  • High-risk indicators (e.g., fear avoidance, nonadherence)
  • Return-to-work
  • Administrative efficiencies
  • Vendor performance
  • Network data

Equally important are when and how these data are being collected. Solicitation of data from providers at key time points enables payers to accurately assess quality along the care continuum, allowing them to more effectively manage patient care and provider networks.

Collecting the right data at the right time requires the right platform. Historically, much of the patient or clinical assessment data has not been codified or structured in a way that is actionable to the claims professional. Crucial information – for example, evidence of fear avoidance – may be buried in handwritten notes, where it can be overlooked in the clinical decision-making process. A platform that translates anecdotal information into electronic, codified data enables it to be integrated more effectively into care decisions. These triggers become even more valuable when logic is incorporated to proactively alert claims professionals. Having a more comprehensive data set allows for a more complete and accurate view of the quality of therapy and provider performance for the payer.

A Bigger-Picture Perspective

Optimized management of physical medicine must take into consideration the larger role these therapies play in the overall treatment plan for the injured worker. This requires a comprehensive, integrated platform that has the capability to consider costs and utilization of physical medicine services within the greater context of the claim. This means having the ability to merge data that are traditionally disparate in order to accurately measure the impact on other components of treatment, both pharmacologic and non-pharmacologic.

Areas of potential therapy improvements and costs savings with optimized management of physical medicine include:

  • Reduced opioid usage
  • Excessive/ineffective visits
  • Delayed return-to-work
  • Prescription medications
  • Advanced imaging
  • Therapeutic injections
  • Surgery

A physical medicine management program that takes a holistic approach to delivering clinically appropriate, quality-based care can drive patient outcomes while also limiting inappropriate utilization and lowering unnecessary or avoidable costs. “When better care decisions are made,” adds Dr. Goldberg, “outcomes improve for all stakeholders. The injured worker regains function, the employer benefits from their employee’s faster return to work, overall costs are lowered for the payer, and the care provider is rewarded for the value they are delivering.”

Healthesystems provides an enhanced physical medicine model that allows payers to effectively assess quality and manage utilization of physical medicine services. To learn more about Healthesystems’ physical medicine program or to read our whitepaper “Physical Therapy and the Injured Worker,” visit

Healthesystems is a leading provider of Pharmacy Benefit Management (PBM) & Ancillary Benefits Management programs for the workers' compensation industry.
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Drug Utilization Management Tools: Have You Tapped Their Full Potential?

With the right tools, payers can take a more proactive approach to managing drug therapy.
By: | October 22, 2015 • 2 min read

Managing appropriate utilization of prescription medications is a critical component of balancing quality and cost of care in workers’ compensation. The concept seems intuitive: by delivering the most appropriate care to a patient, you’ll also reduce costs – with better outcomes, shorter claim durations, a lower likelihood of chronic treatment, and fewer complications requiring additional treatment. But all too often utilization management tools are not effectively applied to take full advantage of their potential. There is a significant opportunity to enhance the application of these tools to improve patient care and better control costs.

The key to successful drug therapy management is the ability of the claims professional to take quick action. And this requires a comprehensive utilization management strategy that deploys tools as needed throughout the care continuum. Many of these tools are more powerful enhancements to the traditional way of doing things. For example, if there is concern regarding a prescribed medication, the right tool can facilitate early dialogue with the prescriber regarding clinically appropriate alternatives. This proactive approach has demonstrated a change in prescription in 2 out of 3 cases.1 And this is just the tip of the iceberg when considering the long-term patient safety and financial benefits of avoiding inappropriate or high-risk medications within a claim. There are a number of patient risk factors that can arise at any point during a claim lifecycle, and these risk factors can translate into significant dollars when not managed efficiently and aggressively.

Consider the opportunities for intervention:

  • Adding benzodiazepines to a short-acting opioid regimen can triple the average claim cost ($43,438 vs $123,311)2
  • Opioid misuse, abuse or dependence cost payers an extra $15,000 or more per patient, per year3
  • Claims with long-acting opioids are nearly 9x as likely to cost more than $100,000 than claims without opioids present4
  • Compounds and private-label topical products are not clinically proven for safety or efficacy, and can cost thousands of dollars for a month of treatment
  • Opioid-induced constipation (OIC) can double the total healthcare costs in the first year following opioid initiation5
  • Opioid-related drug interactions can incur an additional $600 per month, per patient6

The fact is, these are all concerns that can be addressed before they even happen. It is just a matter of having the right strategy.

Do you have an effective utilization management strategy that truly maximizes its fullest potential with the right supporting tools?  Look for the article “Making the Most of Drug Utilization Management Tools” in our Fall 2015 issue of RxInformer journal to see how earlier and more aggressive application of utilization management tools can dramatically improve patient care and cost. Sign up for free at

References: 1. Healthesystems data. 2. Lavin RA, Tao X, Yuspeh L, Bernacki EJ. Impact of the combined use of benzodiazepines and opioids on workers’ compensation claim cost. J Occup Environ Med. 2014;56:973-8. 3. White AG, Birnbaum HG, Schiller M, et al. Economic impact of opioid abuse, dependence, and misuse. Am J Pharm Benefits. 2011;3:e59-e70. 4. Tao X, Lavin RA, Yuspeh L, et al. The association of the use of opioid and psychotropic medications with workers’ compensation claim costs and lost work time. J Occup Environ Med. 2015;57:196-201. 5. Wan Y, Corman S, Gao X, et al. Economic burden of opioid-induced constipation among long-term opioid users with noncancer pain. Am Health Drug Benefits. 2015;8:93-102. 6. Pergolizzi JV Jr, Ma L, Foster DR, et al. The prevalence of opioid-related major potential drug-drug interactions and their impact on health care costs in chronic pain patients. J Manag Care Spec Pharm. 2014;20:467-76.

Healthesystems is a leading provider of Pharmacy Benefit Management (PBM) & Ancillary Benefits Management programs for the workers' compensation industry.
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