Paying for Detox
Helping patients addicted or dependent on the very medications that were designed to ease their pain is driving workers’ comp claims payers in some cases to fund tapering and detoxification programs.
Study results in recent years have boosted that initiative by identifying multidisciplinary treatment approaches as offering an improved chance for success.
The treatment approaches call for weaning patients off of pain medications while also addressing a range of complex issues contributing to addiction and dependency, experts said.
Success, though, is frustratingly hard to come by, so payers have been cautious, or even reluctant to fund detox treatments — although more are doing so, they added.
Recidivism is common, even after someone successfully completes a good detoxification treatment program and appears to be winning the struggle to turn their life around. Experts said it can take several attempts or “episodes of care” to wean someone off narcotics. Long-term support is often necessary.
“The success rate is poor enough that it becomes difficult to feel that even the best programs by reputation are delivering,” said Dr. Dwight Robertson, national medical director in Glendale, Calif., for EMPLOYERS, a workers’ compensation insurer.
“Where we have a case that just goes on and on and we are trying to intervene … it can be very frustrating because the patient may not be ready to change.” — Dr. Dwight Robertson, chief medical officer for EMPLOYERS
“It is so tough that you often have a lot of cases you send to the best programs, it costs you a lot of money, and you still don’t get success. But having said that, you can’t just sit back and do nothing.”
Payers have several reasons for helping workers struggling with addiction or drug dependency, including the drugs’ direct costs, the expense of treating drug side effects, a desire to cut their ongoing liability by closing complex claims, and a sincere goal of helping workers recover, said Dr. Steven M. Moskowitz, senior medical director for Walnut Creek, Calif.-based Paradigm Outcomes, a catastrophic care management company.
But several hurdles often frustrate attempts to help, especially if the overuse or abuse of addictive prescription narcotics has escalated over time without eliminating the chronic pain responsible for prescribing opioids in the first place.
The hurdles include a dependent or addicted worker’s refusal to seek help, especially when their judgment is clouded by an intense desire for drugs that someone else is paying for; caregivers who might understand detoxification but not chronic pain issues or vice versa; and a range of personal or psychosocial problems such as mental health complications or a claimant’s troubled home environment.
To help overcome those hurdles, more payers are working to identify detox treatment and tapering programs nationwide that they expect will provide the best chance of success, said Mark Pew, senior VP of product development for PRIUM, a workers’ comp medical management company.
In addition to the cost of the programs, they are paying for travel and other expenses necessary to get addicted or drug-dependent claimants into treatment.
Yet, with treatment programs ramping up marketing efforts to push their services, and recidivism a very common problem, worker’s comp payers are also cautious about selecting treatment programs and patients who might benefit.
“They are not doing it willy-nilly and they are not doing it generously,” Moskowitz said of workers’ comp payers funding detox treatments.
“They are doing it cautiously, as they should, because everyone now is [selling detox services]. It’s a lot of money. It’s an expensive resource.”
In cases where they feel the patient’s treating physician lacks the expertise necessary to address severe pain or treat addiction, insurers, excess insurers and TPAs are funding detoxification treatments.
That’s doubly true when patients have a documented history of consuming multiple medications, including narcotics, in high doses, Pew said.
Dependency Versus Addiction
With addicts, the withdrawal and the lengths to which an injured worker will go to get drugs are extreme.
True addiction manifests itself in aggressive drug-seeking behavior, such as visiting multiple prescribers or claiming the loss of a prescription to obtain early refills.
“Basically you are out of control in terms of your utilization and you are doing whatever you can to get as much of the drug as quickly as possible,” said Dr. Robert Goldberg, chief medical officer for Healthesystems, a workers’ comp pharmacy and ancillary benefits management company in Tampa, Fla.
Among workers’ comp claimants, full-scale addiction is less common than psychological or physical dependence. However, dependent cases may also require detoxification or tapering assistance, Goldberg said.
Detoxification describes the process of helping individuals safely withdraw from substance use, and may involve gradually tapering dose amounts or prescribing alternative drugs to minimize withdrawal symptoms.
“An injured worker’s treating physician that has the proper experience should be capable of addressing simpler cases and helping patients taper off drugs,” Goldberg said.
“A more complicated situation [includes patients with] co-morbidities, a lot of psychosocial factors, higher doses, and longer term dependency,” Goldberg added.
“That is where you have to decide if you need a more formal detox program, either inpatient or outpatient. That is where you are stepping up the game and the intensity of treatment and the cost.”
Reluctance to Seek Treatment
Complicating matters is that workers’ comp payers can’t force a claimant to seek treatment for drug dependency or addiction. In addition, reluctance to seek treatment is typical, so payers must act quickly when a patient indicates a willingness to seek help.
“Where we have a case that just goes on and on and we are trying to intervene … it can be very frustrating because the patient may not be ready to change,” EMPLOYERS’ Robertson said.
“Yet we have to be ready for that moment when maybe they soften up and say they do want to change their life. We have to be ready to evaluate them at that moment and say, ‘Is a true detox program needed?’ ”
There are several opioid detoxification program settings. Selecting one can depend on a claimant’s specific needs and the severity of the problem, experts said.
Settings include hospital-based detoxification with 24-hour service, non-hospital detoxification programs with 24-hour service, intensive ambulatory outpatient services and ambulatory detoxification, said Dr. Adam L. Seidner, national medical director for The Travelers Cos. Inc.
“Our nurses help ensure that the services and facility match the required detoxification needed,” Seidner said.
“Multiple service types may be involved. The worker needing detoxification may need to start in the hospital and progress to an ambulatory facility.”
A patient who desires to leave drugs behind and has a supportive home environment may succeed with outpatient care, Paradigm’s Moskowitz said. Others may need the added structure provided by an inpatient program, he added.
The decision whether to use an outpatient or inpatient facility may also depend on a worker’s mind-set. If they don’t consider themselves addicted or dependent, they may object to an inpatient program and only accept outpatient assistance.
Regardless of the care level, though, failure is always possible despite a program’s reputation, Robertson said.
“Sometimes the intervention in a hospital — and there are some great hospital programs — can be most impacting and work best,” Robertson said.
“But you may appear to have a good result then you send the patient home and they go right back into the same set of complex issues that created the problem to begin with.”
That is why experts said a process that only weans patients off medications often is inadequate. They advocate a multidisciplinary approach that includes help with addiction, functional restoration and addressing psychosocial issues that can lead to relapses.
Detox and Chronic Pain Management
Some programs are capable of helping address chronic pain, but not addiction and detoxification, while others excel at helping with the latter but not pain, Moskowitz said.
“We have found the best luck identifying a handful of good programs around the country that are really good at pain management as well as detoxification,” Moskowitz said.
“Most of these cases that have the substance problems also [complain of pain stemming from work injuries]. So you have to address the rehab of the underlying pain diagnosis. In addition, they need to get somebody to change their mind-set to cooperate with coming off the medication.”
To succeed, experts said, payers may also have to fund mental health treatment such as cognitive behavioral therapy that helps patients learn coping skills and managing psychosocial conditions.
“If you don’t do it properly,” Pew said, “you can spend $15,000, $20,000, $25,000 for a functional restoration or chronic pain management program and then they relapse two or three months later because you didn’t deal with how they cope with pain or manage their condition and change their lifestyle.”
But Robin Orchard, president and owner of Orchard Medical Consulting, a case management company that provides detox services in Phoenix, said that simultaneous detox and chronic pain management programs are often not necessary.
She has seen an increase in claimants seeking detoxification help since workers’ comp payers have learned about the pitfalls of opioid prescribing and curtailed their spending on the medications.
Many of those claimants are psychologically dependent on opioids and have benefited from detox treatment alone, she said.
Once off the drugs, they find that it was their opioid dependence that was helping to drive their pain.
“What we are seeing is when people are off of narcotics, they are not experiencing pain,” Orchard said.
“The overwhelming fear that the pain might occur once they are off the narcotics is what is driving them” to continue using the drugs, she said.
Recently, I had coffee with an old work colleague. He had started a new senior management job for a manufacturing company about a year and half prior. I almost did not recognize him when he walked into the coffee shop. He looked tired, resigned and truly depressed. I could not believe this was the same vivacious leader that I once worked with.
I asked how things were going at his “new” job. Almost as though he was embarrassed, he told me his story.
He said he was struggling. He was dealing with a veteran employee that clearly had sought his job prior to his arrival. To date, the veteran had not reconciled the fact that he did not get the role. This employee has been with the organization for more than 26 years.
Since my friend’s arrival at the company, this employee has challenged and undermined him. The employee pushed other employees to deliberately not meet my friend’s deadlines, undermine his meeting agendas and act disrespectfully.
When my friend tried to manage these behaviors, his efforts seemed to only make things worse. The group, through the encouragement of the ringleader, filed false complaints about my friend to human resources. Some of the allegations were quite serious and difficult to disprove.
When the complaints were investigated, my friend found himself trying to defend unfounded he-said/she-said allegations. He told me that HR gave too much credence to these allegations. As a new manager, he felt he had little protection from his own employees’ intimidating and bullying tactics.
He felt alone. He did not share his feelings with higher management as he believed that admitting he was struggling to control his own staff was admitting failure. He wanted to impress senior management and assert himself in his new workplace. But instead, the whole experience was giving him bouts of anxiety, sleeplessness and shaken confidence. He now was thinking of resigning.
I was so struck by his story. We tend to perceive intimidating behaviors as moving only downward, where a person of authority victimizes a junior person. But clearly, managers can be targets of troubling behaviors in the workplace on the part of their own subordinates. Colloquially, this behavior has been known as “boss bashing;” experts now call it “upward bullying.”
Upward bullying is attracting increased attention as organizations realize the risks attached to the toxic effects this behavior has on an organization’s culture, morale and productivity.
The reality is that most companies will always have groups of lax employees whose performance is under scrutiny. Or they will have pockets of resentful staff who have been denied promotions or pay raises. These employees may retaliate by abusing their managers or filing false complaints against them.
Does your organization pay attention to this risk? Are policies in place to protect the safety and welfare of the leaders who are there to drive success in your business?
The costs associated with upward bullying can be substantial. Consider how much time and energy is dedicated to addressing false allegations, the increased absenteeism of line managers, the overall effect of undermined leadership and the compromised ability of leaders to push an organization to achieve its objectives.
Bottom line, we clearly need stronger risk mitigation and support systems that defend employees at all the ranks of an organization.
The Next Wave of Workers’ Comp Medical Cost Savings
Managing medical costs for workers’ compensation claims is like pushing on a balloon. As you effectively manage expenses in one area, there are bound to be bulges in another.
Over the last decade, great strides have been made in managing many aspects of workers’ compensation medical costs. Case management, bill review and pharmacy benefits management are just a few categories that produce significant returns.
And yet, according to the National Council on Compensation Insurance (NCCI), medical costs remain the largest percentage of workers’ comp expenses. Worse still, medical costs continue to be the fastest growing expense category.
Many medical services are closely managed through provider negotiations, bill review, utilization review, pharmacy benefits management, to name a few. But a large opportunity for medical cost containment remains largely untouched and therefore represents a significant opportunity for cost savings.
Ancillary medical services is a term used to describe specialty or supplemental health care services such as medical supplies, home health care, durable medical equipment, transportation and physical therapy, etc.
According to Clifford James, Vice President of Strategic Development at Healthesystems in Tampa, Fla., modernizing the process for managing ancillary medical services presents compelling opportunities for cost savings and improved patient care.
Source: 2014 Healthesystems Ancillary Medical Services Survey
“The challenge of managing these types of medical products and services is a cumbersome and extremely disconnected process,” James said. “As a result, it represents a missing link in an overall medical cost management strategy, which means it is costing payers money and patients the most optimal care.”
James singled out three key hurdles:
Lack of transparency
As the adage goes, you can only manage what you can measure.
Yet when it comes to the broad range of products and services that comprise ancillary benefits, comprehensive data and benchmarking metrics by which to gauge success are hard to come by.
The problem begins with an antiquated approach to coding medical services that was developed in the 1970s. The coding system falls short in today’s modern health care environment due to its lack of product and service level detail such as consistent units of measure, quantity and descriptors.
As a result, a meaningful percentage of ancillary benefits spending is coded as “miscellaneous,” which means a payer has little to no visibility into what product or service is being delivered — and no way to determine if the correct price is being applied or if the item is even necessary or appropriate.
Source: 2014 Healthesystems Ancillary Medical Services Survey
“It’s a big challenge. Especially when you consider that for many payers, it’s difficult to determine exactly what they are spending, or identify what the major cost drivers are when it comes to ancillary services,” James said. And when frequently over 20 percent of these types of services are billed as miscellaneous, payers have zero visibility to effectively manage these costs.
Measurement and monitoring
Often, performance that is monitored is given the most attention. Therefore, ancillary programs that are closely monitored and measured against objective benchmarks should be the most successful.
However, benchmarks are hard to determine because multiple vendors are frequently involved using disparate data and processes. There isn’t a consistent focus on continuous quality improvement, because each vendor operates off of their own success criteria.
“Leveraging objective competitive comparisons breeds success in any industry. Yet for ancillary services there is very limited data to clearly measure performance across all vendors,” James said. “And for payers, this is a major area of opportunity to promote service and cost containment excellence.”
Source: 2014 Healthesystems Ancillary Medical Services Survey
If you ask claims executives about their strategies for improving the claims management process, a likely response may be “workload optimization.” The goal for some is to enable claims professionals to handle a maximum case load by minimizing administrative duties so they can leverage their expertise to better manage the outcome of each case.
But the path towards “workload optimization” has many hurdles, especially when you consider what needs to be coordinated and the manual way it frequently is done.
Ancillary benefits are a prime example. For a single case, a claims professional might need to coordinate durable medical equipment, secure translation services, arrange for transportation and confirm the best physical therapy plan. Unfortunately they often don’t have the needed time, or the pertinent information, in order to make quick, yet informed, decisions about the ancillary needs of their claimants.
In addition there is the complexity of managing multiple vendor relationships, juggling various contacts, and accessing multiple platforms and/or making endless phone calls.
“We’ve been called the ‘industry integrator’ by some people, and that’s accurate. We are delivering a proven platform connecting payers with providers and vendors on the ancillary medical benefit front. It’s never been done before.”
– Clifford James, Vice President of Strategic Development, Healthesystems
Modernizing the process
To the benefit of both payers and vendors, Healthesystems offers Ancillary Benefits Management (ABM).
The breakthrough ABM solution consists of three foundational components — a technological platform, proprietary medical coding system and a comprehensive benefits management methodology.
The technological platform integrates payers and vendors with a standardized architecture and processes. Business rules and edits can be easily managed and applied across all contracted vendors. All processes – from referral to billing and payment – are managed on a single platform, empowering the payer with a centralized tool for managing the quality of all ancillary providers.
But when it comes to ancillary products, the critical and unique challenge Healthesystems had to solve is the antiquated coding system. This was completed by developing a highly granular, product-specific coding system including detailed descriptions and units of measure for all products and services. This coding provides payers with the clearest understanding of all products and services delivered including pricing and all the necessary utilization metrics.
“We bring the highest level of transparency and visibility into all ancillary products and services,” James said, adding that the ABM platform uses an extensive preferred product coding system 15 times more detailed than any other existing system or program.
This combination of sophisticated technology, proprietary coding system and benefit management methodology revolutionizes the ancillary category. Some of the benefits include:
- Crystal-clear transparency
- A more detailed and comprehensive view into ancillary products and services
- An automated process that eliminates billing discrepancies or resubmittals
- Integrated and consistent processes
- Strategic program management
Taken together, the system leapfrogs over the existing hurdles while creating entirely new opportunities. It’s a win for vendors and payers, and ultimately for patients, who receive the optimal product or service.
“We’ve been called the ‘industry integrator’ by some people, and that’s accurate,” James said. “We are delivering a proven platform connecting payers with providers and vendors on the ancillary medical benefit front. It’s never been done before.”
To learn more about the Healthesystems Ancillary Benefits Management solution visit: http://www.healthesystems.com/solutions-services/ancillary-benefits