Focus on the Patient, Not the Pain
4 key steps to redefine an opioid management strategy.
The upcoming release of the new ACOEM opioid treatment guideline reflects new evidence associated with opioid risks. Of note, one of the recommendations is to significantly lower the maximum daily morphine equivalent dose (MED) to 50 from the 120 MED recommended in earlier guidelines. Morphine is the standard against which the potency of all other opioids is measured. While it is tempting to focus on the MED reduction, the real story is the opportunity the new guideline presents for payers to redefine their opioid strategy.
Robert Goldberg, MD, FACOEM, an occupational medicine specialist and chief medical officer at workers’ compensation PBM Healthesystems, expects the new guideline to help reshape the opioid discussion. “Once physicians consistently approach pain relief as a tool for helping speed recovery instead of as the ultimate goal of treatment, everything will change,” noted Dr. Goldberg. “When physicians focus on pain relief as the primary goal and prescribe opioids on the first visit, they open up patients and payers to well-documented risks. The outcomes data show that this approach is not working.”
A past president of ACOEM, Dr. Goldberg recommends payers include four key steps when updating or redefining their current opioid strategy. The steps involve developing a new treatment philosophy; gaining access to the right information systems and clinical expertise; establishing new policies and procedures to support the new approach; and deploying precisely timed clinical tools and strategies to keep claims on track.
Step 1 – Refocus treatment goals
The most effective opioid strategy is one that takes a holistic approach and makes recovery and functional improvement the ultimate goal of treatment. Dr. Goldberg advises physicians and payers to refocus the goal of treatment as a critical first step in updating their opioid strategy.
“A key principle in occupational medicine is to minimize the effects of an injury and help injured workers remain at work whenever possible, or regain function and return to work,” explained Dr. Goldberg. In addition to reframing treatment goals, he recommends implementing these supporting strategies:
- Focus on adequate pain relief — reduce pain sufficiently so that injured workers can participate in treatment plans to speed recovery.
- Follow the updated opioids guideline — use non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen as a primary treatment and physical therapy when indicated.
- Incorporate alternative therapies — adjunctive therapies such as cognitive behavioral therapy, massage, yoga, chiropractic and acupuncture can aid in pain relief and help injured workers cope with the presence of some pain.
Step 2 – Gain access to the right information systems and clinical expertise
Another step needed to update an opioid strategy is to ensure that the claims organization has access to the right data and expert analysis so they can identify claims requiring close attention. To achieve this, payers should:
- Develop state-of-the-art information systems — or rely on a PBM — to provide reliable data that can quickly identify cases that are moving toward prolonged or accelerated use of opioids.
- Work with a team of well-trained claims professionals and nurse case managers who can coordinate efforts and make good decisions.
- Tap the expertise of clinical pharmacists and knowledgeable physicians.
“The ultimate goal is for a patient to physically recover, not to simply manage their pain. Once physicians consistently approach pain relief as a tool to help speed recovery, everything will change.”
– Dr. Robert Goldberg, Occupational Medicine Specialist and Chief Medical Officer, Healthesystems
Step 3 – Establish new medical policies and procedures
Clear policies and procedures that reflect the most current evidence-based medical guidelines are an important component of an up-to-date opioid strategy. Dr. Goldberg recommends payers revise policies and procedures to:
- Approve opioids only when appropriate, per current evidence-based guidelines.
- Approve alternative therapies such as cognitive behavior therapy and physical therapy to reduce reliance on pain medication when appropriate.
New policies and procedures should delineate:
- The jurisdictional and professional guidelines that will be applied.
- What circumstances will trigger clinical interventions — such as MED levels, a defined number of prescriptions or prescribers or other factors.
- Which cases will be escalated for higher level clinical intervention — such as claims that reach a certain dollar value or involve certain complex conditions or injuries.
- Which tools and interventions will be deployed and by whom.
Step 4 – Deploy precisely timed tools
An updated opioid strategy should include a robust suite of tools and clinical expertise, as well as define how and when to use them to help keep opioid therapies on track. Claims organizations need a strategic PBM partner with a robust toolkit and a deep bench of clinical expertise to guide them in deploying tools such as:
- Alerts to pharmacies and claims organizations about issues involving prescription dosing, quantities, early refills and other concerns.
- Monitoring and analyzing MED levels to ensure patient safety.
- Real-time therapeutic interventions as part of a prior-authorization process to help prevent risks.
- Letters of medical necessity that document the need for opioid therapy.
- Informed consent forms that alert injured workers to the risks associated with opioid therapy.
- Pain contracts with injured workers that detail what is expected of them while they are receiving opioid therapy.
- Peer-to-peer interventions by clinical pharmacists or physicians.
- Screening and assessment tools for substance abuse, opioid risks, depression, pain and other conditions that contraindicate opioid therapy.
- Compliance monitoring programs using urine drug testing.
- Drug regimen reviews.
An opioid strategy that focuses on achieving functional improvement will yield benefits for the payer, patient and employer that include:
- Reduced length and cost of opioid drug treatment
- Reduced adverse effects of treatment
- Enhanced recovery
- Increased likelihood that the injured worker will return to work quickly
- Decreased temporary and permanent disability
- Reduced overall medical and total case costs
This article was produced by Healthesystems and not the Risk & Insurance® editorial team.
Minnick Engineering 911
Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.
To a disinterested observer, the sight of a middle-aged civil engineer using the company parking lot on a spring afternoon as a dressing room would be, at best, an example of bad taste.
But former Minnick Engineering employee Bill Hayes wasn’t getting ready for a game that afternoon. No, he had mayhem on his mind.
Hayes, terminated just two hours previously, got his jersey on and grabbed a metal softball bat from the back of his SUV.
Hayes paused, arched his back and let out a wounded scream. Then he charged the front door of the civil engineering company.
Matthew Forrester, just two years out of college, was the first Minnick employee to see Hayes coming.
“Stop Bill, don’t do it!” Forrester yelled and picked up a plastic chair in an attempt to slow Hayes down.
With one swipe of the bat, Hayes knocked the chair out of Forrester’s grasp and shattered Forrester’s left forearm.
Forrester’s scream of pain alerted a handful of employees, including Linda Minnick, the daughter of the company founder and current CEO, who was in the process of interviewing a job candidate in a nearby conference room.
Linda jumped up, the shocked job candidate right behind her, and tried to get to the conference door before Hayes did. But Hayes, a former college middle linebacker, was too strong and too quick.
He stuck the bat in the narrowing door crack, then used it to violently thrust the door back open. Hayes got in three swings before the job candidate chased him out of the room.
The attack left Linda Minnick with some cracked ribs and the job prospect with a shattered jaw.
“Who you gonna’ fire next, Linda?” Hayes yelled as he ran deeper into the building. Some employees ran for cover and others set off after Hayes.
Linda Minnick had terminated Bill Hayes a scant 127 minutes previously, but it had been a long time coming.
The interview with the young job prospect filled her with optimism — at least until Bill Hayes roared back into the building and carried out his act of revenge.
In pain but trying to focus, Linda Minnick looked out the window to see a Channel 4 television crew rolling into the company parking lot.
“How did they get here so fast?” she said to no one in particular, as an administrative assistant knelt down next to the stricken job applicant, who was sitting in a nearby chair in severe pain.
Right behind the news truck was a police cruiser.
“What?” Minnick said again, to no one. In the space of the last two minutes, she felt that she was becoming mentally unhinged.
The shock of the attack wasn’t the only cause of Linda Minnick’s confusion.
When the Springfield Township Police escorted Bill Hayes out of Minnick Engineering, this time for the last time, he was in handcuffs. Channel 4 was there to record the whole thing.
The television crew was there, courtesy of Hayes himself. Before his onslaught, Hayes had called his cousin Tommy, a Channel 4 cameraman, and told him he should come to the Minnick offices that afternoon, that he was going to “see some things.”
Linda was weak and in shock. The pain of her cracked ribs felt like someone was jabbing a knife into her lung. She could only sit and watch the police sergeant shove Bill Hayes’ head down into the cruiser.
But just before Hayes was shoved into the car, he caught Linda’s eye and smiled a demented smile.
A shiver went through Linda as she watched the patrol car roll away.
“This is all my fault,” she said to herself.
Linda’s memory provided it for her all too clearly. Five years ago, Bill Hayes punched an office wall during a meeting that was called to deconstruct some engineering errors in a public sector project.
Then, three years later, Mrs. Yost, a kindly woman who worked in sales administration, was working late one night and saw Bill Hayes urinating in a potted plant by the copy machine.
It was a case of “He said, she said.”
Hayes denied doing it. Mrs. Yost, who was 67 and close to retirement, became emotional when questioned about the incident and seemed to want to put it out of her mind. Again, no action was taken against Hayes.
Minnick was always a family-run operation- handling employee situations like the one Hayes presented was way beyond the realm of what Linda was prepared for.
The day of Hayes’ termination she had finally had enough of his inconsistent performance and took that step without thinking further on the potential reaction that it may have elicited.
Minnick was ill prepared for this tragedy. She knew that now as surely as she felt the stabbing pain in her side where her ribs were cracked.
A paramedic ran up to Linda Minnick.
“See to him first,” Minnick said, nodding to the seriously injured engineering graduate sitting in a nearby chair.
The initial toll from Hayes attack was staggering enough. There was the first wave of injuries to Linda Minnick, Matthew Forrester and the job applicant, Henry Neal, whose jaw injury required extensive and expensive reconstructive surgery.
But Hayes had also injured three more people, two of them seriously, before the police got to him. One injured party was the employee of a contractor, Warren B. White Custodial Services. Hayes had shattered that unfortunate man’s knee with his prized metal softball bat.
The six and ten o’clock local news featured footage of Bill Hayes being led out of the Minnick Engineering offices in handcuffs. Watching the coverage with her husband, Linda Minnick could only hope the story didn’t go national.
From a coverage standpoint, Minnick Engineering was as vulnerable as its employees, prospective employees and contractors were the day Bill Hayes did what he did.
Warren B. White Custodial Services and the family of Henry Neal sued Minnick Engineering, alleging that the company had inadequate physical defenses in place in the event of an act of workplace violence.
Their lawsuits were successful, arguing as they did that the young Harry Neal suffered substantial emotional, not to mention physical trauma, getting hit in the face with a baseball bat at his very first job interview.
The janitor, who supported a wife and four children, also provided a sympathetic portrait for a jury. Linda was deposed as part of the legal proceedings. Under questioning, she admitted what the plaintiffs’ attorneys uncovered in their research.
Hayes presented a potential threat that hadn’t been adequately addressed by company leadership.
There was workers’ compensation coverage for the injuries to Forrester and the two other employees. But everything else hit the company’s general liability policy.
The litigation expenses alone in the Henry Neal case and the separate Warren B. White action amounted to more than $400,000.
Then came the medical and the emotional pain and suffering, which amounted to $1.2 million.
Those amounts tore right through the company’s self-insured retention of $200,000 and kept on going through its $1 million primary layer and into the $5M umbrella layer. Linda’s background was in engineering, not finance. Risk management was something she was sensitive to but now she was getting a real education in it.
There had been nowhere for the company’s general liability policy to run and hide in the aftermath of the Bill Hayes case. The broker trying to place the company’s coverage the following year was really up against it.
The company’s lack of a formal crisis management plan including methodology to deal with workplace violence was front and center with the underwriters.
“But we need coverage,” said Vince Liriano, the COO who handled insurance for the company. Minnick Engineering didn’t have a risk manager as such.
“Well, we’re going to need some premium increases, and larger retentions,” the underwriter said.
Leaving the renewal meeting, Linda felt sick to her stomach.
The only carrier that would talk to them wanted to triple the self-insured retention on the account and wanted a 40 percent premium increase.
There were two images Linda could not get out of her mind. The enraged, demented face of Bill Hayes forcing open that conference door, and the amount of money she and Vince Liriano had just agreed to as a self-insured retention.
The day Linda took over the reins of her father’s company seven years ago was the proudest day of her life. Now, a job doing traffic engineering studies in any other town but this one looked like a dream job.
Lessons Learned – Partner’s Content
Risk & Insurance partnered with XL Group to produce this scenario. Below are XL Group’s recommendations on how to prevent the losses presented in the scenario. This perspective is not an editorial opinion of Risk & Insurance.
1. Security assessments: Pre-incident security assessment and consulting, available through qualified Security Consultants, subsidized by an allowance provided by the Insurer, with Kidnap Ransom & Extortion coverage, could have gone a long way in preventing the injuries and emotional trauma that buffets Minnick Engineering in this scenario. Such a Consultant assessment would have resulted in creation of a formal Crisis Management Plan that would have included premises security recommendations, such as double door implementation and locking mechanisms that may have prevented this attack. That consulting could also include training for employees in how to prevent, diffuse and respond to a workplace violence event.
2. Kidnap, ransom and extortion coverage: The actions that took place in this scenario would have triggered coverage under the definition of Assault in the XL Kidnap Ransom & Extortion policy. This coverage, in addition to providing the Security Consultant pre-incident training, would have mitigated the expenses that accrued to Minnick Engineering’s general liability and umbrella policies. Assault limits are generally available up to $2.5M Personal Accident, Legal Liability, Expenses and Consultant Expenses are all included in cover.
3. Consider medical and legal costs: In this scenario, medical and legal costs ended up constituting the lion’s share of losses. In addition to the physical injuries to the outside contractor and the young job prospect, there is also psychological damage and counseling costs to consider. A KRE policy would not only reimburse an insured for physical and mental medical costs, it would also cover the legal liability in cases where the insured is sued by the victims and those costs assigned to the insured.
4. Spread risk management responsibilities: One of the weak points in Minnick Engineering’s risk management structure was that the burden of determining what should be done with a potentially dangerous employee was siloed. Pre-incident counseling, which the Security Consultants provided by coverage under KRE insurance, could have offered valuable training to key executives who might not have had a protocol in place to handle a potential workplace violence situation. Additionally, a holistic Crisis Management plan could have been crafted, providing clear and concise direction to the senior team on prevention and management of a wide variety of situations that could harm a company’s personnel, property and reputation.
5. Consider your portfolio: Just as a key executive should not work in isolation when it comes to making risk management decisions, neither should a single insurance policy be left to take the brunt of all possible risks. Getting renewals for Minnick Engineering’s general liability policy became a nightmare after the company was hit by a workplace violence event. A KRE policy could have handled many of the expenses in this case and spared the more expensive general liability policy.