Attitudes Shift on Medical Marijuana
The tide is turning towards paying workers’ compensation claims involving medical marijuana, but many payers remain reticent.
Industry professionals would prefer that the federal government stop classifying the drug as an illegal controlled substance before paying such claims.
Four states — Connecticut, Maine, Minnesota and New Mexico — approved workers’ comp reimbursement for the use of medical marijuana, at least publicly, according to Mark Pew, senior vice president at PRIUM in Duluth, Ga.
Courts in New Mexico ruled that carriers must pay for marijuana if a doctor in that state recommends it as part of a claimant’s treatment.
However, some carriers are defying the state court’s order, arguing that it’s illegal under federal law. Still, there seems to be an ongoing shift in risk management and insurance toward paying claims that involve marijuana use.
“I think increasingly, more people with whom I’ve spoken are open to the possibility — that includes physicians, nurses, claims adjusters, and those that influence decisions,” he said.
“They will review based on the clinical efficacy for that particular patient.”
However, not everyone is convinced, as the studies conducted on marijuana are not as definitive as those for FDA-approved drugs, Pew said.
Moreover, professionals still point to the fact that marijuana is classified as illegal by the federal government.
Paying claims for its use could create a legal quandary.
“I think those that not convinced are still the majority of the workers’ comp industry,” Pew said.
“It is a loaded question, because marijuana is a divisive and partisan issue, and personal biases of individuals within the workers’ comp system influence their perceptions on it.”
On top of this, payment decisions based on utilization reviews (UR) are problematic because there are no medical guidelines for medical marijuana, Pew said. In some states UR is the arbiter, in other states UR is but an opinion, and in still others, UR is not supported.
Within workers’ compensation, the two treatment guidelines most used by states are Official Disability Guidelines and ACOEM, although some states have created their own. None currently recommend the medical use of marijuana, regardless of condition.
As such, if UR decisions rely on those guidelines, “the answer would be ‘no’ ” on payment for the drug use, Pew said.
But when reimbursement decisions are made outside of UR, individual biases on the subject of marijuana could have an impact, he said.
“Some will absolutely not consider marijuana as medicine and refuse reimbursement,” Pew said.
“Others may have personal experience or know someone that cannabis helped and be willing to consider it.”
“At no time in our history has a state government required the reimbursement for use of a substance that is illegal under in the eyes of the federal government.” — Nichole Wilson, director, pharmacy product development, Coventry Workers’ Comp Services
When it comes to evaluating the clinical efficacy of medical marijuana, practitioners should look at whether benefits exceed the risks, level of function and activity, quality of life, and whether the addition of medical marijuana could help discontinue the use of such dangerous drugs such as OxyContin, Alprazolam, Xanax and Soma, he said.
“In other words, evaluate the appropriateness of cannabis as you would any other drug or treatment — does it work or not for that specific patient? That has been the case in the four states where reimbursement is being done, and the way in which the tide seems to be turning,” Pew said.
The use of medical marijuana for chronic pain is growing more and more popular — as of February 2016, 26 percent of all registered medical cannabis patients in New Mexico usde it for chronic pain, Pew said.
Moreover, 46 percent of registered patients use it for PTSD.
These numbers include all registered patients, not just injured workers, but those conditions are obviously applicable to workers’ comp.
Chronic pain is typically included as a qualifying condition for medical cannabis programs around the country, with Minnesota adding a very narrowly defined “intractable pain” to its list of approved uses as of Aug. 1.
“All of this means that medical cannabis is a burgeoning issue, with evolving science and opinions, and is absolutely pertinent to workers’ comp both now and into the future,” Pew said.
“And if marijuana is ever made legal and/or rescheduled at the federal level, the conversation changes dramatically.”
Lisa Anne Forsythe, senior consultant, regulatory business consulting and analysis, at Coventry Workers’ Comp Services in Sacramento, Calif., said “the tide is definitely turning.”
She has been working on the issue from a regulatory, legal and financial/billing perspective.
There were no medical marijuana claims whatsoever until after the recent appellate rulings in New Mexico, the first state in the country to allow medical marijuana as a compensable benefit.
“It simply wasn’t an issue from a legal, regulatory and financial standpoint until then,” Forsythe said.
Paucity of Evidence
Don Lipsy, Coventry’s manager, pharmacy regulatory communications in Tucson Ariz., said there are “burgeoning pockets” of utilization of medical marijuana related to workers’ comp injuries. While Coventry has not had claims, they’ve heard secondhand of claims being paid by others.
“We’re seeing an expansion of use as an alternative to opioids, and my concern is that we might be trying so hard to address the opioid epidemic that we are treating medical marijuana as a silver bullet,” Lipsy said.
“I’m not so sure we aren’t trading one issue for another.”
From a clinical perspective, there are still a lot of people on the fence on whether or not marijuana is useful, said Nichole Wilson, Coventry’s director of pharmacy product development in Omaha, Neb.
“The evaluation of benefits versus risks are on most clinicians’ minds,” Wilson said.
“Since it’s still classified by the federal government as an illegal Schedule 1 controlled substance, there is not a preponderance of clinical evidence evaluating the drug, and that is a challenge to the medical community.”
“The tide is turning towards public acceptance of medical marijuana, with 169 million people living in the jurisdictions that have legalized it.” — Gregory McKenna, vice president and counsel for governmental affairs, Gallagher Bassett Services
Moreover, there’s a lot of concern about possible interactions of medical marijuana might have with other treatments as well as its potential benefits, Forsythe said.
“But there is also comparatively little discussion on the practical, legal and financial implications associated with the adoption of medical marijuana as a compensable benefit at this time, and that is something that really needs to be talked about,” she said.
“That was definitely one of the larger topics within the New Mexico bill. When we tell an insurance company that medical marijuana is a mandated covered benefit, this is precedent-setting — at no time in our history has a state government required the reimbursement for use of a substance that is illegal under in the eyes of the federal government.”
The Federal Conundrum
The liability implications of paying for an illegal substance need to be more thoroughly examined, experts said.
For example, the use of the federal banking system to pay for the illegal drug could that trigger federal criminal action under the Racketeer Influenced and Corrupt Organizations Act (RICO), Forsythe said.
“Financial institutions are loathe to potentially run afoul of RICO and have avoided doing business with dispensaries, etc., due to liability concerns,” she said. “Insurance companies face a similar exposure.”
Gregory McKenna, vice president and counsel for governmental affairs for Gallagher Bassett Services in Itasca, Ill., said the TPA’s workers’ comp resolution managers “are on the front line,” since they decide whether medical marijuana is a compensable treatment.
First, since federal banking restrictions make it illegal for providers of medical marijuana to use FDIC-approved banks, payment to them has to be made in cash, McKenna said. As such, the claimant needs to pay the provider in cash, and then the claimant has to be reimbursed by check.
“Payors have to make decisions to proceed with a reimbursement to the claimant, which is further complicated by a series of federal criminal statutes related to marijuana transactions,” he said.
“This is out of the realm of what we do normally, so it is a new frontier.”
Another significant challenge lies in the fact that the industry has few decision-support tools for medical marijuana, such as clinical intervention to alert workers’ comp decision-makers to potential interactions between medical marijuana and other medications or medical bill review processes to ensure proper dosage or utilization.
“However, the tide is turning towards public acceptance of medical marijuana, with 169 million people living in the jurisdictions that have legalized it,” McKenna said.
“Because of that volume of people, now the DEA and other federal agencies are taking a very careful look at reclassifying medical marijuana to make it legal.”
The agencies are also looking at naming very specific components of marijuana, to determine whether there may be some additional benefits to those components. That could open up additional research to take a clinical look at the efficacy of medical marijuana.
“This and decriminalization could lead to more workers’ comp payments within the industry,” he said.
Opioid Abusers Cost Employers $8 Billion Annually
Opioid-abusing employees cost their employers up to $8 billion a year, according to a new study.
Castlight Health, a health benefits platform provider, found that companies paid nearly twice as much in health care expenses for opioid abusers than non-abusers — $19,450 compared to $10,853.
“Based on Castlight’s estimate, opioid abuse could be costing employers as much as $8 billion per year,” according to “The Opioid Crisis in America’s Workforce.”
“Considering that absenteeism and presenteeism tied to opioid misuse and abuse is costing employers an additional estimated $10 billion, this crisis represents a significant drain on America’s employers.”
“Many employees do not recognize the serious risk of addiction before they accept or fill an opioid prescription of any length.” — “The Opioid Crisis in America’s Workforce,” Castlight Health
Castlight examined nearly 1 million health care claims involving opioid prescriptions for the period 2011 to 2015 for workers at large, self-insured companies.
Leveraging Analytics and Education
Employers may save money by leveraging data and analytics to identify opportunities to help employees who abuse opioids.
“Whether it’s guiding an employee away from unnecessary back surgery (and the resulting opioid prescriptions) or offering programs that provide access to opioid abuse treatment, Castlight believes that data and analytics are part of the solution.
“For example, better insights can help a benefit leader identify where lower back pain or depression, two conditions closely associated with opioid abuse, are most prevalent in their company.”
Targeting educational content to such employees will help inform them of the dangers of opioids.
Individuals with a behavioral health diagnosis of any kind are three times more likely to abuse opioids than those without such a diagnosis.
“Many employees do not recognize the serious risk of addiction before they accept or fill an opioid prescription of any length,” the study said.
The report also identified some common themes about workers more likely to abuse opioid prescriptions.
• Individuals with a behavioral health diagnosis of any kind are three times more likely to abuse opioids than those without such a diagnosis, and nearly 9 percent of people with a single behavioral health diagnosis such as anxiety or depression were found to abuse opioids, compared to 3 percent of individuals without a behavioral health diagnosis.
“This finding is striking given the prevalence of behavioral health issues in the workforce,” the report said. “Twenty-five percent of employees have a diagnosable behavioral health condition; yet 70 percent of impacted employees go untreated.”
• Opioid abusers also have twice as many pain-related conditions as non-abusers, especially joint, neck and abdominal pain.
• Baby boomers are four times more likely to abuse opioids than millennials. More than 7 percent of workers age 50 and older were classified as opioid abusers, compared to 2 percent of those aged 20 to 34.
• States with medical marijuana laws are nearly twice as likely to have a lower opioid abuse rate than those that don’t, by a margin of 5.4 percent to 2.8 percent.
• Opioid abusers are more likely to live in the rural South and live in low-income areas.
• Opioid abuse rates range from 11.6 percent of individuals in Wilmington, N.C., to 7.5 percent of individuals in Fort Smith, Ark..
• Alabama, Florida, North Carolina, Oklahoma, North Carolina, Tennessee and Texas have multiple cities that are in the top 25 for opioid abuse rate. The three non-southern cities in the top 25 are: Terre Haute, Ind.; Elmira, N.Y.; and Jackson, Mich.
Advocacy: The Impact of Continuous Triage
In the world of workers’ compensation, timing is everything. Many studies have shown that the earlier a workplace incident or injury is acted upon, the more successful the results*. However, there is further evidence indicating there is even more of an impact seen when a claim is not only filed promptly, but also effective triage is conducted and management of the claim takes place consistently through closure.
Typically, every program incorporates a form of early intervention. But then what? While it is common knowledge that early claims reporting and medical treatment are the most critical parts of a claim, if left alone after management, an injured worker could – and often does – fall through the cracks.
All Claims Paths are Not Created Equal
Even with early intervention and the best intentions of the adjuster, things can still go wrong. What if we could follow one injury down two paths, resulting in two entirely different outcomes? This case study illustrates the difference between two claims management processes – one of proactive, continuous claims triage and one of inactivity after initial intervention – and the impact, or lack thereof, it can have on the outcome of a claim. By addressing all indicators, effective triage can drastically change the trajectory of a claim.
While working at a factory, David, a 40-year-old employee, experienced sudden shoulder pain while lifting a heavy box. He reported the incident to his supervisor, who contacted their 24/7 triage call center to report the incident. After speaking with a triage nurse, the nurse recommended he go to an occupational medicine clinic for further evaluation, based on his self-reported symptoms of significant swelling, a lack of range of motion and a pain level described as greater than “8.”
The physician diagnosed David with a shoulder sprain and prescribed two weeks of rest, ice and prescription strength ibuprofen. He restricted David from any lifting over his head.
By all accounts, early intervention was working. Utilizing 24/7 nurse triage, there was no lag time between the incident and care. David received timely medical attention and had a treatment plan in place within one day.
A critical factor in any program is a return to work date, yet David was not given a return to work date from the physician at the occupational medicine clinic; therefore, no date was entered in the system.
One small, crucial detail needs just as much attention as when an incident is initially reported. What happens the third week of a claim is just as important as what happens on the day the injury occurs. Involvement with a claim must take place through claim closure and not just at initial triage.
The Same Old Story
After three weeks of physical therapy, no further medical interventions and a lack of communication from his adjuster, David returned to his physician complaining of continued pain. The physician encouraged him to continue physical therapy to improve his mobility and added an opioid prescription to help with his pain.
At home, with no return to work in sight, David became depressed and continued to experience pain in his shoulder. He scheduled an appointment with the physician months later, stating physical therapy was not helping. Since David’s pain had not subsided, the physician ordered an MRI, which came back negative, and wrote David a prescription for medication to manage his depression. The physician referred him to an orthopedic specialist and wrote him a new prescription for additional opioids to address his pain…
Costly medical interventions continued to accrue for the employer and the surmounting risk of the claim continued to go unmanaged. His claim was much more severe than anyone knew.
What if his injury had been managed?
A Model Example
Using a claims system that incorporated a predictive modeling rules engine, the adjuster was immediately prompted to retrieve a return to work date from the physician. Therefore, David’s file was flagged and submitted for a further level of nurse triage intervention and validation. A nurse contacted the physician and verified that there was no return to work date listed on the medical file because the physician’s initial assessment restricted David to no lifting.
As a result of these triage validations, further interventions were needed and a telephonic case manager was assigned to help coordinate care and pursue a proactive return to work plan. Working with the physical therapist and treating physician resulted in a change in David’s medication and a modified physical therapy regimen.
After a few weeks, David reported an improvement in his mobility and his pain level was a “3,” thus prompting the case manager’s request for a re-evaluation. After his assessment, the physician lifted the restriction, allowing David to lift 10 pounds overhead. With this revision, David was able to return to work at modified duty right away. Within six weeks he returned to full duty.
With access to all of the David’s data and a rules engine to keep adjusters on top of the claim, the medical interventions that were needed for his recovery were validated, therefore effectively managing his recovery by continuing to triage his claim. By coordinating care plans with the physician and the physical therapist, and involving a case manager early on, the active management of David’s claim enabled him to remain engaged in his recovery. There was no lapse in communication, treatment or activity.
After 24/7 nurse triage is conducted and an injured worker receives initial care, CorVel’s claims system, CareMC, conducts continuous triage of all data points collected at claim inception and throughout the life of a claim utilizing its integrated rules engine. Predictive indicators send alerts to prompt the adjuster to take action when needed until the claim is closed – not just at the beginning of the claim.
This predictive modeling tool flags potentially complex claims with the risk for high exposure, marking claims that need intervention so that CorVel can assign appropriate resources to mitigate risk.
Claims triage is constant – that is the necessary model. Even on an adjuster’s best day, humans aren’t perfect. A rules engine helps flag things that people can miss. A combination of predictive systems and human intervention ensures claims management is never stagnant – that there is no lapse in communication, activity or treatment. With an advocacy team in the form of an adjuster empowered by a powerful rules engine and a case manager looking out for the best care, injured employees remain engaged in their recovery. By perpetuating patient advocacy, continuous triage reduces claim severity and improves claim outcomes, returning injured workers to the workforce and reducing payors’ risk.