PBM Legislation Worries Workers’ Comp Payers
Legislation introduced in several states seeking to impose new regulatory authority over group health pharmacy benefit managers could harm workers’ compensation PBMs and claims payers, sources said.
Introduction of similar bills in 11 states has raised concerns among workers’ comp insurers, third party administrators, and some large employers, said Brian Allen, VP of government affairs for Progressive Medical, a workers’ comp PBM.
“We have had customers calling us every day worrying about how it is going to impact us and them,” Allen said. “These are big insurance companies … they are nervous about it and want to know how it’s going to impact them.”
Overall, it appears the bills seek greater transparency in the way group health PBMs set their pricing, said Joe Paduda, principal at Health Strategy Associates. But group health PBM practices differ substantially from those of workers’ comp PBMs and the bills seek to address issues that “have nothing to do with workers’ comp,” he added.
Yet while the bills appear aimed at practices among PBMs serving the group health industry and not workers’ comp PBMs, Allen and others say a spillover into workers’ comp is possible. So several organizations want language inserted into the bills that would clearly exempt workers’ comp PBMs.
“It appears that workers’ compensation PBMs are not the target of this legislation,” the American Insurance Association said in a statement. “That said, AIA supports efforts to include clear exemptions for workers’ compensation PBMs in these bills in order to clarify legislative intent and avoid any confusion down the road.”
“Community” pharmacies seeking more revenue from products they dispense are supporting the bills that would put PBMs under certain state regulatory agencies, such as pharmacy boards, Allen said.
State workers’ comp commissions or insurance departments already regulate workers’ comp PBMs, depending on the jurisdiction, Allen explained. But the legislation could add oversight from additional agencies such as state pharmacy boards.
Complying with regulations developed by two distinct agencies with potentially conflicting goals could cause an administrative burden for workers’ comp PBMs, Allen added.
“We want to make sure we are not swept up into crazy regulatory schemes that would be difficult to manage,” he said.
A new oversight body could also decide to impact workers’ comp PBM pricing, which is already regulated by state fee schedules, Allen said.
“If for some reason the pharmacy board said, ‘you have to pay pharmacists more money,’ that potentially would impact our customers because we would have to pass that cost onto payers,” Allen said.
Drug Dangers Beyond Opioids
Opioids are not the only prescription drugs fueling injured worker addiction and overdose deaths.
Workers’ compensation payers are growing increasingly aware that sedative hypnotics and anti-anxiety tranquilizers called benzodiazepines are habit-forming drugs commonly prescribed for chronic pain sufferers, often in dangerous combinations with addictive opioid narcotics.
“There are extreme dangers with mixing these types of products with opioids,” said Brian Carpenter, a registered pharmacist and director of product at Healthcare Solutions, an Optum company.
The dangers include addiction and death, familiar fates met by chronic pain sufferers introduced to polypharmaceutical regimens of drugs that are neither recommended in combinations nor for long term use.
Hypnotics are sleeping pills, such as Ambien used to treat insomnia. They are among the most prescribed pharmaceuticals in workers’ compensation, according to several drug trend reports.
Chronic pain often prevents sufferers from sleeping at night, especially when the pain-relief effects of opioids taken during the day wane. That drives the prescribing of hypnotics.
Opioid consumption can also contribute to sleeplessness, making some patients agitated, Carpenter said.
About 60 percent to 70 percent of the chronic pain patients he sees suffer from sleep problems, said Michael Coupland, a psychologist at IMCS Group, which provides chronic-pain management services.
“It’s the combination of the pain and the medications they are taking for the pain,” Coupland explained. “So when they report that to their medical doctor the medical doctor often gives them a hypnotic and just throws more drugs at it instead of getting to the core problem.”
Taking as few as 18 Ambien a year alone increases the likelihood of death fourfold, said David Randolph, an occupational physician. Combining the hypnotics or benzodiazapines with opioids synergistically increases their toxicity level and increases the risk of death by more than 330 percent, he added.
“It’s not the dose or the duration that leads to the death, it is simply the drug combination,” said Randolph, who also holds a Ph.D. and researches chronic pain issues.
” … the medical doctor often gives them a hypnotic and just throws more drugs at it instead of getting to the core problem.” — Michael Coupland, psychologist, IMCS Group
Yet long-term, daily consumption of the drug combinations is common enough that he witnesses almost daily.
A common scenario involves pain suffers prescribed opioids. Weeks later when they complain of difficulties getting out of bed their doctor prescribes an amphetamine to make them more alert, Randolph said.
Then they feel anxious, so the doctor prescribes Xanax and Ambien to help with sleep, he continued.
“This is a practice pattern I see all the time,” Randolph said. “Just this past week I saw another death associated with this polypharmacy.”
The Danger of Euphoria
Benzodiazepines, or benzos, such as Valium and Xanax for treating anxiety are also commonly prescribed to patients consuming opioids.
Various forms of benzos and hypnotics are similar in structure to each other and closely related, Carpenter said.
Benzodiazepines, muscle relaxers and opioids in combination are often abused for the high they create, Carpenter said.
One reason benzos are prevalent in workers comp is they have synergistic impact when combined with opioids, enhancing the drugs’ euphoric qualities, Carpenter said. An injured worker may not initially seek that euphoria, but once introduced they may grow to desire it.
The synergy created when combining benzos and opioids, however, also boosts the potential for addiction beyond each drug’s individual capacity to become habit forming, Randolph said.
Healthcare Solutions workers’ comp claims data shows that most doctors are managing their patients well by following safe practices regarding opioid and benzodiazepine prescriptions, Carpenter said.
But the inappropriate mixture is often seen among costly chronic pain cases that drag on without resolution.
Researchers reporting in the July 2014 issue of Journal of Occupational and Environmental Medicine reviewed 11,394 lost-time claims filed in Louisiana between 1999 and 2002. They observed that despite medical guidelines advising against prescribing benzos in combination with opioids, the practice frequently occurs.
They found that adding benzos to an opioid regimen prolongs claims durations and when the two are prescribed together claims costs are three times higher than when benzodiazepines alone are prescribed. Costs are also 50 percent higher when benzodiazepines are combined with long-acting opioids than when opioids alone are prescribed.
The concomitant use of benzodiazepines and opioids has not been well studied, including within workers’ comp, the researchers stated in their report. The studies that do exist show the combinations are connected to increased risk of addiction and death, they said.
“I don’t think I ever admit a work comp patient who is not on a habit forming sedative.” — Mel Pohl, medical director, Las Vegas Recovery Center
Discussions about death and addiction associated with opioids spread across the workers’ comp landscape before the narcotic pain relievers became a nationwide concern. The inappropriate prescribing of benzos and hypnotics, though, has not reached a similar level of attention.
“I don’t know that people are as aware of the potential dangers of benzodiazepines and sedatives as they are of the dangers of opioids,” said Mel Pohl, an M.D. and medical director at the Las Vegas Recovery Center, which treats addiction, including the abuse of opioids and other substances among workers’ comp chronic pain sufferers.
Yet “I don’t think I ever admit a work comp patient who is not on a habit forming sedative,” Pohl added.
But awareness about the abuse of benzos and hypnotics may be growing, as drug and claims costs push payers to learn more about addressing the underlying problems, such as sleep problems, that drive prescribing of the drugs.
A workers’ comp insurer, for instance, recently asked him to adopt a cognitive behavioral therapy program for treating chronic-pain claimants whose consumption of hypnotic sleep medications “seems to go on and on,” amid increasing costs, Coupland said.
“A lot of these people have been on hypnotics (and opioids) for longer than they should be,” said the insurer who asked not to be identified.
Increased discussion about drugs prescribed concurrently with opioids is also occurring as workers’ comp claims payers are increasingly agreeing to fund detox programs for injured workers who have grown dependent on opioid narcotics.
“If you are addressing opioid dependence, in my opinion, you have to address benzo and sedative dependence,” Pohl said. “To just take people off opioids and leave them on their sedatives and anti anxiety drugs is not good care.”
The Doctor as Partner
Professionals helping employees return to work after being on disability or a leave of absence face many challenges. After all, there is a personal story behind each case and each case is unique.
In the end, the best outcome is an employee who returns to the job healthy and feeling well taken care of, while at the same time managing the associated claim costs.
Learn what most employers want from their group disability and life benefits program.
While many carriers and claims managers work toward these goals, in the end they often tend to focus on minimizing costs by aggressively managing claims to get the worker back on the job, or they “fast track” claims, approving everything and paying little attention to case management.
Aggressively managed claims can leave many employees and their doctors feeling defensive and ill-at-ease, creating an adversarial relationship that ultimately hinders return to work and results in higher direct and indirect employee benefit costs for the employer. Fast track or non-managed claims can lead to increased durations, costs and workforce productivity issues for employers.
Is it possible to provide a positive employee benefit experience while at the same time effectively managing disability and lowering an employer’s overall benefit costs?
A Unique Approach
Liberty Mutual Insurance’s approach to managing disability and absence management focuses on building consensus among all stakeholders – the disabled employee, treating physician, employer and insurer. And a key component of this process is a large team of consulting physician specialists, leading practitioners from a variety of specialties, highly regarded experts affiliated with leading medical universities across the country.
“About 16 years ago, our national medical director, Dr. Ed Crouch, proposed that if we worked with a core group of external consulting medical specialists – rather than sending most claims for Independent Medical Evaluations – we could do a better job making disabled employees and their attending physicians comfortable, and therefore true partners in producing better disability management outcomes and employee benefit experiences,” said Tim Kastrinelis, senior vice president, Distribution Partnerships at Liberty Mutual Benefits.
“In this way, our consulting physician and the attending physician are able to work with the disability case manager, the employee and the employer to deliver a coordinated, collaborative approach that facilitates a productive lifestyle and return to work.”
The result of Dr. Crouch’s initiative has produced positive results for the clients of Liberty Mutual Insurance. This consensus building approach to managing disability with consulting physician expertise has helped achieve industry leading client retention results over the past decade. In fact, 96 percent of Liberty Mutual’s group disability and group life clients renew their programs.
“By getting all stakeholders on the same page and investing heavily in consulting physician specialists, we have been able to lower claim costs and shortened claim duration for our group disability policyholders. …In the end, it’s a win-win for all.”
–Tim Kastrinelis, Senior Vice President, Distribution Partnerships, Liberty Mutual Benefits
A Collaborative Approach
In the case of complex disability medical health situations, Liberty Mutual’s disability case managers play a vital role in seeking additional expertise—an area where the industry’s standard has been to outsource the claimant for independent medical examinations.
However, Liberty Mutual empowers its disability case managers with the ultimate responsibility for the outcome of each claim. The claimant and the case manager stay together throughout the life of the claim. This relationship is the foundation for a collaborative approach that delivers a better employee benefit experience and enables the claimant to return to work sooner; which more effectively controls total disability claim and absence costs.
Sending a disabled employee with complex medical needs to an external specialist may sound like a cost-effective path, but it often comes at the cost of sacrificing the relationship and trust built between the employee and case manager. The disabled employee must explain their medical history to a new clinician, which he or she is often reluctant to do. The attending physician may be uncooperative as this move can appear to question his or her treatment plan for the employee.
As a result, the entire claims process takes on an adversarial atmosphere, building major roadblocks to the ultimate goal of helping the claimant return to a productive lifestyle.
Liberty Mutual takes a different approach. Nearly 100 physicians representing more than 30 medical specialties are available to consult with its medical and claims professionals, working side-by-side with case managers.
More than 95 percent of these consulting physicians are in active practice, and therefore up-to-date on the latest clinical best practices, treatment guidelines, therapies, medications, and programs. Most of these physicians are affiliated with leading medical universities across the country. “We recruit specialists from around the country, getting the best from such prestigious institutions as Harvard, Yale, and Duke,” said Kastrinelis.
These highly-credentialed physicians help case managers focus on providing the support needed for the disabled employee to successfully return to work as quickly as appropriate. Their collaborative work with the attending physicians provides the behind-the-scenes foundation that leads to a positive claimant experience, results in a better outcome for the claimant, and more effectively reduces total claim costs.
Coordinated Care Plan
When one of these consulting physicians reaches out to an attending physician, there’s an immediate degree of respect and high regard for his or her opinion. This helps pave the way to working together in the best interest of the employee, improving treatment plans and return to work results.
In this process, the claimant is not sent to yet another doctor; instead, the consulting specialist works with the attending physician to help fill in the gaps of knowledge or provide information that only a specialist would have. Although not an opportunity to direct care, these peer-to-peer discussions can help optimize care with the goal of helping the employee return to work.
The attending physician may have no knowledge of the challenges the employee faces in order to return to work. A return to work plan created in concert with the specialist, disability case manager, employer, and attending physician can set expectations and provide the framework for a proactive and effective return to a productive lifestyle.
“Our consulting physicians bring sophisticated medical expertise to the discussion, and help build consensus around a return-to-work plan, helping us more effectively impact a claim’s outcome and costs, and at the same time provide a better claimant experience,” said Kastrinelis.
“We can work more collaboratively with the attending physician, manage expectations, and shepherd the employee through the process much more effectively and in a much more high-touch, caring, and compassionate manner. Overall, we’re able to produce better outcomes as a result of this consensus building approach.”
“Our approach – including the use of consulting medical experts – helped us significantly reduce disability costs over two years for one large health service company,” notes Kastrinelis. “We cut average short-term disability claim durations by 4.2 days in that time, while increasing employee satisfaction with our unique disability management model and collaborative, partnership approach.
How did Liberty Mutual’s unique approach lower claim costs, reduce disability duration and improve the benefit experience for one customer?
“By getting all stakeholders on the same page and investing heavily in consulting physician specialists, we have been able to lower claim costs and shortened claim duration for our group disability policyholders,” said Kastrinelis.
“Plus, we, the employee, and the employer also get the bonus of creating a better employee benefit experience. This model has shaped our disability and absence management program to more aptly reflect our core mission of helping people live safer, more secure lives. In the end, it’s a win-win for all.”
How does Liberty Mutual provide a superior employee benefit experience?
Tim Kastrinelis can be reached at email@example.com. More information on Liberty Mutual’s group disability and absence management offerings can be seen at https://www.libertymutualgroup.com/business-insurance/business-insurance-coverages/employee-benefits.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty Mutual Insurance. The editorial staff of Risk & Insurance had no role in its preparation.