Chronic Pain In-Depth Series (Part 2): Carriers' Chronic Burden
By PETER ROUSMANIERE, an expert on the workers' compensation industry and our workers' comp columnist
Back in 2001, a Plainsfield, Mich., auto mechanic began to note pain in his upper body. The next year, he reported that, when working under a car, he made a movement that caused pain in his upper and lower back. His symptoms failed to subside, and on Nov. 23, 2002, a doctor put the mechanic on full disability. Within a month an orthopedist diagnosed him for thoracic outlet syndrome, nerve compression between the neck and the arm.
Over the next several years, he saw many specialists who evaluated him for carpal tunnel syndrome, degenerative disc and joint disease, chronic regional pain syndrome, osteoarthritis and other conditions. He went under the knife three times for shoulder and cervical surgery. Migraines afflicted him. Doctors prescribed for him mountains of opioids, sedatives, and other drugs for pain relief and to cope with the side effects of opioid use.
This workers' comp claimant's story is familiar: pain symptoms circumnavigating much of the body, daisy chains of specialists, repetitive MRIs, lots of pet diagnoses and theories for treatment, patient behaviors suggesting depression, an avalanche of medical notes suggesting impairment by drugs.
After three years of this, the worker's insurer referred the case to medical experts retained by Best Doctors. They concluded that the patient's complaints were not job related. They ordered him off opioids, recommended a detox program and, finally, some psychological counseling.
Welcome to the maze of chronic pain.
Over the past decade, the rise of chronic pain care has staggered the workers' comp system, unsettling claimants, doctors, insurers and regulators alike. Cases such as this mechanic's now eat up at least a third of claims costs.
The system has responded intermittently, often timidly and in a scattershot manner. Insurers have been paying for medical care strategies, many of which have been criticized as being ineffectual and even harmful. Yet the carriers are partly themselves to blame for treatment failures, because they often resist paying for best practice.
Opioid painkillers, a controversial form of treatment, and multiple surgeries have increased the risk of iatrogenic illness, a medical condition that itself is the result of medical care. As a result, the workers' comp system is wrestling with patients who get sicker, abuse their treatment and even die from their prescribed treatment.
An article published in the August 2005 issue of the American Journal of Industrial Medicine should have jolted insurers and regulators into action on patient safety. The journal reported on prescribed drug care of injured workers in Washington state. The authors, a diverse group led by Gary Franklin, an occupational physician and researcher, tracked opioid use between 1996 and 2002.
Opioids are typically the most powerful drugs to combat pain. They are included among Schedule II drugs, a designation created by the Drug Enforcement Administration to control use of pain drugs. Schedule II drugs are legally prescribable, but they bear a high risk of abuse with potentially severe psychological or physical harm.
Over the study's six-year period, more potent and longer-acting drugs had taken on a larger share in Washington, and dosages had increased. Yet there was little evidence that this trend helped patients to recover, the authors found.
Then the authors dropped the bomb: "Thirty two deaths were definitely or probably related to accidental overdoses of opioids," they wrote. About half of the deaths involved the patient's use of alcohol or other drugs like cocaine.
Washington state regulators have since promulgated guidelines for opioids in treating injured workers, but even in that state, the risk of death remains because opioids are still prescribed as the main tool for long-term pain care.
HOW DID WE GET HERE?
Chronic pain among workers' comp patients can be defined as persistent pain associated with a patient's failure to recover from injury within normally expected recovery time frames. It is both an elaboration of the original injury and a disease in itself. The condition has been studied and treated for decades. Specialized pain care centers emerged in the 1970s. Drug-focused pain management gained its first beachhead under the panoply of the American healthcare system as palliative care for terminally ill patients. It then expanded into hospital-based care for cancer.
Advocacy for pain sufferers grew in the 1990s. Outpatient pain care spread to work-related musculoskeletal pain. Before then, clinicians surmise, injured workers with chronic pain had taken to medicating themselves with illicit drugs and alcohol. The cost of chronic pain within the annual $50 billion-plus workers' comp benefits bill cannot be easily estimated. Chronic pain does not have a universally accepted definition, and medical coding specific to chronic pain is usually not used in claimant records.
But data provided by several insurers, which did not want to be identified, suggests that at least one-third of total claims costs incurred for lost-time claims are pain-related. Almost half of medical payments in the first year post-injury are for claims with a pain problem, acute or chronic. Doctors prescribe opioids for many claims of short duration, including even medical-only claims.
It appears that about 5 percent of lost-time claimants have a significant chronic pain problem. Their claims account for about 30 percent of all lost-time claims payments in the first year alone. Chronic pain is linked to more than half of all the claims that lengthen into permanent awards. In fact, chronic pain claims account for more than half of all claims costs, according to some estimates.
Maria Sciame, director of clinical services at PMSI, the pharmacy benefits management firm, reports that 70 percent of the long-term (at least five years) claimants for whom it manages medications are receiving drugs for chronic pain.
"As a reinsurer, we're seeing the phenomenon of noncatastrophic (workers' comp) claims spiking just like catastrophic claims--for example, back injuries that cost $50,000 to $70,000 a year--much of it is due to prescription costs," says Lewis P. Palca, chief claims officer of General Reinsurance Corp., quoted in the Coalition Against Insurance Fraud's 2007 report "Prescription for Peril."
Progress in managing chronic pain has been made, but the long-term prospect remains uncertain. Genex and Intracorp, the managed care companies, are launching specialized chronic pain programs to equip case managers with more resources to work on chronic pain cases.
Two leading publishers of treatment guidelines for the workers' comp community have been active.The Official Disability Guidelines issued its chronic pain guidelines in 2007.
The American College of Occupational and Environmental Medicine is issuing its version this year, but enforcement remains thorny and patient safety problems persist.
Some insurers are worrying about their legal ability to enforce patient safety procedures for opioids. State medical societies, the Drug Enforcement Administration and treatment guidelines urge--but do not require--prescribing doctors to scrupulously monitor their patients.
Drug therapy, like about every other type of chronic pain treatment, remains difficult to do well. Ameritox, a national drug-testing laboratory, reports that 77 percent of opioid drug patients are not in strict compliance with their prescription. Dominion Diagnostics, another drug laboratory, estimates that half of injured workers with opioid prescriptions are not adhering to their drug program.
"One of the primary strategies we have is the identification of patients in trouble or headed to trouble. We then educate and reach out to physicians to identify what we perceive as possible, probable or definitely overuse of opioids, identifying various strategies the (physician) can employ," explains Darryl Corr of Healthesystems, a pharmacy benefits manager.
PBMs have introduced automated data screens to detect aberrant prescription behavior. These screens may catch prescribed dosages well above the norm and doctor shopping by the patient. Some PBMs receive real-time alerts from pharmacies when a claimant presents a prescription for a drug on a watch list, such as OxyContin.
"We find the better the PBM and the closer they are willing to work with you the better the outcomes," says Troy Prevot, case manager for LUBA Workers Comp, one of Lousiana's largest insurers. "We get feedback on trends and over utilization frequently, then work with our adjusters to make changes."
In the face of patient risks and of scanty evidence of long-term benefit, drug companies engaged in aggressive marketing undoubtedly helped to drive up use of painkillers in treating injured workers. The worst abuses, thankfully, may be behind us.
The Hartford Financial Services Group Inc. reported that OxyContin was the top drug it paid for in 2003, in terms of dollars spent. A federal court in 2007 fined Perdue Pharma LP, the manufacturer of OxyContin, $634 million for deceptively marketing the drug as safer than it actually was.
Neurontin was the second most paid for drug in 2003. Its manufacturer, the Warner-Lambert Co., pleaded guilty in 2004 to criminal fraud charges for illegally marketing of this epilepsy drug for pain treatment. It was fined $250 million. And Vioxx, No. 5 on Hartford's list, was pulled off the market because of its side effects.
REJECTING LOW-RISK CARE?
Some insurers compound their victimhood by blunders of their own in how they have been approving medical care for these patients.
Insurers have for the most part allowed the common adjuster practice of brushing aside the least expensive and least risky types of chronic pain care. Claims adjusters often refuse to pay for behavioral counseling and exercise and therefore for balanced assessments of patients.
The sticking point is typically psychological treatment for pain. Research has found a strong psychological component in chronic pain. The evidence is also strong that a psychological--often called cognitive--assessment should be done before expensive and risky surgeries and opioid care.
According to Tron Emptage, a pharmacist and vice president for the PBM Progressive Medical Inc., many adjusters even refuse to approve use of antidepressants, known to be safe, which are effective and relatively inexpensive in relieving pain.
Defense lawyers may argue that even to authorize a psychological assessment opens the insurers up to "buying" a mental condition that may never be cured.
Scott Anderson, a medical practice administrator who has worked for pain clinics in Chicago and Boston, says that adjusters allow themselves to be pushed into more expensive surgical and interventional care.
Interventional care, delivered mainly by anethesiologists, includes epidural injections, spinal blocks and spinal cord stimulators. These stimulators cost $50,000. There have been no long-term studies of their effectiveness.
Anderson says that doctors can find plausible reasons for charges of from $20,000 to more than $200,000 for these cases. Expensive interventions have their place. But adjuster practice allows for too much reliance on them.
"If they focused more on early assessment, before expensive treatment, they would save a fortune," he says. As practice administrator, he can often obtain approval for expensive surgery or spinal cord stimulators more easily than safer care at a fraction of the cost.
Treatment guidelines and utilization review have been too weak to steer care towards the least expensive and least risky paths. They don't succeed, Anderson has found, in inducing doctors into doing assessments for options they don't believe in. An anesthesiologist ready to inject is rarely willing to seriously consider counseling and exercise.
Insurers who aspire to meet chronic pain challenges head-on need to take three steps:
First, they need to prod painkiller-prescribing doctors to police patients more effectively. They must figure out how to advocate for patient safety.
Second, they must become more skillful at promoting low-cost, low-risk treatment. For many adjusters, this may require change from hostility to support for scientifically endorsed use of counseling and exercise. Insurers must stop fighting best practice.
Third, they need to demand more focused advice from their managed care team--pharmacy benefits managers, utilization reviewers, case managers and preferred provider organizations.
Even with years of experience in managing chronic pain, the workers' comp system still needs to skill up.
November 1, 2008
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