Central to the rise in severity--measured in both dollars and personal suffering--is chronic pain.
Philadelphia-based ESIS Inc., the third-party administrator, finds that, along with patients with unresolved back problems, upward of 90 percent of workers with amputations or burns have chronic pain.
Accounting for chronic-pain sufferers isn't an exact science. We can't count the number of claims involving chronic pain, but we surely feel its smarting whip.
It shows its hand in the proliferation of painkillers. The lion's share of drug costs are for opiates, and most opiate use is for long-duration injuries.
The conventional tools of utilization review, pharmacy management and case management, have simply failed to control the number of chronic-pain cases or the duration of these cases. Why? They've been pushing solutions that don't match the problems.
Problems we should be addressing are primarily the mind/body complexity of these conditions, but also the wide variance in physician know-how, the confusing array of proposed clinical strategies and the inadequate controls over patient behavior.
A good sign that we are facing up to the challenge is the decision by California to use the chronic pain guidelines of the Encinitas, Calif.-based Work Loss Data Institute. WLDI's approach to chronic pain is comprehensive and subtle.
In that vein, I like how San Antonio, Texas-based AT&T Inc. is addressing highly addictive Class II narcotics such as Oxycontin, which is widely thought to be overprescribed. The employer has arranged for its third-party claims administrator to educate physicians about approved formularies for specific injuries. Class II narcotics are excluded from the formularies. After a patient presents a prescription for a Class II narcotic, the TPA gets an alert from its pharmacy management partner. A clinician then calls the doctor to talk about options. Only when there is clearly a medically appropriate need for a Class II narcotic is payment approved.
AIM Mutual Insurance Cos., a Massachusetts insurer, has structured things so that, if a claimant shows up with a script for Oxycontin or some other Class II drug such as Actiq, Fentora or Duragesic, the insurer will be alerted as the claimant stands at the pharmacy counter.
Maybe my sample is skewed, but I notice more pain clinics taking very seriously the problem of patient behavior. At a Florida conference, I heard every pain-management panelist say he would hesitate before admitting for treatment claimants who were obese and smokers.
Boston PainCare Center is a clinic outside Boston owned by anesthesiologists. As a group, anesthesiologists are not known for recognizing behavioral factors. But every patient at Boston PainCare is first given a behavioral assessment. There is even a sleep-disorder unit there because so many painkiller users develop sleep problems.
Overall, I don't think any other common work-injury treatment is as fraught with patient noncompliance risks as chronic-pain management is. I include fatality as one of those risks.
Many claims staffs persist in a reactive mode, doing not much more than hiring a pharmacy manager to negotiate lower drug costs. They better become a lot more active if they really want to tame this beast.
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October 1, 2007
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