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Pain medications for these claimants rose to or exceeded $1,000 a month. These claimants now account for a third to a half of all claims costs.

And they are at the heart of the workers' compensation field's first serious crisis in patient safety. It is conceivable that more than 100 claimants die each year from misuse of prescribed pain killers.

In the main, however, our industry's approach was been way off. Until we correct this, chronic pain issues will remain demoralizing in various ways for claimant, clinician and adjuster.

To present a coherent, disciplined approach to chronic pain, I offer a program introduced in 2009 by Connecticut's self-insurance pool of 390 healthcare employers, called simply The Workers' Compensation Trust.

The Trust is using a five-pronged approach. Each of the five advances the effectiveness of the other four. Consider how many of the five you or your vendors apply.

First, the Trust works with its PBM to identify aberrant prescribing and to discourage inappropriate drugs. While lower unit costs of drugs is fine, the Trust focuses on what really drives drug costs, which is utilization.

Second, it screens early for high-risk claimants. Brian Downs, vice president for quality and claims, told me that the key indicators include nontraumatic soft-tissue injury, smoking, obesity, a clinical finding that surgery is not indicated for a patient and other underlying medical issues such as diabetes.

Third, the Trust has created a pain treatment network of doctors to whom to refer chronic pain patients. Downs said that if he limited the network to doctors he considers qualified, he would enroll only 10. That's rather sobering considering that Connecticut has a population of 3.5 million.

To meet state guidelines for access to doctors, he enrolled 33 into the pain network, triple his wish list. All of them are either anesthesiologists or physiatrists with a lot of experience in treating injured workers. The Trust is trying to avoid doctors who are intermittent pain treaters or who are not in tune with the issues of functional recovery and return to work.

Connecticut allows for employer/insurer choice of doctor. Downs said that he would build a network even if this formal power were absent.

Fourth, the Trust is stepping up to the challenge of drug misuse. It asked its network of doctors to have their patients sign a so-called opioid agreement, which expressly proscribes bad behavior. And it asks that patients be urine tested randomly.

Fifth, the Trust is pushing for exercise programs for chronic pain patients. Downs wants at least 50 percent of chronic pain patients enrolled in such programs and he wants them enrolled as part of a multidisciplinary program.

With this fifth prong, the Trust is correcting the habit of many insurers to fight against the least expensive and least risky treatments, which are exercise and counseling.

By refusing to pay for these treatments, insurers implicitly bolster the more expensive and risky treatments, such as surgeries.

PETER ROUSMANIERE is an expert on the workers' compensation industry.

March 1, 2010

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