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By CYRIL TUOHY, managing editor of Risk & Insurance®

Every so often, there comes an idea so simple and effective that it begs the question: Why on God's green Pacific Northwest earth hasn't anyone thought of it before?

Headquartered in Tacoma, Wash., True Blue supplies the service, retail, wholesale, manufacturing, transportation and construction industries. Its tagline may say it all: "We do the hard work," the company likes to boast. Well, the hard work for Maw was going to be the task of weaning workers off of addictive medications.

By now the issue facing the workers' compensation system regarding the dispensing of Schedule II narcotics is well known and understood by case managers, doctors and regulators.

In workers' comp, there are simply too many doctors prescribing too many potent drugs to patients who don't always need them, or would do fine with a non-narcotic alternative.

Drug dispensation is one reason workers' comp medical severity is growing faster than the medical consumer price index, according to the National Council on Compensation Insurance Inc., and why medical losses now comprise 58 percent of the total workers' comp loss, up from 47 percent in 1989. As a result, there's incentive for the industry to reduce the use of narcotics.

Despite nearly 30 years in the business, Maw, who came to True Blue in 2004, was facing that sort of challenge.

Her employer, which had been doing business in all 50 states by the time she'd been made director of workers' comp in 2004, had since bought several other temporary labor brands, including Spartan Staffing, CLP, Centerline and PlaneTechs, a supplier of technical labor to the airline industry.

Many of the acquisitions came with long-tail claims, several of which had been open for many years. A push was made to get these workers off the habit-forming narcotics, Maw said. Efforts included expensive withdrawal programs and drug testing to see if workers were actually taking the prescribed medications.

"In a couple of cases this proved to be the only thing necessary to document there was no narcotics in the worker's systems, allowing the claim to close and the lifetime reserve on the claim to be eliminated, which is a saving of several hundred dollars," Maw said.

For Maw and True Blue's third-party administrator ESIS Inc., the payoff is likely to be even greater in the future.

With the help of its TPA, True Blue is tracking narcotic prescription requests, Maw said. Once a request is identified, it is reviewed by a nurse who prepares a letter to the doctor encouraging the use of other, less addictive alternatives.

The letter reminds doctors of Official Disability Guideline recommendations governing the use of opioids for only severe cases and for periods of less than two weeks.

The letter also advises the physician of the employer's goal to provide safe and cost-effective medication therapy while supporting the desired therapeutic outcomes.

Nonsteroidal anti-inflammatory drugs, for example, often treat injured workers, help return employees to work sooner and reduce employees' exposures to addiction, Maw said.

"We don't tell doctors that they can't prescribe opioids, only that we want them to consider the long-term effects," Maw said. The letter, sent out to doctors for the price of a postage stamp, appears to be paying off in spades, because doctors are listening.

Comparing two separate groups of claims culled from the ESIS database, the number of narcotics prescriptions per claim at True Blue went from 4.5 per claim in the control group to 2.2 narcotics prescriptions per claim. Pharmacy-paid on the claim went from $1,474 in the control group down to $574 in the other group.

The average dollar paid per claim went from $20,436 in the control group to $12,522 per claim, a reduction of $7,914 per claim, according to True Blue.

THE PILL BUSINESS

Sold under the household brands Oxycontin, Vicodin and Percocet, many powerful drugs have no trouble relieving injured workers of pain.

The medications have a dark side, too. Workers sometimes become dependent on them, and find themselves going back to the doctor for more. Such is the stranglehold of addiction.

The statistics are worrisome, and no one disputes those. In the United States, the use of opioids is a reason for the inexorable increases in the medical portion of the workers' comp claim over the past decade.

In 1997, there were 4.44 million grams of Oxycodone sold in the United States. By 2005, that number had grown to 30.62 million grams, an increase of some 588 percent, according to opioid use data by the Tampa, Fla.-based pharmacy benefit manager Healthesystems.

In 1997, there were 8.66 million grams of the opiate Hydrocodone sold in the United States. By 2005, that amount had shot up to 25.80 million grams, Healthesystems data reveals. In eight years, from 1997 to 2005, usage of the painkiller Fentanyl has gone from 74,086 grams to 387,928 grams, according to data provided by Healthesystems. That's an increase of 423 percent.

Data compiled by the Workers' Comp Research Institute and the National Council on Compensation Insurers Inc. also show that narcotics use is on the rise in workers' comp. In an interview with Risk & Insurance® earlier this year for a series on the unintended consequences of workers' comp reform in California, Florida and Texas, Krista Fergason, division director of risk management services, workers' comp administration, for the Texas Association of School Boards, said the best way to control claims costs is at the very beginning.

"I very strongly believe that you can control a claim if you can control the drugs at the very beginning of the claim," Fergason said. The longer workers' comp managers wait to intervene, the more difficult and expensive it becomes.

And so, as the workers' comp industry at large finds itself struggling with rising opioid medication use, True Blue is bucking the trend. The company is in the midst of a downward usage narcotic spending cycle.

"The average paid per claim in total impacted by these letters came down substantially," said Joel Raedeke, assistant vice president of ESIS Strategic Outcomes. The data appears to show a broader benefit than just a simple reduction in the pharmacy spending, Raedeke said. "It's true that the average paid per claim in pharmacy has decreased but the average paid per claim has dropped quite a bit, as well, beyond savings in pharmacy costs."

Maw said the numbers have dropped because managers are questioning attending physicians more frequently regarding the medications they are prescribing. Taking a page out of Fergason's playbook, Maw said her employer no longer waits for narcotic use to become an issue. "It's easier to address it before the worker is addicted and we honestly feel that this benefits the worker," Maw said. Raedeke said that the effect of any trigger needs to demonstrate improved outcomes. In this case, average paid was used as the key metric to judge the outcome and the number of opioid-type pharmacy prescriptions was used as a supporting indicator.

While there are hundreds of trigger events that third-party administrators have designed to reduce pharmacy costs, the more a given trigger is customized to a client's program, the better, Raedeke said.

When ESIS designs a trigger, statisticians look at patterns in data that indicate opportunity for improved claim outcomes. On the medical side, it may involve looking at the doctors associated, the number of doctor visits, the type of injury suffered by the worker, the pharmacy being used or other key elements in medical cost, litigation patterns and claim durations.

In the case of True Blue, the results of the trigger were "remarkable," Raedeke said.

December 1, 2010

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