Inappropriate Use of Narcotics Worries Workers' Comp Insurers
The growing use and abuse of narcotics among injured American workers is emerging as the primary concern of workers' compensation insurers today.
Narcotics are the No. 1 cost driver in the workers' comp industry, accounting for 34 percent of workers' comp medication expenses. Narcotics are considered safe and effective if used properly, but they have the potential for leading to addiction and abuse if their use is not monitored and controlled.
And while narcotics have a long and effective history of being used to treat both acute and chronic pain resulting from on-the-job injuries, there are serious risks involved when they are not used properly. What's more, studies show, the longer an injured worker is on narcotics, the longer the delay in that worker's ability to return to work in a timely manner. There's also an increased likelihood that payors will have to pay for rehabilitation programs for addiction. Data show that there was a significant increase in the treatment of substance abuse cases related to abuse of narcotic painkillers from 2000 to 2006.
"Sometimes," said Beth Kuschner, a clinical pharmacist with Progressive Medical Inc., a national workers' comp cost-management company headquartered in Westerville, Ohio, "an injured worker will be in great pain and at a loss for what to do. Other pain medications haven't helped, so a physician, usually a family physician who might not have the training in pain management, will prescribe a narcotic painkiller.
"But if the patient is on narcotics for a long time, problems can arise because the use of the narcotic escalates beyond the point of being a benefit. Either function (the ability to perform activities of daily living) has not improved or the pain has not decreased, or both," Kuschner said.
Continued oversight of the patient's narcotic use by the prescriber is also an issue. A recent study by the researchers at Albert Einstein College of Medicine of Yeshiva University found that monitoring of narcotic medications in primary care settings is less than ideal. "While alarming, this finding is not surprising to us" said Tron Emptage, chief clinical and compliance officer. "We see this frequently in our evaluations of some of these cases ? very few prescribers document narcotic agreements or perform urine drug screens to make sure the prescribed narcotics are being used and drugs that aren't prescribed don't show up in the screen."
WHAT CAN BE DONE
"We're a society of pill-takers," Craig Crager, a Progressive Medical nurse, said. "People will say, 'I want to be fit but I don't want to exercise, so I'll just take a pill. I want to lose weight but I don't want to diet, so I'll just take a pill.'
"But there's an appropriate time and need for medication, including medication for pain control. Sometimes narcotics are appropriate, but sometimes injured workers need to do therapy or whatever kind of rehabilitation that will get them back to work," Crager said.
To that end, Progressive Medical has an aggressive and proactive program to reduce narcotics abuse, get injured workers back to work and reduce workers' compensation claims costs. "We have developed an injury-specific medication program," Kuschner said. "It doesn't prevent narcotics from being utilized, but we have guidelines and recommendations to make sure the injured worker has the appropriate medication at the appropriate time, safely, successfully and cost effectively."
"It's essential that insurers take proactive measures to monitor for potential misuse or abuse," Crager added.
The most effective means, they said, is to partner with a pharmacy benefit manager, who can use best practices to help workers' compensation payors control narcotics use and thus reduce risk.
The first step is for the pharmacy benefit manager to review the injured worker's prescription history, which then can be used to develop a customized medication plan. The plan will identify which medications are appropriate for the injury type and body part, and also will indicate the proper duration of use and quantity limits.
When new claims are filed information about when and what type of medication is filled at the onset of the injury should be recorded. That information can begin to tell the story of the medication history and medication therapy to come. One method of capturing this data is through first-fill cards distributed by the employer to the injured worker at the time of the injury.
In addition, retail and home delivery programs are recommended because they provide insurers an effective means of monitoring and controlling the injured worker's use of medication. They also provide payors an opportunity to leverage pharmacy network participation and discounts, therefore reducing medication expenses.
The pharmacy benefit manager also should have a clinical management process, managed by clinical pharmacists, to govern narcotics use. The clinical drug utilization review program should use a combination of evidence-based guidelines, peer review journals and government standards. Both prospective and concurrent review processes are necessary for a successful program.
According to Crager, a retrospective utilization review also is important. After prescriptions are filled, a pharmacy benefit manager's clinical pharmacist team should audit those prescriptions for indications of inappropriate use such as the sole use of narcotics as treatment, multiple prescriptions for narcotics by multiple doctors and the excessive duration and use of narcotics, Kuschner said.
Of course, identifying a problem is not enough, she added. Pharmacy benefit managers should have a range of clinical intervention programs that include registered pharmacists, nurses and other health professionals to assist with clients' evaluation needs--everything from consultation on medication questions to detailed evaluations such as peer reviews and consultations with prescribing physicians. "Our pharmacists are accessible by e-mail and phone to assist in what to look for to see whether medications are appropriate and whether or not they should be continued," Kuschner said.
Recommendations for specific claims that require further evaluation using information gathered in prospective, concurrent and retrospective review processes should be offered.
"Retrospective reviews look at the amount of medications, narcotics in particular, that an injured worker is taking. Is the patient going to multiple physicians? Is there an accepted use or duration based on evidenced based clinical standards?" Crager said. "We can then make recommendations through analyzing the prescription history and thus work with the client to manage the applicable issue moving forward.
"A retrospective review looks at the medications already dispensed, evaluates the trend, and has the potential to positively affect future fills of the prescription.
"Education is the key," he said. "Physicians get very little training in pain management and they need to understand what the most clinically appropriate and cost effective treatment would be."
"There's a lot of bad press about the expense of narcotics," Kuschner said. "We don't ever want to lose sight of the fact that narcotics can be an effective way to treat acute and chronic pain.
"We know narcotics are a cost driver, so we are paying attention to how they're used because we want to make sure that injured workers have a good quality life on the appropriate medication," she said.
"Our ultimate goal is to get people back to work as quickly and as safely as possible, that they take safe and effective medication in an appropriate way," Crager said.
"We want to do this because clinically it's the right thing to do for the patient and has the added advantage of cutting costs."
For a copy of Progressive Medical's clinical services study, Reducing Narcotics Use in Workers' Compensation, e-mail email@example.com.
(The above piece is part of our continuing Perspectives series designed to highlight key products and services to our readers. This paid-for Perspectives was written and edited by Risk & Insurance®
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April 1, 2011
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