The cautionary tone is sounded in Reducing Narcotics Abuse in Workers' Compensation, a report from Progressive Medical. The Ohio-based pharmacy benefit management company highlights some of the stark realities of Schedule II narcotics and explains strategies that can help workers' comp payers reduce the fiscal, legal, and personal risks involved.
"Workers' comp payers that do not take proactive measures to monitor utilization or communicate with physicians could face lawsuits for negligence," the paper says. "This is especially critical in cases where one or more narcotics are prescribed for more than six months at a time."
Challenges of narcotics use. Narcotic spending accounts for more than one-third of workers' comp medication expenses, according to an earlier analysis from Progressive. The medications go by various generic names, such as fentanyl, hydromorphone, methadone, oxycodone, and oxymorphone.
The Substance Abuse and Mental Health Services Administration says there was a significant increase in the treatment of substance abuse cases related to abuse of opioid analgesics from 2000 to 2006. A study co-released by SAMHSA and the Centers for Disease Control and Prevention said emergency room visits linked to nonmedical use of narcotics rose 111 percent between 2004 and 2008.
"Opioid therapy is often an appropriate treatment option, but it is not without risk," said Tron Emptage, chief clinical and compliance officer for Progressive.
While the use of opioids to treat acute pain in injured workers can be safe and effective, misuse and abuse raises three areas of concern:
- Potential for serious health risks.
- Higher percentage of medical expenses as claims age.
- Risk of litigation.
According to the Food and Drug Administration, narcotics abuse can cause respiratory depression, central nervous system depression, addiction, and death. The FDA has taken steps to monitor whether the benefits of narcotic medications outweigh the risks.
The costs associated with narcotics use increase as claims age -- from 15 percent in the first year to up to 35 percent in the fifth year, according to the National Council on Compensation Insurance. Also adding to the cost is the fact that the longer an injured worker is on narcotics, the longer the delay in the claimant's ability to return to work and the increased likelihood of the need for rehabilitation for addiction.
Perhaps most startling to workers' comp payers is the legal risk. Litigation that has thus far targeted physicians and pharmacies may focus on payers since they have access to data showing patterns of abuse and misuse and may have the duty to warn claimants and prescribers in cases involving potential misuse.
"With respect to paying questionable claims, many payers have done so rather than face the expense and time of litigation. Morally, this poses a key question for insurers: Is it acceptable for insurers to settle fraudulent claims or does it position them as aiding and abetting the perpetrator?" the report says. "This could change if payers become defendants in lawsuits related to narcotic abuse."
Monitoring. Developing a strategy is key to getting control of narcotics usage. "The earlier the intervention, the better," Emptage said.
The process begins with creating a customized plan for each claimant to identify which medications are appropriate for the injury type and body part, the proper duration of use, and quantity limits.
Technology can be effective in tracking and monitoring claimants before, during, and after they use opioids. For example, a system can be set up to warn of potential "doctor shopping" where claimants try to obtain multiple prescriptions.
"What it can do is immediately help through electronic connectivity to find instances of that to design medical treatment plans that at the point of sale alert pharmacists or adjusters that [the injured worker] is trying to purchase drugs outside of those that are allowed," Emptage said.
Emptage says PBMs are well-suited to help payers design plans that control narcotics usage because of their extensive use of technology to synchronize the many players involved in a workers' comp claim. He says several best practices can be deployed by PBMs, such as:
- Capturing prescriptions at first fill to immediately gather data about when and what type of medication is filled at the onset of injury.
- Home delivery programs and retail drug cards, both of which offer payers more control over the medications a claimant obtains.
- Managing prospective and concurrent drug utilization programs by using evidence-based guidelines and other information to provide cost control and utilization control.
- Conducting retrospective drug utilization reviews and clinical intervention programs to quickly identify indicators of inappropriate use.
"We want to take care of claimants and make sure they get back to work quickly and safely," Emptage said. "Using PBMs can help identify if [narcotics] therapy is potentially escalating and might need intervention."
Read more at the WorkersComp Forum homepage.
May 19, 2011
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