Four essential strategies, visible in at least one state and among a handful of workers' compensation claims payers, cry out for adoption by many.
Pain treatment costs drive claims costs today. Poor treatment also drives up indemnity costs. Every major claims payer, every team engaged in claims analysis, every lobbying arm of the business and insurance community needs to focus on executing these four strategies.
First, use state regulation and claims payer collaboration to solve the public health crisis of the overuse of opioid (narcotic) pain medication. State regulation addressing all overprescribing in workers' compensation and healthcare is needed.
A leading architect of this strategy, Dr. Gary Franklin, is medical director of the Washington State Department of Labor & Industries, Washington's state fund. His department has orchestrated a policy of education and control around overprescribing. Part of his strategy is to mandate physician oversight where prescriptions exceed a given threshold.
Workers' comp payers with large market shares in states need to use their moral authority and their claims resources to move regulation ahead and execute the policy on a claim-by-claim basis.
Second, claims payers can do a lot more to document and make public the adverse effects of a very small share of physicians who engage in aggressive use of opioids and other controversial treatments.
Alex Swedlow and his team at the California Workers' Compensation Institute recently released a study about opioid prescriptions in that state. Edward Bernacki of Johns Hopkins University and Larry Yuspeh of the Louisiana Workers' Compensation Corporation spearheaded a similar study of extreme outliers in medical treatment.
This kind of analysis, while resource intensive, should be done. We need to document how much a very small number of outliers drives a huge share of medical cost severity, by introducing drugs, injections and surgeries to hapless workers with no documented benefit on outcomes. Claims departments are usually not aware of this skewing.
Third, claims payers need finally to invest in medical intelligence to develop a "supply chain'' of preferred clinicians to address chronic pain issues, along the spectrum of cases ranging from early intervention to old open claims. I estimate that today there is about one truly trustworthy provider of chronic pain services to workers per million of state population--300 in the country. Broad discount networks are clueless about who these providers are. They also are incapable of tripling that number, which is what it needs to be.
Superior caregivers for workers in chronic pain vary in their treatment models. While some standardization is desirable, it is not necessary. A claims payer should use physician/nurse teams to compensate for gaps in service and to link providers.
It is a rare insurer that knows these providers, systematically monitors them and follows a proper approach for referral and compensation.
Fourth, claims payers have to buy in to very close monitoring, intervention and referral. This is a vital step to severely cutting down on unnecessary surgeries--half of them can be eliminated--and injection-happy doctoring.
Claims payers that adopt these four strategies in their states have a chance to solve the problem of excessive medical severity.
PETER ROUSMANIERE is an expert in workers' comp.
June 1, 2011
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