Although narcotics are an important part of the treatment of pain from work-related injuries, their increasing misuse is spurring insurers to find better, more efficient ways to manage their use and reduce their misuse, to ensure injured-worker safety and control workers' compensation claims costs.
The Centers for Disease Control has reported significant increases in the misuse and abuse of narcotics in the past decade.Prescription opioid analgesics, or narcotics, are the most abused prescription drug category to date.In fact, misuse and abuse of prescription medications is at an all-time high."Unfortunately, people may assume that prescription medications are 'safer' than using illegal substances," said Beth Kuschner, clinical pharmacist at Progressive Medical, a national network that provides cost management services and programs to the workers' compensation industry."Abuse of prescription medications poses a significant risk, up to and including death."
According to a study by Progressive Medical, narcotics account for 34 percent of workers' compensation medication expenditures. In fact, narcotics' total share of medication expenses increases as claims age--from 15 percent in the first year to as much as 35 percent in the fifth year--and the longer an injured worker is on narcotics, the longer the delay in the injured worker's ability to return to work in a timely fashion.
"It's a huge problem," said Tron Emptage, Progressive Medical's chief clinical and compliance officer. "Looking at historical prescribing data, if an injured worker complained of pain or presented an injury, the doctor would prescribe pain medication and the insurer would approve it.
"But it takes more than just narcotics to alleviate pain and get a worker back to functionality," he said, "and if people go on excessive long-term use of narcotics, the trends suggest that it can be harder to return the injured worker to pre-injury functioning."
Long-term use of narcotics can be costly, Emptage said; some say overprescribing of narcotics is a key source of inflated medical costs. "It's not that patients don't need pain medication, but it needs to be managed appropriately up front," he said.
Kuschner said, "It can also lead to addiction for those who might be predisposed to it, and can present serious health risks down the line, such as respiratory depression, central nervous system depression and more."
That's why Progressive Medical advocates early intervention to help drive better decisions, and therefore better outcomes, and provides tools, educational opportunities and management programs to assist in narcotics utilization monitoring, Emptage said. The most effective way to do that is to partner with a pharmacy benefit manager, an administrator of prescription drug programs, experienced in the workers' compensation industry.
Pharmacy benefit managers can follow several best practices to help payers control narcotics use and reduce risk, including:
-- Defining a Strategy for Each Medication
-- The pharmacy benefit manager should develop a customized narcotics strategy for each medication plan, identifying which medications are appropriate for the injury type and body part, and accounting for proper duration of use and quantity limits.
-- Capturing the First Prescriptions Processed on Claims
-- Pharmacy benefit managers should be able to capture when and what type of medication is filled at the onset of injury. First-fill cards, distributed by the employer to the injured worker at the point of accident or injury, are a good way to do that.
-- Electronic prescription capture programs are also a key to success.By moving prescriptions into network early through this capture, management starts early.
-- Offering Home Delivery Programs and Retail Drug Cards
-- These provide workers' compensation payers an effective way to monitor and manage an injured worker's medication use. They also provide payers the opportunity to utilize pharmacy network discounts to reduce medication expenses.
-- Retail drug cards should contain injured worker-specific drug use review information to ensure that only appropriate medications are filled through the use of evidence-based medicine and national or state approved medical guidelines.
-- Home delivery programs offer injured workers the convenience of ordering online or on the phone and another opportunity to get information on the risks associated with narcotics through direct interaction with the pharmacist dispensing the prescriptions.
-- Managing Narcotics Use Review Programs
-- A prospective utilization review plan allows for cost and utilization control by planning for future outcomes using upfront information, such as historical data and practices to guide future decisions.
-- Concurrent utilization reviews allow pharmacy benefit managers to alert dispensing pharmacists to question a prescription if there are indications of abuse, including the use of multiple pharmacies and physicians for different narcotics or excessive early refill attempts. This ensures that prescriptions for narcotics will not be filled at the point of sale unless the medication is allowed or the pharmacy benefit manager receives authorization from the payer.
-- Conducting Retrospective Drug Utilization Reviews and Clinical Intervention Programs
-- Retrospective reviews involve pharmacy benefit manager clinical pharmacist teams auditing prescriptions that have been filled for indicators of inappropriate use such as sole use of narcotics as treatment, multiple physicians, use of multiple short- or long-acting narcotics or excessive duration and use.
-- Physician and pharmacy monitoring involves continually monitoring for the use of multiple providers by an injured worker.
--A Range of Clinical Intervention Programs
-- Should consist of having registered pharmacists, nurses and other health professionals available for consultation on medication questions and more detailed evaluations including peer reviews and direct consultation with prescribing physicians.
-- The pharmacy benefit manager's clinical intervention team should provide recommendations for specific claims that require further evaluation by using the information gathered in prospective, concurrent and retrospective review processes.
Providing Ongoing Narcotics Utilization Consultation
-- Essential to controlling narcotics use. Pharmacists managing the programs should take proactive measures to expand utilization review programs as changes in the workers' compensation industry evolve.
Validating Narcotics Use Through Reporting
-- User-run reports from the pharmacy benefit manager are a tool to allow a client to run a wide range of reports to gain an in-depth understanding of all activity.
-- Drug utilization review reports can provide information on savings achieved as a result of the narcotic utilization program.
"We're constantly striving to make our system smarter by acting earlier on the claim, by pinpointing the appropriate alerts to the appropriate claims professional or clinical personnel involved in the process, by providing approved, optimal therapy and care to get injured workers back to functionality sooner, with fewer complications and with a better quality of life," Emptage said. "Ultimately, this will translate to savings for the payer."
(The above piece is part of our continuing Perspectives series designed to highlight key products and services to our readers. This paid-for Perspective was written and edited by Risk & Insurance®
on behalf of our marketing partner. Additional Perspectives can be found on our Web site at www.riskandinsurance.com/.)
October 15, 2011
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