According to a 2010 National Survey on Drug Use and Health published by the Substance Abuse and Mental Health Services Administration, 2.7% of the American population used a prescription drug non-medically in the past month. The government also estimates that more than 33 million U.S. residents misused long-acting opioids.
Payers of workers' compensation claims should be concerned about these statistics as 6 of the top 11 most abused drugs identified in the study are commonly prescribed in workers' compensation claims, including oxycodone, hydrocodone, carisoprodol, morphine, zolpidem and fentanyl.
Substance abuse, diversion and dependence are all problems that can occur when injured workers are prescribed pain medications.In fact, it's not uncommon for injured workers to be taking prescribed prescription medications inappropriately or not at all.
"While diversion is a problem we seek to identify and address, patients not taking medications as the doctors prescribe, or who are over-utilizing pain medications, is an even greater issue," said Jim Andrews, R.Ph., senior vice president of pharmacy services for Healthcare Solutions, the parent company of pharmacy benefit manager Cypress Care.
"It's essential for payers and their pharmacy benefit managers to work together to identify, communicate and coordinate programs to address potential abuse and long-term dependence," said Andrews.
Education is an important factor in changing behavior.While news stories abound about the abuse of prescription drugs, many workers' compensation payers don't know how to address the problem.
"Every day we're working to educate payers and physicians of the potential problems that can occur when opioid use is not monitored effectively," said Scott Phillips, Pharm.D., clinical pharmacist for Healthcare Solutions "While this is an issue that affects the overall health care industry, it is particularly important in workers' compensation because of the disproportionate share of opioid medications that are dispensed relative to total drug volume."
As part of a complimentary service offering for customers, Healthcare Solutions uses proprietary algorithms and data mining to identify injured workers with potentially inappropriate medication profiles.The company looks at early, chronic or high use of opioids, the presence of multiple pharmacies or physicians, or other aberrant behavior.
"Results from our data mining can be a tell-tale sign of potential problems," said Phillips. "In addition to email alerts and automated reporting, we use on-site stewardship meetings to discuss our findings and review strategies that can be taken to identify whether there is a real problem," said Phillips.
Depending on the nature of the potential problem, Healthcare Solutions' clinical pharmacy team recommends the use of various interventions such as physician outreach letters, nurse case management, urine drug monitoring, physician peer reviews or medication therapy management.
These strategies are part of the company's Clinical Rx suite of services, which combines medical expertise and advanced technology to help ensure appropriate utilization while reducing drug expenditures. The Clinical Rx program offers a strong line of defense against medical inappropriateness, excessive drug costs, fraud, waste and abuse.
The most intensive intervention program utilized by Healthcare Solutions is its physician peer review program named CPRx. For claims reviewed under this program in 2011, approximately 75% of the prescribed medications were not supported by evidence-based medical treatment protocols. According to Andrews, in over 50% of these cases, the treating physician agreed that the current treatment is inappropriate and has been willing to modify the patient's treatment plan.
"Once claims are identified for intervention, it's also important to understand state regulations, as jurisdictions vary in the authority permitted for payers to enforce clinical recommendations," said Chip Robison, Pharm.D., director of clinical services for Healthcare Solutions.
"For example, in direction of care states, Healthcare Solutions may recommend changing the injured workers' physician to one who is committed to closely monitoring each patient's opioid therapy and who is open to restructuring treatment plans to assist the patient in weaning off a medication," said Robison.
A handful of states including Washington, Texas, California, New York, Montana, Rhode Island and Georgia are considering or have implemented medical treatment guidelines or opioid protocols.
"With its new closed formulary, Texas is a recent example of a state that has taken action to more closely monitor drug utilization and leverage Official Disability Guidelines," said Andrews. "Although it's too early to know what outcomes this program will bring, it could be one step in the right direction."
Healthcare Solutions actively monitors legislative activities and provides comments on proposed reforms.Although state drug monitoring programs are becoming more wide-spread and successful, Healthcare Solutions remains committed to using both prospective and retrospective management solutions to manage the financial and health burdens inherent in medication abuse and dependence.
"As a PBM we know it's our responsibility to help customers rein in rising drug costs," said Andrews."This includes identifying potential diversion or abuse and working with our customers to mitigate these risks."
About Healthcare Solutions
Healthcare Solutions, Inc. is the parent company of Cypress Care and Procura Management.Through its affiliated companies, Healthcare Solutions serves as a health service company delivering integrated solutions to the property and casualty markets, specializing in workers' compensation and auto liability/PIP.The company's customers include insurance carriers, third party administrators (TPAs), managed care organizations (MCOs), government agencies and self-insured employers.Utilizing market-leading technology, Healthcare Solutions delivers demonstrated benefits and savings complemented by deep industry expertise.For more information, visit www.healthcaresolutions.com.
(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance®
on behalf of our marketing partner. Additional Insights can be found on our Web site at www.riskandinsurance.com/.)
October 19, 2011
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