Insurer uses 'shocking' research findings to wean injured workers off opioids
After its research delivered a wake-up call about the true extent of opioid use among injured workers, Accident Fund Holdings leveraged data analytics, technology, and common sense to address the issue. About 5 percent of the patients targeted have been weaned off opioids in just a few months.
"It's a very unique approach that does, at the end of the day, work for everybody," said Patrick Walsh, vice president and chief claims officer for corporate claims at Accident Fund Holdings. "It's about the employee's wellness. It's about getting them healthy and getting them back to work, which helps the employer and lets the physician focus on other patients."
Higher claim costs.
The program followed the company's research that paired its pharmacy and claims data to gain a better understanding of why medical costs among injured workers were increasing so rapidly. After looking at some 10 million claims records, company officials determined that three classes of drugs -- opioids, antidepressants, and anti-convulsants -- were driving pharmacy costs, but they were not sure why. Research on the issue is scarce.
"A lot of [industry] reports focused on the costs of drugs increasing," said Jeffrey Austin White, director of medical management practices and strategy. "It didn't match up with the rate at which costs were rising. So I had a suspicion as to what it was."
White contacted researchers at Johns Hopkins University School of Medicine. They teamed up for a study that ended in December.
"What we realized was, since I had been so focused on inflationary costs, I had failed to link those records to claim outcomes to realize it's really not the cost of the drugs. They only make up less than 3 percent of medical spend," White said. "When you actually link those pharmacy records to claims, we saw a four to eight times increase in claims costs on the average for any claim linked to opioid use."
They found claims involving short-acting opioids were generally four times more expensive while those with long-acting opioids were eight times pricier than similar claims without the opioids.
"What was shocking was the fact that opioids" themselves increased the cost, White said. "The average person will say it is because opioids are used with really severe injuries or long-term chronic injuries. That actually wasn't the case."
With research indicating up to 80 percent of injured workers are using narcotics, the company took a deeper look. White says only one out of five injured workers is educated on the use of the opioids.
"There's a general lack of protocols for the injured workers who receive opioids to monitor their use and make sure they are provided in a safe manner," White said. "We struggle with that issue."
Armed with the research, the company developed a program to target injured workers who are prescribed opioids. It is based on the premise that time is of the essence.
"The only way to address the issue of opioid use was to catch it early," White said. "Opioid addiction happens really quickly. We are looking at catching it within the first week."
White and his team used data analytics and developed a solution called Care Analytics, a software app that monitors medical and pharmacy billing in real time.
"The moment the prescription hits, it triggers the business process by alerting the adjuster and nurse case manager that this is happening on this file," Walsh said. "Then it becomes an issue of execution on the part of the claims professional."
The thrust of the process is getting the treating provider to communicate with the injured worker and enter into a contract to monitor usage. It's important to develop the most appropriate plan for each patient.
"It's about trying to pick the best set of options for that case," Walsh said. "Is the doctor willing to talk to us about this person's condition, his wellness, the effects or dangers of drugs he is on? And being creative on a case-by-case basis to make sure the prescription is the right one."
That may mean setting a plan in place to get the injured worker off the opioids. In other cases, it may be important for the injured worker to stay on the opioids to be able to regain normal physical functioning and get back to work.
"So really it's about talking to the doctor to make sure they have a plan consistent with evidence-based medicine," White said.
"A lot of it is verbal interaction on the phone or face-to-face with the physician," Walsh said. "The creativity probably comes in determining who is the right person or resource to talk to that treating physician."
Since the program was implemented, the team has found the majority of its physicians are more than happy to cooperate.
"The feedback I hear is that oftentimes the doctor is looking for some help," Walsh said. "They might have inherited this person from another doctor. They might be trying to deal with the issue already but need somebody to support what they are trying to do. ... It is amazing how that's made a difference, having that other voice."
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March 19, 2012
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