The relatively recent expansion of quantitative urine drug tests to control the risks of opioid prescribing shows how when workers' compensation learns to use a tool, the tool in turn learns how to use workers' compensation. This test, usually known a UDT or drug screen, confirms at an extremely high level of accuracy what drugs a subject has recently taken. The search targets are typically prescribed opiates as well as illicit recreational drugs. Most, if not all, care guidelines endorse UDTs as the gold standard for detection of drugs.
How it works: A central lab receives a urine specimen by overnight mail, puts it into an expensive machine, and issues a detailed report the next day.
Five years ago, the testing labs could not even give these away to workers' compensation claims payers, which showed scant interest and ignored care guidelines. Today, most payers buy them in volume. The marginal cost to a lab for performing a typical test for, say, four drugs is likely around $25. Nonetheless, the lab may charge $400. In fact, adjusters are seeing invoices exceeding $1,000 for a single test for certain drugs.
The risks of misuse of opioids and illicit drugs justify the costs of the tests. Studies show that patients often (for whatever reason) misstate their prescribed drug use. Drugs are often diverted. Patients die.
Today, doctors are advised to perform a baseline test at the outset of opioid treatment and to randomly tell opioid patients several times a year to provide a urine sample the moment they arrive at an appointment.
Many payers find doctors partnering with a UDT vendor to perform a screen every 30 days like clockwork. State fee schedules often do not deter aggressive billing. The worst financial abuse involves a doctor who does the analysis in her or his clinic and manipulates billing codes to shake down the payer. And the doctor might fail to address aberrant findings, meaning the UDT was pointless.
A handful of national testing labs began calling on claims payers, pharmacy benefit managers and managed care firms in the mid-2000s. They wanted people to start asking for UDTs from treating doctors with whom their sales force had already set up a urine sample intake site.
At the time, PBMs were unresponsive. Claims payers generally kicked the tires and walked away. Tests that were performed at a doctor's initiative tended to be paid for and filed unread.
I asked some informed individuals why the market initially failed to respond. One factor was lack of know-how, notably among medical case managers, about how to use test results. Not the least of worries were potential tangles with doctors and plaintiffs' attorneys. Lawyers for one large insurer cautioned about violation of privacy rules. In some instances, the tests appeared to conflict with the prospect's business model for making money.
But claims payers began to actively order and buy tests in 2011 or so. Health Strategy Associates and the Workers' Compensation Research Institute report that claims payers are sharply more interested now in urine testing than just a year or so ago.
Claims payers probably came to see that testing could actually simplify their increasingly heavy burden to monitor opioid misuse by claimants. They are including tests, and assured response to aberrant findings, as standard parts of their opioid strategy.
Testing, while necessary, has engendered a new malady of profiteering. The body-contact sales style of testing labs and opportunism by doctors, albeit a small share of them, have carved out an exciting and extractive industry, funded out of claims budgets.
PETER ROUSMANIERE is an expert in the workers' compensation industry.
October 15, 2013
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