1. Highlights Of WCRI Research
CANE Spring Meeting
March 20, 2017

2. Topics Covered In Today’s Discussion
Shifts in provision of workers’ compensation medical services
Trends in indemnity benefits per claim: Effects of reforms in selected states
Impact of physician dispensing reforms
Interstate variation in opioid use
© Copyright 2017 WCRI. All Rights Reserved.

3. About WCRI And Our Mission
Independent, not-for-profit research organization
Mission:
“Be a catalyst for improving WC systems by providing the public with high-quality, credible information on important public policy issues.”
Diverse membership support
Peer-reviewed studies with a focus on benefit delivery
Do not make recommendations or take positions; serve as a resource for public officials & stakeholders
Content-rich website:
© Copyright 2017 WCRI. All Rights Reserved.

4. WCRI Provides Broad Scope Of Studies
State
CompScope™
Worker Outcomes
Longer-Term Use Of Opioids
MCC
Inventory
Medical
Price Index
Physician Dispensing In WC
Prescription
Benchmarks
Hospital
Cost Index
Interstate
Variation In Use Of Narcotics
Hospital/ASC
FS Inventory
Payments To ASC
© Copyright 2017 WCRI. All Rights Reserved.

5. Shifts In Provision Of Workers’ Compensation Medical Services
Evidence From WCRI Studies

6. Less Use Of Hospital Care In WC: Follows Trends In General Health Care
Decrease in hospital inpatient care
Shift to free-standing facilities from hospital outpatient facilities, such as ambulatory surgery centers (ASCs)
Decreased use of hospitals for some services that are more expensive when provided in hospitals; shift to nonhospital
WC: Workers’ Compensation
© Copyright 2017 WCRI. All Rights Reserved.

7. Factors That May Influence Shifts In Provision Of WC Medical Services
Federal interventions:
Changes in Medicare approach, reimbursement, and billing
Affordable Care Act /replacement??
Changes in business models: such as consolidations, facility and physician practice ownership, contractual incentives
Competition for access: WC reimbursement vs. other payors
Local and state medical care delivery models/practice norms
Legislative or administrative system features and changes focused on WC reimbursement or utilization of medical care
Choice, convenience, and cost
© Copyright 2017 WCRI. All Rights Reserved.

8. All Payors: Hospital Outpatient Use Grew Much Faster Than Inpatient Use, 2000–2014
32.9
12.1
8.0
6.7
6.9
Source: American Hospital Association, AHA Hospital Statistics from Health Care Spending and the Medicare Program: A Data Book, June Medpac (Medicare Payment Advisory Commission). Located at
Source: American Hospital Association, AHA Hospital Statistics
© Copyright 2017 WCRI. All Rights Reserved.

9. WC: Decrease In % Of Claims With Hospital Inpatient Episodes In Most Study States
Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Not Adjusted For Injury/Industry Mix Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

10. % Point Change 2009 To 2014 In % Of Claims With Inpatient Episodes
% Claims With Inpatient Episodes Decreased In Many Study States 2009–2014
% Point Change 2009 To In % Of Claims With Inpatient Episodes
Key: ASC: Ambulatory surgery center. Note: Trends in percentage of claims with hospital inpatient episodes are not shown for Arkansas because the cell sizes underlying the data are too small to support a trend analysis.
Claims With Hospital Inpatient Episodes As A Percentage Of Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Not Adjusted For Injury/Industry Mix; Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

11. Increase In Hospital Payments Per Inpatient Episode In Most Study States, 2009–2014
Median State: 24% (or 4% per year)
.Note: Arkansas is excluded from this chart because the cell sizes underlying the data are too small to support a meaningful analysis. The trend in Illinois was related to the 30 percent decrease in fee schedule rates, effective September 1, The trend in Indiana reflected up to 9 months of experience under the hospital fee schedule, implemented July 1, The trend in North Carolina was related to the 2013 interim fee schedule changes. Kentucky is not included in this chart because data in this state in 2008/09 are not available.
Cumulative % Change 2009 To 2014 In Hospital Payments Per Inpatient Episode; Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Not Adjusted For Injury/Industry Mix; Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

12. NJ Low Back Disc Cases With Surgery: Shift From Inpatient To Outpatient
% Of Low Back Disc Cases With Inpatient Surgery
% Of Low Back Disc Cases With Outpatient Surgery
Key: ICD-9: International Classification of Diseases, 9th Revision.
722.10: displacement of lumbar intervertabral disc w/out myelopathy : thoracic or lumbosacral neuritis or radiculites unspecified
Note: Low back disc cases are defined as low back claims with at least half of the medical dollars spent on a set of seven disc-related ICD-9 codes; the most frequent codes included are and
Low Back Cases With Disc Conditions, Claims With > 7 Days Of Lost Time, Not Adjusted For Injury/Industry Mix; Source: CompScope™ Medical Benchmarks For New Jersey, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

13. Payments Higher, Growing Faster For Low Back Disc Cases With Inpatient Surgery
Low Back Disc Cases With Outpatient Surgery
12 Mos.
24 Mos.
36 Mos.
AAPC
4.0%
6.2%
2.7%
12 Mos.
24 Mos.
36 Mos.
AAPC
1.0%
2.9%
2.6%
Key: AAPC: Annual average percentage change. Mos.: Months. ICD-9: International Classification of Diseases, 9th Revision.
It is important to note that even within this relatively homogenous group of cases, there could be differences in the mix and complexities of surgery performed at inpatient and outpatient settings.
Note: Low back disc cases are defined as low back claims with at least half of the medical dollars spent on a set of seven disc-related ICD-9 codes; the most frequent codes included are and
Average Medical Payment Per Episode, Low Back Cases With Disc Conditions With Surgery, Claims With > 7 Days Of Lost Time, Not Adjusted For Injury/Industry Mix; AAPC: Annual Average Percentage Change Source: CompScope™ Medical Benchmarks For New Jersey, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

14. Less Use Of Hospital Care In WC: Follows Trends In General Health Care
Decrease in hospital inpatient care
Shift to free-standing facilities from hospital outpatient facilities, such as ambulatory surgery centers (ASCs)
Decreased use of hospitals for some services that are more expensive when provided in hospitals; shift to nonhospital
© Copyright 2017 WCRI. All Rights Reserved.

15. Rapid Increase In Medicare-Certified ASCs Through 2008, Then More Modest Growth
Source: Medpac (Medicare Payment Advisory Commission) Health Care Spending and the Medicare Program: A Data Book, June Located at
Source: MedPAC (Medicare Payment Advisory Commission), A Data Book: Health Care Spending And The Medicare Program, June 2016 And Earlier Years
© Copyright 2017 WCRI. All Rights Reserved.

16. % Of Claims With Facility Services
Many States Had Decreases In % Claims With Hospital Outpatient Facility, Increases In ASC
Hospital Outpatient Facility Services
% Of Claims With Facility Services
Ambulatory Surgery Center (ASC) Facility Services
Key: ASC: Ambulatory surgery center.
Claims With Facility Services (hospital and ASC treatment/operating/recovery room services) As A Percentage Of Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Not Adjusted For Injury/Industry Mix Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

17. % Point Change In % Of Claims With Facility Services, 2009 To 2014
Shift In % Of Claims From Hospital To ASC Facility In Many Study States 2009–2014
% Point Change In % Of Claims With Facility Services, 2009 To 2014
Key: ASC: Ambulatory surgery center. Note: 2014 refers to 2014/15. Other injury year/evaluation combinations are denoted similarly.
Claims With Facility Services (hospital and ASC treatment/operating/recovery room services) As A Percentage Of Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Not Adjusted For Injury/Industry Mix Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

18. Average Facility Payment Per Surgical Claim
ASC Facility Payment/Surgical Claim Lower Than Hospital Outpatient In Many States
More Than 15% Higher For ASC Than Hospital Outpatient
Average Facility Payment Per Surgical Claim
More Than 15% Lower For ASC Than Hospital Outpatient
Average Facility Payment Per Surgical Claim, 2014 Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Adjusted For Injury/Industry Mix; Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

19. Less Use Of Hospital Care In WC: Follows Trends In General Health Care
Decrease in hospital inpatient care
Shift to free-standing facilities from hospital outpatient facilities, such as ambulatory surgery centers (ASCs)
Decreased use of hospitals for some services that are more expensive when provided in hospitals; shift to nonhospital
© Copyright 2017 WCRI. All Rights Reserved.

20. % Point Change In % Of Claims With Physical Medicine, 2009 To 2014
Shift From Hospital To Nonhospital Physical Medicine In Most Study States
% Point Change In % Of Claims With Physical Medicine, 2009 To 2014
Key: PM: Physical medicine and chiropractic care
Claims With Physical Medicine As A Percentage Of Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Not Adjusted For Injury/Industry Mix; Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

21. Average Payment/Service For Physical Medicine
Hospitals Billed Higher Payments/Service For Physical Medicine Than Nonhospital
Average Payment/Service For Physical Medicine
More Than 50% Hospital-Nonhospital Difference In Payment Per Service
Up To 50% Hospital-Nonhospital Difference In Payment Per Service
Note: Nonhospital is based on price index, hospital outpatient is based on payment per service.
Average Payment Per Service For Physical Medicine, 2014 Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Adjusted For Injury/Industry Mix; Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

22. Average Payment/Service For Major Radiology
Major Radiology Payment/Service: Hospital Outpatient Mostly 2–4 Times Nonhospital
Average Payment/Service For Major Radiology
Average Payment Per Service For Major Radiology, 2013 Claims With > 7 Days Of Lost Time At 24 Months Of Experience, Adjusted For Injury/Industry Mix; Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

23. % Point Change In % Of Claims With Major Radiology, 2009 To 2013
Increased Use Of Nonhospital Major Radiology Services In Some Study States
% Point Change In % Of Claims With Major Radiology, 2009 To 2013
Key: PM: Physical medicine and chiropractic care. PT/OT: Physical/occupational therapist.
Claims With Major Radiology As A Percentage Of Claims With > 7 Days Of Lost Time At 24 Months Of Experience, Not Adjusted For Injury/Industry Mix; Source: CompScope™ Medical Benchmarks, 17th Edition (2016)
© Copyright 2017 WCRI. All Rights Reserved.

24. Topics Covered In Today’s Discussion
Shifts in provision of workers’ compensation medical services
Trends in indemnity benefits per claim: Effects of reforms in selected states
Impact of physician dispensing reforms
Interstate variation in opioid use
© Copyright 2017 WCRI. All Rights Reserved.

25. Trends In Indemnity Benefits Per Claim: Effects of Reforms In Selected States

26. Indemnity Benefits Per Claim: NC Among Highest, IN Among Lowest Of Study States
Median State: $18,424
Key: HB: House bill.
Note: The reader should be aware that all lump-sum payments are reported as indemnity payments. This achieves consistency and comparability in this measure across all states because lump-sum payments to close out future obligations are rarely separated into medical and indemnity components in the data.
Note: NC results reflect more than two years of experience under HB 709 (effective 6/24/11).
2013/16 Claims With > 7 Days Of Lost Time, Adjusted For Injury/Industry Mix
Source: CompScope™ Benchmarks , 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

27. Recent Indemnity-Related Reforms In Indiana and North Carolina
Low maximum benefit one factor in lower indemnity benefits per claim
HEA 1320 (2013) increased the maximum statutory weekly benefit and permanent partial impairment benefits
North Carolina:
Longer duration of temporary disability and higher lump sum settlements: drivers of higher indemnity benefits per claim
HB 709 (2011) capped duration of TTD and TPD benefits
© Copyright 2017 WCRI. All Rights Reserved.

28. 2013 Legislation In Indiana Increased Indemnity Benefits

29. HEA 1320 Increased Income Benefits Over 3 Years, Beginning In 2014
Maximum statutory weekly benefit increased 20% overall, from $650
To $ effective 7/1/2014 (6.7% increase)
To $ effective 7/1/2015 (6.3% increase)
To $ effective 7/1/2016 (5.9% increase)
Permanent partial impairment benefit amount per degree of impairment increased 16%–25% overall; more for lower categories
Maximum compensation payable increased from $325,000 to $390,000
Source: CompScope™ Benchmarks For Indiana, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

30. 5% Increase In Indiana Indemnity Benefits Per Claim In 2015; Had Been Fairly Stable
AAPC
2004 To 2013
12 Mos.
2.3%
24 Mos.
2.7%
36 Mos.
3.2%
48 Mos.
n/a
-1.8%
-0.4%
4.9%
Key: AAPC: Annual average percentage change. Mos.: Months.
Claims With > 7 Days Of Lost Time, Not Adjusted For Injury/Industry Mix
Source: CompScope™ Benchmarks For Indiana, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

31. Indemnity Benefits/Claim 2010–2015 Stable Overall; Several Factors Drove 2015 Growth
1.9%/Year
1.1%/Year
2.0%/Year
Claims With > 7 Days Of Lost Time At 12 Months Of Experience, Not Adjusted For Injury/Industry Mix
Source: CompScope™ Benchmarks For Indiana, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

32. After 2 Of 3 Increases: IN Maximum Statutory TTD Benefit Lower Than Many States
Increases In Maximum Benefit
7/1/14
$694
7/1/15
$737
7/1/16
$780
Maximum Weekly TTD Benefit
After 2 of 3 Increases
Key: TTD: Temporary total disability.
Maximum Weekly Statutory Temporary Total Disability Benefit As Of July 1, 2015
Source: CompScope™ Benchmarks For Indiana, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

33. Mostly After First Increase: 1 In 6 IN Injured Workers Had Benefits Limited By Maximum
Median State: 10.8%
Estimate: 10%
Key: TTD: Temporary total disability.
Note: Data for Indiana reflect mostly the first of three increases in the maximum weekly statutory TTD benefit.
2015/16 Claims With > 7 Days Of Lost Time, Adjusted For Injury/Industry Mix
Source: CompScope™ Benchmarks For Indiana, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

34. 2011 Legislation In NC: Aimed At Drivers Of Higher Indemnity Costs

35. Factors That Contribute To Higher Indemnity Benefits Per Claim In North Carolina
North Carolina has aspects of both a wage-loss and PPD benefit system
An injured worker who has not returned to work at the end of the healing period either continues to receive TTD benefits (as in a wage-loss benefit system) or elects to receive PPD benefits, resulting in
Longer duration of temporary disability (no limit prior to HB 709)
Higher % of claims with lump-sum settlements and higher lump-sum settlements than many states
Key: PPD: Permanent partial disability.
Source: CompScope™ Benchmarks For North Carolina, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

36. HB 709 Capped Duration of TTD and TPD Benefits
500 week cap on TTD benefits from date of disability (provision for extended benefits)
500 week cap on TPD benefits beginning at first TPD payment, less any TTD
Specifies a more precise and narrower definition of suitable employment for pre-and post-MMI cases
Worker access to VR services, including education, if no RTW or RTW at < 75% of preinjury AWW
Source: CompScope™ Benchmarks For North Carolina, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

37. NC Indemnity Benefits Per Claim Fairly Stable Since 2009, After Rapid Growth
Recession/ Early Recovery
AAPC
2004 To 2009
Since 2009
12 Mos.
7.7%
2.0%
24 Mos.
7.1%
0.4%
36 Mos.
6.3%
-1.3%
48 Mos.
6.2%
-3.8%
2.6%
5.2%
Key: AAPC: Annual average percentage change. HB: House bill. Mos.: Months.
Note: The reader should be aware that all lump-sum payments are reported as indemnity payments. This achieves consistency and comparability in this measure across all states because lump-sum payments to close out future obligations are rarely separated into medical and indemnity components in the data.
Claims With > 7 Days Of Lost Time, Not Adjusted For Injury/Industry Mix
Source: CompScope™ Benchmarks For North Carolina, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

38. Cumulative % Or PPT Change
Most NC Indemnity Components Fairly Stable Except Weeks Of Temporary Disability
Performance Measure
2009/12 (pre-HB 709)
2013/16
(post-HB 709)
Cumulative % Or PPT Change
Indemnity Costs/Claim
$26,666
$25,305
-5.1%
Average Weekly Wage
Of Injured Workers
$639
$687
+7.5%
Duration Of Temporary Disability (weeks)
24.6
20.0
-4.6 weeks (-18.6%)
% Lump-Sum Claims
41.4
43.0
+1.6 ppt
Lump-Sum Payments/ Claim With Lump Sum
$35,373
$35,045
-0.9%
Key: HB: House bill. ppt: Percentage points.
Claims With > 7 Days Of Lost Time At 36 Months Of Experience, Not Adjusted For Injury/Industry Mix And Wages; Source: CompScope™ Benchmarks For North Carolina, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

39. Cumulative % Change, 2009/12 To 2013/16
Weeks Of Temporary Disability Decreased More In NC Than In Other States
Median State: -3% (0.6 weeks)
4.6 Weeks
Cumulative % Change, 2009/12 To 2013/16 3%
Weeks Of Temporary Disability, Claims With > 7 Days Of Lost Time At 36 Months Of Experience, Not Adjusted For Injury/Industry Mix; Source: CompScope™ Benchmarks For North Carolina, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

40. NC Weeks Of TD Decreased 2009–2013 (Pre & Post-HB 709); Little Recent Change
AAPC
2004 To 2009
2009 To 2013
12 Mos.
2.1%
-2.3%
24 Mos.
2.4%
-4.0%
36 Mos.
2.3%
-5.0%
48 Mos.
n/a
HB 709
+0.6%
Key: AAPC: Annual average percentage change. HB: House bill. Mos.: Months. n/a: Not applicable. TD: Temporary disability.
Claims With > 7 Days Of Lost Time, Not Adjusted For Injury/Industry Mix
Source: CompScope™ Benchmarks For North Carolina, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

41. TD Per PPD/Lump-Sum Claim (weeks)
TD Duration Decrease Since 2012 May Partly Reflect Earlier Settlements Under HB 709
TD Per TD Claim (weeks)
TD Per PPD/Lump-Sum Claim (weeks)
-0.8 Wk
-1.0 Wk
-1.6 Wk
-0.5 Wk
0.5 Wk
Key: Mos.: Months. n/a: Not applicable. PPD: Permanent partial disability. TD: Temporary disability. Wk: Weeks.
Claims With > 7 Days Of Lost Time, Not Adjusted For Injury/Industry Mix And Wages
Source: CompScope™ Benchmarks For North Carolina, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

42. Recent NC Trends In % Lump-Sum Claims And Amounts May Relate To HB 709
% Of Claims With Lump Sums
Lump-Sum Settlements/Claim
HB 709
-5%
-6%
+4%
HB 709
Key: HB: House bill. Mos.: Months.
Claims With > 7 Days Of Lost Time With Lump-Sum Settlements, Not Adjusted For Injury/Industry Mix And Wages; Source: CompScope™ Benchmarks For North Carolina, 17th Edition (Forthcoming)
© Copyright 2017 WCRI. All Rights Reserved.

43. Topics Covered In Today’s Discussion
Shifts in provision of workers’ compensation medical services
Trends in indemnity benefits per claim: Effects of reforms in selected states
Impact of physician dispensing reforms
Interstate variation in opioid use
© Copyright 2017 WCRI. All Rights Reserved.

44. 20 States Changed Rules Governing Reimbursement For Physician-Dispensed DrugsID MI PA CT NV IL IN DE KS
Reform States Focusing On Cost Reduction Only CA NC AZ TN OK SC AL GA
Reform States Further Limiting Physician Dispensing To Short Timeframe Or Certain Drugs MS FL
States Where Physician Dispensing Not Allowed In General Or Infrequent HI
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45. Illustrative: In Illinois, The Same Drugs, When Physician-Dispensed, Are Much Higher Priced
Common WC Drugs Prescribed By Physicians
Price Per Pill
% Difference
Physician Rx
Pharmacy Rx
Hydrocodone-acetaminophen (Vicodin®)
$1.41
$0.52
172%
Ibuprofen (Motrin®)
$0.49
$0.27
81%
Tramadol HCL (Ultram®)
$1.55
$0.73
114%
Cyclobenzaprine HCL (Flexeril®)
$1.85
$0.99
88%
Meloxicam (Mobic®)
$5.86
$3.19
84%
Illinois 2011/12 Claims With > 7 Days Of Lost Time With Prescriptions. Source: The Prevalence And Costs Of Physician-Dispensed Drugs (2013)
© Copyright 2017 WCRI. All Rights Reserved.

46. Physician Dispensing Is More Expensive, Even After Recent Reforms
Many physicians continued to dispense after reforms
Price-focused reforms reduced prices, but still ~30% higher than pharmacy filling same Rx
Frequent physician dispensing of higher-priced new strengths drove up prices paid to physicians for 3 top drugs
© Copyright 2017 WCRI. All Rights Reserved.

47. Fewer Prescriptions Filled At Offices Post-Reform, But Physician Dispensing Is Still Common
Pre-Reform
Post-Reform
% Of All Prescriptions That Were Physician-Dispensed Prescriptions
Calendar Quarter Relative To Reform
Data include prescriptions filled up to March 31, 2014, for all medical claims with dates of injury within 24 months of the observation quarter.
© Copyright 2017 WCRI. All Rights Reserved.

48. Avg. Price Per Pill Paid For Physician-Dispensed Cyclobenzaprine
Substantial Price Reductions After Reforms In Most States, Except IL and FL
Avg. Price Per Pill Paid For Physician-Dispensed Cyclobenzaprine
Key: Rx: Prescriptions. 2014Q1: First Quarter Of 2014 (Latest Quarter Of Study Period). For Each Drug Product, States Are Presented In The Order Of Dispensing Frequency.
© Copyright 2017 WCRI. All Rights Reserved.

49. Price Paid To Physicians For Cyclobenzaprine Increased At Different Times
Pre-Reform
Post-Reform
Avg. Price Per Pill Paid For Cyclobenzaprine Dispensed By Physicians
Calendar Quarter Relative To Reform
Data include prescriptions filled up to March 31, 2014, for all medical claims with dates of injury within 24 months of the observation quarter.
© Copyright 2017 WCRI. All Rights Reserved.

50. Price Paid To Physicians For Cyclobenzaprine Increased At Different Times
Snapshot As Of 2013Q1
Pre-Reform
Post-Reform
Avg. Price Per Pill Paid For Cyclobenzaprine Dispensed By Physicians
Calendar Quarter Relative To Reform
Data include prescriptions filled up to March 31, 2014, for all medical claims with dates of injury within 24 months of the observation quarter.
© Copyright 2017 WCRI. All Rights Reserved.

51. Price Paid To Physicians For Cyclobenzaprine Increased At Different Times
Snapshot As Of 2013Q2
Pre-Reform
Post-Reform
Avg. Price Per Pill Paid For Cyclobenzaprine Dispensed By Physicians
Calendar Quarter Relative To Reform
Data include prescriptions filled up to March 31, 2014, for all medical claims with dates of injury within 24 months of the observation quarter.
© Copyright 2017 WCRI. All Rights Reserved.

52. Price Paid To Physicians For Cyclobenzaprine Increased At Different Times
Snapshot As Of 2013Q3
Pre-Reform
Post-Reform
Avg. Price Per Pill Paid For Cyclobenzaprine Dispensed By Physicians
Calendar Quarter Relative To Reform
Data include prescriptions filled up to March 31, 2014, for all medical claims with dates of injury within 24 months of the observation quarter.
© Copyright 2017 WCRI. All Rights Reserved.

53. Price Paid To Physicians For Cyclobenzaprine Increased At Different Times
Snapshot As Of 2013Q4
Pre-Reform
Post-Reform
Avg. Price Per Pill Paid For Cyclobenzaprine Dispensed By Physicians
Calendar Quarter Relative To Reform
Data include prescriptions filled up to March 31, 2014, for all medical claims with dates of injury within 24 months of the observation quarter.
© Copyright 2017 WCRI. All Rights Reserved.

54. Price Paid To Physicians For Cyclobenzaprine Increased At Different Times
Snapshot As Of 2014Q1
Pre-Reform
Post-Reform
Avg. Price Per Pill Paid For Cyclobenzaprine Dispensed By Physicians
Calendar Quarter Relative To Reform
Data include prescriptions filled up to March 31, 2014, for all medical claims with dates of injury within 24 months of the observation quarter.
© Copyright 2017 WCRI. All Rights Reserved.

55. Pharmacy Prices For Cyclobenzaprine Changed Little Or Decreased After Reforms
Pre-Reform
Post-Reform
Avg. Price Per Pill Paid For Cyclobenzaprine Dispensed At Pharmacies
Calendar Quarter Relative To Reform
Data include prescriptions filled up to March 31, 2014, for all medical claims with dates of injury within 24 months of the observation quarter.
© Copyright 2017 WCRI. All Rights Reserved.

56. Frequent Physician Dispensing Of New Strengths, Paid At Higher Prices
Example of cyclobenzaprine in Florida
5 and 10 milligrams most common prior to introduction of new strength (7.5 milligrams)
7.5-milligram cyclobenzaprine dispensed by physicians in Florida before reform, large increase in frequency after reform
New strength not seen in pharmacy-dispensed prescriptions for cyclobenzaprine
Average wholesale price for new strength
Higher than AWPs for existing strengths
Assigned by manufacturer, not repackager
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57. % Of Prescriptions For Cyclobenzaprine HCL (Flexeril®) By Strength
Rapid Increase In Physician Dispensing New Strength Cyclobenzaprine In Florida
Physician Dispensed
Pharmacy Dispensed
% Of Prescriptions For Cyclobenzaprine HCL (Flexeril®) By Strength
Included are prescriptions dispensed by physicians and pharmacies in Florida from first quarter of (2012Q1) to first quarter of 2014 (2014Q1).
© Copyright 2017 WCRI. All Rights Reserved.

58. Much Higher Price Paid To Physicians Who Dispensed New Strength Cyclobenzaprine In FL
Physician And Pharmacy Prices For Cyclobenzaprine HCL, By Strength
Pre-Reform (2013Q2)
Post-Reform (2014Q1)
Physician-Dispensed Prescriptions
7.5 Milligrams – New Strength
$3.43
$4.11
5 Milligrams
$1.83
$1.75
10 Milligrams
$1.42
$1.29
Pharmacy-Dispensed Prescriptions
7.5 Milligrams—New Strength
n/a
$1.37
$1.38
$0.91
$0.93
Physician And Pharmacy Prices For Cyclobenzaprine HCL, By Strength
Pre-Reform (2013Q2)
Post-Reform (2014Q1)
Physician-Dispensed Prescriptions
7.5 Milligrams—New Strength
$3.43
$4.11
5 Milligrams
$1.83
$1.75
10 Milligrams
$1.42
$1.29
Physician And Pharmacy Prices For Cyclobenzaprine HCL, By Strength
Pre-Reform (2013Q2)
Post-Reform (2014Q1)
Physician-Dispensed Prescriptions
7.5 Milligrams – New Strength
$3.43
$4.11
2013Q2: Second Quarter Of 2013; 2014Q1: First Quarter Of 2014
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59. High-Priced New Strength/Formulation Frequently Dispensed By Physicians In Several States
% Of Physician-Dispensed Drug That Were For New Strength, In 2014Q1 CA FL IL TN
7.5 Milligrams
Cyclobenzaprine HCL
55%
49%
22%
19%
150 Milligrams ER
Tramadol HCL
47%
26%
41%
21%
Milligrams
Hydrocodone-Acetaminophen
32%
n/a
11%
Lidocaine-Menthol
Topical Pain Patches*
14%
24% –
* Prescriptions for lidocaine-menthol as % of prescriptions for topical pain patches Q1: First Quarter Of 2014 (Latest Quarter Of Study Period)
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60. Prices For All Generic Drugs Dispensed By Physicians Increased More Rapidly
Included are prescriptions dispensed by physicians and pharmacies in Florida from first quarter of (2012Q1) to first quarter of 2014 (2014Q1).
© Copyright 2017 WCRI. All Rights Reserved.

61. Topics Covered In Today’s Discussion
Shifts in provision of workers’ compensation medical services
Trends in indemnity benefits per claim: Effects of reforms in selected states
Impact of physician dispensing reforms
Interstate variation in opioid use
© Copyright 2017 WCRI. All Rights Reserved.

62. Amount of Opioids Decreased In Several States, Large Interstate Variations Still Persist
54–86% of injured workers with pain meds received opioids across 25 states
Substantial interstate variation in amount of opioids received by injured workers, higher in LA, NY, and PA
Injured workers received opioids on a longer-term basis in several states, highest in LA
Sizable reductions in amount of opioids over the study period in several states
Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2009, To September 30, 2012, Average 24 Months Of Prescriptions Filled Up To March 31, 2014
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63. 3 In 4 Injured Workers With Pain Meds. Received Opioids In Most States
86%
54%
2012/14: Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2011, To September 30, 2012, Prescriptions Filled Through March 31, Rx: Prescriptions
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64. Opioid Drugs Commonly Prescribed To Injured Workers, Paid Under Workers’ Comp.
% Of Pain Medication Rx That Were For …
Federal Schedule
25-State Median
25-State Range
Hydrocodone-APAP (Vicodin®)
III*
30%
10%–46%
Tramadol (Ultram®) IV
14%
11%–24%
Oxycodone Products (Percocet®, OxyContin®) II 9%
1%–29%
All Other Opioids (Morphine, Fentanyl, Buprenorphine, etc.)
II & III 4%
2%–8%
Non-Opioid Pain Medications –
41%
30%–54%
* DEA issued a final rule to reschedule hydrocodone-combination products from Schedule III to Schedule II, effective October 2014.
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65. % Pain Rx For Hydrocodone-Combination Products Dropped By 7 PPT In NY
% Of Pain Medication Rx That
Were For …
2010/12
2012/14
% Point Change
Hydrocodone-APAP (Vicodin®), Upscheduled from III to II in 02/2013
26%
19% -7
Tramadol (Ultram®)
11%
14% 3
Oxycodone Products
(Percocet®, OxyContin®)
16% 2
All Other Opioids (Morphine, Fentanyl, Buprenorphine, etc.)
10% 8% -3
Non-Opioid Pain Medications
38%
43% 5
2012/14: Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2011, To September 30, 2012, Prescriptions Filled Through March 31, Similar Notation Used For 2010/12
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66. Amount Of Opioids Per Claim Was Unusually Higher In LA, NY, And PA
Average Morphine Equivalent Amount (MEA) Per Claim With Opioids
Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2011, To September 30, 2012, Prescriptions Filled Through March 31, 2014; Excluded Claims With Extreme Values
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67. Higher Amount Could Be Driven By Longer Duration Or Stronger Doses
MEA per claim = Number of Rx * Quantity * Strength * Morphine conversion factor(CF)
Stronger doses
Rx Fill Date
Drug Name
Morphine CF
Narcotic Strength
Qty.
MEA
01/01/2012
Vicodin® 1
5mg 40
200
01/10/2012
Percocet®
1.5
10mg 60
900
1100
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68. Had Longer-Term Use Of Opioids % Of Claims With Opioids That
In LA, 1 In 6 Injured Workers With Opioids Received Opioids On Longer-Term Basis
Had Longer-Term Use Of Opioids
% Of Claims With Opioids That
Longer-term use: Injured worker received an opioid Rx in first 3 months after injury and had 3+ visits to fill opioid Rx between 7th and 12th month post-injury
Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2011, To September 30, 2012, Prescriptions Filled Through March 31, 2014
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69. Average Opioid Dose Was 350–450 Per Rx In Most Study States, Higher In PA & NY
Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2011, To September 30, 2012, Prescriptions Filled Through March 31, 2014
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70. Small Proportion Of Claims Have Large Amount Of OpioidsNY LA PA
Percentile Distribution of MEA Per
Claim With Opioids, 2012/2014
Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2011, To September 30, 2012, Prescriptions Filled Through March 31, 2014
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71. Higher Amount Of Opioids Per Claim In LA, NY, PA Even 6 Months Post-Injury
Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2011, To September 30, 2012, Prescriptions Filled Through March 31, 2014
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72. State Policies Addressing Opioids Prescribing And Dispensing
Prescription drug monitoring programs (PDMP)
Drug formularies
Guidelines
Limits on prescribing and dispensing
Insurer and pharmacy benefit manager initiatives
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73. Significant Reductions In Amount Of Opioids Per Claim Seen In Most States
Nonsurgical Claims With > 7 Days Of Lost Time, Injuries Occurring From October 1, 2009, To September 30, 2012, Average 24 Months Of Prescriptions Filled Up To March 31, 2014
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74. Several Reforms Coincided With Reductions In Opioids Filled Over The Study PeriodMI OK MA NC MD TX
% Decrease in Mean/Median Amount of Opioids per Claim
31%/
20%
29%/
13%
24%/
14%
21%/ 5% 0%
20%/
PDMP 
Treatment Guidelines
Formulary
Others
Spillover effects of group health limits
Regulated pain clinics
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75. Thank You! For comments/questions about the findings:
Follow WCRI on social media:
Carol Telles
Senior Analyst
Vennela Thumula
Policy Analyst
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