1. The Risks of Opioid Mismanagement
Identifying and Managing Your Exposure from Opioids
Good afternoon, everyone. We’re delighted to be here and appreciate the opportunity to speak with you today.
Our topic for today is medical management and the TPA model. Our approach for the conversation may be a bit unique. Here’s how we’ve segmented the presentation:
The first thing we’re going to discuss is an employer’s typical program goals for workers’ compensation.
By a show of hands, how many employers do we have here today?
How many attorneys?
Vendors?
The second thing we’re going to discuss is a quick snapshot of some industry trends and how they are impacting your ability to achieve your goals.
The third thing we’re going to discuss is hopefully what you were expecting to hear – what are some of the solutions available to help us achieve our goals.
© 2013 CorVel Corporation.

2. Key Terms Opioid: psychoactive chemical used as an analgesic
PBM: Pharmacy Benefit Management
NDC: National Drug Code
UR: Utilization Review
Clinical Modeling: In-depth look at claimant’s behaviors to determine risk and next steps

3. Workers’ Comp Pharmacy Costs
At the same time we’ve seen a recent increase in lost time claims, and continuing increase in severity of the past decade, we’ve seen certain components rise much more rapidly than others.
Rx has moved from 5-6% of medical to 10-12%, to an estimated 19% of total medical expenses. This was from a report released by NCCI in just the last few weeks.

4. Pharmacy Exposure and Medical and Other Exposure
Known and expected
Pill Price (location, inflation, brand/generics, physician dispensing)
Utilization
Behavior (prescriber and patient – dependency & addiction)
Extending employer exposure
Addiction and third party liability
Addiction and reputational exposure

5. Narcotics on the rise What is your exposure?
627% Increase
© 2011 CorVel Corporation.
At the same time we’ve seen a recent increase in lost time claims, and continuing increase in severity of the past decade, we’ve seen certain components rise much more rapidly than others.
Rx has moved from 5-6% of medical to 10-12%, to an estimated 19% of total medical expenses. This was from a report released by NCCI in just the last few weeks.
296% Increase
National Vital Statics System, multiple cause of death data set and DEA ARCOS system, 2007 opioid sales figure is preliminary

6. Drug Overdose Death Rate
At the same time we’ve seen a recent increase in lost time claims, and continuing increase in severity of the past decade, we’ve seen certain components rise much more rapidly than others.
Rx has moved from 5-6% of medical to 10-12%, to an estimated 19% of total medical expenses. This was from a report released by NCCI in just the last few weeks.
National Vital Statics System, multiple cause of death data set and DEA ARCOS system,

7. Drivers of addictive pain meds
“Fix me”
Lack of physician prescriber education
Lawsuits over withholding “needed pain meds”
Big Pharma profits
Pain meds in comp are easy to attain and “free”
Doctor shopping

8. How many of my claimants are addicts?
Expected outcomes and costs of addicted claimants in comp – beyond the pill price
Delayed return to work
Fatal overdoses = death benefit
Non-fatal overdoses = long term care
How many of my claimants are addicts?

9. The Heffernan Decision
Mr. Heffernan suffered chronic pain from a compensable 2002 lower back injury.
At some point between 2002 – 2007, he became addicted to his pain meds.
The Heffernan Decision
December 2011, PA appellate court upheld death benefit
June 2007
U/R ruling No more Dr. Rodriguez!
10 am
Dr. R appt.
Need new script for pain meds
OMG – meds denied!
I need my meds!
Call Dr. R at his home #.
8:30 am
Appt. w/ Dr. R’s sister, Daisy
WHERE ARE THEY!
Fed Ex here
Thank God!
4 – 6 pm
Heffernan Wake
Boyle Funeral Home
10 am
Funeral Mass
St. Agnes
9 am
Meeting with lawyer
The Decision
In December 2011, PA appellate court upheld death benefit.

10. The Appellate Court’s Rationale
It did not matter that the fatal dose was denied by U/R. U/R is not a defense.
Retro U/R is not enough.
Employer has a duty/responsibility to take care of the addicted claimant
Clear extension of employer/payor liability
20PACO% xml&docbase=CSLWAR CURR

11. What does this mean for my organization?
You might have to defend your company
Drug addicts causing mayhem is big news
Potential exposure:
Potentially no statutory limits to third party liability
Damage to reputation/brand

12. What your PBM may not be telling you
What I am going to do about all the transactions I don’t see?
PBMs are losing traction every year
Ok. Now we know our goals. Is everyone comfortable with our goals? Pretty simple and straightforward. Now, let’s look at the trends as it relates to our goals.

13. Dispensing channels

14. The view of the work comp PBM

15. What’s wrong with my doctor dispensing drugs?
Growing annually in SC
2007 / = 12% of scripts
2010 / = 18% of scripts

16. Total Exposure Management
Solutions
Total Exposure Management
Ok. Now we know our goals. Is everyone comfortable with our goals? Pretty simple and straightforward. Now, let’s look at the trends as it relates to our goals.

17. Real-time Integration with PBM and Bill Review
More resources
100% visibility to timely and actionable Rx data
Maximize prospective management and stop the penetration games
Retro U/R is not enough

19. Clinical Profiling and Peer to Peer Intervention
Assess the risk of all your claims with 100% of the pharmacy data set
Pharmacist reviews have limited value
Most treating physicians need help
Board certified pain management physicians
Address the needs of the patients, functional and behavioral

20. This is an example of a patient that was identified after we took over a program managed by another organization. Medical incurred was $358K. But, look at the Rx ratio to the medical spend ratio.
We have over a dozen triggers, and our clients are able to select the weighting of those triggers. This particular patient met 7 of those triggers, including narcotics dispensed by multiple parties.
I don’t know the specifics of the follow-up on this claim, but I can imagine it may have involved more than an adjustment in the patients treatment plan.

21. Summary
Pharmacy exposure continues to increase, and your exposure goes far beyond unit cost
PBMs are critical for managing your exposure, but they have limits
Integration with bill review and PPO yields better results
Leverage data and clinical resources

22. Tracy Snell Account Manager CorVel Corporation (O) 803.451.3404