1. Rx Abuse in Workers’ Compensation
Statistics and Methods for Combating the Problem
Patrick Cronin, CPCU, AIC, AIM, AAI, ARM, CWCP
Branch and Claims Manager – CorVel HealthCare Corporation

2. Discussion Points Federal Classification of Controlled Substances
Statistics
Rx Impact on WC Expenditures
Problems Compounding the Problem (no pun intended)
Adverse Effects of Opioid Abuse
Potential Tools in the Battle (Cost Savings)
Potential Tools in the Battle (Preventing the Adverse Health Effects)

3. Federal Classification of Controlled Substances

4. Statistics
Prescription abuse is the fastest growing drug issue in America
In terms of controlling the cost of indemnity claims, prescription opioids are the number one problem
Nationally, 55% to 86% of all claimants are receiving opioids for chronic pain relief
Evidence based medicine only supports its long term use in very specific cases, most of which involve end-stage cancer treatment
Overdose deaths (involving opioids) have increased 300% since 1999
The misuse of prescription pain-killers was responsible for 475,000 ER visits in 2009

5. Rx Impact on WC Expenditures
1990 – Rx accounted for approximately 2% of medical expenditures
2001 – Impact increased by 400% (from 1990)
Today – WC Rx accounts for approximately 19% of total medical expenditures
Opioids account for approximately 25% of the current Rx spend
Opioids account for approximately 35% (or greater) of Rx spend in claims open for three (3) or more years
Based on projected Rx utilization (and, specifically, opioids), the cost of MSA calculations are increasing exponentially

6. Rx Impact on WC Expenditures (continued)
Less than proactive pharmacy management increases TTD
Less than proactive pharmacy management results in greater PPI ratings
The treatment of comorbidities (when coupled to opioid abuse) results in 20-30% of workers’ compensation’s ultimate developed cost
Bottom line – the ship has sailed on Rx’s relatively minor impact on workers’ compensation claim costs
In general, employers are unaware of the sizable impact of Rx on their workers’ compensation costs
Injured workers prescribed even one (1) opioid had total claim costs 4-5 times greater than claimants with similar claims who didn’t get opioids

7. Problems Compounding the Situation
Some PBMs (pharmacy benefits management) protocols do not capture leakage of prescriptions written and dispensed by doctors (40%-50%)
Some PBM stewardship reports only speak of discounts achieved through network utilization
Some PBMs lack aggressive protocols for intervention into potential opioid abuse
Some PBMs do not measure (via bill review protocols) the potential interventions associated with doctor prescribed/dispensed Rx

8. Adverse Affects of Opioid Abuse
Increased frequency of emergency room visits from overdose
Death
Addition treatment
Comorbidities
Abuse and misuse of prescription drugs
Estimates show that approximately 35% of patients receiving long- term opioid treatment protocols may be addicted
Since opioids reduce a patient’s pain by 30%-40%, it is common for opioids to be combined with other, non-opioid analgesics

9. Potential Tools in the Battle
Cost saving measures
Generic equivalents
PBM penetration
Network steerage
Mail order protocol for long term Rx treatment

10. Potential Tools in the Battle (details to follow)
Methods to help avoid the adverse health effects of Rx (and, specifically, opioid) abuse
Aggressive tier based formulary (established in concert with your PBM)
Ensure that all opioid prescribed claimants are routinely drug tested
Link Rx trends to your bill review provider (captures and measures drugs prescribed AND dispensed out of network)
Don’t over-ride formulary denials without specific justification and medical guidance
Review PBM reports (both monthly and claim specific)
Look for opportunities to engage the treating physician in intervention
Risk Assessment Tools (clinical modeling, clinical modeling and medication reviews

11. Aggressive Tier Based Formulary
PBMs can provide valuable assistance in the process
Restrict first fills and non-approval required medications to minor pain medications and anti-inflammatories
Limit the type and duration of potentially addictive pain-killers and muscle relaxants to a prior approval protocol
Set a protocol with your PBM and TPA for dealing with potentially problematic, long-term cases
Rx Review
EME
Nurse case management intervention

12. Ensure Routine Drug-Testing for Opioid Prescribed Claimants
Injured workers’ may not be taking the correct amounts, as prescribe, which could lead to addiction problems and comorbidities
Lack of evidence in testing can ascertain ulterior motives for seeking and obtaining opioids (they may be selling the discussed medications)
Certain outcomes can lead the adjuster to make recommendations for alternative methods of containment (surveillance and activity checks)
If the claimant is not taking the medications, why should you pay for them? (most doctors will suspend, or even terminate, the prescribing of certain opioids if there’s evidence of lack of use)

13. Link Rx Trends to Bill Review Provider
Doctor prescribed/dispensed medications can be measured and certain cost saving methods can be utilized
Doctor prescribed/dispensed medications can be entered into clinical modeling analytics for future treatment management protocols
Your PBM can sometimes re-direct these types of prescribing patterns into your network

14. Don’t Over-Ride Formulary Denials Without Specific Justification and Medical Guidance
You set up the formulary to prevent abuse – don’t disregard it’s efficacy
Know when to get aggressive, based on the circumstances surrounding the injury
Obtain nurse case management intervention, when circumstances warrant it
Obtain independent medical interventions, when warranted (pharmacy review and employer medical evaluations)
Utilize treatment guidelines, when warranted

15. Review PBM reports (Both Monthly and Claim Specific)
Look for trends in prescribing patterns, across the board
Look for outliers – claim specific
Develop plans for intervention
Review of opportunities for formulary adjustment, when necessary
Review of geographical trends – adjust for them, going forward

16. Look for Opportunities to Engage the Treating Physician(s)
Reach out to the medical provider to discuss possible changes
Nurse Case Management intervention
Pharmacy reviews – peer to peer
Employer Medical Evaluations – utilize when necessary

17. Risk Assessment Tools – Clinical Modeling

18. Risk Assessment Tools – Clinical Modeling

19. Risk Assessment Tools – Clinical Modeling