Combating Opioid Abuse in Workers' Compensation Claims

Prescription drug abuse is a national problem that is having a serious effect on workers’ compensation costs. Consider the following facts:
  • Research by the National Council on Compensation Insurance (NCCI) shows that prescription drugs account for 19% of all workers’ compensation medical costs.
  • Increased utilization of prescription drugs plays a big role in driving up per-claim drug costs, which grew 12% in 2009, the last year for which NCCI published data.
  • Also on the rise, according to NCCI, is physician dispensing of drugs (doctors filling prescriptions from their office rather than a pharmacy), which is associated with increased drug costs per claim.
  • OxyContin® is now the number one prescribed workers’ compensation drug, up from number three, and accounts for 6% of workers’ compensation medication costs.
  • A recent study found that when certain opioid painkillers were prescribed for workers’ compensation injuries, the total cost of those claims were almost four times more likely to exceed $100,000 than claims where opioids were not prescribed.
The addictive nature of opioid medication is driving some of the abuse, as injured workers become addicted to the painkillers during treatment and seek ever increasing doses or seek to stay on the drugs for a prolonged period of time. But “prescription diversion” is also an issue. The street value of a single OxyContin® pill is $40 and, in one study, 35% of workers were not taking the narcotics prescribed for them but instead were selling them.

Finding Patterns in Opioid Abuse

The good news is that the abuse is surprisingly concentrated as opposed to wide-spread. A recent study by the California Workers’ Compensation Institute looked at the number of physicians prescribing Schedule II drugs, including OxyContin® and other drugs with a high potential for abuse. The study found that a mere 1% of the physicians prescribing Schedule II narcotics wrote a whopping 33% of all the Schedule II prescriptions and that almost 80% of the prescriptions were written by only 10% of the physicians.

The Institute also looked for patterns in opioid prescription abuse by that top 10% of physicians and found that within that group, there were an average of 3.3 prescribing physicians per claim, an average of 57.4 prescriptions per claim and an average prescription cost per claim of $34,541.
The same pattern of concentration of abuse holds true for workers’ compensation claimants. An NCCI Workers' Compensation Drug Study shows that 70% of the narcotics prescribed in workers’ compensation claims went to only 5% of all claimants. The other 95% of workers’ compensation narcotics users received the other 30%. When the study drilled in closer, it found that 40% of the prescriptions for narcotics went to a mere 1% of all claimants.
Battling Opioid Abuse in Texas

The Workers’ Compensation Research Institute examined opioid use data from 21 states and found longer-term use of opioids was most prevalent in New York, Louisiana, Texas, Pennsylvania, South Carolina, California and North Carolina.

However, according to the “Healthcare Cost and Utilization, 2012” report issued by the Texas Department of Insurance-Division of Workers’ Compensation (TDI-DWC), Texas is having some success in battling opioid abuse within the workers’ compensation system:
  • The total cost of opioid use began decreasing in 2007 for both lost time claims and medical-only claims.
  • The cost for opioids in lost time claims fell from more than $40 million in 2007, to just under $35 million in 2011.
  • The cost of opioids in medical only claims fell from $6 million in 2007, to just over $3 million in 2011.
Texas’ most recent efforts to battle this problem include a recently passed “pill mill” law to try and eliminate pain management clinics that dispense narcotics to patients without an exam. It appears that utilization of Schedule II narcotics is being reduced as a result.

Implementation of the Texas Closed Formulary appears to have impacted the prescription of opioids as much, if not more, than any other initiative. As a part of that implementation, in 2011 the TDI-DWC began using Appendix A of the Official Disability Guidelines (ODG) for the Status N Drug list. For any date of injury on or after September 1, 2011, any drug prescribed from that list had to be pre-authorized. As a result of this initiative, many carriers and pharmacy benefit managers (PBMs) note a reduction in utilization of the Status N Drugs of as much as 70% for those new (post September 1, 2011) claims.

Application of the Status N Drug list to the older, legacy claims (those with dates of injury prior to September 1, 2011) was delayed until September 1, 2013. This staged implementation allowed the TDI-DWC and other stakeholders two years to review and evaluate the legacy claims in order to work with the medical community and injured workers to identify alternative drug treatments and, in many cases, properly wean injured workers off of powerful opioids. Beginning September 1, 2013, the Status N Drug list will apply to the legacy claims as well, which will mandate preauthorization for drugs on the Status N Drug list. Two practical exceptions to the preauthorization requirement apply to requests within the first 7 days from the date of injury and requests within 7 days from the date of surgery.

How JI, Our WellComp Team, and Our Other Managed Care Partners Can Help Reduce and Manage Opioid Abuse

The results from these studies show that it is possible to identify possible abusers and manage abuse by physicians and injured workers.  To do just that, some of the best practice approaches utilized by JI and our WellComp managed care team include:

Certified Networks or Physician Panels (where applicable)
  • Utilizing physicians who use a conservative approach to opioids based upon evidence based medicine
  •  Directing treatment to physicians versed in treatment guidelines
  •  Identifying physicians/provider groups prescribing and/or dispending inappropriate medications
Patient Education/Screening
  •  Educating injured workers about the dangers of opioids, including Schedule II medications (controlled substances)
  •  Identification of injured workers on long term use of medication (beyond 60 days)

    • Develop a collective approach designed to halt continued use
  • Random, periodic and targeted drug testing after prescribing to identify high risk patients based on pre-established criteria

    •  Number of prescriptions or length of time medication continues
Pharmacy Benefits Management Program
  • Establishing a formulaic approach to pharmacy treatment designed to  expedite appropriate medication by injury diagnosis and duration of care
  • Tying into Drug Utilization Review Program (DUR) to ensure clinical review of medications falling outside of nationally recognized guidelines and specifically in Texas the Official Disability Guidelines (ODG)
  • Replacing brand prescriptions with generic unless prescribed as Dispense as Written (DAW)
  • Ensuring early identification of opioid prescriptions, including prescription history
  • Offering additional program support for weaning/termination of inappropriate medications
  • Application of the Texas Closed Formulary for the Status N Drug monitoring and management
Drug Utilization Review/Guidelines Application
  • Application of nationally recognized evidence based medicine (EBM) guidelines, including the ODG
  • Clinical evaluation of pharmacy treatment falling outside of ODG
  • Physician pharmaceutical review/peer to peer physician review of pharmacy treatment plans, as required under the Texas Closed Formulary for Status N Drugs
Medical Bill Review
  • Retrospective capture of prospective utilization review decisions
  • Identification of compounds and repackaged medications to ensure appropriate price is recommended and to attempt a change of treatment via communication with the prescribing physician
  • Documentation of physician dispensing practices – resulting in targeted education to providers in the medical community
With the more recent application of cost containment measures such as medical provider networks and utilization review, there remain only a small number of claims in which pharmaceutical abuse occurs. For those cases, JI and our Managed Care Partners offer an additional medical intervention program that pulls together a clinical team approach designed to change both provider and injured worker behavior via targeted intervention.  This approach makes it possible to find and prevent opioid abuse while still ensuring that seriously injured workers or those dealing with severe pain have access to appropriate pain medications.

An Approach That Works

The big question, of course, is “do these best practices have a practical effect?” And the answer is a resounding “Yes!”

In comparison to the NCCI studies referenced above, JI / York’s customers average just 14% in pharmacy treatment of all workers’ compensation medical costs, 5% less than the national average. These savings result in real dollars that can be directed to other resources desperately needed in this financial environment. Identifying and preventing opioid abuse means injured workers can be spared the pain of addiction.