Download Risk and Claims Managers` Comprehensive Guide

Risk and Claims Managers’
Comprehensive Guide to the
Management of Pharmacy Benefits
Management Programs
August 2012 • Lockton Companies
I.OVERVIEW
KEITH E. ROSENBLUM, MS, MPA,
MPH, CSP, ARM, RF, MLIS, CPEA,
CHSP, CHCM
Senior Risk Consultant
Lockton Companies
816.960.9405
[email protected]
Prescription drug abuse is the nation’s fastest-growing drug issue;
an epidemic affecting all of society and workers’ compensation
in particular. Prescription opioidsA are presently the number
one workers’ compensation problem in terms of controlling the
ultimate cost of indemnity losses. There has never been a more
damaging impact on the cost of workers’ compensation claims
from a single issue than the abuse of opioid prescriptions for
the management of chronic pain. Nationally, an estimated 55
to 86 percent of all claimants are receiving opioids for chronic
pain relief. However, the overwhelming consensus of evidencedbased medicine does not support its long-term treatment protocol
Prescription opioids are presently the
outside of very specific cases, most of which involve end-stage
cancer treatment.
number one workers’ compensation
The aggressive prescribing of opioids to treat chronic pain is a
ultimate cost of indemnity losses.
problem in terms of controlling the
relatively new phenomenon in workers’ compensation’s 100-year
history. Overdose deaths from prescribed painkillers have increased
A
L
Traditionally drugs derived from the poppy plant were known as narcotics, and
technically that term does denote a substance derived from the opium poppy. However,
law enforcement adopted the phrase “narcotic” to refer to all controlled substances,
which includes non-opiate drugs such as amphetamines, marijuana, benzodiazepines,
etc. Therefore, to avoid confusion, the medical community adopted the term opiate to
refer to all drugs derived from opium, and more specifically, opioids to refer to synthetic
derivatives. The phrase ‘opioids’ will consistently be used in this paper.
O
C
K
T
O
N
C
O
M
P
A
N
I
E
S
300 percent since 1999, when the nation experienced
approximately 15,000 fatalities, more than cocaine and
heroin combined, and they originate from prescriptions,
not home labs (see Figure 1). The misuse and abuse of
Table of Contents
prescription painkillers was responsible for more than
475,000 ER visits in 2009, doubling in just five years1.
Overview������������������������������������������������������������ 1
What Do Pharmacy Benefit Management
Employers’ workers’ compensation claims are caught
(PBM) Stewardship Reports Really Tell You?������������ 3
right in the middle of the fray.
There Is a Crisis in Opioid Prescribing
UNINTENTIONAL DRUG OVERDOSE DEATHS BY MAJOR
TYPE OF DRUG—UNITED STATES 1999-2008
Proliferation and The Subsequent Misuse
and Abuse of These Opioids�������������������������������� 11
Understanding The Key Financial Components
of a Pharmacy Benefit Management Program��������� 14
How Should Chronic Pain Patient Claims
Be Managed?���������������������������������������������������� 15
Best Practices and Recommended Program
Guidelines�������������������������������������������������������� 19
References........................................................22
Figure 1. Source: National Vital Statistics System, Slide courtesy of
National Institute on Drug Abuse
APPENDICES����������������������������������������������������� 23
™ ™ VIIAD Health Ticket
Pharmacy is growing disproportionately to total medical
™ ™ Cautious, Evidence-Based Opioid Prescribing
costs. Pharmacy only accounted for about 2 percent of
medical in 1990, grew by 400 percent by year 2001 and
almost another 90 percent by 2010. Today, on average,
workers’ compensation prescription drugs account for
19 percent of total medical spend, which equates to
slightly less than 11 percent of “ultimate developed”
total incurred claim costs2. Opioids themselves account
for an average of 25 percent of that pharmacy spend,
and 35 percent or greater for claims over three years old.
But those are just the direct costs. The indirect impact
on indemnity costs is equally dramatic. Claimants on
long-term opioid care, greater than 90 days, are not
typically going back to work, have become tolerant or
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August 2012 • Lockton Companies
even dependent on the drugs, and suffer a multitude
Ask most CFOs and corporate managers of risk how
of associated illnesses and debilitating side effects
much influence prescription drugs have on their cost
secondary to the drugs’ use. The Medicare Set-Aside
of claims and the answer will typically be “a very small
(MSA) calculations become heavily burdened by the
percentage.” They will, however, state that they are
chronic use of these drugs of nearly indefinite duration.
saving large sums of money from discount pricing
These losses become exceptionally expensive and very
as communicated by their third-party administrator.
difficult to settle.
Typical pharmacy stewardship reports are inadequate
Combining the direct and indirect costs of an undermanaged pharmacy benefit program and its impact
on indemnity losses caused by longer temporary total
disability (TTD), greater permanency ratings, and the
treatment of comorbidities, we are looking at total
pharmacy representing somewhere in the neighborhood
of 20-30 percent of workers’ compensation ultimate
developed claims costs. Pharmacy is no longer of
minor importance in the management of workers’
compensation claims.
II. WHAT DO PHARMACY BENEFIT
MANAGEMENT (PBM) STEWARDSHIP
REPORTS REALLY TELL YOU?
Most Employers Don’t Know What They
Don’t Know
The crisis is made worse by the fact that most, if not
nearly all, employers simply don’t know what they don’t
and not representative of the complete picture. They
tell the favorable money-saving discount story that
the employer is anxious to hearB. In nearly all cases,
there is an absence of factual data on pharmacy
clinical utilization or absence thereof (the control of
inappropriately prescribed medications, unreasonable
dosage, duration of use, etc.). There is usually too much
fluff and not enough substance for effective employer
decision making. Remember, managed care reports
represent only those prescriptions processed through
the pharmacy benefit management provider, which may
only be between 50-60 percent of the total pharmacy
spend. We have yet to see a stewardship report include a
slide on “Total Estimated Losses in Net Savings through
PBM Leakage.” The cost of leakage will normally be
greater than the PBM savings from network discounts,
as leakage represents the absence of clinical utilization
controls.
know about workers’ compensation pharmacy and how
Without near-term clinical intervention into a claim
seriously impactful this lack of knowledge is to their
involving both early and high-dose prescribing of
bottom line. Pharmacy Benefit Management (PBM)
opioids, the savings from drug repricing is but a fraction
stewardship reports are typically not quantifying the
of the total potential savings in ultimately developed
severity of the problem when they do not represent
total claims costs.
both direct and indirect savings.
B
In nearly all cases, there is an absence of factual data on pharmacy
clinical utilization (the control of inappropriately prescribed medications,
unreasonable dosage, duration of use, etc.).
3
Typical pharmacy stewardship reports are inadequate
and not representative of the complete picture.
So What Is the Problem?
The problem is that the executive information provided to employers by their TPAs and Managed Care Organizations
(MCOs) is falling short of telling the whole story. We have found that TPAs simply do not know what the employer
is actually spending on pharmacy. The reason is that between 40 to 50 percent of pharmacy is dispensed and billed
by physicians, or the claimant filled their prescriptions without a pharmacy card, and the pharmacy sold the script to
a third-party, who subsequently bills the TPA. In these cases, the paper bills seldom go through the pharmacy benefit
management company where formulary controls and clinical edits may be applied. There are some exceptions out
there with TPAs having the sophistication to extract pharmacy from physician-embedded billings and out of network
paper bills and consolidate that information into the claimant’s pharmacy file. They are, however, few in number.
When combined with consensus statistics, our marketplace data as a whole suggest a mere 60 percent of pharmacy
is running through PBMs. CorVel Corporation, a TPA that integrates its bill review and pharmacy platform, in its
exhibit below, “visibility” refers to the actual identification of all pharmacy, including paper bills. Penetration only
refers to the percent of total pharmacy going directly through the PBM. Employers whose TPAs report penetration in
the high 80s or greater should view that as a big red flag and ask for proof.
CORVEL’S PROSPECTIVE MODEL OF TYPICAL TPA “VISIBILITY” OF
PHARMACY BILLING
60% PROSPECTIVE
In Network
40% RETROSPECTIVE
Out of Network
Retain Pharmacy
Default Process
PBM
Physician
Dispensing
Third-Party
Biller
Line Charge
from Provider
Specialty
Workers’ Comp
Pharmacies
Third Party
Biller
Paper Bill
Paper Bill
Paper Bill
Bill Review
Bill Review
Bill Review
Visibility and True Penetration
Traditional PBM = 70% Visibility, 60% Penetration
Integrated PBM + Bill Review = 100% Visibility, 75% Penetration
Figure 2. Courtesy CorVel
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August 2012 • Lockton Companies
Let’s break this down for clarity, as we must impress
and are paid immediately. The third-party biller
upon employers the importance of this “leakage” from
will later identify the payer and charge a very hefty
what most think is automatically running through
markup over the pharmacy contracted rate. What
their PBM. There are three general categories in which
is worse, and quite typical, the pharmacy may
prescriptions are dispensed and paid outside of the
continue to sell the same claimant’s refills to the
employer’s pharmacy benefit management program:
third-party, who, in some cases, hides the name of
the original pharmacy so the employer cannot call to
™™
Physician-dispensed drugs
™™
Local pharmacies sales of Rx to 3rd party billers
™™
Non-PBM mail order pharmacies
no effort to make the necessary communications to
1.
Physicians are dispensing drugs directly to their
convert future fills. This high cost prescription cycle
convert future prescriptions to their PBM. What is
interesting is that many TPAs and their PBMs make
continues and the claimant’s prescription history
patients for increased revenue. No pharmacy is
is not centralized into a database against which to
involved. According to the NCCI (National Council
conduct continuous drug utilization reviews for
on Compensation Insurance), this costs about 10-20
safety, dosage, or medical efficacy.
percent more per script than through a pharmacy3.
Or, physicians use repackaged drugs and dispense
2.
3.
these drugs directly to their patient. Again, no
pharmacies providing mail order
pharmacy is involved. This is far more lucrative, and
service directly to the claimant. These also are not
the NCCI states that repackaged drugs cost around
screened by the PBM. Furthermore, these alternative
2-3 times that of a pharmacy.C
mail order operations may use repackaged drugs in a
Local pharmacies sell their prescriptions to
manner similar to dispensing physicians in order to
inflate drug costs.
third-party billers. These prescriptions are typically
not run through the PBM formulary. Here is what
is important about this category. Many claimants
will show up at a pharmacy without a prescription
card before their claim has even been set up by
the TPA/carrier. The pharmacy does not have
the time to figure out which PBM to bill, so they
In summary, employers must consider that 40-60 percent
of pharmacy without point of sale controls is very
costly. Recommendations to reverse this leakage are
addressed in Section VI, Best Practices and Recommend
Program Guidelines.
sell the script to a third-party biller at a discount
C
Then, there is the smaller category of alternate
Drugs have unique National Drug Codes (NDC) that are specific to both
the drug strength and formulation, and in the case of physician-dispensed
drugs, to the repackager. Thus, the repackager can set their own inflated
average wholesale price (AWP) of the drug from which a percentage of
that AWP is paid, according to usual and customary payment formulas.
This artificially inflated AWP is substantially higher than the same drug
through a pharmacy.
5
Generic vs. Brand Penetration Report
When evaluating the effectiveness of a PBM to increase savings through the use of generic substitution, there are
three significant reports that a TPA/carrier (payors also include self-insured programs, state agencies, guaranty
associations, excess carriers, and others responsible for the payment of workers’ compensation claims—for our
purposes, we will label payors solely as “TPAs”) must evaluate: 1) generic substitution; 2) generic efficiency; and
3) upcoming patent expiration dates.
The first of these reports, generic substitution, is a measure of the percent of prescriptions that are dispensed
as a generic out of a TPA’s entire book of business and provides a good baseline to compare one’s own book of
business to industry reports. This number should be in the 80 percent range for most workers’ compensation payors.
However, for those TPAs that are below this number, the generic substitution report does not delineate between
poor performance on behalf of the PBM versus a patient population that may require the use of more drugs that
are still considered “single-source” brands, meaning that only brand names are available for certain drugs because
they are still covered under patent. Fortunately for workers’ compensation, most of the common drug categories are
overwhelmingly available as generics. For example, in the nonsteroidal anti-inflammatory drug (NSAID) category,
Celebrex is the last remaining single source brand. Ironically it is within the opioid category where the preponderance
of single-source brands remains, e.g., OxyContin®, Exalgo®, Fentora®, and others.
In order to make this delineation between the prevalence of generic dispensing versus the opportunity for generic
dispensing, a generic efficiency report is necessary. Generic efficiency is a measure of how often a generic drug is
dispensed when a generic is available. In other words, single-source brands which have no generic substitute are kept
out of the equation. Generic efficiency should approach 100 percent, and most payors should see efficiency ratings
equal to or greater than 98 percent with the remaining 2 percent of brand dispensing being attributed to restrictions
on generic dispensing either through regulatory limitations or market conditions.
A report on upcoming patent expiration dates is also critical in evaluating one’s drug spend because this gives some
insight into potential savings through the introduction of new generic alternatives. Brand name drugs are protected
by patent for 17 years, during which time no other company may produce that same drug. A significant portion of
those 17 years is consumed by simply getting a drug through the FDA approval process. As a result, a new drug may
only have a few years of patent protection remaining once it hits the market. Once the patent expires, the FDA then
typically gives one generic company exclusive rights to market a generic version during the next six months, and
only after that exclusion period has ended may other generic companies launch their generic version. As a result, the
average wholesale price (AWP) of the new generic only drops about 10 percent during that exclusivity period, and
only after multiple generic companies launch their version will the market see a significant decline in AWP. To further
6
August 2012 • Lockton Companies
complicate the process, the original brand name version
The PBM Penetration Report
will often see a corresponding rise in AWP just before
PBM Penetration reports, also
patent expiration. However, knowing these generalities
may help a company better define its reserves for
the period just before market expiration, for the six
months of generic exclusivity, and for the period past
that six-month mark. In fact, being armed with such
knowledge could directly influence the timing of
conducting an MSA settlement. If the timing of an
MSA may be postponed a short period of time in order
to see if a generic is launched, then the payor may realize
known as Retail Pharmacy Network
Utilization reports, are crucial to
evaluating the performance of a
workers’ compensation PBM. Simply
stated, if pharmacy is not running
through the PBM, the employers simply
will not realize the savings from its
structured program.
significant savings over the lifetime of the patient if
PBMs have varying methods of
that settlement may be based on a generic drug versus
encouraging this utilization, but it is
a single-source brand. The lesson here is to check each
only through a measure of network
MSA analysis. Simply contact the PBM for information
CLI that these methods can be
penetration
Fast.
Clinicallong-term
Programs
Generic
Utilization
drugDrive
used byHigher
a claimant
at the time
of an
NIC
AL
proven to work. In order to perform
myMatrixx
converts nearly all multisource brands to
on patent
expirations.
this measurement,
the payor typically
FO
generic where it is appropriate
S
its out-of-network
or paper bills so that
Simple.
Generic Substitution 82.26%
Generic Efficiency 98.3%
CU the PBM with copies of
must provide
the PBM may use these to calculate its
degree of success at promoting network participation.
82.26%
17.74%
Generic
Single Source Brand
Multisource Brand
Effective.
Most TPAs are unable or fail to provide bills to PBMs.
16.04%
Example: Payor With $10M in Annual Drug Spend
at a Fee Schedule
PBM ‘A’
PBM ‘B’
Results.
-15%
-10%
$1,500,000
$1,000,000
Actual penetration rate
50%
90%
$750,000
$900,000
1.70%
Figure Courtesy of myMatrixx
Effective discount rate
Calculated Savings off fee
schedule
3 myMatrixx Confidential – © All Rights Reserved 2011
Actual savings off fee
schedule
7
Sample Report Card
Sample Report Card Courtesy of myMatrixx
In this example, it becomes readily apparent that a greater contracted discount rate will not equal greater actual savings
Fast.
Network
Penetration
if the PBM
does not actively promote network utilization by both the injured worker and the network pharmacy.
Figure 3 below illustrates how a TPA may see network utilization increase over time with active network management:
Client Network Penetration Results
CLIENT NETWORK PENETRATION RESULTS
90%
80%
70%
50%
Client B
Client C
Client D
Client E
40%
0
1
2
3
4
5
Effective.
60%
Client A
Simple.
100%
Program Quarters
Results.
Figure 3. Courtesy of myMatrixx
It is also crucial that an TPA understands how competing PBMs define what is included in the measure of Network
Penetration. Therefore, the following questions are offered as a guide to navigate through this process:
2 myMatrixx Confidential – © All Rights Reserved 2011
1.
Are first-fill prescriptions included in the calculation?
2.
Are prescriptions that are not actually processed online ever considered to be “network” transactions?
3.
What prescriptions are excluded from the calculation, and under what circumstances?
8
August 2012 • Lockton Companies
As stated previously, it is crucial to understand how the PBM defines its reports. In the case of network utilization,
be aware that some PBMs may include certain paper bills as “in-network” if those bills are repriced but never actually
processed online. These should never be included as “in-network” penetration. Alternatively, a PBM may exclude
certain bills, such as physician dispensing bills, because they are not dispensed from a pharmacy. If you provide your
PBM with copies of these bills, be sure you understand how they factor into the calculation.
Clinical Savings Report
It is a poorly kept secret that the more drugs that are processed, the more money a PBM makes. In fact, the business
model for both pharmacies and PBMs is dependent upon the sale of drugs. Consequently, the PBM industry has been
compared to the “fox watching the henhouse” when it comes to the curtailment of prescribing, especially with regard
to opioids. Hence, this is truly a case of “buyer beware” when it comes to the evaluation of PBMs. If the expectation
is to simply provide a discount off of fee schedule, then there are plenty of providers that can offer an efficient
processing platform at a low-cost model (keeping in mind the statements in the previous section regarding network
penetration). On the other hand, if the expectation is for the PBM to provide the payor with the tools necessary to
curtail overutilization of prescription drugs and to identify potential fraud, waste and abuse via a clinical pharmacy
program, then both the program and its measurement must be clearly defined and understood.
First of all, it must be acknowledged that clinically-based
DRUG REGIMEN REVIEW OUTCOMES
decisions regarding pharmacy treatment may not always
1.74%
involve the selection of a lower-priced drug. There will
be valid situations in which a more expensive therapy
1.47%
1.25%
0.14%
4.51%
is actually the best choice for the patient in terms of
outcomes. With that said, the vast majority of clinical
10.71%
38.93%
pharmacy recommendations do represent cost savings
primarily because the majority of decisions represent
12.61%
either discontinuation of a drug or weaning from a drug.
As a result, a clinical savings report is a valid measure of
the success of such a program.
28.65%
Discontinue or wean
No changes
Reduce supply
Figure Courtesy of myMatrixx
9
Switch medications
Switch to generic
Confirmed discontinued
Not compensable
No recommendations
Increase supply
These measurements may include many, if not all, of the following components:
1.
Savings from rejected transactions: prescription transactions that are rejected at the
point of sale represent savings only if they stay rejected. In other words, if the rejection
is overridden by a retail pharmacist, an adjuster, or an adjuster authorizes payment for a
subsequent third-party billing, then no actual savings are realized. It is not unusual for a TPA’s
adjusters to override rejections 50 percent of the time. Make sure your PBM does not include
these transactions as savings. However, when a transaction is blocked for reasons such as
nonformulary, unauthorized physician, coverage terminated, refill too soon, duplication of
therapy, dangerous drug interactions and other drug utilization review edits, and that reason is
not overridden, then those blocked transactions are a valid component of clinical savings.
Savings from physician outreach programs: educational-based intervention programs
will have an impact on the drug selection process. However, it is not valid to accept what a
physician states that he or she will do. Instead, the PBM must measure and document a true
change in prescribing patterns.
PROGRAM RESULTS—FENTORA
7.00%
6.00%
0.40%
6.00%
0.35%
Total Script %
0.34%
0.30%
5.00%
4.00%
4.00%
0.25%
4.09%
0.22%
0.20%
0.19%
3.00%
2.87%
0.15%
2.19%
2.00%
1.59%
0.11%
1.00%
0.07%
0.05%
0.00%
0.10%
0.05%
0.00%
2007
2008
2009
2010
Cost %
Script %
2011
Q1 2012
PROGRAM RESULTS—ACTIQ
14.00%
12.00%
Total Script %
2.
0.40%
0.38%
0.35%
11.73%
0.30%
10.00%
0.25%
8.00%
0.20%
5.78%
6.00%
4.79%
4.00%
0.15%
0.13%
2.71%
3.15%
0.10%
2.13%
0.08%
2.00%
0.05%
0.05%
0.04%
0.03%
0.00%
0.00%
2007
2008
2009
2010
Cost %
Script %
Courtesy of myMatrixx
10
2011
Q1 2012
August 2012 • Lockton Companies
3.
Savings from pharmacist to physician
becoming clearer as new research data is being published
interventions: Teleconferences conducted by clinical
at an increasing rate. Previously, pharmacy was only
pharmacists have an impact on guideline compliance
looked at in terms of its percentage to total medical
from physicians. Oftentimes, physicians are not
spend. As we have addressed thus far, that percentage
aware that they are practicing outside of guidelines
has been communicated as artificially low due to
or that they are placing their patients at risk by doing
substantial underreporting of total filled prescriptions
so. Inclusion of the nurse case manager in this
through the PBM.
equation also increases compliance.
4.
Savings from peer to peer interventions: Similar
to pharmacist to physician interventions, peer to
peer interventions (physician to physician) can
improve guideline compliance and may be a crucial
step in those difficult cases that must be managed
one on one.
Its total impact on claims is just now being estimated
from large population data. Potentially, the author
believes savings from combining (1) the reduction in
overexpenditure in total pharmacy, (2) the potential
reduction in costs of treatment for addiction recovery
and morbidities secondary to opioid use, and (3) the
reduced number of disability days and permanency
Unfortunately, there is no magic bullet that will “fix”
ratings from those claimants on long-term pain
the prescription drug abuse epidemic. Each case is
management, and (4) proactive management of
unique and must be treated as such. Even so, there is a
Medicare Set-aside settlements, could potentially equate
downstream effect of these interventions, sometimes
to 8 to 15 percent of total incurred costs. That’s a
known as a “shotgun” effect, that is difficult to measure
powerful incentive to gain control of pharmacy.
but is valid nonetheless, and that is the impact that one
intervention has on a physician’s treatment of other
patients in his or her practice. Once a physician adopts
best practice guidelines, it is likely that those guidelines
will be applied to all patients under his or her care.
III.THERE IS A CRISIS IN OPIOID
PRESCRIBING PROLIFERATION AND THE
SUBSEQUENT MISUSE AND ABUSE OF
THESE OPIOIDS
The recent Hopkins-Accident Research Fund Study
(2012) 5,6 found “workers prescribed even one opioid
had average total claims costs four to eight times greater
than claimants with similar claims who didn’t get
opioids.”
Swedlow, et al., reported “Average claim costs of
workers receiving seven or more opioid prescriptions
were three times more expensive than those of workers
Opioids Influence on Impacting Both Pharmacy
and Overall WC Costs
who receive zero or one opioid prescription, and these
The financial impact of pharmacy, especially opioids
had 4.7 times as many days off work.”7
and opioid/acetaminophen combination analgesics, is
workers were 2.7 times more likely to be off work and
Another study involving a large database indicated that
11
total indemnity benefits paid for those on long-term opioid therapy at high doses were more than
three times greater than those on short-term acute care or no prescribed opioids8.
The NCCI, in its 2009 Research Brief on Opioids in Workers’ Compensation, simply stated that the
longer a worker is on opioids, the longer he is off work. California’s MTUS Chronic Pain Medical
Treatment Guidelines state that “The likelihood of return to work diminishes significantly after
approximately three months of sick leave.”9
There are a multitude of costs directly linked to prescribed opioids. Many can occur after only a
short-term use following an injury and then increase in frequency and severity as the claim ages.
These increased costs can be summarized into the following categories:
™™
Increased frequency of emergency room visits from overdose
™™
Death
™™
Addiction treatment
™™
Comorbidities (illness)
™™
Abuse and misuse of prescribed drugs
It is estimated that about 35 percent of patients receiving long-term treatment with opioids may be
addicted10. Addiction is individual in nature. It can affect some patients after only a few weeks and
not others after many years of chronic use.
Medical research suggests opioids, as a pain management tool, can only reduce a patient’s pain by
30-40 percent. Therefore, it is common for opioids to be prescribed in combination with other,
non-opioid, analgesics such as acetaminophen.
Research from 1998 to 2000 showed acetaminophen was the leading cause of acute liver failure
in the United States11. Extra Strength Tylenol was reformulated just for this reason. Yet, it is
not unusual to find numerous claims involving the long-term use of acetaminophen at or well
exceeding maximum FDA recommended dosage. Combine the daily intake of acetaminophen at
high levels with alcohol consumption, which would not be uncommon, and liver toxicity increases
proportionally. Liver failure may result in the need for liver transplants for which the employer is
responsible.
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August 2012 • Lockton Companies
The list of comorbidities (illnesses) secondary to opioid
to address the following facts14, significant improvement
therapy seems endless. The following are the most
can be experienced with claims outcomes:
typical side effects and are frequently found with those
on long-term therapy 12,13:
™™
™™
™™
Evidence of long-term efficacy of chronic
noncancer pain (≥ 16 weeks) is limited and of low
Respiratory depression (very common)—slow,
quality. Opioids are effective for short-term pain
shallow breathing causing sleep apnea, which can
management. But for many patients with chronic
result in heart attack and stroke.
pain, analgesic efficacy is not maintained over long
Hyperalgesia (the patient becomes more sensitive to
time periods.
pain)
™™
With daily opioid use, physical dependence and
tolerance can develop in days or weeks.
™™
Serious fractures
™™
Depression
™™
Infertility
™™
Decreased libido
™™
Erectile dysfunction
™™
Bowel obstruction
™™
Chronic constipation
™™
Immunosuppression
™™
Myocardial infarction
™™
Tooth decay (from dry mouth)
™™
Testicular atrophy
Many patients on high doses continue to have
™™
Chronic obstructive pulmonary disease
substantial pain and related dysfunction.
Each of the above disorders becomes secondary to
™™
opioids can be difficult, even for patients who are
motivated to discontinue opioid use.
™™
Estimates vary. Between 4 percent and 26 percent
of patients receiving chronic opioid therapy have an
opioid use disorder.
™™
Opioids have significant risks besides addiction and
misuse. These risks include respiratory depression
and unintentional overdose death.
™™
No randomized trials show long-term effectiveness
of high opioid doses for chronic, noncancer pain.
™™
When treating chronic pain, dose escalation has not
been proven to reduce pain or increase function, but
the prescribing of drugs for pain relief and in and of
can increase risk.
themselves become compensable medical conditions,
rapidly increasing the medical and indemnity cost
Successfully tapering chronic pain patients from
of claims. These expenses are not necessary in the
The Impact of Opioids on Pharmacy Spend on
Claims Open Greater Than 2-3 Years
treatment of most workers’ compensation claimants.
A study by the NCCI in 2009 determined that although
If the employer and TPA understand and integrate
countermeasures into their claims management program
opioid use declined over time, its use could continue
for many years. A more recent study 15 found that high
13
use of opioids in the first quarter following an injury is related to that injured patient continuing to
receive opioids in subsequent quarters. One conclusion that may be drawn from this study is that
early intervention to ensure evidence-based guideline compliance may also lead to a decrease in use in
subsequent years.
The Impact of Pharmacy, and Opioids in Particular, on Medicare Set-Aside Calculations
and Settlements
The 80:20 “Paretto’s Rule” applies to many things, including workers’ compensation. Approximately 20
percent of a claim’s medical cost is for pharmacy, while the claim is open, and 80 percent for medical
expenses. When the claim moves to the closure stage and a Medicare Set-Aside (MSA) is required, this
percentage is inverse; 80 percent of the MSA cost is pharmacy, and the numbers can be staggering,
so staggering that many self-insured companies want to leave the medicals, or at least the pharmacy,
“open” and settle the indemnity.
CMS regulations coupled with the increased use of opioids in older claims (up to 40 percent of
medical cost according to the NCCI’s 2011 data) are the major cost drivers. An effective PBM program
will apply clinical protocols to get ahead of the claim and ensure that therapy is within guidelines and
cost-effective measures are in place well before time for an MSA.
IV. U NDERSTANDING THE KEY FINANCIAL COMPONENTS OF A PHARMACY
BENEFIT MANAGEMENT PROGRAM
How Does Prescription Pricing Work and What Is Its Impact on Total Savings From an
Effective PBM Program?
When it comes to pharmacy spend, the majority of attention is always focused on the “cost per pill”.
This is an obvious choice to look at when purchasing any item – however, its significance should be
placed in perspective: the “cost per pill” approach is based on a contracted rate for the purchase of
brand and generic drugs, and is typically a discount off of AWP plus a dispensing fee:
™™
AWP per unit, times quantity, plus dispensing fee = contracted price
Since most states have a fee schedule based on similar formulas, the savings model is simply:
™™
Contract price minus fee schedule = Savings
Unfortunately, this approach does not account for the significance of savings that may be realized from
an effective PBM program that ensures the following: 1) maximize the network pharmacy utilization—
14
August 2012 • Lockton Companies
remember, one will not realize contracted savings on
superior to another, and that drug also happens
out-of-network prescriptions that likely go through
to be more expensive, the vast majority of clinical
a third-party biller; 2) maximize generic utilization—
interventions involve less expensive alternatives or
generic substitution represents one of the single greatest
discontinuation of a drug altogether. An effective
cost savings strategies, but it also diminishes a PBM’s
PBM program will measure those efforts and provide
top-line revenue—therefore, look for generic efficiency
measurable savings tied to these activities. Caution:
rates in the high 90th percentile to ensure that the PBM
make sure that clinical savings are “real” savings—the
has your interests in mind and not their own; 3) ask for
transaction was reversed or the prescription cancelled—
your refunds—many prescriptions are never picked up
and not “soft” savings—this is what might happen.
by the patient, but the pharmacy bills for prescriptions
at the time of dispensing. If the prescription is not
picked up, then the pharmacy “reverses” the transaction
V. HOW SHOULD CHRONIC PAIN PATIENT
CLAIMS BE MANAGED?
through the PBM, generating a credit. When was the last
First, Make Sure All Is As It Appears
time you or your TPA received a credit? Do you know?
The hydrocodones, oxycodones, and morphine sulfates
Does your PBM measure and record these refunds?
And, 4) clinical savings—discussed in detail below—
there is no greater savings than cost avoidance.
What Is Clinical Utilization Management and
What Is Its Impact on Total Savings From An
Effective PBM Program
Most PBMs are very efficient at processing prescription
transactions, though those that follow best practices will
also provide clinical pharmacy oversight, such as:
™™
Formulary management
™™
Guidelines compliance
™™
Identification of potential fraud, waste and abuse
™™
Identification of risk factors
™™
Identification of medication therapy alerts
™™
Physician and patient intervention programs
seen time and again with long-term claims may not
always be actually taken by the patient, may be taken in
higher dosages than prescribed or even taken along side
illicit substances. The Workers’ Compensation Research
Institute, in a study involving 17 states, found that fewer
than 7 percent of treating doctors conduct baseline and
periodic urine drug screens. That number has apparently
doubled in recent years but is still a very low percentage
given the following concurrent research facts:
™™
71 percent of workers’ compensation claimants on
chronic opioid therapy greater than three months
are not taking their pain medication as prescribed
due to misuse or abuse.16
™™
38 percent of patients were found to have no
detectable level of prescribed medication; 29 percent
had nonprescribed medication; 27 percent had
drug levels higher than expected; 11 percent had
Although there may be situations where clinical
illicit drugs.17 (Based on a sample of 939,000 drug
guidelines indicate that one drug is therapeutically
screens)
15
Does your PBM/TPA ensure all opioid-prescribed claimants are being routinely drug tested?
Responsible Treatment Protocols
There is no short supply of evidence-based medical treatment guidelines for the long-term
treatment of chronic pain. There are numerous references cited here that are closely aligned with
the Centers for Disease Control and Prevention (CDC) recommendations. These guidelines have
been published in response to the increasing morbidity and mortality associated with the increasing
use of opioids18.
Adjusters are responsible for ensuring, to the extent permitted by state laws, that treating
doctors follow medical treatment guidelines or seek appropriate remedies through
consultants’ support or the workers’ compensation statutory process. In brief, the following
are some of those key evidence-based medical guidelines:
1.
Use opioid medications for acute or chronic pain only after determining that alternative
therapies do not deliver adequate pain relief. The lowest effective dose of opioids should be
used.
2.
In addition to behavioral screening and use of patient agreements, treating doctors must
consider random, periodic, targeted urine testing for opioids and other drugs for any patient
under 65 years old, with noncancer pain, who has been treated with opioids for more than six
weeks.
3.
Do not prescribe long-acting or controlled-release opioids (e.g. OxyContin®, fentanyl patches,
and methadone) for acute pain.
4.
The total daily dose of opioids should not be increased above 120 mg oral MED (morphine
equivalent dosage) without either the patient demonstrating improvement in function and
pain or first obtaining a consultation from a practitioner qualified in chronic pain
management (emphasis added).
5.
Risks substantially increase at doses at or above 100 mg, so early attention to the 120 mg MED
benchmark dose is worthwhile.
6.
Chronic opioid therapy (more than 90 days) should only be initiated on the basis of an explicit
decision and agreement between prescriber and patient.
Patients prescribed greater than the morphine equivalent dose (MED) of 100 mg opioids daily had
a ninefold increase in overdose risk; most medically serious and 12 percent were fatal.
16
August 2012 • Lockton Companies
What Is the PBM’s Role?
OVERDOSE RISK IN CHRONIC PAIN PATIENTS
Ideally a PBM will have access to all data involving
10
pharmaceuticals, which includes not only those
9
8
prescriptions processed online via the PBM provider,
7
but also those prescriptions processed through a third-
6
party biller, processed via a group healthcare PBM
5
(and available through the states’ PDMP databases),
4
dispensed by a physician or delivered via an implantable
3
2
drug delivery device, such as an intrathecal morphine
1
pump. Each PBM may have different methodologies to
0
1mg to 20mg
50mg to 99mg
100mg +
Courtesy of myMatrixx
Who Is a Qualified Pain Management Specialist?
obtain this data, but the end result should be to provide
you with a complete picture of what your claimants
are receiving in terms of number of opioids, number
Any physician can hang out a shingle as a pain
of physicians, total dosage, duration, etc. Only with
management specialist. All too frequently, the pain
this kind of 360-degree view can your PBM evaluate
specialists are no better in their improper prescribing
guideline compliance.
patterns than the inadequately trained treating doctor.
TPA claims handling instructions should specifically
require that adjuster approval of a pain management
specialist be contingent on the physician having
either completed a fellowship in pain management or
hold a board certification by the American Board of
Anesthesiology or a psychiatrist or neurologist with pain
management expertise (fellowship preferred). Other
pain management board certifications are self-serving,
and most are not recognized by the American Board of
Medical Specialties (ABMS). It is easy for an adjuster
A note about PDMPs: because of concerns over
privacy, access to PDMPs is typically restricted to law
enforcement and physicians and pharmacists licensed in
that state. Furthermore, any information discovered in
accessing that database cannot be shared with anyone
else. However, a pharmacist may use what he or she
discovers from the PDMP in a treatment discussion with
the treating physician.
What Is the Adjuster’s Role?
to verify fellowships and board certification by simply
The adjuster’s primary role is to stay on top of claims
visiting the American Board of Anesthesiology and
with prescribed opioids either within the first 10 days
looking up the physician. The extra five minutes of
of an acute injury or where these opioids are being
research may be worth thousands in claim costs savings.
prescribed beyond 45 days.
17
What this translates to is:
™™
Not overriding formulary denials without specific justification and seeking medical guidance
from internal professional staff to assist in making override decisions
™™
Engage the PBM as often as necessary if medical reports show the onset of illnesses not
normally associated with workers’ compensation claims and are typically side effects from
prolonged opioid use.
™™
Follow PBM recommendations for engaging the treating doctor in modifying prescribing
patterns.
™™
Ensure physician-patient agreements are in place where opioid use extends beyond 30 days.
™™
Encourage the treating doctor to make use of tools for assessing the risk of opioid addiction in
advance of prescribing opioids
™™
Ensure the opioid prescribing doctor conducts a baseline urine drug test, where opioids are
being prescribed beyond 30 days, and for patients under age 65, periodic, unannounced random
urine drug tests are conducted.
™™
Only approve referrals to qualified pain specialists.
™™
Above all else, engage and challenge the treating doctor as to the validity of continuing opioid
prescribing where periodic medical reports do not indicate progress in work and life skills
functions and reduction in pain.
18
August 2012 • Lockton Companies
VI.B EST PRACTICES AND RECOMMENDED
PROGRAM GUIDELINES
much of total prescribing through the PBM with its
Consensus
hindered. There is no more effective and efficient
TPA claims handling instructions should be modified
to require adjusters to follow the consensus guidelines
established by the Centers for Disease Control and
Prevention, American College of Occupational
and Environmental Medicine, the Washington
State Department of Labor and Industries AMDG
Guidelines, the California MTUS, and many others that
are uniform in their standards.
The TPA/carrier and its managed care PBM have
joint responsibility for the effective management of
pharmacy. The PBM, through its formulary edits and
point-of-purchase controls, may restrict the dispensing
of nonformulary drugs, early refills, or inactive
claimants. Pharmacies can circumvent the formulary
denials by filling the prescriptions and selling the scripts
to a third-party biller. The PBM should also be reviewing
individual claimant prescription trending and alert the
TPA when a claimant’s prescribing history raises red
flags. Adjusters can and do override the PBM formulary
denials. With some exceptions, this option should be
removed and centered with a designated TPA triage
nurse, who acts in compliance with the employer’s claims
handling instructions.
This suggests a whole new paradigm in claims
management, but it is driven out of necessity.
Pharmacy First Fills
Getting early control of a claimant’s clinical utilization
of pharmacy is of course critical. Without directing as
point-of-sale controls, utilization management is severely
approach to this control than capturing that injured
worker and the treating doctor at the point of initial
treatment with an immediate authorization to fill the
first prescription (Rx First Fill) at a participating PBM
pharmacy While no system is perfect, there is a tool
combined with an outsourced vendor solution to gain
very early control combined with numerous attendant
co-advantages.
While this paper is focused on pharmacy, it is necessary
to expand the employer’s understanding of the greater
process in which pharmacy is a vital component. By
early soft (recommended) or hard (mandatory) direction
of an injured worker to a designated PPO medical
provider, there is a greater opportunity to control
pharmacy.
There are two further considerations for employers
with respect to gaining early control of the claim.
The first involves 24/7 nurse triage. This very simple,
low cost remedy to reduce the frequency of workers’
compensation claims and to direct care is greatly
underutilized. The second is the use of an inexpensive,
real time, controlling document called a health ticket by
VIIAD Systems. While VIIAD’s products can be used
separately with impressive results, these two resources,
when used in concert, can yield extraordinary outcomes.
24/7 Nurse Triage. There are a number of qualified
vendors (Medcor, CorVel, Coventry NT24, Bunch &
Associates’ Care Solutions) who provide around-theclock registered nurses as the initial claims intake and
19
medical triaging of a worker’s injuries. On average across all industry classifications, these services
will divert more than 30 percent of injured worker calls to self-care, eliminating the need to file
claims. Some industry classifications, such as manufacturing, grocery, retail, and hospitality, will
see upward of 50 percent self-care. The injured worker is directed to a toll free number to report
his injury, which commences what can be a very specific initial claims process with incredible
results. Besides the sizeable direction to self-care, the nurse will pull up a client-specific list of
predesignated PPO providers by geographic location. The injured worker can then be either soft
channeled, with high success ratios, where states prohibit direction of care, or hard channeled to a
mandatory panel provider. Many insureds will have company profiles on file with these respective
providers addressing return to work, prescription formulary controls, etc. Now, add to the triage
process a health ticket, and the results continue to improve.
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Both the nurse triage and health ticket are completed within roughly 25 minutes of the injured
worker’s initial call to triage, and the health ticket is usually in the hands of the medical provider
before the injured worker arrives for treatment. The combined process is well orchestrated,
maintaining very low costs while hopefully yielding sizeable returns.
Summary of Best Practices
The following is a consolidation of minimum best practices guidelines for an effective pharmacy
benefit management program
TPA Responsibilities (Adjuster)
™™ Drug Regimen Reviews. In lieu of leaving the discretion of ordering DRRs to adjusters, service instructions should
reflect orders to the PBM to commence these reviews when very specific flags are first raised.
Adjuster Performance Standards. Have objective opioid reduction goals as a substantial part of adjuster
performance standards for insured.
20
4)
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™™
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August 2012 • Lockton Companies
™™
Adjuster Intervention. Adjuster to obtain and review monthly
narcotics reports on insured’s claimants combined with review
of latest physician notes to ensure regular intervention to
challenge physician’s ongoing use of opioids if claimant is not
showing positive signs of continuous improvement in function
and reduction in pain .
™™
Adjuster Validation of Patient Screening. Adjuster to ensure
that physician has engaged in both initial patient behavioral
screening for the potential of opioid abuse and addiction as
well as physician-patient signed agreements (contracts) in all
cases where claimants are receiving prolonged opioid therapy
(>60 days).
™™
Patient Drug Screens. Adjuster to monitor file for physician
reports of baseline and periodic (at least quarterly
unannounced) urine drug screening for all patients under
age 65 following the short acute stage of an injury or postoperatively where opioids are continuing in use.
™™
Pain Management Consult. Adjuster to require/request
(depending on state rules for directed care) a pain
management consult where opioids therapy has not shown
a reduction in pain or improvement in function after 30 days
or where the prescribed opioids following the acute sage of
treatment equal or exceed 120 mg. of morphine equivalent
dosage daily. Consults should only be authorized for board
certified rehabilitation/anesthesiologist pain specialists.
™™
Conditioned Rx Prior Approval Authority. Limit adjuster prior
approval authorization only after following patient Rx history
review and nurse consult.
™™
Mail Order Pharmacy. Monitor all claims for actual or expected
Rx greater than 90 days to ensure claimants are enrolled in
mail order pharmacy.
™™
Adjuster Prior Approval Reviews. TPA and employer jointly
hold quarterly reviews of all adjuster approvals of “Rx Prior
Approvals” to monitor adjuster compliance with service
instructions.
involving opioids, including initial physician communications
and coordination with adjusters. Interventions should not be
left to adjuster discretion.
™™
Routine Narcotics Reports. Run at least monthly PBM narcotics
reports by claimant to evaluate acetaminophen and morphine
equivalent dosages.
™™
Monitor Physician Compliance with Evidenced Based Medical
Guidelines. Identify physician requirements associated
with prescribing opioid pain therapy, i.e., initial behavioral
assessment, non-opioid therapy, opioid trial, initial and routine
urine screening, pain management consult after 30-45 days of
opioids pain therapy. Communicate with all treating doctors
upon initial treatment when opioids are first used.
Pharmacy Benefit Management (PBM)
Provider
™™ Automatic DRRs. Initiate automatic drug
regimen review (DRR) after 60 days if
prescribing patterns have been unaltered
by earlier interventions (TPA or PBM).
Notification of employer and adjuster when
activated. This process should not be
adjuster-centric. PBM to use automatic flags
to trigger DRR.
™™
P2P Communications. Include physician to
physician (P2P) communications with each
DRR.
™™
DURs. Ensure drug utilization
reviews (DURs), performed with each
new prescription, carefully monitor
acetaminophen dosage and duration.
™™
PBM Daily System Sweeps. PBM to ensure
client that daily, not monthly or quarterly,
sweeps of incoming prescriptions are
engaged in an alert process whereby the
designated nurse, adjuster, employer, and
physician are automatically notified of
prescribing patterns with red flags, i.e.,
multiple opioids within 21 days of injury,
opioid treatment beyond 45 days, 120
MED or greater daily, prescribed drugs with
interactions, etc.
TPA Designated Nurse Responsibilities (Optional but highly
recommended)
™™ Designated Nurse. TPA should designate (dedicate for large
clients) an RN triage nurse to first handle all of the insured’s
TCM claims as well as manage the pharmacy oversight on all
claims where opioids are prescribed.
™™
Nurse Opioid Reduction Goals. Have objective opioid reduction
goals as a substantial part of the nurse’s performance
standards.
™™
Centralize Prior Approvals. Centralize all Rx prior approvals
with the designated/dedicated triage nurse.
™™
Review Open Claims. Review 100% of open claims for all years
with current opioid use greater than 30 days. Order DRR’s as
needed.
™™
Managed Care Bill Review Vendor
™™ Separation of 3rd Party and Physician-dispensed Billing. Bill
review vendor guarantee that all third party pharmacy billers
and physician dispense pharmacy in physician billing is broken
out and immediately forwarded to the PBM for repricing and
attempted conversion to future PBM fills.
™™
Engage Physicians. Engage in direct communication with
treating doctors. Manage timely intervention in all claims
21
Future Rejection of 3rd Party Bills. Create mechanism to reject
future invoices for third party billing in states with directed care
where the third party biller has been repeatedly informed of
required processing through the PBM on specific claims.
References
1
Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Division of Unintentional Injury Prevention. Policy Impact:
Prescription Painkiller Overdoses. November 2011 <http://www.cdc.gov/homeandrecreationalsafety/rxbrief/index.html>
2
Lipton, Barry, Laws, Chris, Li, Linda. “Opioids in Workers’ Compensation.” NCCI Research Brief. NCCI Holdings, Inc. December 2009.
<https://www.ncci.com/nccimain/IndustryInformation/ResearchOutlook/Pages/Opioids_in_WC.aspx>
3
Lipton, Barry, Laws, Chris, Li, Linda. “NCCI Research Brief. Workers Compensation Prescription Drug Study, 2010 Update- Exhibit 14” NCCI Holdings, Inc.
January 2011. <https://www.ncci.com/documents/2010_ncci_research_rxdrug_study.pdf>.
4<http://www.deadiversion.usdoj.gov/fed_regs/notices/2006/fr09062.htm>
5
“Accident Fund Holdings, Inc. Launches Opioids Program to Protect Injured Workers from Drugs Used to Manage Chronic Pain”. Accident Fund Holdings, Inc.
News. February 6, 2012. Accessed February 10, 2012. <http://afhi.com/news/2012/pr_02_06_2012_1.asp.
6
Noonan, Mark. “The Opioid Tipping Point (Part Two).” Risk and Insurance Online. March 8, 2012. Accessed March 14, 2012.
<http://www.riskandinsurance.com/story.jsp?storyId=533345981&query=the opioid tipping point>.
7
Joe Paduda, Proceedings of the National Rx Drug Abuse Summit, April 11, 2012: Compliance with Opioids Guidelines, April 11, 2012, Orlando, FL.
8ibid
9
California State. Title 8, California Code of Regulations Sections 9792.20 - 9792.26, Filed with secretary of state June 18, 2009, Effective July 18, 2009.
Medical Treatment Utilization Schedule Regulations.
10 “Long-term Opioid Therapy Often Leads to Addiction.” HealthDay July 29, 2011. Accessed April 15, 2012
<http://consumer.healthday.com/article.asp?AID=655130 >
11 Larson, A, Polson, R, et al. “Acute Liver Failure Study Group (ALFSG)”. Hepatology 42(6): 1364-72.
12 Washington State. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain Guideline on use of Opioids for Chronic Non-cancer pain- Frequently
Asked Questions. June 2010. <http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf>
13 Von Korff, M., Kolondy, A, Deyo, R, Chou, R. “Long-term Opioid Therapy Reconsidered.” Annals of internal Medicine 155:5 (2011): 325-328.
14 “Cautions, Evidence-based Opioid Prescribing.” Physicians for Responsible Opioid Prescribing. Ed. Andrew Kolondy, MD. Accessed March 1, 2012.
<http://www.supportprop.org/index_9_2167612031.pdf>
15 Laws, Chris, NCCI Research Brief. “Narcotics in Workers’ Compensation”. NCCI Holdings, Inc. May 2012.
16 “Urine Drug Testing for Opioid Use in Workers’ Compensation Cases.” White Paper. Ameritox, Ltd., Baltimore, MD. 2011.
17 Couto, J. et al. “High Rates of Inappropriate Drug Use in the Chronic Pain Population.” Population Health Management. 12 (4) (2009): 185
18 Glass, L., ed. “Occupational Medicine Practice Guidelines, 3rd edition: Guidelines for the Chronic Use of Opioids.” American College of Occupational and
Environmental Medicine. 2011. <http://www.acoem.org/Guidelines_Opioids.aspx>
22
August 2012 • Lockton Companies
AP P E N DI C E S
Sample Employer Dear Employee: This Health Ticket is your I.D. card for your work‐related injury. In many cases, it has already been sent to the medical provider to whom you have been referred for treatment. We are committed to ensure you receive the best medical care available to facilitate your safe return to work. Please sign this document on page 2. The medical provider will do the rest. If at any time you have questions, please contact your TPA claims professional at 800‐XXX‐XXXX ext. XXXX. Patient Name: Employer: Date of Injury: Claim #: Body Park: State of Jurisdiction: John Smith Sample Employer 05/30/2012 123456789 Left Arm SD Pharmacy Information: Send bills to: 2 East Main Street, Towne Centre Building, Suite 208, Danville, IL 61832‐5852 Ph. 800‐XXX‐XXXX / Fax 800‐XXX‐XXXX TPA Fax: 800‐XXX‐XXXX Email: [email protected] Authorizations and treatment questions: 800‐XXX‐XXXX ext. XXXX THIS CARD DOES NOT CERTIFY COMPENSABILITY OR GUARANTEE PAYMENT PreAuthorization Requirements Contact an TPA claims adjuster at 800‐XXX‐XXXX for information regarding state‐specific regulations or for the following treatment requests: 


Non‐emergency hospitalizations, surgeries, outpatient surgery and transfers Psychiatric or psychological therapy Chiropractic treatment Physical therapy greater than six visits Work hardening or work conditioning programs Pain, chemical dependency, or weight loss clinics Nursing home or convalescent home admissions/transfers Home health Non‐emergency dental services 
Myelogram/discogram






• Biofeedback • Imaging procedures • Facet, trigger point, or epidural steroid injections • Bone growth stimulators • Durable Medical Equipment (DME) • Experimental/investigational procedures • Request for unusual procedures • Repeated diagnostic studies • Radiation therapy or chemo. • Second surgical opinions • Inpatient rehabilitation • Acupuncture Use this Care Ticket for any prescriptions that you need to get filled. Participating Pharmacies: Walgrees ACME Group: 10602592 Albertson’s Duane Reade COSTCO Sam’s Club BIN: 014211 PCN: mymatrixx Safeway Rx Helpdesk: 1‐877‐804‐4900 x2 The pharmacy benefit card is only to be used for medications prescribed for your work‐
related injury. By using this card, you acknowledge and accept financial responsibility for any prescriptions billed under this card that are later found to be unrelated to your injury. Preferred Drug List: generics should always be considered as the first line agents for prescribing. The following therapeutic categories and the drugs listed are not all inclusive but instead represent cost‐effective first‐line agents that should be tried before second‐line agents. 
Skeletal Muscle Relaxants: cyclobenzaprine, baclofen. Carisoprodol should not be considered because of its abuse potential 
Non‐Steroidal Anti‐inflammatory Agents (NSAIDs): naproxen, ibuprofen 
Neuropathic Pain Agents: amitriptyline, venlafaxine, gabapentin 
Opioid Analgesics for chronic pain: morphine sulfate immediate release, morphine sulfate extended release. Hydrocodone with acetaminophen may be appropriate in short term situations. Opioid analgesics should only be considered after non‐opioid products have been tried. Trans‐mucosal fentanyl citrate (TIRF) products should not be used except for end‐stage cancer patients. Medical Provider: Due to concern for our employees, our PBM has removed certain prescription drugs from our formulary that prove to be harmful if used in excess. Please contact myMatrixx at 1‐800‐804‐4900 for details. Scheduling Services If the patient requires any of the following services/treatments, Scheduling should be provided by calling the following: DME – myMatrixx 877‐804‐9400 x4 Diagnostic Imaging – One Call Medical 1‐800‐872‐2875 PT – Network Synergy Group 1‐888‐533‐0727 Transportation ‐ Optimal 1‐866‐672‐5797 To be completed by Treating Physician We have a return to work program designed to return injured employees to productive work as soon as possible. If John Test is unable to return to work at full duty, please return this form to our office. This information will be used in identifying other transitional employment opportunities. Injured employees are aware of our desire to have them return to productive employment as soon as they are physically capable. If necessary, we will consider rearranging work schedules around medical appointments to facilitate an early return to work. Thank you for your participation in our efforts to return employees to a safe and productive workplace. Upon completion, please fax the entire form to 800‐XXX‐XXXX We would appreciate your cooperation in completing the following items on this form. It is important to our efforts in determining this person’s work potential. Any item that you do not believe you can answer should be marked N/A. Thank you. Sit Occasionally = 1% to 33%
Total Hours Able to Perform Tasks: 0 ½ 1 2 3 4 5 6 7 8 Stand 1)
Walk Frequently = 34% to 66%
3) Person Can Carry Up to 10 lbs 11‐20 lbs 21‐50 lbs 51‐100 lbs 100+ lbs Constantly = 67% to 100% Never Occasionally Frequently Constantly 2)
Person Can Lift Up to 10 lbs 11‐20 lbs 21‐50 lbs 51‐100 lbs 100+ lbs Never Occasionally Frequently Constantly Doctor’s Signature _______________________________ Date _________________ 4)
Person Can Push/Pull Never Occasionally Frequently Constantly Up to 10 lbs 11‐20 lbs 21‐50 lbs 51‐100 lbs 100+ lbs 5)
Person Can Do Repetitive Movements As in Operating Controls Right Hand/Arm Right Foot/Leg Left Hand/Arm Left Foot/Leg Yes No Yes No Yes No Yes No
23
PHYSICIANS FOR RESPONSIBLE OPIOID PRESCRIBING
www.responsibleopioidprescribing.org
Cautious,
Evidence-Based
Opioid Prescribing
Despite low-quality evidence
supporting practice change,1-6
use of chronic opioid therapy
(COT) for chronic non-cancer
pain increased dramatically
over the past two decades.34-36
Concurrently, opioid analgesic
overdose deaths, addiction,
misuse and diversion have
increased markedly.20,37
COT may provide modest, variable
short-term pain relief for some patients
with chronic pain. Long-term benefits
of COT for chronic pain have not been
established. Potential medical and
behavioral harms of opioids are an
important concern, particularly at
higher dosage levels and in higher risk
or medically complex patients. While
COT at lower doses may be a useful
treatment for some patients, it should
The content printed in this guide has
been distributed, uploaded to the web
and/or endorsed by the following
agencies and organizations:
only be considered for carefully evaluated, closely monitored patients when
a cautious, structured and selective ap-
• The American College of Medical Toxicology
• Group Health Research Institute, Seattle, Washington
• Maimonides Medical Center, Brooklyn, New York
proach is employed, and clear benefits
• New York State Office of Alcoholism and
Substance Abuse Services
for pain and function are documented.
• SAMA Foundation, Seattle, Washington
COT always entails risks for patients,
• Washington State Industrial Insurance
Medical Advisory Committee, Olympia, Washington
their families and the community, so
vigilance and caution are essential.
24
August 2012 • Lockton Companies
Myths and Facts about
Chronic Opioid Therapy (COT)
PHYSICIANS FOR RESPONSIBLE OPIOID PRESCRIBING
www.responsibleopioidprescribing.org
Myth: COT for chronic pain is
supported by strong evidence.
Fact: Evidence of long-term efficacy for chronic non-cancer pain (≥16 weeks) is
limited,1,2,3 and of low quality.4,5 Opioids are effective for short-term pain management. But, for many patients with chronic pain, analgesic efficacy is not maintained
over long time periods.6
Myth: Physical dependence only happens
with high doses over long periods of time.
Fact: With daily opioid use, physical dependence and tolerance can develop in
days or weeks.7,8
Myth: Patients who develop physical
dependence on opioids can easily be tapered off.
FACT: Successfully tapering chronic pain patients from opioids can be difficult –
even for patients who are motivated to discontinue opioid use.33
Myth: Addiction is rare in patients
receiving medically prescribed COT.
Fact: Estimates vary. Between 4% and 26% of patients receiving COT have an opioid use disorder.9-12 Among patients without an opioid use disorder, more than one
in ten misuse opioids by: intentional over-sedation; concurrently using alcohol for
pain relief; hoarding medications; increasing dose on their own; and borrowing opioids from friends.9,15
Myth: Addiction is the main risk to be
concerned about when prescribing opioids.
Fact: Opioids have significant risks besides addiction and misuse.18,19 These risks
include respiratory depression and unintentional overdose death;20,21 serious fractures from falls;22,23 hypogonadism and other endocrine effects that can cause a
spectrum of adverse effects;24 increased pain sensitivity,25 sleep-disordered breathing,26 chronic constipation and serious fecal impaction,27,28 and chronic dry mouth
which can lead to tooth decay.29
Myth: Extended-release opioids are better than
short-acting opioids for managing chronic pain.
Fact: Extended-release opioids have not been proven
to be safer or more effective than short-acting opioids for managing chronic pain.30
Myth: Prescribing high-dose opioid
therapy (≥120 mg morphine equivalents/day)
is supported by strong evidence that benefits
outweigh risks.
Fact: No randomized trials show long-term effectiveness of high opioid doses for
chronic non-cancer pain. Many patients on high doses continue to have substantial
pain and related dysfunction.32 Higher doses come with increased risks for adverse
events and side effects including overdose, fractures, hormonal changes, and increased pain sensitivity.18-26
Myth: Opioid overdoses only occur among
drug abusers and patients who attempt suicide.
Fact: Patients using prescription opioids are at risk of unintentional overdose and
death.20 This risk increases with dose and when opioids are combined with other
CNS depressants like benzodiazepines and alcohol.21
Myth: Dose escalation is the best response
when patients experience decreased pain control.
Fact: When treating chronic pain, dose escalation has not been proven to reduce
pain or increase function, but it can increase risks.32
Do’s & Don’ts for
Acute Pain Management
DO explain that opioids are for time-limited use. With the
first opioid prescription, set expectations that opioids should
be discontinued when the pain problem is no longer acute.
DON’T stock your patients’ medicine cabinets with unused opioids. Limit all initial and refill prescriptions for acute
pain. A 30-day supply is often excessive – many patients only take
a pill or two then leave the rest in their medicine cabinet. This increases the risk of diversion, which in turn increases the risk of addiction and fatal overdose in families and communities. For those
patients who use the medicine daily for several weeks, physiologic
dependence develops within days or weeks. Due to risks of accidental poisoning, it is important to store opioids in a medication
lock box and flush unused opioids down a sink or toilet.
DON’T start long-term use of opioids by accident. Longterm opioid prescribing should only occur after careful patient
evaluation, discussion of risks and realistic expectations of benefits, and clear explanation of rules for safe use. Routine authorization of refills may cause patients to expect the prescription to
continue indefinitely.
DON’T prescribe extended-release opioids for acute pain
or to opioid-naïve patients. Extended-release opioids are not
appropriate for managing acute pain and should never be prescribed
to an opioid-naïve patient.
25
PHYSICIANS FOR RESPONSIBLE OPIOID PRESCRIBING
www.responsibleopioidprescribing.org
Do’s & Don’ts for
Chronic Pain Management
DON’T initiate chronic opioid therapy (COT) before considering safer alternatives such as primary disease management, cognitive-behavioral therapy (CBT), participating in
pleasant and rewarding life activities, physical therapy, non-opioid analgesics and exercise.
DO screen patients for depression and other psychiatric
disorders before initiating COT. Patients with depression
and other mental health problems often present with pain problems. They may not know that mental health problems can contribute to chronic pain. These patients are at higher risk of
opioid addiction. They may be better served by mental health
treatment.
DO talk with patients about therapeutic goals, opioid
risks, realistic benefits, and prescribing ground rules.
Therapeutic goals should include increased activity and improved quality of life, not just pain relief. Patients should understand the full range of opioid risks and the limited benefits they
can reasonably expect. The rules for safe and appropriate use of
opioids need to be explicit, preferably documented in a written
treatment agreement.
DO realize that patients are reluctant to disclose a history of substance abuse. A history of substance abuse indicates greater risk of opioid addiction, but getting an accurate
picture of past and current drug use can be difficult. If a patient
denies past or current substance abuse, recognize that they may
be afraid to tell you the truth. Consult the medical record, a prescription drug monitoring database, and third parties as needed.
DO perform a thorough medical evaluation and a urine
drug screen before initiating COT. Starting chronic opioid
therapy should be an affirmative decision based on adequate assessment of risk, urine drug screening, and use of a treatment
agreement. Because it can be difficult to know if a patient is
seeking opioids for addiction or diversion purposes, COT
should only be considered by a physician who has an ongoing
relationship with the patient. The prescribing physician should
be willing to continue working with the patient if problems arise.
DO explain to patients that discontinuing opioids may
be difficult. Some patients find it difficult to taper off of opioids, particularly from higher dose regimens, even when they
are eager to do so. Patients can experience increased pain, insomnia, or anxiety when tapering from opioids. These unpleasant withdrawal symptoms can last for several weeks. Do not
abandon chronic pain patients after discontinuing opioids.
26
DO perform random urine drug screens on patients receiving COT. Urine drug screening helps identify patients
using illicit drugs or not taking the medicine as prescribed.
DON’T continue COT with patients who show no
progress toward treatment goals defined by increased
function and reduced pain.
DON’T assume patients know how to use opioids safely.
Opioids are powerful drugs that patients sometimes use in unsafe ways. Risks of unsafe use increase with prescribed dose
and are greater for extended-release medications with long halflife. Patients often do not understand that it can be unsafe to
take extended-release opioids “as-needed for pain.” Take time to
talk with patients about how they are using opioids. Ask patients
about their problems and concerns.17
DON’T assume patients use opioids as you intend. Many
patients vary their dose and use combinations of other CNS depressant drugs or alcohol in ways that you may not know about.
Patients may also sell their medications or share them with others. Opioid misuse often occurs among patients who do not
have an opioid use disorder.9,15 Vigilance for unsafe use is essential.
DON’T start a treatment that you are not prepared to
stop. Don’t initiate COT without benchmarks for stopping, a
procedure for tapering that you are willing and able to use, and
an approach to managing physical and psychological withdrawal symptoms. If substance abuse is identified, taper opioids
and make arrangements for substance abuse treatment.
DON’T assume patients are doing well with COT without
careful evaluation. Careful and compassionate interviewing
about opioid use and misuse, questions about your patients’
problems and concerns,17 screening questionnaires, urine drug
screening, and information from prescription drug monitoring
databases often reveal problems with prescription opioids that
would otherwise be missed.
DON’T abandon patients with a prescription drug problem. For patients who are misusing or addicted to prescription
opioids, offer help or referral to someone who can treat substance abuse.
August 2012 • Lockton Companies
PHYSICIANS FOR RESPONSIBLE OPIOID PRESCRIBING
www.responsibleopioidprescribing.org
Contributors
Physicians/Scientists:
Andrew Kolodny, MD
Gary Franklin, MD, MPH
Stephen Gelfand, MD
Petros Levounis, MD, MA
Rosemary Orr, MD
Len Paulozzi, MD, MPH
Jon Streltzer, MD
Art Van Zee, MD
Michael Von Korff, ScD
External Reviewers:
Jane Ballantyne, MD
Roger Chou, MD
Mark Edlund, MD, PhD
Richard A. Deyo, MD, MPH
Thomas Kosten, MD
Patient/Family Advocates:
Peter Jackson
Betts Tully
Mark Sullivan, MD, PhD
Judith Turner, PhD
For additional information, please contact Physicians for Responsible Opioid Prescribing:
Andrew Kolodny, MD, [email protected] or Michael Von Korff, ScD, [email protected]
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2. Papaleontiou M, Henderson CR, Turner BJ, Moore AA, Olkhovskaya Y, Amanfo L, Reid MC. Outcomes associated with opioid use in the treatment of chronic non-cancer pain in older adults:
A systematic review and meta-analysis. JAGS 2010; 58:1353-1369.
3. Martell BA, O’Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction.
Ann Intern Med 2007; 146:116-27.
4. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O’Connor PG, Passik SD, Pasternak GW,
Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C; American Pain Society – American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic
opioid therapy in chronic non-cancer pain. J Pain 2009; 10:113-130.
5. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons.
JAGS 2009; 57:1331–1346, 2009.
6. Ballantyne JC, Shin NS. Efficacy of opioids for chronic pain: a review of the evidence. Clin J Pain 2008; 24:469-78.
7. McQuay H. Opioids in pain management. Lancet 1999, 353: 2229-2232.
8. Baily CP and Connor M. Opioids: Cellular mechanisms of tolerance and physical dependence. Current Opinion in Pharmacology 2005; 5:60-80.
9. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy. J Pain 2007; 8:573-582.
10. Banta-Green CJ, Merrill JO, Doyle SR, Boudreau DM, Calsyn DA. Measurement of opioid problems among chronic pain patients in a general medical population.
Drug and Alcohol Dependence 2009; 104:43-49.
11. Becker WC, Fiellin DA, Gallagher RM, Barth KS, Ross JT, Oslin DW. The association between chronic pain and prescription drug abuse in Veterans. Pain Medicine 2009; 10:531-536.
12. Boscarino JA, Rutstalis M, Hoffman SN, Han JJ, Erlich PM, Gerhard GS, Stewart WF. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system.
Addiction 2010; 105:1776-1782.
13. Manchikanti L., Fellows B., Damron K.S., Pampati V., McManus C.D. Prevalence of illicit drug use among individuals with chronic pain in the
Commonwealth of Kentucky: an evaluation of patterns and trends. J Ky Med Assoc 2005; 103: 55-62.
14. Ives TJ, Chelminski PR, Hammett-Stabler CA, Malone RM, Perhac JS, Potisek NM, Shilliday BB, DeWalt DA, Pignone MP. Predictors of opioid misuse in patients with chronic pain:
a prospective cohort study. BMC Health Services Research 2006; 6:46-55.
15. Banta-Green CJ, Merrill JO, Doyle SR, Boudreau DM, Calsyn DA. Opioid use behaviors, mental health and pain – Development of a typology of chronic pain patients.
Drug and Alcohol Dependence 2009; 104:34-42.
16. Goldsworthy RC, Schwartz NC, Mayhorn CB. Beyond Abuse and Exposure: Framing the Impact of Prescription-Medication Sharing. Am J Public Health 2008; 98:1115–1121.
17. Sullivan MD, Von Korff M, Banta-Green C, Merrill JA, Saunders K. Problems and concerns of patients receiving chronic opioid therapy for chronic non-cancer pain. Pain 2010; 149:345-353.
18. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med 2003; 349:1943-53.
19. Von Korff M. Commentary on Boscarino et al. (2010): Understanding the spectrum of opioid abuse, misuse and harms among chronic opioid therapy patients. Addiction 2010; 105:1783-1784.
20. Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med 2006; 31:506-11.
21. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic
pain and overdose: a cohort study. Annals of Internal Medicine 2010; 152:85-92.
22. Saunders KW, Dunn KM, Merrill JO, Sullivan MD, Weisner CM, Braden JB, Psaty BM, Von Korff M. Relationship of opioid use and dosage levels to fractures in older chronic pain patients.
Journal of General Internal Medicine 2010; 25:310-315.
23. Takkouche B, Montes-Martinez A, Gill S, Etminan M. Psychotropic medications and the risk of fracture. Drug Safety 2007; 30(2):171-84.
24. Vuong C, Van Uum SH, O’Dell LE, Lutfy K, Friedman TC. The effects of opioids and opioid analogs on animal and human endocrine systems. Endocr Rev 2010; 31:98-132.
25. Zhou HY, Chen SR, Chen H, Pan HL. Opioid-induced long-term potentiation in the spinal cord is a presynaptic event. Neuroscience 2010; 30:4460-4466.
26. Walker JM, Farney RJ, Rhondeau SM, Boyle KM, Valentine K, Cloward TV, Shilling KC, Chronic Opioid Use is a Risk Factor for the Development of Central Sleep Apnea and
Ataxic Breathing. J Clin Sleep Medicine 2007; 3:455-461.
27. Tuteja AK, Biskupiak J, Stoddard GJ, Lipman AG. Opioid-induced bowel disorders and narcotic bowel syndrome in patients with chronic non-cancer pain. Neurogastroenterol Motil 2010; 22:424-30.
28. Bell TJ, Panchal SJ, Miaskowski C, Bolge SC, Milanova T, Williamson R. The prevalence, severity and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey
(PROBE 1). Pain Medicine 2009; 10:35-42.
29. Murray Thomson W, Poulton R, Mark Broadbent J, Al-Kubaisy S: Xerostomia and medications among 32-year olds. Acta Odontol Scand 64:249-254, 2006
30. Chou R, Clark E, Helfand M. Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review. J Pain Symptom Manage 2003; 26:1026-1048.
31. Lusher J, Elander J, Bevan D, Telfer P, Burton B: Analgesic addiction and pseudoaddiction in painful chronic illness. Clin J Pain 2006; 22:316–324.
32. Franklin GM, Rahman EA, Turner JA, Daniell WA, Fulton-Kehoe D. Opioid use for chronic low back pain. A prospective, population-based study among injured workers in
Washington State, 2002-2005. Clin J Pain 2009; 25:743-751.
33. Blondell RD, Ashrafioun L, Dambra CM, Foschio EM, Zielinski AL, Salcedo DM. A clinical trial comparing tapering doses of buprenorphine with steady doses for chronic pain
and co-existent opioid addiction. J Addict Med 2010; 4:140-146.
34. Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs 2000. Pain 2004; 109(3):514-519.
35. Boudreau D, Von Korff M, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf 2009; 18(12):1166-1175.
36. Sullivan MD, Edlund MJ, Fan MY, et al. Trends in use of opioids for non-cancer pain conditions 2000-2005 in commercial and Medicaid insurance plans: the TROUP study. Pain 2008; 138(2):440-449.
37. Zacny J, Bigelow G, Compton P, Foley K, Iguchi M, Sannerud C. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse:
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27
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Our Goal
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www.lockton.com
© 2012 Lockton, Inc. All rights reserved.
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