Rx16 tpp tues_200_1_bartlett-peak_2fisher

Workers’ Compensation:Dangerous Prescribing Practices

and At-Risk PatientsPresenters:• Teresa Bartlett, MD, Senior Vice President of Medical Quality,

Sedgwick• Paul Peak, PharmD, Director, Clinical Pharmacy, Sedgwick• Stephen Fisher, MD, PhD, Director of Health Services, Medical

Advisor to the CEO, Chesapeake Employers Insurance

Third-Party Payer Track

Moderator: Christopher M. Jones, PharmD, MPH, Director, Division of Science Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and Member, Rx and Heroin Summit National Advisory Board

Disclosures

Teresa Bartlett, MD; Stephen Fisher, MD, PhD; Paul Peak, PharmD; and Christopher M. Jones, PharmD, MPH, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:

Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Identify dangerous prescribing practices observed in management of workers’ compensation insurance claims.

2. Describe strategies that have proven successful in resolving dangerous prescribing practices.

3. Outline approaches to identify and manage high-risk claims within the workers’ compensation population.

4. Provide accurate and appropriate counsel as part of the treatment team.

Teresa Bartlett, MDSVP, Medical QualitySedgwickTeresa Bartlett, MD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Paul Peak, PharmDDirector Clinical PharmacySedgwickPaul Peak, PharmD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Presenters & disclosures

• Identify dangerous prescribing practices observed in management of worker’s compensation insurance claims

• Describe strategies that have proven successful in resolving dangerous prescribing practices

• Outline approaches to identify and manage high-risk claims within the workers’ compensation population

• Provide accurate and appropriate counsel as part of the treatment team.

Learning objectives

In group health, typically 3% of drug spend is on prescription opioids – in workers’ compensation, the drug spend on opioids is between 25% and 40%. It is 29% for the Sedgwick book of business.

Addition of opioids to a WC claim means a 53 week increase in the duration of the claim (on average).

In the WC population, 60% of patients taking opioids for at least three months are still on opioids 5 years later.1

Studies show that overall the effectiveness of chronic opioid therapy on addressing pain is modest and effect on function is minimal.2,3

Opioid use in workers’ compensation

1. Martin BC, Fan MY, Edlund MJ, Devries A, Braden JB, Sullivan MD. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med 2011; 26:1450-7.

2. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012;2012:953139.

3. Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. The Cochrane database of systematic reviews 2010:Cd006605.

The Sedgwick approach

Best practices

• Avoid compounds• Avoid dangerous combinations of medications• Use over the counter topical medications when needed

• 66 year old female• Industrial injury occurred when she was 23 years of

age – has not worked since 1979• Hurt back during a fall at work• Diagnosis: Failed back with bilateral legs and psych

issues also accepted• Pre-interventional status:

Medications - [MED: 555mg] oxycodone ER (OxyContin®), oxycodone IR, sertraline

• Years since a taper attempt• Current status:

Medications – [MED:60mg] oxycodone/APAP

Jane’s story

Glenn’s StoryGlenn’s story

• 52 year old male• Industrial injury occurred when he was 35 y/o –

Patient is still at work• Suffered head contusion which also caused cervical

and low back strain• Pre-interventional status:

Medications – [MED: 840mg] oxycodone ER (OxyContin®), hydrocodone/APAP, zolpidem, methylphenidate

• Physician did not want to taper• Current status:

Medications – [MED: 60mg] hydrocodone/APAP

Carla’s story

• 55 year old female• Industrial injury occurred when she was 42 y/o and

involves a right foot injury and right shoulder• Intentional overdose with hospitalization in 2007• UDS unprescribed medications• Caregiver for grandchild• Physician only sees the patient every 6 months and the

husband picks up her prescriptions• Pre-interventional status (recently started on this claim):

Medications – [MED: 630mg] oxymorphone ER, hydromorphone, ziprasidone, duloxetine

Attempt to bring about change

Discuss the health and safety of the injured workers

To represent our clients

To call attention to aberrant prescribing patterns

To enhance communication with their office staff

To let them know how carefully we are watching

Sometimes it takes a personal visit

Our team includes over 50 nurses, 11 pharmacists, and 5 physicians

2015 Reduced the average number of medications per claim by 31%

Decreased the Morphine equivalent dosage by 49% 38% of urine drug screen results are not consistent with prescribed

medications

The next evolution: Pain coaching

Pharmacy program results

Workers’ Compensation: Dangerous Prescribing Practices and At-Risk

PatientsStephen Fisher, M.D., Ph.D.Director of Health ServicesMedical Advisor to the CEO

Chesapeake Employers’ Insurance

Disclosure

• Stephen Fisher, MD., Ph.D., has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Learning Objectives

• Identify dangerous prescribing practices observed in management of workers’ compensation claims• Describe strategies that have proven successful in resolving

dangerous prescribing practices• Outline approaches to identify and manage high-risk claims within

the workers’ compensation population• Provide accurate and appropriate counsel as part of the treatment

team.

Chesapeake Employers’ Overview

• Insures primarily small to medium employers- approx. 21,000 policy holders• Large percentage of policyholders in construction and the

trades• Insures 70% of all Maryland municipalities and counties• Third party administrator for the State of Maryland

2015 RX COUNT BY THERAPEUTIC CLASS

Therapeutic Chapter Description Rx Count Rank Rx Count

IngCostRank

NARCOTICS 1 8,114 1

COMBINATION NARCOTIC /ANALGESICS 2 5,269 4

ANTICONVULSANTS 3 4,492 2

MUSCLE RELAXANTS & ANTISPASMODIC AGENTS 4 4,051 3

NSAIDS 5 3,951 8

MISCELLANEOUS ANALGESICS 6 2,208 7

MISCELLANEOUS ANTIDEPRESSANTS 7 1,916 5

ANXIOLYTICS 8 1,328 17

HYPNOTIC AGENTS 9 1,141 12

SELECTIVE SEROTONIN REUPTAKE INHIBITORS 10 850 21

(Chesapeake Employers’ Insurance 2015)

Top 20 Oxycodone Scripts by Count & Quantity

RANKED BY QUANTITY

# RXs QuantityOXYCODONE HCL 10 MG TABLET 510 50,179

OXYCODONE-ACETAMINOPHEN 10-325 366 39,457

OXYCODONE HCL 15 MG TABLET 355 39,116




OXYCONTIN 20 MG TABLET 341 23,364















RANKED BY RX COUNT

# RXs QuantityOXYCODONE HCL 10 MG TABLET 510 50,179




















TOTAL 5,413 443,019

Highly Prescribed Drugs/Doses

drug name dose # scripts quantity avg pills/ script

Oxycodone 10 mg 1,787 181,119 101

Oxycodone 5 mg 1,925 122,187 63

Oxycontin 1,130 75,512 67


How is Prescription Drug Use Different in WC

• 75% of Injured Workers are Prescribed Opioids but Rarely Receive Associated Services (UDS, PT, Psychological Eval and Support (Thumula and Wang, Interstate Variations in Use of Narcotics, 2nd Ed) (Longer Term Use of Opioids, 2nd Ed, May 2014)

• 1.75 deaths per 1000 patients/yr if on opiates vs. 1/1000 for high risk occupations- fishing, logging (Property Casualty360.com, July , 2015)

Low Back InjuriesHigher amounts of narcotics in treating acute work-related low backpain cause injured workers to be:

• Away from work longer (up to 69 days longer)• Have higher medical costs • Be 3X more likely to have surgery • Have a 6X greater chance of using narcotics beyond

the recommended time (WorkComp Central 7/20/09)• Receiving more than a one week supply of opiates following an injury doubles

the risk of disability one year later (Franklin, G.M., Stover, B.D., Turner, J.A., Fulton-Kehoe, D., & Wickizer, T.M. (2008). Disability Risk Identification Study Cohort. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine, 199- 204.)

Chesapeake Employers-Prescribers by Specialty

Rank by Cost Specialty % of Rxs % of Cost

# of Rxs with MED > 90

1 Physical Medicine & Rehabilitation 10.9% 14.4% 6622 Internal Medicine 12.9% 13.9% 1953 Physician Assistant 12.6% 11.5% 6874 Nurse Practitioner 9.8% 10.2% 5955 Family Medicine 8.4% 8.0% 2206 Specialist 6.1% 5.9% 1987 Psychiatry & Neurology 5.7% 5.8% 738 Pain Medicine 3.6% 5.8% 2749 Anesthesiology 4.5% 4.9% 271

10 Orthopaedic Surgery 6.5% 3.2% 22011 Registered Nurse 1.1% 2.2% 9612 General Practice 1.5% 1.4% 29113 Clinical Nurse Specialist 0.2% 0.8% 2314 Neurological Surgery 1.4% 0.8% 5515 Emergency Medicine 1.2% 0.6% 3016 Surgery 0.7% 0.6% 24


Chesapeake Employers’ Program Initiatives

• Pharmacy Benefit Manager (PBM) partnership on Fraud, Waste and Abuse

• Pain Management team• Pharmacy Nurse• Behavioral Health Assessments• Functional Restoration Programs• Identifying groups prescribing and or dispensing inappropriately• Education of injured workers of the dangers of long term opioids• Soft tissue algorithm to prevent medical and drug over utilization• Internal educational programming for adjustors, nurses, attorneys

Clinical Programs• Soft Tissue Algorithm training for adjustors and health services staff- early

intervention tool

• Pain Management Program:• Pain Management Nurse• IME tracking• Peer to Peer programs• Behavioral Health- Cognitive Therapy• Functional restoration• Legal representation• Pharmacy Benefit Manager• Adjuster participation• Coordination of inpatient/ outpatient detox programs• Monitoring by urine drug screens

Pharmacy • Rules based formulary for establishing pre-authorization at point of sale• Limits number of opioid fills to (3) before requiring pre-authorization• Pharmacy PBM portal:

―Houses all prescription data in one program―Irregular prescribing pattern or drug regimen―Point of sale messaging (example: Drug not covered. Please contact prescriber

for an alternative medication.)―Sets MED limit (90-120)- by individual drug and accumulative

• Fraud, Waste, and Abuse Program• Opioid educational letter to prescriber and injured worker

Pharmacy Benefit Manager (PBM) Reporting

• Comprehensive reporting:- Top prescribers by drug name, rx count and quantity- MED- individual and accumulative- Escalating MEDs- Narcotic Alert Report (date of 1st script and most recent fill, number of days,

and count of scripts)- RX Alert Report- 16 rules based criteria- High risk drug combinations- Ad hoc reports

Nurse Case Management

• Utilize pharmacy portal for management of drug use • Nurse Case Management Intervention Program for NCM assignment-

trigger of MED >90 in addition to other high risk drug combinations (Houston Cocktail)• Field case management- high risk, non-compliance, non-cooperative

providers, managing weaning regimen• Consultations with in-house Medical Advisors • Works closely with adjusters • All case managers are accountable for drug assessments and

continuous monitoring

Mental Health Issues In WC• Depression present in 7-16% of workers in the U.S. (Paradigm Outcomes Symposium, Oct.

2015) “We Can’t Remain Complacent About Mental Health. Step Out of Your Comfort Zone.” (Renee-Louise Franche)

• Depression has been diagnosed in 18% of WC patients within one year of suffering a minor injury (Healthcare Solutions. Drug Trends 2013. Available at: http://hsdrugtrends.com/. Accessed November 12, 2013.)• 33% of Chronic pain patients also have depression and 45% of those

with one mental health diagnosis have at least one additional,often anxiety. (Wideman TH, Scott W, Martel MO, Sullivan MJL. Recovery from depressive symptoms over the course of physical therapy: a prospectivecohort study of individuals with work-related orthopaedic injuries and symptoms of depression.J Ortho Sports PT. 2012;42(11): 957-968)

Behavioral HealthCognitive Behavioral Therapy

― Delayed recovery and Return to Work―Psychosocial dysfunction- fear avoidance, catastrophic thinking, depression

and anxiety―Unsupported opioid use- pain and function unchanged or increases―Escalating MED―Use of Physical Medicine Diagnosis

• 96150 – Health and Behavioral Assessment• 96125 – Health and Behavioral Intervention• 98968 – Telephonic Case Consultant

Behavioral Health Outcomes

• 98% of treating providers agreed to make referral• 87% represented by an attorney• 100% RTW referrals did return to work• 71% non-compliance have documented pre-existing psych dx• 33% full and final settlement• Workers’ Compensation Commission support of cognitive behavioral

therapy


Legal

• Maryland Workers’ Compensation Commission• Highly litigious state• According to WCRI, 50% of injured workers in Maryland obtained an

attorney (Claims Journal, May 17, 2012)• Resolution of prescription drug related issues frequently at the Workers’

Comp Commission• Legal Round Tables – in-house attorneys are well versed on pain

management and opioid abuse • Commission rulings in this area are often times favorable for provider

weaning or outpatient/ inpatient detoxification.

Percentage of Narcotics to Total Scripts

• 2011 (39.1%)

• 2012 (38.4%)

• 2013 (36.6%)

• 2014 (35.8%)

• 2015 (34.5%)

(Chesapeake Employers’ Insurance)

2011 2012 2013 2014 201532

33

34

35

36

37

38

39

40

% Narcotic to Scripts

Morphine Equivalent Dose (MED) Tracking

Number of Injured Workers Using Opioids

(Percent of Claims Receiving PBM Benefits)

Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 201534.0%

34.5%

35.0%

35.5%

36.0%

36.5%

37.0%

37.5%

38.0%

38.5%

% Injured Workers Using Opioids

(Express Scripts)

# Workers Receiving Opioids 1/2015-1/2016

# injured w

orkers

January

2015

# injured w

orkers

July 2015

# injured w

orkers

October 2

015

# injured w

orkers

January 2016

050

100150200250300350400450500

≤ 5051-9091-119≥ 120

(Express Scripts)

Number of Opioid Prescriptions Monthly

1000

1050

1100

1150

1200

1250

1300

1350

1400

1450

1500 # Opioid Prescriptions

(Express Scripts)

# of Prescriptions <90 MED Monthly

700

750

800

850

900

950

1000

1050

1100

# Rx <90 MED

# Rx <90 MEDLinear (# Rx <90 MED)

(Express Scripts)

# Scripts >300 MED

0

10

20

30

40

50

60

70

80 # Rx >300 MED

# Rx >300 MEDLinear (# Rx >300 MED)

(Express Scripts)

MED Category Trend

Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 20150

500

1000

1500

2000

2500

3000

Number of Prescriptions MED <90Number of Prescriptions MED 90-120

(Express Scripts)

External Affairs

• Multi-disciplinary back injury study• Scope of Pain CME sponsorship• DHMH engagement• Heroin and opiate abuse task force participation• Funding of PDMP• Speaking opportunities

Workers’ Compensation:Dangerous Prescribing Practices

and At-Risk PatientsPresenters:• Teresa Bartlett, MD, Senior Vice President of Medical Quality,

Sedgwick• Paul Peak, PharmD, Director, Clinical Pharmacy, Sedgwick• Stephen Fisher, MD, PhD, Director of Health Services, Medical

Advisor to the CEO, Chesapeake Employers Insurance

Third-Party Payer Track

Moderator: Christopher M. Jones, PharmD, MPH, Director, Division of Science Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and Member, Rx and Heroin Summit National Advisory Board

Health & Medicine

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