MSP Compliance Blog

Expert summary, analysis and recommendations on issues impacting Medicare Secondary Payer compliance.

The VA’s Proactive Move on Opioids

Posted on October 3, 2014 by Tower MSA Partners

I don’t need to reiterate how big a problem prescription drugs continue to be not only in the work comp industry as well as society, but I just did anyway. Recently I wrote here about the rescheduling of hydrocodone combination products and how it was a long overdue move for the DEA to make. As a reminder, the reclassification goes into effect on October 6, and this was no doubt the reason that the Veterans Health Administration sent a letter to my dad yesterday.

As well deserved as the scrutiny against the V.A. has been in recent months, the letter that they sent my father was an absolutely needed step and one that hopefully represents the direction in which the disgraced organization is heading.

It was a simple letter and you can see it by clicking on the link below, but the VA decided to take decisive action and inform what appears to be all patients who have been prescribed hydrocodone combination products in the past about the DEA’s decision to reclassify. Furthermore, they took the time to explain to our veterans the changes to the typical process that they will experience.

There are two aspects of the letter that really stick out. First, it explains the reasoning behind the DEA’s decision in a simple, yet alarming way – one I which my dad really took notice to. The letter states:

The DEA did this because these medications were found to be highly abused, habit forming, and potentially deadly in overdoses and need stricter regulations to improve their safe use.

Simple yet effective. It reads a lot like a surgeon general warning on a pack of cigarettes. The second impressive aspect of the letter is the fact that my dad hasn’t had a prescription for any drug that fits this category since his neck surgery 4 years ago. And so who knows how far back the VA went in considering which vets to send this letter to, and perhaps it was everyone who has ever received a hydrocodone combination product. Whatever they did, from my perspective it was above and beyond and so kudos to the Department of Veteran Affairs for stepping up and being proactive.

VA Letter on HC Products

The DEA Finally Decides To Reschedule Hydrocodone

Posted on August 27, 2014 by Tower MSA Partners

Last week the DEA released a final rule on the rescheduling of hydrocodone removing it from the schedule III controlled substances list in favor of a schedule II designation. To be clear, this decision specifically addresses hydrocodone combination products (i.e., hydrocodone-acetaminophen formulations such as Vicodin) as hydrocodone by itself has always been a schedule II drug.

The new parameters surrounding the prescribing of hydrocodone under the more restrictive schedule II classification will go into effect on October 6, but the decision by the DEA in conjunction with the Assistant Secretary for Health of the U.S. Department of Health and Human Services has been a long time coming. Hydrocodone combination products (HCP’s) have been schedule III since the Controlled Substances Act was passed in 1970 despite, as mentioned, the fact that hydrocodone itself has always been a schedule II drug. The thought initially was that by combining hydrocodone with another substance such as acetaminophen would diminish the abuse potential, but in the DEA’s final order they actually point to several different statistics that definitively portray just the opposite. Perhaps the most eye opening of these statistics tells us that high school aged children have actually abused Vicodin at twice the rate of Oxycontin, a more tightly controlled schedule II drug that has in the past, grabbed a lot more of the headlines.

Not surprisingly, there was a lot of pushback from the pharmaceutical community as well as some from the medical community throughout this process which has taken 15 years to come to fruition (the original petition was submitted by a physician in 1999). This dissent however, is misplaced and perhaps even irresponsible considering hydrocodone is the most prescribed drug in the United States. Last I checked, heart disease was the biggest killer in this country, not pain, yet hydrocodone is prescribed more than even ACE inhibitors (for hypertension) or statin drugs (to lower cholesterol).  And if that is surprising to you try to wrap your head around this: the United States is comprised of about 4% of the world’s population yet we use 99% of the world’s hydrocodone.

The affect this will have on the workers compensation industry could prove to be significant. In terms of PBM’s who commonly push for mail order distribution, schedule II drugs have restrictive policies not conducive to this type of service. It would therefore be a good idea to check with your PBM to ensure that they are actively transitioning all applicable injured workers.

A second implication could be in regards to the widely utilized Official Disability Guidelines (ODG) which have long classified several HCP’s as Y drugs (recommended for first line treatment) within their workers compensation formulary. If changed to N drugs, those HCP’s would be subject to immediate utilization review in states such as Texas and Oklahoma that have instituted a closed formulary.

In my world of Medicare Secondary Payer compliance, it’s tough to say exactly where the effect of this rescheduling will be felt, but there are some trends that I hope we begin to see starting with less hydrocodone on MSA’s. It is easy to get caught up in cost drivers and how to mitigate unnecessary medical treatment in my line of work, and rightfully so when a prescription that was never meant to be maintained long term must be allocated for because it is part of the current treatment plan. But oftentimes, payers tend to overlook or not focus on HCP’s due to their relative low cost in comparison to some of their counterparts such as Oxycontin, Opana or Actiq. The result of that is we are consistently including long term use of hydrocodone-acetaminophen (for example) within MSA allocations in spite of the fact that no opioid has ever been recommended for long term use. This sort of tradeoff is unavoidable at times, but I will still hold out hope that the DEA’s most recent stance to reschedule hydrocodone combination products will prove to have a significant impact on the misuse and abuse of prescription painkillers, not just in our little world of work comp, but far reaching into our society as a whole.

New Additions to Tower Executive Team

Posted on August 13, 2014 by Rita Wilson

In our continued commitment  to build a unique MSP compliance model focused on  identification, intervention and involvement to stage claims prior to MSA and settlement, I am pleased to announce the addition of two key individuals to the Tower MSA Partners executive team.

Scott E. Yasko, MBA

Scott joined tower in July to serve as EVP, Business Development.  In his new role Scott is responsible for management of sales and marketing activities for all products and service offered by Tower.  Prior to joining Tower, Scott served in a sales and marketing capacity at PRIUM, a medial cost management firm with focus on prescription drug misuse and above within the workers’ compensation industry.

As an expert in the arena of pharmaceutical knowledge and the impact of drug misuse on workers’ compensation claims,  Scott plays a strategic rol in Tower’s pre-MSA intervention model, a key differentiator for the company in the MSP compliance arena.

Holly Neary, RPh

As Director of Clinical Services, Holly will oversee all aspects of the company’s Pre-MSA review and intervention services, as well as serving as client and physician liaison for issues related to inappropriate medication use, particularly as it relates to the long term use of opioids to manage chronic pain. 

 Prior to coming to Tower, Holly spent the previous 14 years serving in various capacities of pharmacy management within retail and compounding pharmacies. In her role as manager, Holly’s strength throughout her career has been work flow optimization and streamlined processes, balancing expertise with personal attention in an effort to deliver appropriate prescription solutions through drug utilization review.   Holly also served as clinical specialty pharmacist with United Health writing guidelines for Medicare and Private Insurance plans. 

Tower is fortunate to have two such talented individuals to help guide our future. 





Dangers of Tramadol Recognized

Posted on July 23, 2014 by Tower MSA Partners

Recently, the DEA made the decision to reclassify Tramadol as a schedule IV controlled substance and the decision will officially go into effect on August 18th. Tramadol is an opioid analgesic and aside from its generic form it can also be found in brand names such as Ultram, ConZip and Ryzolt.

This is considerably important news for a number of reasons. First, Tramadol is one of the last commonly prescribed opioids to not be scheduled by the DEA. It has long been used by physicians as a “substitute” for other opioids perceived to be more dangerous. The prevailing thought has been that tramadol has a better safety profile and is not associated with dependence or other negative side effects as much as its headline grabbing brethren such as Oxycontin. In work comp and really in health care in general, it has been this type of thinking that has led to the frequent prescribing of Tramadol as a first line treatment even prior to recommending an NSAID.

The DEA however, has now realized that the data shows something different entirely. And because Tramadol was not scheduled upon FDA approval, it had been closely monitored since it hit the market in 1995 … that is until the steering committee tasked with monitoring dissipated in 2005 due to lack of response to their findings. And what they found was that Tramadol had a high incidence report as related to emergency room visits, a high potential for abuse and astonishingly atypical withdrawal symptoms both when the drug was titrated and stopped abruptly. There were 16,000 emergency room visits related to Tramadol in 2010 yet still 40 million prescriptions made it out of doctors’ offices in 2012.

It is unfortunate that it has taken the DEA this long to do what 10 states have already found necessary (states have the right to schedule differently than the feds), but at the very least this action has brought increased awareness to the dangers of all opioids – not just the typical headline grabbers. And to their credit, throughout their process the DEA was faced with pushback from a number of interest groups citing the potential for a new black-market to emerge, fear of criminal action by prescribing physicians and even the complaint that there is a never ending practice of drug-scheduling (give me a break); but through it all they held firm and got this done.

Chronic Pain Can Be Managed With Alternative Therapies

Posted on July 10, 2014 by Rita Wilson

Traumatic injuries and opioid therapy can alter the pain pathways in the central nervous system, and this process is called neuroremodeling. This can cause unwanted or undesirable reactions to pain and negatively impact the recovery process. There are several approaches to reversing the neuroremodeling, some of these alternative treatments include cognitive behavior therapy and opioid tapering.
A patient cannot overcome chronic pain when their mind is at odds with their body, and so psychological therapy can be an effective way to reverse the body’s perception of pain. Cognitive behavior therapy uses teaching strategies to enable patients to control their perception of pain, and to overcome the feeling of defeat about an injury.   Through CBT, patients learn to cope with existing pain using relaxation, distraction, imagery and self-hypnosis.

Chronic pain affects the whole person… mind, body and spirit.  As such, pain management alternatives must consider more than just the physical.

“In some patients, opioid therapy administered to reduce pain has the opposite effect and the patient experiences an increased feeling of pain. This effect is called opioid-induced hyperalgesia (OIH). OIH is an example of neuroremodeling that occurs to the specialized receptors in the body that respond to opioids. The cause is unknown, but sometimes a normal perception of pain can be restored by discontinuing opioid therapy through a medically supervised program. The assistance of a comprehensive pain management center experienced in opioid tapering may be necessary.”

Many are resistant to standard detoxification programs, noting that most are cost-prohibitive, and many times the patient returns to old habits.  While this may occur in some cases,  greater attention is being given in treatment guidelines, especially when opioids are involved, to recommend alternative pain management strategies like CBT in an effort to heal the whole person.  Leveraging the patient’s individual strengths while building compensatory strategies to offset weaknesses, long term success can be achieved. 
What’s the old saying…..

 “Give a man fish and he will have food today.  Teach a man to fish and he will have food for a lifetime.”

Are we, as an industry,  willing to spend the time, money and effort to teach?

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