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Lyrica – High Claim Cost Doesn’t Necessarily Mean High Dollar MSAs

January 13, 2016

Lyrica is one of the most widely prescribed ‘pain’ medications in the workers’ system. Unfortunately, it is also one of the most expensive. Add to that the fact that it is typically prescribed ‘off label’ for injured workers, and you’ve got a recipe for high claim cost. But will this high dollar monthly drug spend translate to a high dollar MSA?

Lyrica’s 2016 price increase

Lyrica is among more than 100 drugs that saw price increases as of Jan. 1, 2016. Drug maker Pfizer said the company had raised the price by a whopping 9.4 percent this year. That follows the 20.5 percent increase in its average wholesale price just two years ago. With patent protection firmly in place, a generic version is not expected for at least two years.

While workers’ compensation stakeholders seek medical treatments that result in the best outcomes for injured workers, and off label drug use is common in both workers’ comp and group health, starting with an off-label medication is unnecessary. First-line therapy should be those medications that are FDA-approved for the patient’s condition.

Lyrica’s off label use

Lyrica is FDA approved for only a limited number of conditions, not chronic pain in general. The Food and Drug Administration has indicated the drug for pain associated with diabetic peripheral neuropathy, post-herpetic neuralgia, partial onset seizures, fibromyalgia and neuropathic pain associated with spinal cord injury.

If you have a claimant on Lyrica who does not have any of the above conditions, Medicare WILL NOT cover it — meaning that while you, the payer, may foot the bill as part of your monthly claim spend, Lyrica would NOT be included in the Medicare Set Aside should you move toward settlement. Many medical providers, as well as insurance carriers, are unaware that the medication is not covered by Medicare for off-label uses.

Tower MSA recently saved a client $179,000 after confirming Lyrica was being prescribed off-label and, therefore, should not be included in the MSA. That’s just one example of a high dollar claim cost that did not translate to a high dollar MSA projection.

What to do

Lyrica is just one of the many medications prescribed off-label in the workers’ compensation system. There are many others, like Lidoderm patches, Terocin cream, ACTIQ, Abilify…. all extremely expensive drugs that are not decreasing in price anytime soon.

If you’re unsure as to whether a drug is being prescribed off label, contact Tower and ask the question. If you’re considering settlement, you might also consider Tower’s Pre-MSA Triage. This service identifies unnecessary/inappropriate treatment and recommends claim specific intervention strategies to optimize claim cost before the MSA.

Whether a recommended intervention involves clarification that a medication is being prescribed for an off label use, contact with the treating physician to obtain discontinuation of medications not intended for long term use, or a complete physician peer review with peer to peer collegial dialogue, Tower’s MSP Automation Suite drives the process, tracking progress through completion. As a result, payers can better manage treatment and proactively lower their costs before discussions of the MSA ensue.

Conclusion

Never underestimate the value of a good doctor in optimizing claim outcomes. Payers should identify good physicians through data analytical resources and tools, and not settle for mediocrity. Next, work with your PBM to established and enforce pharmacy guidelines when authorizing treatment. Finally, be proactive in utilizing state jurisdictional options to avoid inappropriate treatment.

Optimal care, cost and compliance can be achieved.

Pre-MSA Triage Works!

November 17, 2015

Inappropriate and/or unnecessary prescription drugs, along with recommended medical procedures that are recommended, but never performed, are all too common in workers’ compensation claims. Yet they are often overlooked when moving a claim to settlement. But a new tool is helping payers identify and address obstacles, saving millions of dollars in MSA and settlement costs. Several recent cases bear out the program’s success.

Tower MSA Partners developed this unique service to ensure MSAs include only accurate and appropriate medical and pharmaceutical treatment. The Pre-MSA Triage allows payers to stage claims for optimal outcomes by providing a snapshot of MSA exposure before the MSA. By following our recommended interventions, clients are achieving CMS approval of reduced MSAs, with reductions of more than 50% in many cases.

How it works

Tower analyzes 6 months of medical records to identify care and cost issues, including the projected MSA cost of a claim based on the current medical and pharmacy treatment regimen. The review also provides a snapshot view of the MSA exposure in a non-discoverable (not an MSA) format, and offers an overview of inappropriate, unnecessary treatment and cost drivers that may impact MSA and settlement. For example, the review may uncover denied injuries and/or body parts, recommended surgical procedures that were never pursued, spinal cord stimulators that were recommended but never evaluated, gaps in treatment dates, unrelated medications, and off-label drug usage.

We then recommend various interventions, such as physician peer review, clinical oversight and conditional payment searches/negotiations to effect improved outcomes and savings in the overall claim costs, frequently as much as 50 percent!

Example Case Study

Tower’s Pre-MSA Triage projected the MSA cost for a 46-year-old male at $1,300,000. More than $1,000,000 of the total projection was due to extended prescribing of both long and short acting opioids. Tower recommended a Physician Peer Review followed by direct dialogue with the treating physician. Agreement to wean was obtained in writing and Tower initiated its clinical nurse oversight service to track progress.

Through Tower’s MSP Automation Suite, developed and maintained internally, we were able to drive the weaning process with the physician through tracked monthly calls, and to guide the adjuster as to when discontinued medications should be blocked by the client’s PBM.

Upon finalization of the weaning process, Tower worked with defense to obtain the necessary written language from the treating physician to confirm discontinuation and remove past medications. The final MSA was submitted and approved by CMS for $210,641 – a savings of more than $1,000,000 from the original estimate!

Conclusion

The example provided here is one of many success stories we are seeing, and through our MSP Automation Suite, we’ve been able to manage the process from triage through final CMS submission and approval in a secure, digital environment. Whether handled internally by our team of nurses or through a formal intervention and peer dialogue by one of our physicians, our system drives every step in the process.

Many companies can identify problems, and some even make recommendations. At Tower, we believe the key to successful MSA outcomes is a proactive approach to identify, intervene and remain involved through closure.

Enhanced Portal Functionality for Final Conditional Payment Process

November 10, 2015

In its ‘What’s New’ section, CMS announced on November 9, 2015 that as part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final Conditional Payment (CP) process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.

When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP. Once calculated, this amount will remain the Final Conditional Payment Amount as long as:

The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.

How the NGHP recovery process works today

To understand the value of this announcement to simplify the final demand process, we need to revisit the recent changes in NGHP recovery and the new role of the Commercial Repayment Center (CRC).

Effective October 5, 2015, the CRC assumed responsibility for pursuing recovery directly from the applicable plan. Any recoveries initiated by the Benefits Coordination & Recovery Center (BCRC) prior to the October 2015 transition will continue to be the responsibility of the BCRC. The typical recovery case, where Medicare is pursuing recovery directly from the applicable plan, now involves the following steps:

1. Medicare is notified that the applicable plan has primary responsibility

Medicare may learn of other insurance through a Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 report or beneficiary self-report. If Medicare is notified that the applicable plan is primary to Medicare, Medicare records are updated with this information.

2. CRC searches Medicare records for claims paid by Medicare

The CRC begins identifying claims that Medicare has paid that are related to the case, based upon details about the type of incident, illness, or injury alleged. The claims search will include claims from the date of incident to the current date. If a termination date for Ongoing Responsibility for Medicals (ORM) has already been reported, the CRC will collect claims through and including the termination date.

3. CRC issues Conditional Payment Notice (CPN) to the applicable plan

The CPN provides conditional payment information. It advises the applicable plan that certain actions must be taken within 30 days of the date on the CPN or the CRC will automatically issue a demand letter. This notice includes a claims listing of all items and services that Medicare has paid that are related to the case. It also explains how to dispute any items and services that are not related to the case. A courtesy copy of the CPN is sent to the beneficiary and beneficiary’s attorney or other representative. The applicable plan’s recovery agent will also receive a copy of the CPN if the recovery agent’s information was submitted on the applicable plan’s MMSEA Section 111 report or the applicable plan has otherwise appointed a recovery agent by submitting a written authorization to the CRC.

Note: If a beneficiary or his or her attorney or other representative reports a no-fault insurance or workers’ compensation situation before the applicable plan submits a Section 111 report, the applicable plan will receive a Conditional Payment Letter (CPL). The CPL provides the same information as a CPN, but there is no specified response timeframe. When this occurs, the applicable plan is encouraged to respond to the CPL to notify the CRC if it does not have ORM and will not be reporting ORM through Section 111 reporting or if the applicable plan would like to dispute relatedness.

4. Applicable plan submits a dispute

The applicable plan has 30 days to challenge the claims included in the CPN. The applicable plan may contact the CRC or use the Medicare Secondary Payer Recovery Portal (MSPRP) to respond to the CPN.

5. CRC issues recovery demand letter advising plan of monies owed to Medicare

The demand letter advises the applicable plan of the amount of money owed to the Medicare program and requests reimbursement within 60 days of the date of the letter. A courtesy copy of the demand letter is sent to the applicable plan’s recovery agent, the beneficiary and the beneficiary’s attorney or other representative. The demand letter includes the following:

The beneficiary’s name and Medicare Health Insurance Claim Number (HICN);
Date of accident/incident;
A claims listing of all related claims paid by Medicare for which Medicare is seeking reimbursement from the applicable plan; and
The total demand amount (amount of money owed) and information on administrative appeal rights.

If the CRC agrees with disputes submitted timely, unrelated claims will be removed from the case before the demand letter is issued. Please note that the demand letter may include related claims that Medicare paid after the CPN was issued. Relatedness disputes on all claims included in the demand letter may be addressed by submitting an appeal.

6. Applicable plan submits an appeal

An applicable plan has 120 days from the date the applicable plan receives the demand letter to file an appeal. Receipt is presumed to be within 5 calendar days absent evidence to the contrary.

7. Applicable plan submits payment

If the CRC receives payment in full, it will issue a letter stating that the specified debt has been resolved. The letter will also note that new cases may be created if the applicable plan maintains ORM or the CRC receives information on additional items or services paid by Medicare during the period of ORM.

Facilitating timely and more accurate final demands

Because the CRC retains the right to create new cases as long as the applicable plan maintains ORM, timely notification of a final settlement is extremely critical to terminate the recovery efforts of the CRC. We applaud the addition of CP process functionality to the MSPRP as a segue to real time information and data exchange, and a more predictable outcome.

With more timely submissions and a published timeline for the final demand, this new extension of the SMART Act will facilitate better accuracy, a better path to closure and fewer last minute surprises…. all good things for those who represent the settlement interests workers’ compensation and liability carriers.

Closed Formularies Hold Promise for Workers’ Compensation Pharmacy Management

October 12, 2015

Opioids linked to escalation in claim cost

With the signing of A.B. 1124 by Governor Jerry Brown October, California has now joined a handful of states that have adopted closed pharmaceutical formularies in their workers’ compensation systems. While many details have yet to be worked out, the decision comes as good news for injured workers and payers alike.

Closed formularies essentially use evidence-based medicine to identity the prescription drugs that should be allowed for certain injuries. All other medications must go through a preauthorization process. The idea is to ensure the injured worker gets the right medication at the right time for the right reasons – AND to reduce unnecessary pharmacy costs.

Implemented appropriately, a formulary can result in better outcomes and lower costs. In fact, a study last year suggested California’s workers’ compensation system could save between $124 million and $420 million annually by adopting a formulary similar to that in effect elsewhere.

In addition to the states that have already implemented closed formularies or are in the process of doing so, several others are considering the idea. The result could be better efficiencies and significant savings for Tower MSA Partners’ clients in managing workers’ compensation claims even before the Medicare Set Aside review and triage process.

The specifics

Under A.B. 1124, the administrative director of California’s Division of Workers’ Compensation must create a formulary by July 1, 2017 for medications prescribed to injured workers. Between now and then, California regulators must determine a program that best addresses the needs of California’s injured workers.

Four states – Ohio, Oklahoma, Texas and Washington have implemented closed drug formularies. Arizona, Arkansas, California, Louisiana, Maine, Michigan, Montana, Nebraska, North Carolina and Tennessee are among the other states considering the formularies or in the midst of developing them.

There are several different types of formularies in effect. Washington, which adopted the first such formulary in 2004, has a more restrictive program than those in some other states. Texas, on the other hand includes more therapeutic groups and more choices within each group.

Regardless of the type of formulary, the states have touted successes. Texas, Washington and Ohio have all reported lower costs.

Texas, which implemented its closed formulary for new injuries in September 2011 and for all injuries in September 2013, also reported the number of injured employees receiving ‘N’ drugs – those requiring preauthorization – fell 65% and costs dropped 83% for new claims for injuries suffered on or after Sept. 1, 2011. Also important, the formulary has led to a significant reduction in the number of injured workers taking opioids on a long-term basis.

The Ohio Bureau of Workers’ Compensation likewise reported significant utilization and cost declines, including a 74% drop in skeletal muscle relaxants, a 25% decline in narcotics and a total drug cost drop of 16%, for a total of $20.7 million, in fiscal year 2014 compared with fiscal year 2011.

Many decisions must be made before California’s formulary takes effect and a variety of issues must be addressed. For example, the pre-approval process for drugs not allowed, decisions about the strategy for long-time opioid users, and considerations of compound medications must be determined.

Fortunately, a team of workers’ compensation stakeholders involved in helping to craft the legislation ensured some important provisions were included. The law requires the California Division of Workers’ Compensation to update the formulary at least quarterly, establish an independent pharmacy and therapeutics committee, accept public comment and publish two interim status reports

Supporters are confident when all is said and done, California’s formulary will provide effective treatment for injured workers, reduce delays and medical disputes, and reduce costs.

How closed formularies impact claims and MSAs

Closed formularies can serve as a gatekeeper in preventing troublesome medications being prescribed to injured workers. Medical providers in states with closed formularies tend to change their behavior and prescribe more clinically appropriate medications and treatments rather than unnecessary opioids and other drugs that require preauthorization.

While providers need approval to be reimbursed for medications not automatically allowed, supporters say closed formularies do not seek to prevent injured workers from having access to medications that are truly beneficial to them.

Workers’ compensation payers can also look for less adversarial relationships with providers, since there will be fewer questionable medications prescribed for the injured worker. Drugs that are not appropriate for first line therapy are generally those that are not allowed without prior authorization, under the closed formularies.

Many steps must be taken before California’s closed drug formulary will take effect and the devil is surely in the details. However, the fact that the nation’s largest workers’ compensation market is going in this direction is good news indeed!

Tower MSA Partners’ Kristine Wilson Will Participate on the MSP/MSA Compliance Panel at California Workers’ Compensation & Risk Conference

October 1, 2015

Wilson will discuss CMS changes to conditional payments and other compliance issues

DELRAY BEACH, Fla.–(BUSINESS WIRE)–Kristine Wilson, COO and senior legal counsel for Tower MSA Partners, will speak at the California Workers’ Compensation & Risk Conference. Tower MSA Partners provides Medicare Set-Aside compliance services nationally and specializes in reducing medical and pharmacy costs on claims prior to settlement.

Wilson will participate on the “MSP/MSA Compliance Open Mic” panel. Topics include whether or not to submit an MSA to the Centers for Medicare and Medicaid Services, the re-review process, and SMART Act changes that affect claims occurring after October 5, 2015. Moderated by Safety National’s Mark Walls, the panel also features Jake Reason with EK Health, Russell Whittle of Examworks, and Tony Comas with Burns White.

“The SMART Act allows for an appeal process for conditional payment disputes,” said Wilson.

The conditional payment process is also changing. “The big news is that Medicare will seek reimbursement for conditional payments prior to settlement,” Wilson said.

Medicare’s new contractor, Commercial Repayment Center, will issue conditional payment notifications when an entity indicates its ongoing responsibility for medical. “Payers only have 30 days to dispute notifications before a conditional payment demand goes out,” Wilson said. “To mitigate their exposure, payers should ensure their Mandatory Insurer Reporting data is complete and immediately respond to conditional payment notices.”

The California Workers Compensation and Risk Conference will be held September 30 through October 2 at the St. Regis Hotel in Dana Point, Calif., and more information is available at http://www.cwcriskconference.org.

About Tower MSA Partners

Headquartered in Delray Beach, Fla., Tower MSA Partners’ services include pre-MSA Triage, MSAs, physician peer reviews, CMS submissions, MSA administration, medical cost projections, life care plans, conditional payments, and Section 111 reporting. With more than 50 years combined experience in pharmacy, legal oversight and medical care, Tower proactively stages claims, working collaboratively with clients to identify issues and intervene to modify outcomes. Tower remains involved in the claims, through final resolution, MSA and/or other settlement. This model enables Tower’s clients to provide better care to injured workers, reduce claim and MSA costs, and obtain CMS acceptance of the MSA. For more information, visit www.TowerMSA.com and www.MSPComplianceBlog.com.

Contacts
For Tower MSA Partners
Helen Knight, (813)690-4787
helen@kingknight.com

You may view the original article here.

Changes Afoot For Medicare’s Conditional Payment Reimbursement Process

September 5, 2015

Expect potential changes in the Medicare’s conditional payment reimbursement process related to a workers’ compensation claim while the claim is still open, possibly more than once. That is among the changes stemming from a revised process to seek reimbursement of conditional payments made in a claim.

Beginning Oct. 5, Medicare is shifting responsibility for its recovery of conditional payments, where the Centers for Medicare and Medicaid Services (CMS) is pursuing recovery directly from a workers’ compensation entity, to the Commercial Repayment Center (CRC), away from the Benefits Coordination & Recovery Center (BCRC). The transition will result in several changes to the process.

Working with the experts at Tower MSA Partners means your claims professionals need not be experts on Medicare Secondary Payer (MSP) compliance or conditional payments. However, payers should be aware of the new process and take steps to reduce any challenges.

Medicare’s Conditional Payment Reimbursement Process: The Plan

The move by CMS for reimbursement recoveries from non-group health plans to the CRC follows CMS’ previous transition of group health plan recoveries. In addition to workers’ compensation entities, the change will also pertain to CMS’ recovery efforts directly from a liability insurer (including a self-insured entity) and no-fault insurer.

The transition will only affect new conditional payment recovery efforts. Actions pending prior to the transition will continue to be managed by the BCRC. The BCRC will also continue to handle recoveries when a beneficiary self reports that a workers’ compensation or other non-group health entity has primary payment responsibility for a claim where Medicare has made a conditional payment.

CRC will manage cases where the Responsible Reporting Entity (RRE) has reported Ongoing Responsibility for Medical (ORM), ORM Termination or Total Payment Obligation to Claimant (TPOC) on Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and CMS has identified the primary debtor as the RRE.

Changes

One of the biggest changes is in the initial dispute process. Where the BCRC provides a Conditional Payment Letter (CPL), the CRC will issue a Conditional Payment Notice (CPN). Both are information — not requests for payments. Both identify the amount of the current conditional payment, provide a statement of reimbursement, and describe the manner for disputing the charges.

However, where the CPL has no specific date for a response, the CPN must be disputed within 30 days. Failure to do so will result in a demand letter or initial determination issued to the applicable plan for payment. While applicable plans do have appeal rights for recovery demand letters issued on or after April 28, 2015, the demand letter locks the applicable plan in place as the identified debtor. Also, interest accrues from the first day of a demand letter; however it will not be assessed if the debt is paid within 60 days.

The CRC will begin to issue CPNs starting October 25, from Section 111 data processed on or after October 5. A CPN is typically issued when an applicable plan reports under Section 111 that it has ORM or a responsibility for the claim as a primary payer, rather than when a settlement, judgment or award is issued.

To dispute the CPN, the applicable plan may contact the CRC in writing or through the Medicare Secondary Payer Recovery Portal (MSPRP). However, disputes submitted through the portal may only be on the basis of relatedness and in response to a CPN. All other disputes must be in writing.

Applicable plans will have one opportunity to file a dispute. If the CRC does not agree with the dispute, the conditional payments will be reflected in the demand letter.

What you can do

Workers’ compensation payers can help prepare for a smooth transition by taking the following actions:
• Carefully review all correspondence related to conditional payments to determine if they are generated by the CRC or BCRC.
• Develop and implement a process for the timely review of CPNs as well as CPLs.
• Make sure disputes of CPNs are properly filed within the 30-day time limit.
• Ensure Section 111 reporting information is updated.
• Make sure the ORM process is working properly.

More specific details will follow as we track the rollout of this process…. Stay Tuned!

Tower MSA Partners CEO on the Importance of Innovation

August 24, 2015

This weekend we had the pleasure of serving as the first overall sponsor of WCI-TV at the Workers’ Compensation Education Conference in Orlando, Florida. Staying the course in our efforts to lead and educate through technological advances and insight, the Tower MSA team curated valuable content over the course of the conference. Hear the thoughts of Tower MSA Partners CEO Rita Wilson on the importance of driving innovation in the industry and why she felt it was necessary to sponsor the conference content through WCI-TV.

Leading Innovation in Workers Compensation Education

August 21, 2015

Tower MSA Partners – First Sponsors of WCI-TV

As the preparations begin for this week’s WCI – Workers Compensation Education Conference, Tower MSA Partners have yet again positioned themselves as leading innovators in the MSP compliance industry. This year Tower MSA Partners will serve as the first overall WCI-TV sponsors. WCI-TV is as an informational, TV-driven media outlet throughout the course of the conference, produced by Convention News TV.

Workers Compensation Education – WCI-TV

This year’s approach to WCEC convention television programming will include live interviews with key thought leaders in workers’ compensation, valuable recaps of conference content, daily headlines of exciting conference updates and much more. The Tower MSA Partners sponsored interviews with industry leaders will be the highlight of the channel and are set to broadcast across the conference and beyond. Conference attendees and others will have viewing access to the channel via guests rooms, conference areas, websites, and YouTube. The televised coverage of the WCI – Workers Compensation Education Conference combined with the innovative reporting and live segments of thought provoking conference content sponsored by Tower MSA Partners is sure to be a hit. This exciting direction for WCI-TV will continue to move the conference forward in trailblazing fresh new ideas in workers’ compensation education and the industry at large.

Tower MSA is also a key sponsor for the charity event, “Give the Kids the World Dinner and Silent Auction”. The fundraiser will be held on Saturday, August twenty-second at six o’clock in the evening.

Combining the courage of innovation, with the heart of philanthropy; this weekend is sure to be a huge hit for Tower MSA Partners and the 2015 WCI WCEC.

Anthony Segrich Promoted as Chief Technology Officer of Tower MSA Partners

July 29, 2015

Newly positioned as the Chief Technology Officer of Tower MSA Partners, Anthony Segrich will pilot all components of technology at Tower MSA. Segrich’s experience in the architecture of successful business process management systems serves as a huge asset for Tower’s commitment to innovative systems and practices.

Anthony Segrich brings his history of consulting, designing and implementing valuable process management systems to the table for Tower MSA Partners. He has performed extensive consulting and development for Fortune 25 companies, such as Cingular Wireless/AT&T, National Semiconductor, and Pepsi International. He holds a bachelor’s degree in Computer Science from Boston College. Before joining Tower, he developed major process management systems for institutions like Fannie Mae, while serving as the general manager for Foreclosure.com.

“Anthony’s previous experience designing business process management systems for Fortune 25 companies equipped him to use the latest BPM technologies in our Section 111 modules,” said Tower CEO Rita Wilson.

In 2012, Segrich partnered with Tower MSA to develop its custom MSP compliance tracking software. He also served as the lead architect for the Section 111 Reporting and data mapping for claims eligibility exchange.

“We can convert files into CMS-preferred formats and then back into client-preferred formats and overlay advanced business rules to make MSP compliance as simple and effective as possible,” Segrich said. “We can now achieve in weeks what takes legacy systems months.”

Segrich has played an intricate role in equipping Tower MSA Partners with the latest technology to deliver end-to-end visibility for their client’s MSAs while simultaneously creating straightforward integration with multiple claim system platforms.

What Can Data Tell Us About Predictors of Long Term Opioid Use?

July 9, 2015

Virtually every day, I encounter an MSA where the use of opioids has affected not only the cost of settlement, but has impacted quality of life, and even reduced life expectancy as a result of the side effects that often occur with long term opioid use. In each situation, I find myself asking the same question, “Could this have been avoided?” I want the answer to be a resounding “YES”, but when I look at the history of the claim, I find so many different paths taken through the years of treatment, it’s difficult to find the single turning point that took both patient and claim in the wrong direction.

Today I ran across a study that reminded me of a basic problem solving pillar I learned from my early IT days.

When troubleshooting a logic problem, shortcuts rarely work. We must go back to the beginning.

Back to the Beginning

In a recent article published by the Mayo Clinic, a team of researchers headed up by anesthesiologist, Dr. Michael Hooten, studied how many patients prescribed an opioid for the first time progressed to long term prescriptions, even to the point of addiction. The answer: 1 in 4 people. In its findings, the researchers noted that people with histories of nicotine and past substance abuse were likeliest to use opioid pain medications long term.

Researchers used the National Institutes of Health-funded Rochester Epidemiology Project to get a random sample of 293 patients who received a new prescription in 2009 for a short acting opioid pain medication such as oxycodone, morphine, hydromorphone, oxymorphone, hydrocodone, fentanyl, meperidine, codeine and methadone. In their analysis, they found that 21 percent, or 61 people, progressed from short-term use to prescriptions lasting three to four months, and 6 percent, or 19, of the 293 studied ended up with more than a four-month supply of the drugs.

What’s the Connection?

According to Dr. Hooten, it’s “all in our heads”. The actual truth is that neurobiology related to chronic pain, chronic opioid use and addiction is similar. We know that smoking has complex effects on pain perception in humans and has long been considered a risk factor for a number of painful conditions, including low back pain and musculoskeletal pain. There have also been behavioral animal studies (Vihavainen T, Piltonen M, Tuominen RK, Korpi ER, Ahtee L., Eur J Pharmacol. 2008) that have shown that both the rewarding and the psychomotor-activating effects of morphine were enhanced following nicotine treatment. Basically, according to Dr. Hooten,

Nicotine activates a group of receptors, or brain structures, in a way very similar to how opioids and chronic pain may activate them.

Impact On Early Treatment

According to Dr. Hooten, the identification of nicotine use and substance abuse as top risk factors for long-term use of opioids suggests that physicians should be particularly careful about prescribing these pain medications to patients with such histories. For workers’ compensation, however, it is critical to identify the potential risk factors before opioid medications are approved the first time, and if possible, even before the patient sees the physician.

Asking the Right Question

If potential risk factors such as past substance abuse and nicotine use could be obtained through investigative data gathering during the first 72 hours after an injury, is there an opportunity to mitigate exposure, and to optimize claim, patient health and settlement outcomes?

With more access to data via social media investigations, employment and medical history searches , financial / credit checks and general post-injury questioning, early claim data analytics can be a tremendous tool to identify triggers that could indicate future claim complications.