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

January 13, 2016

opioid guidelines

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.


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.

Is Opioid Use Under Control in Workers’ Compensation?

April 15, 2014

With the recent publication of the ACOEM Guidelines for Opioid Use and new guidelines from the American Chronic Pain Association (ACPA) that include very specific recommendations to monitor opioid use, the question was raised generically as to whether opioid use is under control in workers’ compensation.  Certainly, with greater specificity in Morphine Equivalent Dosage (MED) directives, reducing the maximum threshold for potential concern for dependency to 50MED, our experiences and research have intensified our understanding of where and how the problem begins.  Does this, then, mean that opioid use is under control?

According to the CDC, the US makes up only 4.5% of the world’s population, yet consumes more than 80% of all opioids.  My short answer, then, is “No, opioid use is not under control in any industry in the US.”

 The title of the cover article in this month’s (April 2014) issue of ‘The American Legion Magazine’ is “Pain’s Addiction: Opioids and the Military Veteran.’  Quoting from the first line of the article,  

By the time Justin Minyard discovered the video of himself stoned, drooling and unable to help his daughter unwrap her Christmas presents, he was taking enough OxyContin, oxycodone and Valium every day to deaden the pain of several terminally ill cancer patients.

And later, from a veteran’s widow,

Just before Ricky’s overdose and death, his medication list included oxycodone (short-acting opioid, pain), hydrocodone (short-acting opioid, pain), Valium (anti-anxiety), Ambien (insomnia), Zoloft (anti-depressant), Gabapentin (Neurontin, neuropathic pain) and Tramadol (Ultram, ‘narcotic like’ medication for moderate to severe pain).

The shocking realization for me…  I can’t tell you the number of times I’ve seen this exact drug regimen in a legacy workers’ compensation claim referred to Tower for an MSA. 

Other Recent Opioid Related Announcements:

  • March, 2014, Attorneys General from 29 states sent letters to the FDA to request the withdrawal of FDA approval for ZOHYDRO, a pure version of the opioid, hydrocodone.
  • 6 days ago, Business Insurance released its latest white paper, “Opioid Abuse, How to Tackle a Growing Problem.”   
  • March, 2014, the Reed Group announced that it dedicated an entire chapter to its Disability Guidelines to provide opioid guidance, documented and independently researched by ACOEM (the American College of Occupational and Environmental Medicine.)
  • February, 2014, the ACPA (American Chronic Pain Association) released its 2014 Resource Guide to Chronic Pain Management.  The guide specifically noted that 30% of hospital admissions among the elderly can be linked to an adverse drug event or toxic effect of opioids and sedatives.

While it remains the exception, I believe this 16-20% segment of the workers’ compensation population consumes more than its reciprocal 85% of the system’s money, time and expertise.  I believe opioid use, combined with its side effects, interactions and impact on quality of life, to be the key driver of cost and appropriate care with the MSA and associated settlement. I support and follow PROP (Physicians for Responsible Opioid Prescribing  I will also continue use our blog, to communicate issues, strategies, treatment guidelines, etc. 

The more we understand about chronic pain, as compared to acute pain, and the effects of long term opioid use, the more aggressive we will be in our efforts to identify and address its potential for misuse early in the claim. 


Why Workers’ Comp Claims Drag On and On

February 26, 2014

Any employer who has dealt with legacy claims understands the financial strain it can cause.  Does the term ‘creeping catastrophic claims’ resonate?  When you look below the surface, there are a multitude of reasons for a  workers’ compensation claim to stay open for an extended period of time. Inadequate training, inappropriate handling at the beginning of the claim,  too many claims assigned to a single adjuster and claim handling by a TPA that no longer values your business are just a few of the reasons behind the increased financial burden of the ‘old dog’ claims.   This article highlights and explains many of the reasons legacy claims drag on, and offers strategies that can intercept the downward spiral.

If you ask the third party administrator (TPA) adjuster why any particular claim is still open, the adjuster will recite the employee’s medical condition and possibly the industrial commission ruling on the particular claim.

Click here to read more

Request to FDA to Change Opioid Labels

October 1, 2012

FDA Opioid Labeling Petition
FDA Opioid Labeling Petition
To those who may not know, PROP (Physicians for Responsible Opioid Prescribing) is an organization comprised of practicing physicians whose mission is “to reduce morbidity and mortality resulting from prescribing of opioids, and to promote cautious, safe and responsible opioid prescribing practices.”   I follow PROP regularly and use many of their resources to educate my staff on opioid use as it relates to long term prescribing and the MSA.

As a PROP follower, I recently received the email below asking for my support.  I responded immediately and am forwarding to each of you in the hope that you will do the same.


Dear Friends and Colleagues,

As you may know, PROP filed a request to FDA for changes to opioid labels. Specifically, we asked them to add a suggested duration of use, a suggested upper dose and to limit (on-label) use to severe pain. You can read about this here:

If FDA implements our request, opioid manufacturers will be prohibited from advertising long-term use of opioids for chronic non-cancer pain and the medical community will be informed that this practice has not been proven safe and effective. (However, clinicians will still be permitted to prescribe long-term opioids). We believe that this will help reduce overprescribing of opioids. And since it’s overprescribing that’s harming pain patients and fueling the opioid addiction epidemic, the label change could help bring this unprecedented public health crisis under control.

FDA is seeking public comment about the Petition. Thus far, they have received about 200 comments supporting the petition and 130 opposed to the petition. Not surprisingly, industry-funded pain groups (and pain patients misled to believe that this is an effort to ban opioids) have weighed in against the Petition.

Submitting comments to FDA is easy… just click here:!submitComment;D=FDA-2012-P-0818-0001.

A couple of sentences is all you need. Please make sure to state clearly in the first or second sentence that you support the petition.

For example, you can write:

I support this petition. Drug companies should not be permitted to advertise long-term and high dose opioids for moderate chronic pain because this treatment has not been proven safe and effective. The medical community should be informed by a revised label that risks may outweigh benefits when opioids are prescribed long-term.

Please try to do this ASAP. As soon as FDA takes an action on the Petition (which could be very soon), they will close the comment period.

If you are interested in reading comments that have already been posted, you can do this here:!searchResults;rpp=25;po=0;s=fda-2012-p-0818.

Thank you for your support!


Andrew Kolodny, MD
President, Physicians for Responsible Opioid Prescribing

Chair, Department of Psychiatry
Maimonides Medical Center
920 48th St., Brooklyn, NY 11219
Tel: 718 283-7557; Fax: 718 283-6540

Medicare Secondary Payer and Workers’ Compensation Settlement Agreement Act: 30 Days and Counting…. Can it Succeed?

June 18, 2012

Introduced into the US House of Representatives on April 27, 2012, the Medicare Secondary Payer and Workers’ Compensation Settlement Agreements Act of 2012 (HR 5284) aims to streamline the settlement of workers’ compensation agreements by creating an exception to Medicare secondary payer requirements. The bill also provides language that could ease the path toward satisfying these requirements by using qualified Medicare set-aside arrangement (MSA) under these agreements.

Designed to apply to certain workers’ compensation settlements agreements, the bill proposes changes if any of the following criteria is present:

  1. The total settlement is $25,000 or under;
  2. The claimant is not eligible for Medicare at settlement date and is not expected to be eligible within 30 months;
  3. The settlement agreement does not limit or eliminate the claimant’s right to payment of future medical bills;
  4. The claimant is not eligible for future medical bill payments under the settlement.

US representative David Reichert (WA-8) introduced the bill in an attempt to improve the set-aside process for workers’ compensation claims. Current settlements that overlap with Medicare coverage create a lengthy review period on what constitutes the set-aside coverage amounts.

Currently, HR 5284 has been referred to the Subcommittee on Health for review. The bill has gained heavy support from industry organizations, including American Insurance Association (AIA), American Association for Justice (AAJ), American Bar Association (ABA), National Council of Self Insurers (NCSI), Property Casualty Insurers Association of America (PCI), UWC – Strategic Services on Unemployment & Workers’ Compensation (UWC), Washington Self-Insurers Association (WSIA), and Workers Injury Law and Advocacy Group (WILG).

Part of the problem may be that the legislation tries fixing what isn’t governed. There is a lack of any real definition of MSA from a regulatory sense. Would wrapping laws around an undefined practice work?

Also, industry buzz suggests that legislators are treating workers’ compensation issues much like they would group health issues. Also, detractors of the bill believe there is little to address the calculation of allocation amounts and too little consistency in understanding and applying CMS policies.

The success of H.R. 5284 will depend largely on how well the legislation understands the MSA environment. While the idea may be a good one, the actual practice may fall short of its intended goal.

Town Hall Teleconference Events – February through June, 2012

February 17, 2012

Mandatory Reporting for Liability Insurance (including Self-Insurance), No-Fault Insurance and Worker’s Compensation

Implementation of Medicare Secondary Payer Mandatory Reporting Provisions in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007
(See 42 U.S.C. 1395y(b)(8))

The CMS will be hosting combined NGHP Policy and Technical Support related teleconference events. For these calls the format is opening remarks and a presentation by CMS, followed by a question and answer session with the audience. Following is the call schedule for the first half of 2012.

NGHP Policy and Technical Support Questions and Answers: These calls will address both policy and technical questions you have regarding Section 111 reporting. Policy discussions will focus on CMS policy supporting the Section 111 NGHP reporting requirements, and how policy is being and has been translated into procedures. Technical support questions will focus on EDI connectivity and data transmission, use of the COB Secure Website, disposition and error codes, and other aspects of the data exchange process. Both CMS staff and representatives of the CMS COBC EDI Department will be available throughout each call.


  •  February 23 (Thursday), 2012
  •  March 22 (Thursday), 2012
  • April 24 (Tuesday), 2012
  • May 24, (Thursday), 2012
  • June 19 (Tuesday), 2012

Call-in time for all calls: 1:00 PM – 3:00 PM Eastern time. Participation is by telephone only.

Call-in line for all calls: (800) 603-1774

Pass Code: Section 111

Questions for the call: Please submit questions to

Please begin dialing in approximately 20 minutes before the call start time, due to the large number of participants.

Tower MSA Partners Seeks Experienced Salespeople

January 4, 2012

Tower MSA Partners is aggressively seeking experienced salespeople in both workers’ compensation and liability markets. Interested parties should forward their resumes to  To speak with someone directly, please call 888-331-4941 and reference this post.

Top 10 Drugs Prescribed For Workers’ Compensation Claims

November 21, 2011

A recent study by NCCI Holdings, Inc. reports the top 10 most popular drugs prescribed for workers’ compensation claims.


Workers compensation medical costs per claim average more than $6,000 and soar to nearly $25,000 for lost-time claims. The report examined workers compensation prescription drug (Rx) use, a medical expense that makes up 19% of all workers compensation (WC) medical costs.

Other key findings of the report on drugs prescribed for workers’ compensation were:

• The indicated Rx share of total medical is 19%; this is slightly higher than the estimate given in the 2010 update
• OxyContin® climbs from the number 3 WC drug in Service Year 2008 to number 1 in Service Year 2009
• Hydrocodone-Acetaminophen drops from the top WC drug in Service Year 2008 to number 3 in Service Year 2009
• Recent overall cost increases are driven more by utilization increases than by price increases
• Physician dispensing continues to increase in Service Year 2009 in almost every state
• Increased physician dispensing is associated with increased drug costs per claim
• Per-claim Rx costs vary significantly by state