Category Archives: Analytics

An Algorithm a Day, May Keep the Pain Doctor Away

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As previously discussed on this blog, prescription pain medication abuse is a big problem in workers’ compensation, (see Opioid Abuse in Workers’ Compensation: What the Medical Tourism Industry Needs to Know).

There has been a lot of writing on the subject, and a great deal of meetings, webinars, and conferences, with very little solutions being offered, or action taken besides passage of legislation and the creation of state-run databases, as in Kansas and California.

But recently, as reported last week in the Wall Street Journal article, “When Your M.D. Is An Algorithm” by Timothy W. Martin (April 11,2013), a summit was held in Orlando, Florida that brought together patient advocates, policy makers, and law-enforcement officers, as well as representatives of a new cottage industry: companies that are taking a data-driven approach to deal with the drug-abuse problem.

The National Rx Dug Abuse Summit showcased companies that are combining medical research and guidelines with computer analysis to guide doctors about what drugs should be administered, in what doses, or if at all.

These companies, mainly insurers and medical-bill review consultants for companies paying workers’ compensation claims said they are filling an unmet need: that of providing research-driven clinical advice and guidelines to doctors who have not been thoroughly trained on how to treat pain.

There are some doctors, who are skeptical of these programs that have names such as “Opioid Defense Manager” and “VantageComp”. They do not believe that these programs play any role in medical treatment, especially when they are used by companies looking to lower drug costs and medical spending.

One of the 40 analytic companies that attended the conference was Rising Medical Solutions, Inc. Their in-house algorithms, assesses whether an individual is a low, medium or high risk. This is based on a 30-question survey that asks about an injured worker’s optimism about their recovery, their previous injury history and whether they smoke, along with other signs that measure their vulnerability to painkiller addiction.

Rising Medical CEO, Jason F. Beans said that the company had determined that being on painkillers any longer than two weeks, could be an indicator of addiction. Beans also went on to say that, “We enact interventions to prevent the small lower-back claim from becoming a lifelong addiction.”

PMSI’s proprietary Risk Intelligence System, has 18 criteria it says could signal fraud or abuse. According to Ishita Sengupta, director of workers’ compensation at the National Academy of Social Insurance, a nonprofit research group that tracks workers’ compensation benefits and costs, the analytics-driven industry has grown to more than three dozen companies from just a handful a decade ago.

Insurance companies such as AIG, Liberty Mutual and Travelers have added analytical or predictive modeling abilities to their workers’ compensation divisions.

Pharmacy-benefit managers such as Modern Medical Inc.  and consulting firms such as Prium, a Georgia firm that consults to workers’ compensation payers, are also involved with analytics. Michael Gavin, chief strategy office at Prium, said “Your doctor’s approach to pain care may lead you to become addicted—but that is not the case with high cholesterol or high blood pressure.”

All this growth in a nascent industry such as analytics comes about because workers’ compensation spending is soaring. As Martin points out in his article, and as I have pointed out in my white paper, Legal Barriers to Implementing International Medical Providers into Medical Provider Networks for Workers’ Compensation, the average medical cost for lost time claims was $28,000 in 2011, which was nearly double the cost in 2001, when the cost was $15,900.

Both Martin’s article and my white paper cite data from the National Council on Compensation Insurance (NCCI), an industry-created company that tracks workers’ comp spending and the overall health of the industry.

So as the medical tourism grows, and the idea to implement medical tourism into workers’ compensation becomes a reality, medical tourism facilitators and medical tourism providers will be able to know beforehand if a surgical patient who was injured on the job and receiving medical treatment abroad, is already a painkiller abuser or could become one. The provider will have the benefit of the knowledge provided by analytics to determine risk of addiction so that patient addiction can be halted or avoided altogether.

This in turn, will also help the wider medical tourism industry because the very analytics used to determine risk of addiction for injured workers can be used for non-occupational injury patients receiving the same surgery. And that will give the medical tourism industry more credence with the healthcare community at large.