Tag Archives: Pain Medications

Big Insurer to Put Dispensing Docs on Notice

An article in Healthcare Finance yesterday reported that Aetna has put more than 900 opioid prescribing physicians on notice that they fall with the 1 percent of top opioid prescribers.

Here is the link to the article:


What does this mean for workers’ comp?

It means that other insurers need to do the same for the physicians who prescribe opioids for injured workers, but as Joe Paduda recently reported, the drug spend is going down.

But he also said this, earlier this week,  “Medical services for people with opioid dependence diagnoses skyrocketed more than 3,000 percent between 2007 and 2014.”

This was for privately insured people, he continued.

“The dollar cost of the drug itself is the least of the cost issues; dependency is strongly associated with much higher utilization of drug testing, overdose treatment, office visits and (my assumption) higher usage of other drugs intended to address side effects of opioids.”

So just because Aetna is watching does not mean that the problem is going to go away any time soon.

An Algorithm a Day, May Keep the Pain Doctor Away


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.

Opioid Abuse in Workers’ Compensation: What the Medical Tourism Industry Needs to Know

opioid abuseopioid abuse

One workers’ compensation topic that I have avoided discussing so far, given that the tagline of my blog is about implementing medical tourism into workers’ compensation, is the issue of opioid abuse in workers’ compensation.

Many articles and blog postings have been written describing the problem and the ways in which insurance companies, third party administrators, claims management firms, pharmacy benefit management firms, brokers, claims and risk managers, state and federal government agencies, and other interested parties are trying to get a handle on this problem.

It is a very complex and complicated issue, and one that has many in the workers’ compensation industry concerned because it drives up medical costs for claims, adds to the number of claims filed not only due to an injury, but to the abuse and addiction it engenders. It also impairs workers who then get injured again due to the effects of the medication, and it lowers productivity and prolongs the time employees take to return to work.

Business Insurance issued a White Paper on the subject last year entitled, Opioid Abuse & Workers’ Comp. In the paper, the authors describe the growing use of opioids that create abuse issues, the multiple factors causing the persistent problem, the rise of employer costs as abuse widens, the mix of strategies being used to combat this problem, and how to track selected metrics that are being used to support the goals workers comp managers establish to reduce abuse.

It so happens that some of the individuals who are quoted in the paper are people I know from other blogs, such as Joe Paduda, or are one of my LinkedIn connections, or I knew when I did my summer internship at the Third Party Administrator, Broadspire’s Sunrise, Florida office as part of my MHA degree program requirements in 2011.

One of the projects that I worked on while at Broadspire dealt with the dispensing of drugs by physicians, which is another important problem in workers’ compensation, and is related to opioid abuse, since most of the drugs prescribed in workers’ comp are the Schedule drugs being abused the most in the US. What I found was that the most serious problem of prescribing drugs was in California, and was not confined to physicians alone, but to pharmacies as well. Florida was the other state that had the most drugs prescribed by pharmacies or physicians. Time did not allow me to look at the other states of the country.

While not wanting to get too deep into the subject, I believe that it is important for those in the medical tourism industry to be cognizant and aware of the problem. Those who would like to pursue implementation of medical tourism into the workers’ compensation system in the US should realize that such a problem exists, so that in the future, if a self-insured employer or commercially insured employer should send one of their injured workers abroad for medical treatment of a work-related injury, the facilitator and the staff of the hospital where treatment is provided, knows that abuse of pain medication is a rampant problem among US workers’ compensation claimants.

This is even more incumbent upon those who, as I mentioned in my last post, What Role Can Medical Tourism Play in Physical Therapy and Rehabilitation for Workers’ Compensation?, might want to get into the area of physical therapy and rehabilitation, since the goal of rehab and therapy is to get the patient back to work faster, and one of the side effects of abuse is prolonged disability.

This is a serious issue for the workers’ compensation industry at the present time, and before medical tourism can be properly implemented, it is advisable that it is taken just as seriously in the medical tourism industry as well.