By: Steve Pratt, CPCU, ARM, CMSP, Senior Vice President of Professional Competence, Gallagher Bassett Services, Inc.
Inappropriate prescription narcotic use is a widespread and complex problem with no simple solutions. In fact the CDC even considers the issue an epidemic. The industry recognizes that we have to tackle it on many fronts. In my experience, if you do the right thing, cost containment will follow. Part of the answer lies in getting the right information—in a clear, concise, easily digestible format—to the right people, with the right skills, at the right time. It’s about educating all parties. The targeted result is a strategy that helps reduce narcotic use while managing the health and safety of the injured worker.
Early outreach gets results
In claims involving narcotics, early clinical outreach has proven to help avoid many of the problems associated with long-term use of opioid pain medication. As soon as narcotic use is identified, it is important to remind the healthcare provider and the injured worker about the potential dangers and drawbacks of narcotics and to educate them about alternatives. If the payor is using a nurse triage program, this outreach can begin during the very first call – if the reported injury commonly calls for the use of pain medication. If the payor doesn’t use nurse triage, the pharmacy benefit manager (PBM) can reach out to the prescriber and/or the injured worker on first fill to ensure that a plan is in place to avoid extended narcotic use. Letter campaigns to providers have also proved to be helpful in reducing opioid use and decreasing MED substantially.
All PBM programs have alerts. The problem is, alerts are not always meaningful, because they don’t convey anything about function. An alert may point to prolonged or escalating narcotic prescriptions, but it doesn’t give any insight into whether the trend is due to addiction, which is a cognitive issue, or physical dependence. What’s more, an adjuster whose plate is full just keeping up with jurisdictional rules may not have the background or expertise to handle some of the complex issues that arise when prescription narcotics become problematic. In these cases, I believe that a prescription profile is a more useful tool.
Such a profile should start with a claim risk model based on injured worker demographics, prescriber patterns, drug utilization and drug combinations. Based on this model, prescription profiles can be generated automatically by the PBM and sent to the adjusters for all claims that appear to be at risk or have characteristics of future risk. Since early intervention is key with narcotics, it is not unreasonable to have these profiles generated every week for all cases involving narcotics. This frequency can catch new cases on a timely basis. In addition, continually mining the data should also help ensure that unresolved issues do not fall through the cracks. For each high-risk claim, the prescription profile should summarize the 90-day medication history related to the claim as well as key attributes for each of the prescription drugs listed and key information from the claims system.
In order to be helpful, the profile should summarize all drug-related information into a single consolidated view of the case—for the adjuster, the nurse or anyone else involved. It should serve to give the adjuster a sense of context that is not available from individual alerts—and a much clearer picture of relative risk. The adjuster can easily see whether the claim is following the expected prescribing path or whether the claim warrants additional review. In the latter case, an interdisciplinary review further improves the adjuster’s decision-making ability and offers a better approach to managing the total health and safety of the injured worker—more on that in Part II.
About Steve Pratt
Steve Pratt is Senior Vice President of Professional Competence at Gallagher Bassett Services, Inc., where he is responsible for overseeing the technical claim discipline. He has 35 years of experience in the insurance industry, having held senior-level roles in the claims organizations of The Hartford, The Zenith, OBE of the Americas, CNA and Broadspire. Mr. Pratt consulted in the insurance claims environment in quality, reserving, narcotic prescription use and other areas. He also conducts ongoing leadership training in the Ukraine. Mr. Pratt holds a number of professional designations, including Chartered Property Casualty Underwriting (CPCU), Senior Claim Law Associate (SCLA), Certified Medicare Secondary Payer (CMSP), Associates in Underwriting (AU) and Associate in Risk Management (ARM).
About Gallagher Bassett Services, Inc.
Gallagher Bassett Services, Inc., a subsidiary of Arthur J. Gallagher & Co. (NYSE: AJG), is an international risk management services firm headquartered in Itasca, Illinois. GB’s more than 4,500 skilled professionals provide claims management, medical cost containment, analytical and consultative services to its clients worldwide representing virtually every sector of the global economy.