By Anne Sambucini, RN, CCM, CDMS, CNLCP, MSCC, Founding Principal, Chairperson at ANS Solutions
Outside of catastrophic injuries, most people injured at work do not plan on becoming dependent on opioids or other painkillers. But as outlined in last week’s article, this happens far too often – and many times it stems from one single injury. It’s a familiar cycle for those in the workers’ comp industry – short-term prescribed opioid use for pain management turns into long-term opioid dependence. And before we know it, the claim with a non-catastrophic injury has seen treatment costs soar and become the exact case we are discussing today, a large loss Legacy Workers Compensation file.
To truly bring about any changes in treatment, one has to acknowledge, rightfully so, that it must come from the injured worker’s physician. So, at the end of article one, the first question presented was how do you gain a signed agreement from a provider to change prescribing regimens that have been in place for years?
For starters, one can begin by talking about Opioids and Beers. There is a big difference between “Beer Criteria” and “The Beers Criteria”. One is a standard of judgment or principle for evaluating one of America’s favorite beverages. The other is a highly relevant clinical guideline that provides the collective wisdom of leading health professionals in identifying potentially inappropriate drug use in America’s elderly population. Published by the American Geriatric Society (AGS) and updated in 2012, these guidelines identify Potentially Inappropriate Medications in individuals aged 65 and older. With the stated goal of improving quality of care in older individuals, the criteria include 53 medications or medication classes and 14 medical conditions with caution about using specific drugs.
While not all legacy workers compensation claimants are of this population, quite a few of them are. What medications first prescribed 5, 10, or even 15 years ago may have been deemed a non-risk, current research, as outlined in the Beers Criteria may bring to light new concerns relative to their increased age.
Importantly, this ensures that the conversation is grounded in clinical concerns, which is the critical element towards successfully changing a pharmacy regimen on a legacy case. Another crucial factor to maximize chances for success is an investment in that precious commodity, time. It would be difficult to expect that these older, and by definition, more complicated cases could be resolved in a quick phone call. Engaging prescribers, particularly in a face-to-face setting demonstrates respect for the physician-patient history and enables them to articulate their responses, most often culminating in a signed agreement to trial proposed alternatives.
If all of this sounds easy, I must apologize to the reader right now! The reality is that these cases present huge challenges and require skilled expertise and jurisdictional familiarity in order to consistently deliver successful outcomes nationwide.
The truth of the matter is that we’re only half way there. Gaining a physician’s signed commitment to change prescribing patterns is great, but how do you ensure that the newly agreed-to plan is adhered to?
Compliance begins with the physician’s written commitment to a modified drug treatment plan. This signed document confirms that any and all changes are under their direction and with their approval. It also represents a sound meeting of the minds and provides a roadmap for how to implement the alternative care options addressed.
The key towards successful implementation is routine and scheduled reengagement over a significant amount of time. Not only does this demonstrate a level of seriousness to the program, but it sets the stage for successful collaboration. Amongst the country’s finite panel of Workers’ Compensation doctors, building these relationships establishes a solid foundation for future engagement on other injured workers being seen in their practice.
Enhancing the quality of care and producing cost savings are not mutually exclusive, but actually quite the opposite. Successful prescriber engagements centered on patient-specific clinical issues will result in improved patient outcomes while positively impacting a payer’s bottom line. And that, in my book, is a fantastic opportunity for success where everyone can win.
About Anne Sambucini
Anne Sambucini RN, CCM, CDMS, CNLCP, MSCC is a founding principal and the Chairperson of ANS Solutions. Anne has provided medical expertise within the insurance industry for over 30 years, developing and standardizing national catastrophic case programs to maximize positive results. She is highly respected for her ability to drive collaboration in mitigating large loss claims, Anne is a recognized expert in the complex medical management and insurance litigation arenas. With ANS Solutions, Anne oversees all aspects of ANS Solutions’ clinical programs with a focus on product development She is a published author and past president of the American Association of Nurse Life Care Planners (AANLCP).
About ANS Solutions
ANS Solutions offers an industry-leading suite of Workers’ Compensation Medical Cost Containment Services designed to lower clients’ large loss claims costs, improve loss ratios, reduce exposures and enhance the quality of care of the injured employee. ANS Solutions’ flagship product is the industry’s only “Face-to-Face” Pharmaceutical Intervention Program designed to gain an immediate reduction in pharm spend of 25% on large loss workers’ compensation cases while simultaneously improving patient outcomes. For more than 10 years, ANS Solutions has been an innovator and trusted resource for some of the nation’s leading insurance carriers, State Workers’ Compensation Funds, Fortune 1,000 self-insured companies and largest third party administrators in the United States.