By Anne Sambucini, RN, CCM, CDMS, CNLCP, MSCC, Founding Principal, Chairperson at ANS Solutions
Large or small, every workers’ compensation insurer faces the challenge of complex, large loss, legacy cases. These legacy medical claims represent one of the most challenging and significant cost drivers in the insurance industry. I believe that great challenges represent a pathway to enormous success.
Not to date myself, but when I first entered the workers’ compensation world, costs were generally 65% Indemnity and 35% Medical. In an astoundingly short amount of time, that ratio has easily flipped. So what happened?
Let’s start with some key concepts about the number one expense driver in most workers’ compensation legacy claims: Prescription Medications. The use of Prescription Medications (for pain and non-pain relief matters) to treat injured workers has exploded over the last 15 years. The greatest culprit has been the exponential growth in the use of opioids to treat chronic pain in work related injuries. In fact, the use of prescription medications in the workers’ compensation marketplace over the last 15 years has increased by over 400%.
The critical issue here is that well intended long-term opioid usage carries with it significant risks that with many patients, can result in dependence along with a myriad of unintended consequences. When discussing pain medications, it’s important to know the difference between habituation, tolerance, and addiction.
- Habituation is when the body naturally becomes used to a substance, like nicotine, alcohol, or opioids. The body becomes accustomed to a behavior or condition, including psychoactive substance use. Repeated presentation of a stimulus causes a decreased reaction to that stimulus. An individual can function normally on stable high doses, but withdrawing the substance will result in physiological distress.
- Tolerance describes the body’s ability to withstand levels of a substance that would be dangerous to a first time user. It occurs when a person’s reaction to a drug declines, requiring an increased concentration to maintain the needed effect. For example, many cancer patients take very large doses of opioids that would be fatal for someone who had never taken opioids.
- Addiction is the compulsive use of a substance for its psychoactive effects— to get high. It should be noted that genetics, social influences and psychological factors all can contribute to addiction. Addicts crave steadily increasing doses for this purpose as habituation decreases the highs they experience with lower doses.
What often goes unnoticed is that data clearly supports that long-term opioid usage often increases the demand for non-narcotic medications. Cost issues aside, and many of these opioids are incredibly expensive, the real truth is that patients need to be made aware of possible issues that are associated with these regimens. Many claimants utilizing narcotics also find themselves taking sleep aids, anti-depressants, stimulants, and acid reflux medications to address the side effects associated with chronic opioid usage such as, somnolence, insomnia, anxiety, depression, and constipation just to name a few.
The silver lining to this overarching issue is that tremendous strides have been made within the industry to promote injured worker and physician awareness. From Carriers to State Governments, numerous resources are being invested into addressing this national epidemic. New tools exist that enable real-time monitoring and physician engagement that are having a genuine effect in reducing the likelihood of claims even becoming a legacy concern.
Even with these great improvements aimed at curbing acute over utilization, the question remains: how do you tackle the older, legacy files that have had these issues for years, if not decades? Our research has shown a strong success rate from a new and unique pharmaceutical intervention approach taken in the industry: “face-to-face” collaborative meetings between highly credentialed nurse experts and treating physicians in order to address modifications in the drug treatment regimen.
While it may not sound like a lot, when you can average pharmaceutical cost savings of up to 25% without compromising patient care, you have created an opportunity where everyone wins. Yes, cost savings are a reality of these efforts, but what demonstrates credibility in the eyes of the physician and their patient is that clinical issues are given critical importance and primary consideration in all recommendations.
In article 2, we’ll discuss more on addressing three questions 1) How do you gain a signed agreement from a provider to change prescribing regimens that have been in place for years? 2) How do you ensure it is implemented as agreed to? And lastly, 3) What do Opioids and Beers have in common?
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.