By Matthew P. Foster, Pharm.D., Clinical Pharmacy Manager, Helios
Over the last few years, there has been growing momentum in the use of treatment guidelines in the workers’ compensation industry, and rightfully so. Treatment guidelines offer the industry important evidence-based protocols to determine the right treatment for a typical workers’ compensation injury. Through their application, overtreatment, inappropriate treatment, overpayments, misuse, and abuse can be avoided. The Official Disability Guidelines (ODG) and American College of Occupational & Environmental Medicine (ACOEM) are both national standards referenced by nearly half of the states, with several other states moving towards their own state-based treatment guidelines. Most recently, the California Division of Workers’ Compensation (DWC) proposed new guidelines for the treatment of chronic pain to their state-based guidelines, based on the ODG.
Although there are differences in the scope of injuries covered in these guidelines, there are prevailing themes regarding the appropriate use of medications in the treatment of the injured worker, including:
- Patient screening. Prior to prescribing opioid analgesics, first determine if there is a risk due to psychological factors (anxiety, depression, history of substance abuse) that may predispose the injured person to misuse or abuse.
- Therapy selection. Therapy should have pre-set goals, and be discontinued if there is no improvement in pain and function. The physician should also document the injured person’s response to the medication therapy and progress.
- Selection of opioids. Opioid analgesics are recommended only when other analgesics, such as anti-inflammatory medications, have not been effective.
- Number of Prescribers. It is recommended that only one prescriber manage therapy involving opioid analgesics.
- Dosage. Therapy exceeding a daily morphine equivalent above 50 mg (ACOEM), 80 mg (California), or 100 mg (ODG) should occur with caution, and generally under the care of pain management specialists.
- Monitoring. Drug tests should be performed prior to the initiation of opioid therapy, and random tests should be performed two to four times a year to assess compliance with the prescribed therapy.
As advances in medicine occur and treatment guidelines continue to evolve, payers can benefit from the clinical and regulatory expertise of their pharmacy benefit manager (PBM) to help effectively manage their injured worker population. A PBM can also facilitate greater understanding of said guidelines. In addition to state, national, and PBM-level guidelines, clinical programs initiated by the PBM can ensure that a claim continues along the right path. PBMs can:
- Work with regulators and legislators to promote the use of treatment guidelines in conjunction with easy-to-manage authorization rules
- Identify high-risk injured workers who are exceeding treatment guidelines or exhibiting characteristics of fraud, waste, and/or abuse
- Apply clinical oversight and intervention tools and techniques to resolve therapeutic concerns for the betterment of injured workers and payers alike
- Engage payers with practical and relevant guidance regarding appropriate medication therapy, the use of formulary and treatment guidelines, and issues of fraud, waste, and abuse
- Emphasize prevention because it is always more difficult to change behavior after the fact
- Utilize injury-based Medication Plans and formularies and drug utilization review criteria that is based on accepted national guidelines and evidence-based medicine
- Provide actionable data and insight
- Leverage technology to facilitate timely communication and claim management
Helios champions the appropriate use of all medications and we believe treatment guidelines are an important part of an injured worker’s care. Knowing what the guidelines recommend, following the prevailing wisdom, and working collaboratively with payers and injured workers alike has consistently proven to make a positive difference. It also helps ensure an injured worker’s medication therapy regimen is as safe and effective as possible, particularly in cases utilizing opioid analgesics.
We continue to find that the actions underway in various states to adopt new (or otherwise evolve) treatment guidelines are consistent with our long-standing global medication management approach. This consistency in approach and philosophical alignment is significant. In our experience, we have also found there are a few important aspects to keep in mind when reviewing, evaluating, or otherwise considering treatment guidelines.
- First, these are treatment guidelines, not “rules.” They are meant to guide, not mandate, treatment decisions.
- Second, when a treatment falls outside of the recommended guideline due to dose or duration, a careful review of the therapy must occur to determine if the exception is due to patient-specific needs before jumping to the conclusion that inappropriate therapy is being prescribed.
- Third, not every treatment discussed in the guidelines may be applicable to a workers’ compensation claim. For example, diabetes and hypertension are both addressed in the ODG, yet these conditions are typically unrelated to an industrial injury.
Therefore, open communication and collaboration with pharmacies, payers, and injured workers, as well as the treating physician remains critical in confirming that the course is appropriate in terms of both cost and utilization. The result of such a synchronized effort can be an overall decrease in medication costs while maintaining high standards of care. For the workers’ compensation industry, this is a step in the right direction.
About Matthew P. Foster, PharmD
As the clinical pharmacy manager, Dr. Matthew Foster oversees the clinical services production team that is responsible for all of the prescriber intervention services that help ensure that the right medications are being utilized at the right time. He also works closely with the clinical liaisons and design teams to provide enhanced and new clinical services for Helios clients. He holds a Doctor of Pharmacy degree from the University of Florida College of Pharmacy and is licensed as a pharmacist in Florida.
Helios, the new name for Progressive Medical and PMSI, is bringing the focus of workers’ compensation and auto no-fault pharmacy benefit management, ancillary services, and Settlement Solutions back to where it belongs – the injured party. For more information, visit www.HeliosComp.com.