By Tron Emptage & Dr. Robert Hall, Chief Clinical Officer & Corporate Medical Director, Optum for Workers’ Comp and Auto No-Fault
Some would call 2016 “the year of opioid analgesics” or maybe even “the year of addiction.” Others might refer to this year as the “year of opioid misuse.” Whatever the name, reports, statistics and a multitude of stories outlining the adverse consequences of misusing and abusing opioid analgesics made headlines with greater frequency than any other time in our workers’ compensation industry’s recent history. In addition, advertisements for medications addressing opioid-induced side effects began airing during national sporting events. The Centers for Disease Control (CDC) published new treatment guidelines addressing chronic non-malignant pain. President Obama addressed the National Rx Drug Abuse and Heroin Summit for the first time, joining a vast array of stakeholders, to express the importance of collaboration and diligence in working to find solutions to the opioid crisis. Regulatory and legislative changes also occurred throughout the country as numerous states passed laws, rules and regulations addressing naloxone, opioid analgesic prescribing limitations, provider licensing and education, patient education and treatment guidelines. These conversations, discussions and changes highlight the country’s desire to revisit how and when opioid analgesics are prescribed. This activity also shows growing interest, and emphasis, on ensuring the use of the right medication, at the right time, and for the right duration as it relates to pain and pain management.
In workers’ compensation, such efforts are not a new phenomenon. Data show a multi-year declining trend in opioid analgesic use as a result of the collaborative work of stakeholders throughout the system. However, for claims professionals, the complexities involved with confirming the medications being prescribed to the injured worker are bringing about the best outcomes remain. This leads us to a question. How do we perpetuate the positive downward trend in opioid analgesic use without sacrificing the safety and efficacy of care? One way is to keep in the forefront of our minds the following ideas as claim decisions are made.
Changing the conversation can improve understanding. In our very busy professional lives, we may often try to focus on confirming causation and/or the mechanism of injury, or jump to the resolution before we spend some time assessing how the injured worker is feeling and considering what they are thinking about as it relates to their injury and returning to work. When speaking with the injured worker, asking “How are you?” instead of “What happened?” can change the tone and frame of the conversation.
Conveying empathy can open doors. Instead of assuming the injured worker has done something wrong or is intentionally misusing their medications, show empathy for the fact that an injury has occurred and convey a commitment to the injured worker’s return to function and work.
Building rapport can earn trust and remove obstacles. Get to know the injured worker as an individual. Do they like their job? How is it going? Go beyond the job description and learn more about what they really do when at work. Inquiring about some of the injured worker’s life issues and concerns may go a long way in assisting their return to work. Obtaining this insight can also help you better understand the tools and resources that will be most beneficial in helping them return to function. In building rapport, you may also discover there are things holding the injured worker back from returning to work that seem to be manifested medically, but really are not.
Reviewing medical records and medical evidence can highlight opportunity. Is the medication therapy working in conjunction with other therapy (or therapies) to actually address getting the injured worker back to a pre-injury functional level and work? Is the prescriber addressing functional improvement and pain control at each office visit and in the plan of care? If not, highlighting this and discussing it with the prescriber can be extremely beneficial.
Another way is to ask yourself the following ten questions when reviewing the injured worker’s medication therapy:
- 1. Is the medication being used to treat the work-related injury? Review the medical records and take steps to understand the injured worker’s medical history and current medication therapy and it’s appropriateness for the injury. Sounds simple but this is sometimes overlooked.
- 2. Do the long-term benefits of the treatment being prescribed outweigh the risks? Sometimes, treatments are started and not well explained to the injured worker such that a full understanding of the risks and benefits of those treatments is achieved. Your assistance may be needed to get any lacking information to them to mitigate non-compliance with the therapy plan and help advance recovery.
- 3. Is the treatment being provided working? Is the injured worker feeling any better? Is the treatment working for them? Along with a complete understanding of the treatment as noted above, sometimes just verifying the treatment is helping as expected goes a long way to moving towards the expected outcome.
- 4. Did the prescriber pursue a medication agreement with the injured worker? This documentation helps align objectives, establishes expectations, sets a foundation for accountability and may also help outline the risks and benefits of medication therapy, especially when opioid analgesics are part of the treatment plan.
- 5. If taking an opioid analgesic, does the injured worker understand its use? With all the concerns and challenges surrounding long-term use of opioid analgesics, the more that is done to help make sure an injured worker understands the benefits and risks of opioid analgesic medications as part of a medication therapy plan, the better. Taking the time to review how the medication may affect their various body systems can be invaluable to the injured worker. Encouraging the injured worker to talk with their pharmacist and/or prescriber is also important.
- 6. What materials and/or resources can be shared to enhance pharmacy literacy of the injured worker? Pharmacies will provide information about the medication(s) they are dispensing. Asking the injured worker if they have read this information and understand their medications may also be helpful.
- 7. Are there medications and/or combinations of medications I should be concerned about? Connecting with your pharmacy benefit manager or a pharmacist to discuss the injured worker’s medication therapy, along with any associated concerns you may have, is often helpful in moving towards the most appropriate and cost-effective pharmaceutical regimen.
- 8. What education do I need to bring to the table? Do you, as a claims professional, have access to medication or injury information that may benefit the understanding of the injured worker, their family members or caregivers, and/or their prescriber? Do you, as the claims professional, need to gain more understanding of medications and medication therapy to bring about better outcomes? Educational courses and online information is often very beneficial to improving understanding, increasing awareness and ultimately, to making more-informed decisions when managing a claim.
- 9. What tools and resources are available to help? The pharmacy benefit manager can often offer clinical review services to assist the claims professional in better understanding the medication treatment an injured worker is receiving. These services can assist in making recommendations on changes to the medication therapy that would help streamline the regimen and set the injured worker up for return to work.. Utilizing these services is an area that could be explored to bring about better outcomes, particularly for complex claims.
- 10. What are the things that are going to prohibit me from helping the injured worker recover? What should I do next? What am I missing? These are questions that afford the opportunity to look at the claim from a different perspective and may help highlight areas of opportunity to modify or enhance the claim management and/or therapy plan, leading to a better outcome for the injured worker.
As we look ahead to the start of a New Year, let’s keep asking questions.
About Tron Emptage
As chief clinical officer, Tron Emptage oversees our comprehensive suite of clinical programs designed to help payers gain more control over medical costs to achieve better outcomes for injured workers. Tron leverages two decades of pharmacy and managed care experience in developing and managing key program components, such as medication plans and formularies, utilization reviews, physician outreach, clinical intervention, and pharmacist and nursing support. The use of these programs by our customers ensures injured workers receive the right therapy at the right time.
Tron has played instrumental roles in developing a number of innovative clinical initiatives, including our patent-pending data analytics model, our clinical oversight programs, and our urine drug monitoring program – further helping the company transform the way workers’ compensation payers manage claims and contain costs through utilization programs.
About Dr. Robert Hall
As corporate medical director, Dr. Robert Hall advises our customers and employees on evidence-based clinical and rehabilitation guidelines that optimize our pharmacy, home health, and durable medical equipment programs to promote better outcomes and earlier return to work for injured workers. He also offers counsel on our processes and procedures to identify and reduce prescription drug misuse and abuse.
A practicing, board-certified physical medicine and rehabilitation physician, Dr. Hall has treated patients in private practice, private and state-run hospitals, and out-patient clinic settings. His areas of focus include electromyography, pain management, musculoskeletal medicine, and stroke rehabilitation.
About Optum for Workers’ Comp and Auto No-Fault
Helios, Healthcare Solutions and their subsidiaries, as Optum, collaborate with clients to deliver value beyond transactional savings while helping ensure claimants receive safe and effective clinical care. Our innovative and comprehensive medical cost management programs include pharmacy benefit management, ancillary benefit management, managed care services, and settlement solutions.
Optum is a WorkCompWire ad partner.
This is not a paid placement.