Opioids – one insurer’s (successful) approach

While many workers comp insurers and TPAs are lamenting the problems of overuse and abuse of opioids, some are actually implementing solutions. While no one can claim they’ve got this solved, there are some promising approaches.
One of the more sophisticated and comprehensive opioid programs was recently implemented by the Accident Fund and their subsidiaries. It involves early identification of opioids dispensed to claimants, rapid notification of adjusters, and peer-to-peer intervention in claims identified as high priority.
The program grew out of a research collaboration with the Occupational Medicine Division at Johns Hopkins School of Medicine that linked pharmacy data to claims data; the findings revealed a strong link between opioid use and extended disability duration. Equally important, the research team, led by the Accident Fund’s Jeffrey Austin White, determined the number of scripts for opioids “were increasing at a rate of 10% per year across the enterprise since 2006 and dominated the top 5 list of most used drugs by 2008.”
Accident Fund Holdings Inc. (the parent company of the Accident Fund, CompWest, United Heartland, and Third Coast Underwriters) is using an internally-developed software application called “Care Analytics” to monitor incoming pharmacy records in “near real-time”, looking for triggers and patterns that indicate a potential for abuse. When a potentially problematic transaction is flagged, the appropriate adjuster is immediately notified. Depending on the specifics of the claim and the transaction, a nurse case manager and/or the Medical Director may also be notified.
There’s a good deal of peer-to-peer intervention in the program, and to date its been quite successful. According to Paul Kauffman, RN and director of Accident’ Fund’s medical management programs, “Over 70% of our providers have been willing to adjust treatment protocols and monitor the use of opioids by our injured workers…over five percent [of claimants identified] have been weaned from narcotics and are already back to work.”
By no means is this an easy process, and it can be complicated by workers comp regulations and laws that don’t promote effective approaches to addressing opioid abuse and addiction in workers comp. This has to change; the Hopkins-Accident Fund research indicated that workers prescribed even one opioid had average total claims costs 4 to 8 times greater than claimants with similar claims who didn’t get opioids.
I should note that I’ve been working with Accident Fund and their affiliated companies for some time, however I was only tangentially involved in this program. That said, it is obvious that one of the key factors driving the success of this program has been strong and consistent support from senior management, in this case Chief Claims Officer Pat Walsh.
What does this mean for you?
Solving the opioid problem is absolutely realistic, but it requires strong senior management support, careful use of intelligent analytics, and coordination across multiple areas within the payer.