If patients are prescribed opioids, ‘best practices’ calls for
– assessment of risk for dependency and addiction;
– completion of an Opioid Agreement:
– ongoing assessment of pain and functionality; and
– random urine drug testing (UDT).
This last has become – for some – yet another of the myriad ways to suck money out of the workers compensation system. Yet there’s no question UDT is a necessary component of opioid management.
Today’s WorkCompCentral arrived with an excellent piece on the issue authored by Greg Jones. The premise of the article is a flap involving accusations of overbilling by a former employee of a company that allegedly does billing for drug tests.
The details of the controversy aren’t what’s important.
What’s important is for payers to understand two things:
a) drug testing is a critical piece of opioid therapy; and
b) just like physician dispensing, MRIs. PT, surgery, heck almost anything, it can be gamed, over prescribed, abused, and made into the proverbial money tree.
Properly done, drug testing enables physicians to determine if the patient is taking the prescribed drug; if they’re taking other drugs that may be contra-indicated; and/or if the patient is taking illicit drugs. Given the issues with addiction, abuse, diversion, and misuse, drug testing is a critical component of the medical management process.
Grossly over-simplifying the issue, it boils down to this. Fee schedules and reimbursement rules allow physicians and labs to bill multiple codes for multiple ‘tests’ for different drugs – so, the more tests, the more money. Typically, physicians bill for testing that just indicates the likely presence or absence of certain drugs, and a lab bills for ‘confirmation’ using much more sophisticated processes and technology.
There’s a reasonable argument to be made that paying docs to test in their offices encourages compliance with opioid management best practices, as long as the amount paid is also ‘reasonable’. Unfortunately, the research indicates UDT is grossly underutilized; one study found fewer than one of every seven physicians treating patients with opioids test their patients.
In-office testing is also much less reliable than lab-based testing; therefore any office-based test result must be confirmed with a test at an accredited lab.
So, the conundrum is this: payers want to encourage drug testing, but don’t want to get stuck with outrageous bills. There are several tactics payers can use.
1. Inform contracted physicians that drug testing in office will be reimbursed at $XX.XX – a flat rate regardless of the number of drugs tested for.
2. Drop physicians who refuse to comply from your network.
3. Require proof of testing and assurance that the prescribing doc has reviewed the test results and factored those results into ongoing treatment.
4. Contract with a lab for a flat fee to cover a comprehensive list of drugs; this ensures the physician has a full view into the patient’s drug consumption while capping the payer’s fees at a ‘reasonable’ rate.
What does this mean for you?
Drug testing is necessary, it’s also ripe for abuse.
(Disclosure – Millennium Labs is an HSA consulting client)

There’s an excellent webinar on the nuts-and-bolts of work comp pharmacy scheduled for April 12. Put on by National Council for Prescription Drug Programs (NCPDP), the webinar features industry experts Jim Andrews, RPh, SVP Pharmacy Services at Cypress Care and Kevin Tribout, Executive Director Government Affairs for PMSI.
Jim and Kevin are very, very knowledgeable and great communicators as well (full disclosure – they’re also good friends and their companies are members of workers compensation PBM consortium CompPharma, LLC).
hat tip to WorkCompWire for the news…

A lot more than you think.
I met with a large workers comp payer recently to discuss (among other things) their strategy regarding long term work comp claims; they have over forty thousand claimants that have been on opioids for extended periods.
The research strongly suggests most of these claimants are addicted/dependent. Others may be diverting, and still others may be hyperalgesic (much more sensitive to pain as a result of long-term usage of opioids).
None of these are good, and most have serious and very costly implications for claim costs.
– very few individuals on opioids are going back to work (while on drugs)
– very few payers are screening for addiction, so they really don’t know if/how many of their claimants are addicted – and therefore don’t know how the potential financial implications (either pay for opioids forever, settle at a very high cost, or treat and successfully resolve the addiction)
– claimants using opioids are at much higher risk for death; one client identified almost sixty claimants that died last year that appeared to die as a result of prescription drugs prescribed for their work comp injury.
– I get the sense that most payers haven’t adequately reserved for these claimants, although the stiff stance of CMS may force them to do so if they have any hope of settling some portion of the block of claims.
This doesn’t have to inevitably become a financial disaster for insurers or employers, although it undoubtedly will for those who don’t take action.
Payers must work with their PBMs to dramatically reduce their exposure. This requires both parties to:
a) identify long-term users,
b) mine their data to determine which claimants may be abusing/misusing/diverting and involve SIU where appropriate,
c) channel appropriate claimants to addiction screening, allocate the resources necessary for weaning and recovery and recognize this will include behavioral therapy will find they can.

What does this mean for you?
These claims are NOT going to resolve themselves. You own it, and you’re going to own it until you’ve got an effective, working plan in place.

Inflated costs for employers and insurers, higher taxes for state residents, and riskier medical treatment for injured workers – all are on the horizon if Connecticut Workers’ Compensation Commission Chairman Mastropietro allows physicians to dispense repackaged drugs to injured workers.
Mastropietro held a hearing yesterday where 4uDoctor attempted to convince all in attendance that the inflated cost of physician-dispensed repackaged drugs is actually a good deal.
Most weren’t buying their claims, nor should they. On the contrary, as their website states, 4uDoctor highlights their ability to”Generate significant additional ancillary revenue” for physicians.
4uDoctor’s claims for patient benefits are easily debunked.
There’s NO evidence that physician dispensing improves compliance, speeds return to work, or improves outcomes. None. Zilch. Nada. In fact, Chairman Mastropietro may want to focus on the patient safety issue; here’s why.
Work comp claimants are usually treated by docs that haven’t seen the claimant before the occupational injury; this almost always is the case in Connecticut where most employers can send injured workers to physicians who specialize in treating work comp conditions. While the WC doc certainly asks about prior medical history, current medications and the like, it is not uncommon for patients to forget which meds they take or be unable to accurately identify their drugs.
Not so big an issue if the claimant goes to their usual pharmacy, where the system will identify any potential conflicts and notify the dispensing pharmacist.
A bigger issue arises if the treating doc doesn’t get the full story, prescribes and dispenses meds that conflict with the claimants’ other meds. Then, the patient may be harmed, and because this harm comes as a result of treatment for a work comp injury, the employer is on the hook for any additional medical care.
To further rebut 4uDoctor’s argument for patient benefits, note that their dispensing is only for workers comp patients. Why can’t the docs’ other patients benefit from “improved compliance…convenience…confidentiality”? Perhaps it is because Medicare and group health plans won’t pay inflated prices, but work comp payers may be forced to (if the Commission doesn’t do the right thing).
.
What does this mean for you?
Physician dispensing drives up costs for employers, increases taxes, and kills jobs. This is little more than a big money-maker for a few, paid for by the rest of us.
If you agree, please pass this on to the Connecticut Workers Compensation Commission Chair at wcc.chairmansoffice@po.state.ct.us

To date, Automated Healthcare Solutions and other companies owned by their principals have donated over $3 million to various politicians, campaigns, and political organizations. Automated Healthcare Solutions and their sister companies are heavily involved in physician dispensing to workers comp patients in Florida and other states.
The actual number is $3,224,076 since 2002, coming from dozens of companies that are affiliated with or managed by AHCS’ principals, with big dollar donations to committees backing current Senate President, MIke Haridopolous and House Speaker Dean Cannon.
Haridopolous’ and Cannon’s committees each received at least $350,000.
The research was done by the Florida Independent’s Virginia Chamlee, who details the various companies and political donations in her piece on Automated Healthcare Solutions. Chamlee’s piece is the first to provide a full picture of the political donations of AHCS’ principals Zimmerman and Glass, and the $3.2 million total shows clearly just how important Florida is to dispensing companies and their affiliates.
If you are thinking this isn’t a big deal – you aren’t thinking. Physician dispensing increases Florida workers comp premiums by 2.5%. That added cost will disappear if Senate bill 668 passes and is signed into law, but the contributions and political muscle of AHCS and their allies are making that look increasingly doubtful.
SB668 is out of one committee in the Senate, but things get tougher from here. There’s no question Sen Haridopolous has gotten an earful from those who are profiting from physician dispensing, and as the Senate’s boss, he has a lot of influence.
Now he needs to hear from those who are paying the tab.
Send Sen Haridopolous an email, copy Sen Alan Hays, the Senator who is backing the bill to limit the cost of physician dispensed drugs – not ban physician dispensing, but limit the cost to what you’d pay for the same drug at a retail pharmacy.
and send me a copy too.
Tell Sen Haridopolous:
– Florida’s employers can’t afford to enrich a select few who get most of the dollars from physician dispensing.
– If he’s serious about getting the State’s economy back on track, he’ll help employers cut their costs
– if he’s serious about helping taxpayers, he’ll stop backing physician dispensing which adds to their bills while forcing schools, police and fire departments to lay off workers to pay the inflated bills of physician dispensers.
What does this mean for you?
Time to get active, or don’t complain when SB668 is defeated and your costs go up even more.

One of the most powerful firms in the physician dispensing business is sending hundreds of thousands of dollars to elected officials in Florida. [sub req] The donations, to individual politicians and their affiliated organizations, come as the Florida Senate is considering a bill that would limit reimbursement of physician-dispensed drugs to the cost of the underlying (non-repackaged) drug.
This morning Mike Whitely of WorkCompCentral reported Automated Healthcare Solutions “gave more than $32,500 to Florida state lawmakers and more than $500,000 to committees associated with conservative causes and candidates in 2011…”, most of it in the last three months of 2011.
The timing is fortuitous, as Senate bill 668 was moving thru the legislative process last quarter, and is the subject of intense debate. Suffice it to say that passage of SB 688 would greatly reduce the income of companies in the physician dispensing/drug repackaging sector.
The physician dispensing bill made it out of one Senate Committee last week, albeit with a poorly-written and ill-advised amendment.
Writing in HealthNews Florida, Carol Gentry reported: “SB 668 survived its first committee in a 7 to 4 vote. But some senators who voted in favor said they may change their minds if answers to their questions aren’t forthcoming by the time it gets to the Senate floor.”
It’s unknown if the flood of cash from AHCS will affect the votes of key Senators, or cause beneficiaries to use parliamentary procedures to block the bill. The forces allied in support of the bill include the Chamber of Commerce, most of the workers comp insurers, and many employers.
And, in an interview with Whitely, a spokesperson for AHCS said the company is not focusing on the issue, saying their donations are “not a means of affecting public policy”.
Really. That’s what she said. Evidently AHCS’ half-million bucks – donated to key legislators with power over SB 688 – is not related to physician dispensing.
That being the case, I’m sure Florida’s elected legislators will do the right thing, pass the bill, and thereby reduce Florida employers’ work comp premiums by tens of millions of dollars.
What does this mean for you?
Yet another opportunity to watch the ugly, money-driven process that is politics at its worst.