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Focus on the Patient, Not the Pain

4 key steps to redefine an opioid management strategy.
By: | March 3, 2014 • 4 min read

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The upcoming release of the new ACOEM opioid treatment guideline reflects new evidence associated with opioid risks. Of note, one of the recommendations is to significantly lower the maximum daily morphine equivalent dose (MED) to 50 from the 120 MED recommended in earlier guidelines. Morphine is the standard against which the potency of all other opioids is measured. While it is tempting to focus on the MED reduction, the real story is the opportunity the new guideline presents for payers to redefine their opioid strategy.

Robert Goldberg, MD, FACOEM, an occupational medicine specialist and chief medical officer at workers’ compensation PBM Healthesystems, expects the new guideline to help reshape the opioid discussion. “Once physicians consistently approach pain relief as a tool for helping speed recovery instead of as the ultimate goal of treatment, everything will change,” noted Dr. Goldberg. “When physicians focus on pain relief as the primary goal and prescribe opioids on the first visit, they open up patients and payers to well-documented risks. The outcomes data show that this approach is not working.”

A past president of ACOEM, Dr. Goldberg recommends payers include four key steps when updating or redefining their current opioid strategy. The steps involve developing a new treatment philosophy; gaining access to the right information systems and clinical expertise; establishing new policies and procedures to support the new approach; and deploying precisely timed clinical tools and strategies to keep claims on track.

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Step 1 – Refocus treatment goals

The most effective opioid strategy is one that takes a holistic approach and makes recovery and functional improvement the ultimate goal of treatment. Dr. Goldberg advises physicians and payers to refocus the goal of treatment as a critical first step in updating their opioid strategy.

“A key principle in occupational medicine is to minimize the effects of an injury and help injured workers remain at work whenever possible, or regain function and return to work,” explained Dr. Goldberg. In addition to reframing treatment goals, he recommends implementing these supporting strategies:

  • Focus on adequate pain relief — reduce pain sufficiently so that injured workers can participate in treatment plans to speed recovery.
  • Follow the updated opioids guideline — use non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen as a primary treatment and physical therapy when indicated.
  • Incorporate alternative therapies — adjunctive therapies such as cognitive behavioral therapy, massage, yoga, chiropractic and acupuncture can aid in pain relief and help injured workers cope with the presence of some pain.

Step 2 – Gain access to the right information systems and clinical expertise

Another step needed to update an opioid strategy is to ensure that the claims organization has access to the right data and expert analysis so they can identify claims requiring close attention. To achieve this, payers should:

  • Develop state-of-the-art information systems — or rely on a PBM — to provide reliable data that can quickly identify cases that are moving toward prolonged or accelerated use of opioids.
  • Work with a team of well-trained claims professionals and nurse case managers who can coordinate efforts and make good decisions.
  • Tap the expertise of clinical pharmacists and knowledgeable physicians.

SponsoredContent_Healthesystems“The ultimate goal is for a patient to physically recover, not to simply manage their pain. Once physicians consistently approach pain relief as a tool to help speed recovery, everything will change.”
— Dr. Robert Goldberg, Occupational Medicine Specialist and Chief Medical Officer, Healthesystems

Step 3 – Establish new medical policies and procedures

Clear policies and procedures that reflect the most current evidence-based medical guidelines are an important component of an up-to-date opioid strategy. Dr. Goldberg recommends payers revise policies and procedures to:

  • Approve opioids only when appropriate, per current evidence-based guidelines.
  • Approve alternative therapies such as cognitive behavior therapy and physical therapy to reduce reliance on pain medication when appropriate.

New policies and procedures should delineate:

  • The jurisdictional and professional guidelines that will be applied.
  • What circumstances will trigger clinical interventions — such as MED levels, a defined number of prescriptions or prescribers or other factors.
  • Which cases will be escalated for higher level clinical intervention — such as claims that reach a certain dollar value or involve certain complex conditions or injuries.
  • Which tools and interventions will be deployed and by whom.

Step 4 – Deploy precisely timed tools

An updated opioid strategy should include a robust suite of tools and clinical expertise, as well as define how and when to use them to help keep opioid therapies on track. Claims organizations need a strategic PBM partner with a robust toolkit and a deep bench of clinical expertise to guide them in deploying tools such as:

  • Alerts to pharmacies and claims organizations about issues involving prescription dosing, quantities, early refills and other concerns.
  • Monitoring and analyzing MED levels to ensure patient safety.
  • Real-time therapeutic interventions as part of a prior-authorization process to help prevent risks.
  • Letters of medical necessity that document the need for opioid therapy.
  • Informed consent forms that alert injured workers to the risks associated with opioid therapy.
  • Pain contracts with injured workers that detail what is expected of them while they are receiving opioid therapy.
  • Peer-to-peer interventions by clinical pharmacists or physicians.
  • Screening and assessment tools for substance abuse, opioid risks, depression, pain and other conditions that contraindicate opioid therapy.
  • Compliance monitoring programs using urine drug testing.
  • Drug regimen reviews.

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Everyone benefits

An opioid strategy that focuses on achieving functional improvement will yield benefits for the payer, patient and employer that include:

  • Reduced length and cost of opioid drug treatment
  • Reduced adverse effects of treatment
  • Enhanced recovery
  • Increased likelihood that the injured worker will return to work quickly
  • Decreased temporary and permanent disability
  • Reduced overall medical and total case costs

For more information on opioid strategies, request a subscription to Healthesystems’ RxInformer clinical journal or access the latest issue on the app for iPad through the App Store.

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthesystems. The editorial staff of Risk & Insurance had no role in its preparation.




Healthesystems is a leading provider of Pharmacy Benefit Management (PBM) & Ancillary Benefits Management programs for the workers' compensation industry.

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Absence Management

Establishing Balance With Volunteers

It’s good business to allow job-leave for volunteer emergency responders, whether or not state laws apply.
By: | January 10, 2018 • 7 min read

If 2017 had a moniker, it might be “the year of the natural disasters,” thanks to a phenomenal array of catastrophic or severe events— hurricanes, tornadoes, wildfires, ice storms and floods.

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Combined with smaller-scale fires and other emergencies, these incidents tax the resources of local and state emergency services, often prompting the need to call volunteer emergency responders into action.

But as lean as most organizations are already running, volunteer activities can sometimes cause friction between employees and employers. Handling conflicts the wrong way can potentially lead to legal headaches, harm employee morale and batter a company’s reputation.

State by State Variations

Most employers are aware of the various federal and state leave laws protecting their employees, including family and medical leave, pregnancy leave and military leave. But leave laws that protect the livelihoods of volunteer emergency responders are more likely to fly under the radar of some HR managers and risk managers.

Such laws don’t exist in every state, but more than 20 states do have some type of law in place to protect volunteers including emergency responders, firefighters, disaster workers, medical responders, ambulance drivers or peace officers.

Marti Cardi, vice president of Product Compliance for Matrix Absence Management

The laws vary broadly. Nearly all specify that such leave be unpaid, and that employees disclose their volunteer status to employers and provide documentation for each leave. But there is a spectrum of variations in terms of what may trigger an eligible leave. Some, for instance, apply for any emergency that prompts a call from the volunteer’s affiliated responder group. Others may require a government declaration of emergency for the law to be triggered.

While many of the laws do not explicitly require employers to let employees leave work when called to an emergency during a shift, most specify that an employee may be late or even miss work entirely without facing termination or any other adverse employment action.

Some states mandate a maximum number of unpaid leave days that a volunteer can claim. But others may place more significant burdens on employers. In California, for instance, employers with 50 or more employees are required to grant up to 14 days of unpaid leave for training activities in addition to any leave taken to respond to emergency events. For multistate employers, keeping on top of what obligations may apply in each circumstance can be a challenge.

Significant Risks

Large or mid-sized employers may rely on absence management providers to keep them in compliance. For smaller employers though, it may be as simple as looking up a state’s law via Google to find out what’s required. However, checking in with the state department of labor or the company’s attorney may be the best way to get the correct facts.

“I would caution that just because you don’t find something [on the internet], it doesn’t mean it’s not there,” said absence management and employment law attorney Marti Cardi, vice president of Product Compliance for Matrix Absence Management.

For example, Cardi said, an obscure Texas law provides job-protected leave for volunteer ham radio operators called into service during an emergency.

Cardi said employers should task HR to investigate the laws in each state the company operates in, and to ensure that supervisors are educated about the existence of these laws.

“If a supervisor is told by one of his or her employees, ‘Sorry I’m not coming in today … I’ve been called to volunteer firefighter duty for the [nearby region] fire,’” she said, you want to be sure that the supervisor knows not to take action against the employee, and to contact HR for guidance.

“Training supervisors to be aware of this kind of absence is really important.”

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An employer that does terminate a protected volunteer for responding to an emergency may be ordered to pay back wages and reinstate the employee. In some cases, the employee may also be able to sue for wrongful termination.

And of course, “you don’t want to be the company in the headlines that is getting sued because you fired the volunteer firefighter,” she added.

If an employer bars a volunteer from responding, the worst-case scenario may be a third-party claim. Failure to comply with the law could give rise to a claim along the lines of “‘If you had complied with your statutory obligation to give Jane Doe time to respond, my loved one would not have died,’” explained Philadelphia-based Jonathan Segal, partner at law firm Duane Morris and managing principal of the Duane Morris Institute.

“That’s the claim I think is the largest in terms of legal risk.”

Even if no one dies or is seriously injured, he added, “there could still be significant reputational risk if an individual were to go to the media and say, ‘Look, I got called by the fire department and I wasn’t allowed to go.’”

The Right Thing to Do

What employers should be thinking about, Segal said, is that whether or not you have a legal obligation to provide job-protected leave for volunteer responders, “there’s still the question of what are the consequences if you don’t?”

Employee morale should be factored in, he said. The last thing any company wants is for employees to perceive it as insensitive to their interests or the interests of the community at large.

“Sometimes employers need to go beyond the law, and this is one of those times,” — Jonathan Segal, partner, Duane Morris; managing principal, Duane Morris Institute

“How is this going to resonate with my employees, with my workforce, how are people going to see this? These are all relevant factors to consider,” he said.

There’s an argument to be made for employers to look at the bigger picture when it comes to any volunteer responders on their payroll, said Segal.

“Sometimes employers need to go beyond the law, and this is one of those times,” he said. “Think about the case where’s there’s not a specific state law [for emergency responders] and you say to a volunteer, ‘No, you can’t leave to deal with this fire’ and then people die. You as an employer have potentially played a role, indirectly, because you didn’t allow the first responder or responders to go,” he said.

The bottom line is that “it’s the right thing to do, even if it’s not required by law,” agreed Cardi.

“I feel that companies should have a policy that they’re not going to discipline or discharge someone for absences due to this kind of civic service, subject to verification of course.”

Clear Policy

While most employers do strive to be good corporate citizens, it goes without question that employers need to guard their own interests. It’s not especially likely that volunteer responders will try to take advantage of the unpaid leave allowed them, but of course, it could happen.

That’s why it’s important to have policies that are aligned with state laws. Those policies could include:

  • Notifying the company of any volunteer affiliations either upon hire or as soon they are activated as volunteers.
  • Requiring that employees notify a supervisor as soon as possible if called to an emergency (state requirements vary).
  • Requiring documentation after the event from the head of the entity supervising the volunteer’s activities.

If at some point it becomes excessive – someone has responded to emergencies five times in nine weeks, then it’s time to examine the specifics of the law and have a discussion with the employee about what’s reasonable, said Segal. It may also be time to ask specifics about whether the person is volunteering each time, or are they being called.

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In some cases, the discussion may need to be about finding a middle ground, especially if an employee has taken on an excessively demanding volunteer role.

“We encourage volunteers to pick the style that best fits their schedule,” said Greta Gustafson, a representative of the American Red Cross. “Disaster volunteers can elect to respond to disasters locally, nationally, or even virtually, and each assignment varies in length — from responding overnight to a home fire in your community to deploying across the country for several weeks following a hurricane.

“The Red Cross encourages all volunteers to talk with their employers to determine their availability and to communicate this with their local Red Cross chapter.”

Segal suggests approaching it as an interactive dialogue — borrowing from the ADA. “Employers may need to open a discussion along the lines of ‘I need you here this week because this week we have a deliverable on Friday and you’re critical to that client deliverable,’” he said, but also identify when the employee’s absence would be less critical.

No doubt there will be tough calls. An employer may have its hands full just trying to meet basic customer needs and need all hands on deck.

“That may be a situation where you say, ‘First let me check the law,’” said Segal. If there’s a leave law that applies, “then I’m going to need to comply with it. If there’s not, then you may need to balance competing interests and say, ‘We need you here.’” &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]