WC Cost Trends

Increase Seen in Questionable Drug Screens

New research reveals workers’ comp claimants receiving urine drug tests when doctors have not prescribed opioid pain medications.
By: | February 3, 2015 • 5 min read

Research results to be published later this year will document growing incidences of giving workers’ compensation claimants urine drug tests even when doctors have not prescribed opioid pain medications.

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Medical treatment guidelines call for doctors to use urine drug screen testing to determine whether patients they have prescribed addictive opioids to engage in aberrant behavior, such as doctor shopping for multiple prescriptions or selling the drugs rather than consuming them as prescribed.

But new California Workers’ Compensation Institute research results document a growth in cases of injured workers given drug tests even though a doctor has not prescribed opioid pain killers, said CWCI President Alex Swedlow.

“We see people getting tested to a greater and greater extent and more injured workers getting tested regardless of whether or not they have an opioid prescription,” Alex Swedlow, California Workers’ Compensation Institute president

Swedlow plans to publish the new findings in advance of CWCI’s upcoming annual meeting.

Questions about the overuse of drug screens as unnecessary workers’ comp cost drivers are not new, having surfaced nearly three years ago. But the new CWCI research is based on recent claims data and shows “continued significant increases” in drug testing with questionable application, Swedlow said.

“We are seeing continued, significant increases in the percentage of drug tests relative to all lab tests, the average number of tests per claim, as well as the percentage of the injured workers who are receiving drug tests without a corresponding schedule II or III opioid prescription,” Swedlow said. “We see people getting tested to a greater and greater extent and more injured workers getting tested regardless of whether or not they have an opioid prescription.”

Swedlow believes the practice has become “a real revenue center.” His new research will update CWCI’s past findings on opioid-related drug screening.

While CWCI’s research is based on California claims data, observers expect that similar practices occur in other jurisdictions.

Across the nation, geographic pockets exist where drug-testing overutilization occurs and other regions where underutilization occurs, said Michael Gavin, president of PRIUM, a workers’ comp cost containment company owned Ameritox, a pain medication monitoring entity.

Gavin pointed to a Workers Compensation Research Institute study released last year reporting that sizable increases in drug testing occurred across some states while the percentage of longer-term opioid users receiving testing services remained low in other states.

Organizations such as the American College of Occupational and Environmental Medicine (ACOEM) and various state agencies developed medical treatment guidelines that include the recommended drug screening.

Their work followed an alarming epidemic of patients overdosing or becoming dependent or addicted to the medications.

The following increase in drug screening came with criticisms that the overuse of the testing drives unnecessary expenses for workers’ comp payers.

No Evidence of Drop in Pain Meds

CWCI reported in 2012 that drug testing was becoming a significant workers’ comp cost driver. It estimated that for 2011, California insurers and self-insured employers spent $98 million for the drug tests.

CWCI’s study found that the volume of drug testing rose 4,537 percent from 2004 to 2011, increasing from 4,012 tests to 186,023. The average amount paid per test, meanwhile, rose from $81 to $207.

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Observers in other states similarly complained of a sudden spike in bills for drug-testing while raising concerns that the tests were often administered in cases where they were not necessary.

Even though research such as CWCI’s work shows the drug screening of injured workers has skyrocketed, he has yet to observe a corresponding drop, to the extent he would expect, in the prescribing of the narcotic pain medications, said Brian Carpenter, senior VP, product development and clinical programs for pharmacy benefit manager Healthcare Solutions Inc.

Drug tests uncovering claimant’s aberrant behavior have resulted in doctors halting opioid prescriptions and notifying workers’ comp payers who have closed such claims, Carpenter said.

Logically, though, he would expect a greater decrease in the number of opioid medications prescribed by doctors because workers’ comp payers are footing the bill for more and more of the drug tests.

“Drug screening creates some mitigation,” Carpenter said. “I am not saying that it doesn’t. But you are not seeing what you would expect to see with those kinds of increases in uses of those tests. You are not seeing the decreased use in opioids as we should see with increased urine drug screens.”

You would expect to see some decrease in opioid prescribing accompany the urine tests, although not in an exact proportion to the amount of testing, said Kathryn L. Mueller M.D., a medical professor at the University of Colorado in Denver.

Not all drug screen test results pointing to patient abnormal behavior lead to a doctor discontinuing a pain medication prescription, added Mueller, who is also ACOEM president and medical director for Colorado’s Division of Workers’ Compensation.

Drug testing is “the medical standard of care so there shouldn’t be a question of whether it has to be done,” Mueller said.

She knows of plenty of cases where Colorado doctors have immediately stopped prescribing opioids due to test results, Mueller said.

“Part of what you have to understand is we are not doing it for the money, we are doing it for the patient care,” Mueller added.

Testing protects both patients and doctors by preventing overdoses, deaths, the illegal sale of prescribed drugs and other problems, Mueller added.

Yet the overuse of tests does occur, driving claims’ payer expenses, Mueller said. About 10 percent to 20 percent of patients show a need for a “shift in therapy,” away from being prescribed opioids, Mueller continued.

That means drug screen testing can’t possibly be useful every time a script for opioids is written, especially when the majority of patients are not misusing the drugs or are not likely to do so in the future.

But sufficient scientific evidence on how often testing should occur is lacking, so more studies are in order, Mueller said.

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“That is something that should be looked into,” she said.

Care should be taken in making blanket statements regarding the use of drug screening in cases where opioids are not prescribed, Gavin added. Doctors could be evaluating patients for many other prescribed drugs which can also be dangerous if used improperly.

Still, adjusters and medical personnel alike may not be acting on drug test results showing a patient’s questionable behavior, Gavin said. Greater education is needed to improve their responses.

“There are a number of inconsistent urine drug screens that should lead to medical change, but do not because the medical community is under-prepared to use the tool that has been placed at their disposal,” he said.

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

More from Risk & Insurance

More from Risk & Insurance

Risk Manager Focus

Better Together

Risk managers reveal what they value in their brokers.
By: | June 1, 2017 • 11 min read

Michael K. Sheehan, (left) Managing Director, Marsh and Grant Barkey, Director of Risk Management, Motivate International Inc.

Ask a broker what they can do for you and they will tell you. But let’s ask the risk manager.

What do risk managers really need in a broker? And what do the best brokers do to help risk managers succeed in their jobs?

Chet Porembski, system vice president and deputy general counsel, OhioHealth Corp.

Risk managers say it’s a broker who helps them look knowledgeable and prepared to their bosses. It’s someone who sweeps in like a superhero with an ingenious solution to a difficult problem.

Risk managers want to see brokers bring forth better products year after year. They want a broker who shows up at renewal time with new ideas, not just a rubber stamp.

Great brokers embed with the risk management team and learn everything they can about the company and its leaders. They help risk managers prepare and keep tabs throughout the year on changes at the organization with an eye towards planning the future.

“There’s the broker that sees themselves as just a hired ‘vendor,’ or I should say, somebody that basically just does the job at hand,” said Chet Porembski, system vice president and deputy general counsel at OhioHealth Corp.

“And then there’s the broker that views themselves very much as a business partner.  They truly bring added value to the relationship.”

These brokers look at the tough issues the risk manager is facing and bring in the resources to try to help their client in ways even the client might not have thought about yet. They also do advanced planning that makes the risk manager’s job easier when a problem arises.

“That’s the kind of broker I want.” Porembski said.

And that’s the kind of broker many risk managers need more than ever.

“The only way that the relationship is going to be successful is if you build a tremendous amount of trust.” — Frances Clark, director of risk management and insurance, Sentara Healthcare

That’s because risk managers are under increasing pressure these days. They carry more weight as corporations shrink their departments to cut costs.

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Climate change, cyber threats and geopolitical shifts are turning what were once unthinkable losses into risks that are almost commonplace. And this is all happening in an under-insured risk environment, according a study by PwC entitled Broking 2020: Leading from the Front in a New Era of Risk.

Thankfully there are good brokers out there, risk managers say, who can bring more value to a client today than ever before and help ease that fear.

Brokers — the traditional intermediary in the risk transfer chain — do in fact have a tangible and growing role in developing viable and innovative solutions for the risk manager, according to PwC’s study.

They are the “global risk facilitation leaders.”

“[Whatever] organizations are doing in the short term — be this dealing with market instability or just going about day to-day business — they need to be looking at how to keep pace with the sweeping social, technological, economic, environmental and political (STEEP) developments that are transforming the world,” PwC said in the report.

Advisors That Are Getting It Done

Cyber risks are just one growing challenge that all organizations grapple with.

Frances Clark, director of risk management and insurance at Sentara Healthcare, remembers when her broker first suggested that she hold a leadership tabletop cyber drill.

Clark said her broker kept saying, “I know this is going to be a painful experience, but you are going to come out so much better in the long run.”

Frances Clark, director of risk management and insurance, Sentara Healthcare

Her broker was right, and went so far as to help arrange a system-wide drill that included representatives from the legal, finance, security, communications, marketing and medical teams.

They reviewed the many ways a cyber attack can happen and then practiced a response.

“We benefitted greatly from that exercise,” Clark said.

When Doctors on Demand developed a telemedicine app to offer mental health services through mobile devices, the company ran up against insurance limitations across state lines. All states require that the physician giving the advice be licensed in the same state where the patient is located.

The concern was for patient encounters where the patient actually crossed state boundaries during the encounter, due to the utilization of a mobile phone. The patient may have started with a properly licensed physician in the original state, but then crossed into a neighboring state where the physician was not licensed.

Larry Hansard, a regional managing director at Arthur J. Gallagher & Co., and a 2017 Power Broker®, worked to secure medical professional liability coverage without the traditional licensure exclusions placed on medical professionals by insurance carriers.

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The initiative he helped develop actually changes how health care can be delivered to patients. It allows the emerging telemedicine sector to now offer services around the world.

Two-thirds of the risk managers in the PwC Broker 2020 survey labeled their brokers as “trusted advisors.” But the same survey found that some participants see their broker as more of a straightforward service provider rather than as a source for solutions.

The survey results indicate there is plenty of room for brokers to bring more value to clients.

OhioHealth’s brokers meet each year with OhioHealth’s risk management team to review insurance coverages.  And when the health system holds quarterly risk management retreats, the brokers attend. They bring with them education and insights on a broad range of topics, from property insurance markets to cyber solutions.

Porembski’s brokers also collaborate with the risk managers when there’s an upcoming presentation on risk issues to senior management. Sometimes the brokers help prepare the presentation, he said.

“We end up looking exceptionally good to our senior leaders and our board,” he said.

Involving the broker in interactions with leaders outside the traditional risk management team has benefits beyond selling products, he said. It extends the relationship circle.

Clark tries not to think of her brokers as outside vendors just providing a service. She wants them to be as committed and knowledgeable about the organization as she is.

“The only way that the relationship is going to be successful is if you build a tremendous amount of trust,” Clark said.

“You have to be completely open and honest about everything, no matter how bad it is, or how bad it may look to the market or underwriters.”

“Once you establish that trusting relationship, I think everything else falls into place,” she adds.

Sentara underwent significant growth recently, acquiring five hospitals in about six years. The expansion required a vast amount of integration on insurance programs and a merger of risk management departments and claims.

Clark said her brokers rolled up their sleeves and expertly navigated her through the consolidation.

“I can’t reiterate enough how most risk managers don’t know how to deal with an M&A unless you’ve gone through it.”

She said she wouldn’t have been able to manage the risk of the mergers without her broker’s counsel.

Grading the Broker

Mike Lubben, director of global risk management at Henry Crown & Co. in Chicago, sets standard expectations of his insurance brokers: know the exposures, understand how a risk manager has to sell ideas internally and understand the urgency of requests.

He lets his brokers know his expectations with regular report cards, complete with letter grades. And he isn’t shy about giving out Fs.

  • How did the broker service the EPLI coverage?
  • Did the broker provide expertise and coverage analysis?
  • Was there anything creative?
  • Did the broker recommend new endorsements based on the previous exposure?
  • Did the broker recommend any risk mitigation programs?
  • How well did he communicate and help with presentations?

“A good broker will think this is fantastic,” Lubben said.

This method starts the conversation. It helps Lubben establish long relationships with some stellar brokers.  But if the broker misses the mark, Lubben can have a talk with them about ways to do better in the future. Some brokers he has sent away.

Recently a broker failed on what Lubben calls “blocking and tackling,” the basics like returning phone calls within one day and responding promptly to emails.

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Lubben gave him an “F” on those subjects and told him why. The broker still didn’t improve his game and was eventually replaced.

For many people, insurance can seem very routine from renewal to renewal. But a really good broker will break from routine and come back with some kind of enhancement or improvement.

If the renewal is flat with no change in premium, then Clark says she’ll ask, “What are you going to do for me this year?”

The best brokers are always striving for better, she said.

“Without the brokering community, you would be hard pressed to do your job. I really appreciate what the brokers do, they bring a level of expertise that we can’t possibly have on all lines of coverage.” — Mike Lubben, director of global risk management at Henry Crown & Co.

Motivate International Inc., which operates more than half of the bike share fleets in North America, went through a recent renewal.

Their broker, Marsh, explored more than 10 options with different strategies and programs. In the end, after all of that, they decided the expiring coverage was the best fit.

“Those exercises are very valuable for risk managers,” said Grant Barkey, Motivate’s director of risk management.

“As an innovative company committed to delivering best-in-class services, we believe thorough exploration leads to informed decision-making.”

A good broker understands that a company’s day-to-day operations and a highly effective risk management program have implications for what type of policy should be procured, he said.

Brokers need to partner with risk managers to figure out what those options are, and what the markets are saying and then succinctly relay the information to management.
They also need to have the tact and curiosity to inquire about future plans and figure out what resources might be needed to better serve their client.

When PwC surveyed risk managers, most put their insurance carriers and industry groups ahead of their brokers as the primary source of cyber and supply chain risk solutions; yet these areas are still cited as risk managers’ top concerns.

“Becoming the go-to partners for developing and coordinating innovative and effective solutions in these priority risk areas is at the heart of the commercial opportunity for brokers.” PwC said in its report.

“Yet, our survey suggests that these are important areas where brokers are falling short of the market’s demands and therefore need to adapt.

For example, less than a third of respondents are very satisfied with brokers’ analytical and modelling services across a range of areas.”

When participants were asked how their brokers could be more efficient, respondents put risk analysis at the top of PwC’s survey list. Significantly, more than a third also cited ‘big data’ analysis.

Finding the Right Fit

Paul Kim, Co-CBO of U.S. Retail at Aon Risk Solutions, helps match brokers to risk managers. He keeps in mind that insurance companies tend to sell product, while the clients are looking to manage risks. The right broker assists in mapping risks to existing products and also customizing broad solutions, he said.

“The risk manager’s job has become more complex in the current environment, but there are so many tools available for those individuals to make better informed decisions that truly help protect the overall risk profile of their companies,” Kim said.

Paul Kim, Co-CBO of U.S. Retail, Aon Risk Solutions

That’s why finding the right broker should be first and foremost, he said. Look for an individual with strong industry knowledge, product expertise and market relationships. A strong broker is able to effectively communicate what the risk manager’s goals are to the marketplace to be able to execute and achieve those goals.

“Not every broker can do that,” Kim said.

“Not every broker is the right broker.”

PwC said those brokers who quickly master the art and science of identifying ambiguous threats and then mobilize a broad private/public stakeholder pool to economically manage those risks over time will pull ahead of their competition.

“We’re really generalist,” Lubben said.

“Without the brokering community, you would be hard pressed to do your job. I really appreciate what the brokers do, they bring a level of expertise that we can’t possibly have on all lines of coverage.”

When selecting a broker, the risk manager should also take into account the entire organization behind the broker. Ask about the additional support systems that are available to the broker’s clients.

The company should have a deep bench so when the primary broker is out of the office there’s someone else to rely on who is almost as knowledgeable. The broker organization should also be able to assist you with your budgeting and forecasting from a financial risk perspective.

In PwC’s survey of risk managers, nearly three-quarters want analytics from their broker to help inform their decisionmaking, with concerns over new and emerging risks being a strong driver for this demand.

Clark also thinks it is vitally important for a broker to offer a claims advocate, somebody on the outside, when you are dealing with a carrier on a complicated claim.

“Otherwise you are vulnerable to what the carrier says,” Clark said.

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To lead in this new era of risk, it’s also important that brokers forge close relationships with a broader set of stakeholders that includes governments, academia, specialist risk consultancies and even their industry peers, PwC said in the report.

It’s also going to be important to develop shared databases and research capabilities.

In turn, brokers need to assure this diverse stakeholder group that they are the right party to lead.

Clark, at Sentara Healthcare, said she knows what her risk exposures are today, but she’d like her brokers to anticipate her needs before she does.

“It’s kind of crazy, but amazingly some of them do it,” Clark said.

The broker will also use past experience and industry knowledge to anticipate where policy terms and conditions can be tweaked and improved upon.

“They will, say, advise us that we need to change this policy language, and then a year later you have a claim on that and you thank your lucky stars that they changed it,” Clark said.

“It is amazing to me every time it happens.”  &

Juliann Walsh is a staff writer at Risk & Insurance. She can be reached at [email protected]