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

Robotics Risk

Rise of the Cobots

Collaborative robots, known as cobots, are rapidly expanding in the workforce due to their versatility. But they bring with them liability concerns.
By: | May 2, 2017 • 5 min read

When the Stanford Shopping Center in Palo Alto hired mobile collaborative robots to bolster security patrols, the goal was to improve costs and safety.

Once the autonomous robotic guards took up their beats — bedecked with alarms, motion sensors, live video streaming and forensics capabilities — no one imagined what would happen next.

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For some reason,  a cobots’ sensors didn’t pick up the movement of a toddler on the sidewalk who was trying to play with the 5-foot-tall, egg-shaped figure.

The 300-pound robot was programmed to stop for shoppers, but it knocked down the child and then ran over his feet while his parents helplessly watched.

Engaged to help, this cobot instead did harm, yet the use of cobots is growing rapidly.

Cobots are the fastest growing segment of the robotics industry, which is projected to hit $135.4 billion in 2019, according to tech research firm IDC.

“Robots are embedding themselves more and more into our lives every day,” said Morgan Kyte, a senior vice president at Marsh.

“Collaborative robots have taken the robotics industry by storm over the past several years,” said Bob Doyle, director of communications at the Robotic Industries Association (RIA).

When traditional robots joined the U.S. workforce in the 1960s, they were often assigned one specific task and put to work safely away from humans in a fenced area.

Today, they are rapidly being deployed in the automotive, plastics, electronics assembly, machine tooling and health care industries due to their ability to function in tandem with human co-workers.

More than 24,000 robots valued at $1.3 billion were ordered from North American companies last year, according to the RIA.

Cobots Rapidly Gain Popularity

Cobots are cheaper, more versatile and lighter, and often have a faster return on investment compared to traditional robots. Some cobots even employ artificial intelligence (AI) so they can adapt to their environment, learn new tasks and improve on their skills.

Bob Doyle, director of communications, Robotic Industry Association

Their software is simple to program, so companies don’t need a computer programmer, called a robotic integrator, to come on site to tweak duties. Most employees can learn how to program them.

While the introduction of cobots into the workplace can bring great productivity gains, it also introduces risk mitigation challenges.

“Where does the problem lie when accidents happen and which insurance covers it?” asked attorney Garry Mathiason, co-chair of the robotics, AI and automation industry group at the law firm Littler Mendelson PC in San Francisco.

“Cobots are still machines and things can go awry in many ways,” Marsh’s Kyte said.

“The robot can fail. A subcomponent can fail. It can draw the wrong conclusions.”

If something goes amiss, exposure may fall to many different parties:  the manufacturer of the cobot, the software developer and/or the purchaser of the cobot, to name a few.

Is it a product defect? Was it an issue in the base code or in the design? Was something done in the cobot’s training? Was it user error?

“Cobots are still machines and things can go awry in many ways.” — Morgan Kyte, senior vice president, Marsh

Is it a workers’ compensation case or a liability issue?

“If you get injured in the workplace, there’s no debate as to liability,” Mathiason said.

But if the employee attributes the injury to a poorly designed or programmed machine and sues the manufacturer of the equipment, that’s not limited by workers’ comp, he added.

Garry Mathiason, co-chair, robotics, AI and automation industry group, Littler Mendelson PC

In the case of a worker killed by a cobot in Grand Rapids, Mich., in 2015, the worker’s spouse filed suit against five of the companies responsible for manufacturing the machine.

“It’s going to be unique each time,” Kyte said.

“The issue that keeps me awake at night is that people are so impressed with what a cobot can do, and so they ask it to do a task that it wasn’t meant to perform,” Mathiason said.

Privacy is another consideration.

If the cobot records what is happening around it, takes pictures of its environment and the people in it, an employee or customer might claim a privacy violation.

A public sign disclosing the cobot’s ability to record video or take pictures may be a simple solution. And yet, it is often overlooked, Mathiason said.

Growing Pains in the Industry

There are going to be growing pains as the industry blossoms in advance of any legal and regulatory systems, Mathiason said.

He suggests companies take several mitigation steps before introducing cobots to the workplace.

First, conduct a safety audit that specifically covers robotics. Make sure to properly investigate the use of the technology and consider all options. Run a pilot program to test it out.

Most importantly, he said, assign someone in the organization to get up to speed on the technology and then continuously follow it for updates and new uses.

The Robotics Industry Association has been working with the government to set up safety standards. One employee can join a cobot member association to receive the latest information on regulations.

“I think there’s a lot of confusion about this technology and people see so many things that could go wrong,” Mathiason said.

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“But if you handle it properly with the safety audit, the robotics audit, and pay attention to what the standards are, it’s going to be the opposite; there will be fewer problems.

“And you might even see in your experience rating that you are going to [get] a better price to the policy,” he added.

Without forethought, coverage may slip through the cracks. General liability, E&O, business interruption, personal injury, cyber and privacy claims can all be involved.

AIG’s Lexington Insurance introduced an insurance product in 2015 to address the gray areas cobots and robots create. The coverage brings together general and products liability, robotics errors and omissions, and risk management services, all three of which are tailored for the robotics industry. Minimum premium is $25,000.

Insurers are using lessons learned from the creation of cyber liability policies and are applying it to robotics coverage, Kyte said.

“The robotics industry has been very safe for the last 30 years,” RIA’s Doyle said. “It really does have a good track record and we want that to continue.” &

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