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Workers' Comp

Paying for Detox

The opioid epidemic is addressed by detoxification programs.
By: | August 4, 2014 • 8 min read

Helping patients addicted or dependent on the very medications that were designed to ease their pain is driving workers’ comp claims payers in some cases to fund tapering and detoxification programs.

Study results in recent years have boosted that initiative by identifying multidisciplinary treatment approaches as offering an improved chance for success.

The treatment approaches call for weaning patients off of pain medications while also addressing a range of complex issues contributing to addiction and dependency, experts said.

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Success, though, is frustratingly hard to come by, so payers have been cautious, or even reluctant to fund detox treatments — although more are doing so, they added.

Recidivism is common, even after someone successfully completes a good detoxification treatment program and appears to be winning the struggle to turn their life around. Experts said it can take several attempts or “episodes of care” to wean someone off narcotics. Long-term support is often necessary.

“The success rate is poor enough that it becomes difficult to feel that even the best programs by reputation are delivering,” said Dr. Dwight Robertson, national medical director in Glendale, Calif., for EMPLOYERS, a workers’ compensation insurer.

“Where we have a case that just goes on and on and we are trying to intervene … it can be very frustrating because the patient may not be ready to change.” — Dr. Dwight Robertson, chief medical officer for EMPLOYERS

“It is so tough that you often have a lot of cases you send to the best programs, it costs you a lot of money, and you still don’t get success. But having said that, you can’t just sit back and do nothing.”

Payers have several reasons for helping workers struggling with addiction or drug dependency, including the drugs’ direct costs, the expense of treating drug side effects, a desire to cut their ongoing liability by closing complex claims, and a sincere goal of helping workers recover, said Dr. Steven M. Moskowitz, senior medical director for Walnut Creek, Calif.-based Paradigm Outcomes, a catastrophic care management company.

But several hurdles often frustrate attempts to help, especially if the overuse or abuse of addictive prescription narcotics has escalated over time without eliminating the chronic pain responsible for prescribing opioids in the first place.

The hurdles include a dependent or addicted worker’s refusal to seek help, especially when their judgment is clouded by an intense desire for drugs that someone else is paying for; caregivers who might understand detoxification but not chronic pain issues or vice versa; and a range of personal or psychosocial problems such as mental health complications or a claimant’s troubled home environment.

To help overcome those hurdles, more payers are working to identify detox treatment and tapering programs nationwide that they expect will provide the best chance of success, said Mark Pew, senior VP of product development for PRIUM, a workers’ comp medical management company.

In addition to the cost of the programs, they are paying for travel and other expenses necessary to get addicted or drug-dependent claimants into treatment.

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Yet, with treatment programs ramping up marketing efforts to push their services, and recidivism a very common problem, worker’s comp payers are also cautious about selecting treatment programs and patients who might benefit.

“They are not doing it willy-nilly and they are not doing it generously,” Moskowitz said of workers’ comp payers funding detox treatments.

“They are doing it cautiously, as they should, because everyone now is [selling detox services]. It’s a lot of money. It’s an expensive resource.”
In cases where they feel the patient’s treating physician lacks the expertise necessary to address severe pain or treat addiction, insurers, excess insurers and TPAs are funding detoxification treatments.

That’s doubly true when patients have a documented history of consuming multiple medications, including narcotics, in high doses, Pew said.

Dependency Versus Addiction

With addicts, the withdrawal and the lengths to which an injured worker will go to get drugs are extreme.

True addiction manifests itself in aggressive drug-seeking behavior, such as visiting multiple prescribers or claiming the loss of a prescription to obtain early refills.

“Basically you are out of control in terms of your utilization and you are doing whatever you can to get as much of the drug as quickly as possible,” said Dr. Robert Goldberg, chief medical officer for Healthesystems, a workers’ comp pharmacy and ancillary benefits management company in Tampa, Fla.

Among workers’ comp claimants, full-scale addiction is less common than psychological or physical dependence. However, dependent cases may also require detoxification or tapering assistance, Goldberg said.

Dr. Robert Goldberg, chief medical officer for Healthesystems

Dr. Robert Goldberg, chief medical officer for Healthesystems

Detoxification describes the process of helping individuals safely withdraw from substance use, and may involve gradually tapering dose amounts or prescribing alternative drugs to minimize withdrawal symptoms.

“An injured worker’s treating physician that has the proper experience should be capable of addressing simpler cases and helping patients taper off drugs,” Goldberg said.

“A more complicated situation [includes patients with] co-morbidities, a lot of psychosocial factors, higher doses, and longer term dependency,” Goldberg added.

“That is where you have to decide if you need a more formal detox program, either inpatient or outpatient. That is where you are stepping up the game and the intensity of treatment and the cost.”

Reluctance to Seek Treatment

Complicating matters is that workers’ comp payers can’t force a claimant to seek treatment for drug dependency or addiction. In addition, reluctance to seek treatment is typical, so payers must act quickly when a patient indicates a willingness to seek help.

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“Where we have a case that just goes on and on and we are trying to intervene … it can be very frustrating because the patient may not be ready to change,” EMPLOYERS’ Robertson said.

“Yet we have to be ready for that moment when maybe they soften up and say they do want to change their life. We have to be ready to evaluate them at that moment and say, ‘Is a true detox program needed?’ ”

There are several opioid detoxification program settings.  Selecting one can depend on a claimant’s specific needs and the severity of the problem, experts said.

Settings include hospital-based detoxification with 24-hour service, non-hospital detoxification programs with 24-hour service, intensive ambulatory outpatient services and ambulatory detoxification, said Dr. Adam L. Seidner, national medical director for The Travelers Cos. Inc.

“Our nurses help ensure that the services and facility match the required detoxification needed,” Seidner said.

“Multiple service types may be involved. The worker needing detoxification may need to start in the hospital and progress to an ambulatory facility.”

A patient who desires to leave drugs behind and has a supportive home environment may succeed with outpatient care, Paradigm’s Moskowitz said. Others may need the added structure provided by an inpatient program, he added.

The decision whether to use an outpatient or inpatient facility may also depend on a worker’s mind-set. If they don’t consider themselves addicted or dependent, they may object to an inpatient program and only accept outpatient assistance.
Regardless of the care level, though, failure is always possible despite a program’s reputation, Robertson said.

“Sometimes the intervention in a hospital — and there are some great hospital programs — can be most impacting and work best,” Robertson said.

“But you may appear to have a good result then you send the patient home and they go right back into the same set of complex issues that created the problem to begin with.”

That is why experts said a process that only weans patients off medications often is inadequate. They advocate a multidisciplinary approach that includes help with addiction, functional restoration and addressing psychosocial issues that can lead to relapses.

Detox and Chronic Pain Management

Some programs are capable of helping address chronic pain, but not addiction and detoxification, while others excel at helping with the latter but not pain, Moskowitz said.

“We have found the best luck identifying a handful of good programs around the country that are really good at pain management as well as detoxification,” Moskowitz said.

“Most of these cases that have the substance problems also [complain of pain stemming from work injuries]. So you have to address the rehab of the underlying pain diagnosis. In addition, they need to get somebody to change their mind-set to cooperate with coming off the medication.”

To succeed, experts said, payers may also have to fund mental health treatment such as cognitive behavioral therapy that helps patients learn coping skills and managing psychosocial conditions.

“If you don’t do it properly,” Pew said, “you can spend $15,000, $20,000, $25,000 for a functional restoration or chronic pain management program and then they relapse two or three months later because you didn’t deal with how they cope with pain or manage their condition and change their lifestyle.”

But Robin Orchard, president and owner of Orchard Medical Consulting, a case management company that provides detox services in Phoenix, said that simultaneous detox and chronic pain management programs are often not necessary.

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She has seen an increase in claimants seeking detoxification help since workers’ comp payers have learned about the pitfalls of opioid prescribing and curtailed their spending on the medications.

Many of those claimants are psychologically dependent on opioids and have benefited from detox treatment alone, she said.

Once off the drugs, they find that it was their opioid dependence that was helping to drive their pain.

“What we are seeing is when people are off of narcotics, they are not experiencing pain,” Orchard said.

“The overwhelming fear that the pain might occur once they are off the narcotics is what is driving them” to continue using the drugs, she 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

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Risk Focus: Workers' Comp

Do You Have Employees or Gig Workers?

The number of gig economy workers is growing in the U.S. But their classification as contractors leaves many without workers’ comp, unemployment protection or other benefits.
By: and | July 30, 2018 • 5 min read

A growing number of Americans earn their living in the gig economy without employer-provided benefits and protections such as workers’ compensation.

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With the proliferation of on-demand services powered by digital platforms, questions surrounding who does and does not actually work in the gig economy continue to vex stakeholders. Courts and legislators are being asked to decide what constitutes an employee and what constitutes an independent contractor, or gig worker.

The issues are how the worker is paid and who controls the work process, said Bobby Bollinger, a North Carolina attorney specializing in workers’ compensation law with a client roster in the trucking industry.

The common law test, he said, the same one the IRS uses, considers “whose tools and whose materials are used. Whether the employer is telling the worker how to do the job on a minute-to-minute basis. Whether the worker is paid by the hour or by the job. Whether he’s free to work for someone else.”

Legal challenges have occurred, starting with lawsuits against transportation network companies (TNCs) like Uber and Lyft. Several court cases in recent years have come down on the side of allowing such companies to continue classifying drivers as independent contractors.

Those decisions are significant for TNCs, because the gig model relies on the lower labor cost of independent contractors. Classification as an employee adds at least 30 percent to labor costs.

The issues lie with how a worker is paid and who controls the work process. — Bobby Bollinger, a North Carolina attorney

However, a March 2018 California Supreme Court ruling in a case involving delivery drivers for Dynamex went the other way. The Dynamex decision places heavy emphasis on whether the worker is performing a core function of the business.

Under the Dynamex court’s standard, an electrician called to fix a wiring problem at an Uber office would be considered a general contractor. But a driver providing rides to customers would be part of the company’s central mission and therefore an employee.

Despite the California ruling, a Philadelphia court a month later declined to follow suit, ruling that Uber’s limousine drivers are independent contractors, not employees. So a definitive answer remains elusive.

A Legislative Movement

Misclassification of workers as independent contractors introduces risks to both employers and workers, said Matt Zender, vice president, workers’ compensation product manager, AmTrust.

“My concern is for individuals who believe they’re covered under workers’ compensation, have an injury, try to file a claim and find they’re not covered.”

Misclassifying workers opens a “Pandora’s box” for employers, said Richard R. Meneghello, partner, Fisher Phillips.

Issues include tax liabilities, claims for minimum wage and overtime violations, workers’ comp benefits, civil labor law rights and wrongful termination suits.

The motive for companies seeking the contractor definition is clear: They don’t have to pay for benefits, said Meneghello. “But from a legal perspective, it’s not so easy to turn the workforce into contractors.”

“My concern is for individuals who believe they’re covered under workers’ compensation, have an injury, try to file a claim and find they’re not covered in the eyes of the state.” — Matt Zender, vice president, workers’ compensation product manager, AmTrust

It’s about to get easier, however. In 2016, Handy — which is being sued in five states for misclassification of workers — drafted a N.Y. bill to establish a program where gig-economy companies would pay 2.5 percent of workers’ income into individual health savings accounts, yet would classify them as independent contractors.

Unions and worker advocacy groups argue the program would rob workers of rights and protections. So Handy moved on to eight other states where it would be more likely to win.

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So far, the Handy bills have passed one house of the legislature in Georgia and Colorado; passed both houses in Iowa and Tennessee; and been signed into law in Kentucky, Utah and Indiana. A similar bill was also introduced in Alabama.

The bills’ language says all workers who find jobs through a website or mobile app are independent contractors, as long as the company running the digital platform does not control schedules, prohibit them from working elsewhere and meets other criteria. Two bills exclude transportation network companies such as Uber.

These laws could have far-reaching consequences. Traditional service companies will struggle to compete with start-ups paying minimal labor costs.

Opponents warn that the Handy bills are so broad that a service company need only launch an app for customers to contract services, and they’d be free to re-classify their employees as independent contractors — leaving workers without social security, health insurance or the protections of unemployment insurance or workers’ comp.

That could destabilize social safety nets as well as shrink available workers’ comp premiums.

A New Classification

Independent contractors need to buy their own insurance, including workers’ compensation. But many don’t, said Hart Brown, executive vice president, COO, Firestorm. They may not realize that in the case of an accident, their personal car and health insurance won’t engage, Brown said.

Matt Zender, vice president, workers’ compensation product manager, AmTrust

Workers’ compensation for gig workers can be hard to find. Some state-sponsored funds provide self-employed contractors’ coverage.  Policies can be expensive though in some high-risk occupations, such as roofing, said Bollinger.

The gig system, where a worker does several different jobs for several different companies, breaks down without portable benefits, said Brown. Portable benefits would follow workers from one workplace engagement to another.

What a portable benefits program would look like is unclear, he said, but some combination of employers, independent contractors and intermediaries (such as a digital platform business or staffing agency) would contribute to the program based on a percentage of each transaction.

There is movement toward portable benefits legislation. The Aspen Institute proposed portable benefits where companies contribute to workers’ benefits based on how much an employee works for them. Uber and SEI together proposed a portable benefits bill to the Washington State Legislature.

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Senator Mark Warner (D. VA) introduced the Portable Benefits for Independent Workers Pilot Program Act for the study of portable benefits, and Congresswoman Suzan DelBene (D. WA) introduced a House companion bill.

Meneghello is skeptical of portable benefits as a long-term solution. “They’re a good first step,” he said, “but they paper over the problem. We need a new category of workers.”

A portable benefits model would open opportunities for the growing Insurtech market. Brad Smith, CEO, Intuit, estimates the gig economy to be about 34 percent of the workforce in 2018, growing to 43 percent by 2020.

The insurance industry reinvented itself from a risk transfer mechanism to a risk management mechanism, Brown said, and now it’s reinventing itself again as risk educator to a new hybrid market. &

Susannah Levine writes about health care, education and technology. She can be reached at ri[email protected] Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]