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

More from Risk & Insurance

Insurance Executive

A Leader for Turbulent Times

Lloyd’s CEO Inga Beale is tasked with guiding the venerable insurance market through Brexit and the demands of the fiercely competitive global specialty business.
By: | July 6, 2017 • 12 min read

Underwriters at Lloyd’s are accustomed to taking on complex, even daunting, risks. The company’s leader looks at the world today and sees plenty of opportunity, but also much to be concerned about.

“Political instability is something that troubles me more than anything else because I think there is now more uncertainty across the world than there has ever been,” said Inga Beale, CEO of Lloyd’s of London.

“It feels that all of the norms that I grew up with are being challenged — openness, globalization, acceptance, inclusion — on a global scale.”

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Appropriately, we’re sitting around a table in Beale’s modern glass-fronted office at the top of the Lloyd’s Building — itself a vision from the future — to talk about Brexit and Lloyd’s newly announced Brussels subsidiary.

Add to the mix Donald Trump and the threat of nuclear attack from North Korea, the bombing of Syria and a spate of terrorist attacks across Europe, and it’s clear we are living in the most dangerous period certainly since the Cold War, or possibly ever, believes Beale.

That belief received even more chilling reinforcement when terrorists detonated a bomb at an Ariana Grande performance in Manchester, England on May 22.  Twenty two people, some of them children, were killed and more than 50 wounded in that attack.

Three years ago, it was Beale herself making world headlines with her appointment as the first female CEO in Lloyd’s 329-year history. But now Brexit and other seismic disruptions to world order have taken center stage.

Lloyd’s announced at the end of March that it would establish a new European subsidiary in Brussels in time for January 1, 2019 renewals so it can continue writing risks for all 27 European Union (EU) and three European Economic Area states after the UK exits the EU.

Currently, it uses its passporting rights to serve EU customers from London, but the expected loss of those rights after Brexit necessitated the establishment of a new subsidiary.

For now though, it’s business as usual, said Beale, with the UK remaining a full EU member for at least two more years. She added, with a reassuring smile, that there will be no immediate impact on existing policies, renewals or new policies written during that time.

“We were campaigning very much to remain in the EU before the referendum because we knew what the likely impact [of leaving the EU] would be on Lloyd’s,” said Beale, whose impressive resume includes stints with GE Insurance Solutions, Zurich and Canopius.

“We rely very much on our licensing network, and being part of the EU means that from London we can write insurance and reinsurance for all of the EU countries with our passporting authority.

“But with the UK exiting the EU, it now means that we lose those licensing powers to offer insurance with immediate effect. To counteract this, we have determined to set up a subsidiary within the EU, meaning that about five percent of our global revenues will have to go through this subsidiary because it is insurance business offered to our EU-based clients.”

Beale and her team also negotiated that most of Lloyd’s underwriting business will remain in London, as will the majority of the transactions and decision-making powers. Meanwhile, the manpower needed to run the new Brussels operation will be in the “tens rather than hundreds,” she is quick to point out.

“It’s not a huge raft of people having to move over,” she said.

“Lloyd’s will continue to do 95 percent of its business as it has always done — it’s only the other five percent that will have to go through a separate legal entity, and we’re not anticipating any further changes to our business model as a result.”

Beale, whose dual role is both supervisor and advocate for the market’s 100-something member underwriting syndicates, says that the franchise board chose Brussels over other locations including Luxembourg, Dublin and Malta because of its “robust and quality” regulatory regime.

“At the time, I didn’t even know that reinsurance existed, but once I discovered it I absolutely loved it.” — Inga Beale, CEO, Lloyd’s of London

It also provides access to a multilingual talent pool, is near to London, and, most importantly she stresses, is located in a member state with a “very high certainty of staying in the EU.”

“We want people who reflect our customers,” she said.

“The London insurance market is littered with people from all over the world because London is such a global insurance hub, so we need experts here who speak the language and understand the different cultures.”

North American Footprint

Despite its large European market, it’s the other side of the pond where Lloyd’s really thrives. Approximately 46 percent of its business comes from the U.S., mainly California earthquake and East Coast hurricane risks, she said.

Lloyd’s also remains the No.1 excess and surplus lines insurer in the U.S. and the largest non-U.S. domiciled insurer, she added.

“We have done really well in terms of growing our E&S market share over there,” she said.

“That’s our sweet spot; those non-standard risks that are hard to place.”

By contrast, Beale said that reinsurance has become a much more competitive market with new entrants offering alternative types of reinsurance putting a squeeze on prices. As a consequence, Lloyd’s has focused more on insurance, she said.

“We have also done well in Canada and with our delegated authority through our Managing General Underwriters and Managing General Agents,” she said.

“It’s this very local and specialist distribution channel that has been our success story across North America.”

In January, Beale was made a Dame Commander of the Order of the British Empire — the female equivalent of being knighted — and is also the Association of Professional Insurance Women’s Insurance Woman of the Year for 2017.

“What concerns us most is not individual risks such as earthquakes and hurricanes, but rather assessing the aggregation of our exposures to financial and liability-type risks with no geographical boundaries.” — Inga Beale, CEO, Lloyd’s of London

As the person directing Lloyd’s, she is also acutely aware of the shift in power towards emerging economies, with McKinsey recently reporting that 67 percent of commercial insurance growth will come from those markets by 2020.

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In response, Lloyd’s has focused its efforts on Asia and Latin America, transferring more than half of its managing agents to its Shanghai and Beijing platforms; and it was recently granted final approval to open a reinsurance office in Mumbai, she said.

“That’s where the future’s going to be,” she said.

“We know that a lot of the business is no longer coming to London in the traditional way, hence we have set up a Singapore platform and platforms in China, and opened up an office in Dubai as well as in India to be closer to our clients and brokers there.”

Lloyd’s profits last year were flat at $2.7 billion, while GWP was up $3.9 billion.

The market made a profit despite taking a $2.7 billion hit for major claims — the fifth highest such total since the turn of the century — primarily due to Hurricane Matthew and the Fort McMurray Wildfire in Canada.

Although natural disasters are Lloyd’s bread and butter, its real strength is in insuring complex risks, from cargo ships and satellites to political and terrorism risks.

Lloyd’s Role in Cyber

It’s the aggregation of those harder-to-quantify risks such as cyber security that concerns Beale most. Expected to grow to $7.5 billion in global premiums business by 2020, cyber is a big focus for Lloyd’s. It has a 25 percent market share and aggregate limits of approximately $650 million per risk, she said.

“What concerns us most is not individual risks such as earthquakes and hurricanes, but rather assessing the aggregation of our exposures to financial and liability-type risks with no geographical boundaries,” she said.

“We saw that with the financial crisis and the collapse of Fanny and Freddie, and its impact on Greece, but now it’s cyber.

“We have interviewed numerous risk managers and they are telling us that they are only insured against less than 10 percent of the risks that their businesses face on a daily basis. Our challenge is to make sure that we are continuing to adapt as fast as their businesses do and that we are delivering the relevant products that they need.”

Another area where Lloyd’s has seen an uptick is political and terrorism risk, said Beale.

The U.S. standoff with North Korea, Brexit and a swath of ISIS terrorist attacks across Europe have only exacerbated the problem, heightening fears among those countries’ citizens and tearing whole communities apart.

“We would love to get to a stage where a client can track something being quoted or a claim being paid, just like you do with a package being delivered [to your home].” — Inga Beale, CEO, Lloyd’s of London

Just witness the anguish of the victims and families in the Manchester concert bombing.

“We have seen a dramatic increase in demand for these types of products because of the political instability everywhere at the moment, particularly for companies that are trading cross border with countries where governments can suddenly intervene at a moment’s notice,” she said.

“Similarly, businesses are looking to protect themselves against the ever-growing threat of terrorism, which is where Lloyd’s can step in to give them the confidence to keep on trading.”

Reforming Lloyd’s

Within Lloyd’s itself, Beale has been at the forefront of trying to modernize the aging institution. Despite its modern metallic and glass exterior, inside Lloyd’s there’s still very much what some might term a stuffy “old boys’ club” culture.

Men are required to wear a tie and women weren’t allowed into the underwriting room until 1972. Brokers still walk around with leather slipcases crammed full of paper.

The Lloyd’s headquarters on Lime Street.

Beale’s predecessor, Richard Ward, tried to modernize Lloyd’s but left plenty for Beale to address in that respect.

Beale committed $700 million over the next five years to upgrade Lloyd’s aging computer and IT systems, with the end goal of achieving one-touch data capture to speed up the premiums and claims process.

“It’s about following that data all the way through the process from the client to the intermediary and the underwriter, and the processing of the premiums and claims,” she said.

“We would love to get to a stage where a client can track something being quoted or a claim being paid, just like you do with a package being delivered [to your home].”

Another area Beale is keen to shake up is diversity within Lloyd’s itself. Currently the market is two-thirds male, while only 11 percent of the whole London insurance market are non-UK nationals — a damning statistic that Beale is all too aware of.

“The Lloyd’s market doesn’t reflect the demographics of the whole of London and we are very conscious that we’re not tapping into all of the available talent that’s out there,” she said.

“We need to cut out the old ideas, try to challenge the unconscious bias and create an environment that is welcoming for people who are a bit different.”

Beale has also been pushing the [email protected] initiative, currently in its third year, and in September Lloyd’s will host the third annual Dive In festival to promote diversity and inclusion in the insurance industry.

In addition, 95 percent of the Lloyd’s market has already signed up to its Diversity & Inclusion charter to improve diversity, she said.

“To attract the best talent we need to modernize and look at how we can change our working practices and hiring decisions for the better,” she said.

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“There’s a vast amount of work that we are actively doing to encourage people to be more open and seek more diverse talent.”

On a personal level, Beale readily admits that she was late to the leadership game, and it was only her mentor, Annette Sadolin at GE, who convinced her to take her first promotion.

That lack of confidence is something that, as a leader, Beale has witnessed in her own team and she is keen to help overcome.

“Annette became very much a mentor for me throughout my career, so whenever I have had to make key decisions I would always ask her view,” she said.

“The key lesson that I have learnt from her is that things move so quickly and you need to take opportunities when they come along that give you exposure to something new, even if they don’t seem like a natural career path at the time.

“For me, being a leader is all about inclusion and being passionate about the people you work with because you need to inspire and motivate them. But there is also nothing more rewarding than watching people progress their careers.”

A Truly Global Journey

Beale, who initially harbored ambitions of being an architect, admits that she “fell into reinsurance,” starting as a trainee international treaty reinsurance underwriter at Prudential Assurance Company in London in 1982. But once she had a taste there was no turning back.

“At the time, I didn’t even know that reinsurance existed, but once I discovered it I absolutely loved it,” she said.

“I fell in love with the global nature of the risks that came to London; one day you could be looking at a piece of business from Chile, the next from Australia.”

But, back then, working in a male-dominated industry where she was the only woman among 35 men, Beale struggled to fit in. So she quit and went travelling for 10 months.

It was during her time as a receptionist at the BBC in Sydney, Australia that Beale worked under her first female boss, a formidable woman, she said.

Inspired by her boss’s strong work ethic, Beale decided to return to the insurance business.

She soon landed a job with GE Insurance Solutions in Kansas City, where she held various underwriting management roles, before being appointed president of GE Frankona and head of continental Europe, Middle East and Africa for GE Insurance Solutions in Germany.

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After 14 years at GE, Beale moved to Switzerland with Converium as group CEO in 2006.

Two years later, she joined Zurich Insurance Group as a member of the group management board in Zurich before being appointed global chief underwriting officer, prior to her appointment as group CEO at Canopius in 2012.

The breadth and depth of her experience makes Beale a natural fit for the demands of the Lloyd’s top job.

There’s no doubt she’ll be drawing upon every ounce of that expertise and experience to keep Lloyd’s at the cutting edge of this harrowing new world we live in.

Alex Wright is a U.K.-based business journalist, who previously was deputy business editor at The Royal Gazette in Bermuda. You can reach him at [email protected]