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Sharpening the Tools

Improving outcomes by using value-based purchasing, effective chronic pain management, and employing the talent that will help define success for insurers and their customers.
By: | December 14, 2016 • 9 min read

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FROM LEFT, Dan Reynolds, Melanie Armstrong, Tron Emptage and Helen Weber.

Workers’ compensation claims specialists can take well-earned pride in their higher purpose. They help injured workers heal and get back to leading productive lives.

Tempering that glow of good feeling is the certainty that their burden never lightens.

Delivering the best service going forward will mean tackling the advent of medical marijuana use, polypharmacy issues, the challenge of appropriate opioid use, and controlling medical costs through more collaborative interaction with physicians, along with winning the competition to attract and retain the best claims management talent.

In July, Risk & Insurance® and the workers’ compensation and auto no-fault division of Optum convened a roundtable discussion in Chicago with veteran workers’ compensation claims management professionals to gain insight into the challenges that can vex claims management specialists, and what solutions they go to.

With 25 states having passed or enacted laws legalizing the use of medical marijuana, roundtable members agreed that the chronic pain management landscape in workers’ compensation is undergoing a dramatic shift.

Chicago roundtable participant Melanie Armstrong, medical services manager with American Mining Insurance Group, pointed to a number of challenges legalized marijuana presents. For one, she feels legalization has happened too quickly, with not enough consideration for the consequences.

“I think that it should be a slow, methodical process,” Armstrong said.

“For those medical conditions that it has been approved for, there’s not been enough time to look at outcomes and see if there is more benefit than risk.”

 

Tron Emptage, chief clinical officer for the workers’ compensation and auto no-fault division of Optum, agrees more research needs to be conducted especially in the area of chronic non-cancer pain and other work-related conditions.

The roundtable participants also discussed the ongoing battle against opioids. Due perhaps to the efforts of pharmacy benefit managers and the workers’ compensation community in general, the use of opioids is down, but the risk of misuse and abuse is still very much alive.

Having the right tools in place to insure that the use of a pain medication is appropriate is a key to pharmacy claims management. The good news is that detoxification programs, drug monitoring and pharmacy benefit management programs are not only available, but working. So too are functional restoration programs, when paired with claimant-specific weaning processes, and cognitive behavioral therapy.

“From a claims management standpoint, in partnership with our pharmacy benefit manager, it is important to have controls in place to verify the medical necessity of prescribed pain medications that could lead to misuse or abuse,” said Helen Weber, an assistant vice president and head of medical strategy for the Hanover Insurance Group.

Building the right monitoring systems so that payers, insureds and their workers are well protected is a pressing consideration, Emptage said.

“That’s where the tools in our toolbox have to be strong, in order for adjusters to engage the right resources and facilitate those conversations with physicians and the injured workers to support achieving the right outcome,” Weber said.

Yet another concern, according to Optum’s Emptage, is the use of benzodiazepines such as Valium. These medications can cause serious adverse events if not monitored closely and if taken in the wrong combinations, for example with marijuana, other illicit drugs or even an opioid.

Polypharmacy, disparate drugs whose combined effects can overwhelm a patient, are another ongoing worry, Hanover’s Weber said. “Do they understand the potential risks of taking an opioid?” she added.

img_2994-230“For those medical conditions that [marijuana] has been approved for, there’s not been enough time to look at outcomes and see if there is more benefit than risk.”

— Melanie Armstrong, medical services manager, American Mining Insurance Group

That’s one of the reasons why educating patients about the effects of medications, and how combining them can be so dangerous, is such a priority for the industry.

Value-Based Purchasing

It’s well known that pharmacy spend drives medical costs in workers’ compensation.

Getting physicians aligned with your organization’s treatment philosophies and expectations is another important area of claims management focus.

Armstrong manages risk for mining companies. On the one hand, that profession sees severe injuries that can be challenging to manage. On the other, mining is geography specific, so a clinic within a given region could be more easily leveraged to fall in line with a claims executive’s expectations regarding adherence to treatment guidelines and other medical management best practices.

Even with that claimant demographic, American Mining’s Melanie Armstrong impressed her fellow roundtable members with her creative approach to collaborating with prescribers.

Drawing from her background and years of expertise, she has started a new program in which a physician or group of physicians is hand-selected, based on their service and performance, to hold themselves and their peers accountable to best practice standards of care.

 

“You’ve got a group of physicians who are strategically placed to help you with the program, making sure that there is one physician in the group who can hold the others accountable. I’ve found that it drives outcomes,” she said.

So, how to accomplish that?

Armstrong says to find one physician who agrees with your company’s vision and objectives.

“You meet with them and you say, ‘This is the program. This is what we’re trying to accomplish. Do you agree with that?’”

“What we’re starting to see is this …,” Armstrong said. “This doc nudges that doc to do the right thing, who nudges this doc … and it just keeps going. In the end, you’re meeting your goals, you’re meeting your objectives because it’s peer-to-peer, and importantly, the claimant’s therapy plan is safer, more efficacious and cost-effective.”

That approach may be easier said than done when it comes to opioid use management, she said.

“Finding the right provider with the philosophies that are in line with our vision and making sure we are aligned in our approach has been quite difficult,” she said.

“It keeps me up at night finding the prescribers that will work with us,” she said.

Hanover’s Weber said that’s where she’d expect her pharmacy benefit manager to help out; utilizing their larger network to identify care providers focused on achieving improved functional restoration, recovery and return-to-work outcomes.

helen-230“How do we advertise to say you’re going to touch on all of these different skill sets and opportunities as an adjuster that you might not experience in another role?”

— Helen Weber, assistant vice president; head of medical strategy, Hanover Insurance Group

Emptage agrees that pharmacy benefit managers can assist a payer by leveraging prescription data to help identify prescriber trends across an entire book of business. Data mining can show global trends that might be missed in a smaller book of business or at an adjuster’s desk.

“Our most successful client partnerships include those who want to dig into our data as much as we do, and who use our data to have conversations with physicians, or allow us to do so,” he said.

“Some of our most successful clients include those that want to partner on data analysis whether to trend on prescribers with improved outcomes or new dispensing trends.”

The Talent Question

The third major bucket that the Chicago roundtable participants tackled was the talent question.

Drive down the highway and you see billboards. Turn on the radio and you hear advertisements.

Click on your favorite web page and you see pop-ups.

As integrated as insurance and risk management is in modern business, it’s a bitter irony in our marketing-saturated culture that the insurance industry struggles to market itself to new talent and faces a painful talent crunch in workers’ compensation claims management.

Our Chicago roundtable members have some good ideas in that regard. For one, according to Hanover Insurance Group’s Weber, getting a new generation to see the value in being a claims adjuster means taking over the narrative and giving it the proper color.

“It’s interesting when you think about what a claims adjuster’s responsibilities are,” she said.

“The adjuster wears many hats throughout the life of the claim; that of a skilled communicator, negotiator, problem solver, medical professional, and financier, to name a few. They interact with a wide variety of industries and individuals. They provide customer service. But most importantly, they help injured workers navigate the complex workers’ compensation system in order to receive the appropriate care to recover from their injury, restore their function, and get them back to their livelihood. How do we advertise to say you’re going to touch on all of these different skill sets and opportunities as an adjuster that you might not experience in another role?”

 

That quest for new talent can also find reinforcement in what we mentioned at the top. Workers’ compensation has a noble higher purpose. It’s about loss prevention and helping people get better if they do suffer an unfortunate accident.

That oft-discussed generation born in the 1980s — don’t call them millennials, they hate that — are saddled with a number of traits. Some that may be relevant are that they are technologically savvy and seek connectivity and higher purpose in their work.

What better place for this group than in workers’ compensation claims management, where data is king and the idea is to heal people?

Again, American Mining’s Armstrong reports some approaches that have produced good results.

She’s in frequent communication with nursing schools, seeking, as she put it, “the cream of the crop” and as staffing needs dictate, is bringing those candidates into her organization’s mentorship program.

“It’s been nice to have some fresh talent in our organization over the last couple of years,” she said.

tron-emptage-230“Our most successful client partnerships include those who want to dig into our data as much as we do, and who use our data to have conversations with physicians, or allow us to do so.”

— Tron Emptage, chief clinical officer, Optum Workers’ Comp

That fresh talent can also help more established workers over the technology hump. As many of us can attest, teaching up-to-date technology skills to someone in their 50s or 60s has its own challenges.

Inexperienced new hires may benefit from exposure to multiple areas in their first couple of years of their career, which also can foster continued engagement and help support the establishment of strong foundational claims expertise, according to Hanover’s Weber.

Back in the day, as we say, claims adjusters were trained across all lines of business. That approach has waned, many say.

“Building that foundational claims expertise that can be leveraged wherever the needs may take you as the business changes, allows us to be more nimble to feed the future of claims handling,” she said.

It can be said of many in the insurance industry that they weren’t quite sure what they wanted to do when they got out of college. They might enter an internship, or take that first job at an insurance company and wind up engaged for life.

Mention the terms “workers’ compensation” and “insurance” at a dinner party and some guests might start fiddling with their napkins out of boredom and embarrassment. But for those charged with managing workers’ compensation claims, there is plenty to keep them engaged.

There is so much yet to play out in the intersection of legal and illegal drugs and how they will impact workers’ compensation claims. Engaging a new generation in this field and taking advantage of their energy could be a game changer. Giving them the right tools to read, interpret and implement best medical practices could be a game winner.

Opinions of the roundtable participants are the opinions of each individual contributor and are not necessarily reflective of their respective companies.
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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 Optum.




Healthcare Solutions, Helios and their subsidiaries, as Optum companies, collaborate with our clients to deliver value beyond transactional savings while helping ensure injured workers receive safe and effective clinical care. Our innovative and comprehensive medical cost management programs include pharmacy benefit management, ancillary benefit management, managed care services, and settlement solutions.

More from Risk & Insurance

More from Risk & Insurance

Pharma Under Fire

Opioids Give Rise to Liability Epidemic

Opioids were supposed to help. Instead, their addictive power harmed many, and calls for accountability are broadening.
By: | May 1, 2018 • 8 min read

The opioid epidemic devastated families and flattened entire communities.

The Yale School of Medicine estimates that deaths are nearly doubling annually: “Between 2015 and 2016, drug overdose deaths went from 33,095 to 59,000, the largest annual jump ever recorded in the United States. That number is expected to continue unabated for the next   several years.”

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That’s roughly 160 deaths every day — and it’s a count that’s increasing daily.

In addition to deaths, the number of Americans struggling with an opioid disorder disease (the official name for opioid addiction) is staggering.

The National Institute on Drug Abuse (NIDA) estimates that 2 million people in the United States suffer from substance use disorders related to prescription opioid pain relievers, and roughly one-third of those people will “graduate” to heroin addiction.

Conversely, 80 percent of heroin addicts became addicted to opioids after being prescribed opioids.

As if the human toll wasn’t devastating enough, NIDA estimates that addiction costs reach “$78.5 billion a year, including the costs of health care, lost productivity, addiction treatment, and criminal justice involvement.”

Shep Tapasak, managing principal, Integro Insurance Brokers

With numbers like that, families are not the only ones left picking up the pieces. Municipalities, states, and the federal government are strained with heavy demand for social services and crushing expenditures related to opioid addiction.

Despite the amount of money being spent, services are inadequate and too short in duration. Wait times are so long that some people literally die waiting.

Public sector leaders saw firsthand the range and potency of the epidemic, and were among the first to seek a legal reckoning with the manufacturers of  synthetic painkillers.

Seeking redress for their financial burden, some municipalities, states and the federal government filed lawsuits against big pharmaceutical companies and manufacturers. To date, there are more than 100 lawsuits on court dockets.

States such as Ohio, West Virginia, New Jersey, Pennsylvania and Arkansas have been hit hard by the epidemic. In Arkansas alone, 72 counties, 15 cities, and the state filed suit, naming 65 defendants. In Pennsylvania, 16 counties, Philadelphia, and Commonwealth officials have filed lawsuits.

Forty one states also have banded together to subpoena information from some drug manufacturers.

Pennsylvania’s Attorney General, Josh Shapiro, recently told reporters that the banded effort seeks to “change corporate behavior, so that the industry can no longer do what I think it’s been doing, which is turning a blind eye to the effects of dumping these drugs in the communities.”

The volume of legal actions is growing, and some of the Federal cases have been bound together in what is called multidistrict litigation (MDL). These cases will be heard by a judge in Ohio. Plaintiffs hope for a settlement that will provide funding to be used to help thwart the opioid epidemic.

“From a societal perspective, this is obviously a big and impactful issue,”  said Jim George,  a managing director and global claims head with Swiss Re Corporate Solutions. “A lot of people are suffering in connection with this, and it won’t go away anytime soon.

“Insurance, especially those in liability, will be addressing this for a long time. This has been building over five or six years, and we are just now seeing the beginning stages of liability suits.” 

Basis for Lawsuits

The lawsuits filed to date are based on allegations concerning: What pharma knew or didn’t know; what it should have known; failure to monitor size and frequency of opioid orders, misrepresentation in marketing about the addictive nature of opioids; and false financial disclosures.

Opioid manufacturers, distributors and large drugstore chains together represent a $13 billion-a-year industry, meaning the stakes are high, and the pockets deep. Many have compared these lawsuits to the tobacco suits of the ’90s.

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But even that comparison may pale. As difficult as it is to quit smoking, that process is less arduous than the excruciating and often impossible-to-overcome opioid addiction.

Francis Collins, a physician-geneticist who heads the National Institutes of Health, said in a recorded session with the Washington Post: “One really needs to understand the diabolical way that this particular set of compounds rewires the brain in order to appreciate how those who become addicted really are in a circumstance where they can no more [by their own free will] get rid of the addiction than they can get free of needing to eat or drink.”

“Pharma and its supply chain need to know that this is here now. It’s not emerging, it’s here, and it’s being tried. It is a present risk.” — Nancy Bewlay, global chief underwriting officer for casualty, XL Catlin

The addiction creates an absolutely compelling drive that will cause people to do things against any measure of good judgment, said Collins, but the need to do them is “overwhelming.”

Documented knowledge of that chemistry could be devastating to insureds.

“It’s about what big pharma knew — or should have known.  A key allegation is that opioids were aggressively marketed as the clear answer or miracle cure for pain,” said Shep Tapasak, managing principal, Integro Insurance Brokers.

These cases, Tapasak said, have the potential to be severe. “This type of litigation boils down to a “profits over people” strategy, which historically has resonated with juries.”

Broadening Liability

As suits progress, all sides will be waiting and watching to see what case law stems from them. In the meantime, insurance watchers are predicting that the scope of these suits will broaden to include other players in the supply chain including manufacturers, distribution services, retail pharmacies, hospitals, physician practices, clinics, clinical laboratories and marketing agencies.

Litigation is, to some extent, about who can pay. In these cases, there are several places along the distribution chain where plaintiffs will seek relief.

Nancy Bewlay, global chief underwriting officer for casualty, XL Catlin

Nancy Bewlay, XL Catlin’s global chief underwriting officer for casualty, said that insurers and their insureds need to pay close attention to this trend.

“Pharma and its supply chain need to know that this is here now. It’s not emerging, it’s here, and it’s being tried. It is a present risk,” she said.

“We, as insurers who identify emerging risks, have to communicate to clients. We like to be on the forefront and, if we can, positively influence the outcome for our clients in terms of getting ahead of their risks.”

In addition to all aspects of the distribution chain, plaintiffs could launch suits against directors and officers based on allegations that they are ultimately responsible for what the company knew or should have known, or that they misrepresented their products or signed off on misleading financial statements.

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Shareholders, too, could take aim at directors and officers for loss of profits or misleading statements related to litigation.

Civil litigation could pave the way, in some specific instances, for criminal charges. Mississippi Attorney General Jim Hood, who in 2015 became the first state attorney general to file suit against a prescription drug maker, has been quoted as saying that if evidence in civil suits points to criminal behavior, he won’t hesitate to file those charges as well.

Governing, a publication for municipalities and states, quoted Hood in late 2017 as saying, “If we get into those emails, and executives are in the chain knowing what they’ve unleashed on the American public, I’m going to kick it over to a criminal lawsuit. I’ve been to too many funerals.”

Insurers and insureds can act now to get ahead of this rising wave of liability.

It may be appropriate to conduct a review of policy underwriting and pricing. XL Catlin’s Bewlay said, “We are not writing as if everyone is a pharma manufacturer. Our perception of what is happening is that everyone is being held accountable as if they are the manufacturer.

“The reality is that when insurers look at the pharma industry and each part of the supply chain, including the pharma companies, those in the chain of distribution, transportation, sales, marketing and retail, there are different considerations and different liabilities for each. This could change the underwriting and affect pricing.”

Bewlay also suggests focusing on communications between claims teams and underwriters and keeping a strong line of communication open with insureds, too.

“We are here to partner with insureds, and we talk to them and advise them about this crisis. We encourage them to talk about it with their risk managers.”

Tapasak from Integro encourages insureds to educate themselves and be a part of the solution. “The laws are evolving,” he said. “Make absolutely certain you know your respective state laws. It’s not enough to know about the crisis, you must know the trends. Be part of the solution and get as much education as possible.

“Most states have ASHRM chapters that are helping their members to stay current on both passed and pending legislation. Health care facilities and providers want to do the right thing and get educated. And at the same time, there will likely be an uptick in frivolous claims, so it’s important to defend the claims that are defensible.”

Social Service Risk

In addition to supply chain concerns, insurers and insureds are concerned that even those whose mission it is to help could be at risk.

Hailed as a lifesaver, and approved by the Food and Drug Administration (FDA), the drug Naloxone, can be administered to someone who is overdosing on opioids.  Naloxone prevents overdose by blocking opioid receptor sites and reversing the effects of the overdose.

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Some industry experts are concerned that police and emergency responders could incur liability after administering Naloxone.

But according to the U.S. Department of Justice, “From a legal standpoint, it would be extremely difficult to win a lawsuit against an officer who administers Naloxone in good faith and in the course of employment. … Such immunity applies to … other professional responders.”

Especially hard hit are foster care agencies, both by increased child placements and stretched budgets. More details in our related coverage.

While the number of suits is growing and their aim broadening, experts think that some good will come of the litigation. Settlements will fund services for the addicted and opioid risk awareness is higher than ever. &

Mercedes Ott is managing editor of Risk & Insurance. She can be reached at [email protected]