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Shifting Our Focus to Preventing Negative Outcomes from Opioids

Preventing negative outcomes from the treatment associated with a workplace injury is just as critical as preventing the injury from happening.
By: | May 18, 2017 • 6 min read

Providing people who want to work, the opportunity to work is not only important to individual families but also the economy. When workers are injured, they may lose that opportunity. Preventing work injuries from happening in the first place is far and away the best way to keep workers from becoming injured workers. When injuries do happen, it is imperative for all involved, to focus on getting workers healthy and back to their lives.

Once an injury has taken place, a lot can happen during the course of treatment that ultimately will lead to positive or negative outcomes. Preventing negative outcomes from the treatment associated with an injury is just as important as preventing the workplace injury in the first place. To prevent injuries we implement and encourage proper training, awareness and safety protocols. Similar protocols should be used to prevent negative outcomes during the course of treatment so injured workers can return to the most productive life possible.

How can we prevent negative outcomes from happening in the course of treatment of an injured worker? If the course of treatment was process mapped, we might find several gaps in care that could affect outcomes. Importantly, a major gap in care for many would relate to the opioid epidemic. The Centers for Disease Control and Prevention (CDC) report that as many as 1 in 4 patients receiving long-term opioid therapy in a primary care setting, struggle with addiction.1 And, “we now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths.”2 At their best, opioids are valuable tools in mitigating intense acute pain helping injured workers get through the toughest portions of their pain and onto the road to recovery. At their worst, opioids are an intensely addictive therapy that has led to 91 Americans dying every day from overdoses.2

While recent initiatives such as improving access to care for those addicted to opioids, and expanding access to the life-saving drug naloxone used in opioid overdose are important steps towards addressing the epidemic for those that have already developed a negative outcome, we also need to focus on preventing negative outcomes from happening in the first place. To do this, it has become clear that there needs to be a multifaceted approach that identifies a goal and establishes a methodology to achieve that goal for the injured worker. Process models would challenge us to capitalize on available resources and remove wasted steps to be able to identify, maintain and sustain process improvement towards improving opioid epidemic related problems. The process of treatment within Workers’ Compensation is a team effort among many people who influence the care an injured worker receives and as such an approach that utilizes each team member’s expertise as a resource will be useful.

Stephanie Labonville, PharmD, CPE, BCPS, Director of Clinical Operations

The pharmacist role is an evolving and often underutilized available resource that can be instrumental in a multifaceted approach towards preventing negative outcomes. As experts in medication, pharmacists’ skills and knowledge are valuable resources and they have the ability to contribute to integrated care teams by detecting and resolving or preventing drug related problems, helping to ensure the safe and efficacious use of medicines and providing comprehensive drug information to patients and other health care professionals, thereby reinforcing prevention of negative outcomes.

As an industry, we must focus on our role in appropriate and safe pain management. This focus must take into consideration the CDC’s calling on dispensing pharmacists to be on the front lines of addressing prescription opioid abuse and overdose.3 Dispensing pharmacists as part of a Workers’ Compensation PBM must take this front-line role to a value-added level and develop specific program solutions focused on opioid related problems such as Prescription Drug Monitoring Program (PDMP) reviews and education of injured workers and communication with their physicians regarding high-risk drug combinations, high risk opioid doses and safer alternative treatment regimens.

Some drug combinations can be extremely dangerous. For example, there has been much written about the “holy trinity” of drugs: opioids, benzodiazepines and carisoprodol (Soma) and the serious danger inherent in taking 2 or 3 of these together.4,5 Can we really afford to use a pharmacy or PBM that doesn’t have a standardized approach to this combination or one who does not take action before the combinations of medications are dispensed? We need specific programs that reach out to the patient and prescribing physicians on these specific risky drug combinations prior to their dispensing.

Pharmacists who can access state PDMPs can help identify patients at increased risk of overdose, such as those taking high dosages or obtaining opioids from multiple prescribers. They can then help monitor the patient and their prescriptions allowing for proactive consultation with the injured worker and prescriber prior to dispensing high-risk medications.

In addition to consulting with physicians regarding opioid addiction and high-risk drug combinations, it is important for the pharmacist to be able to alert a prescriber to pertinent legislative rule(s) for their state and their patient’s morphine milligram equivalent (MME) before the pills are dispensed. Choosing a PBM with this capability can be critical to preventing negative outcomes.

As injured workers are educated about what medications may work best for them as well as potential risks of various medications or combinations of medications, they are provided the opportunity to become advocates for themselves. We need to ensure that dispensing pharmacists have experienced insight into pain management within Workers’ Compensation, which they can then use to educate patients. Pharmacists as part of the injured worker’s treatment team can use a variety of ways to educate patients including direct phone calls and subsequent informational pieces that address pain management e.g., “If not opioids, then what?”

Many injured workers are scared that their pain will be unmanageable without opioids. Learning that outcomes and pain management are often improved through the use of tapers, other non -addictive medications, non-drug therapies like; cognitive behavior therapy (CBT), massage, movement therapies, socialization, healthier food and lifestyle decisions, will provide the injured workers the resources and support to get on the road to recovery and return them to what they deserve: the opportunity to return to a productive life. The equipped dispensing pharmacist must be an integral member of the medical treatment team to make that a reality.

We can, as an industry, work towards this goal of keeping workers participating in the workforce and in their life by ensuring that we involve knowledgeable, experienced dispensing pharmacists in the treatment plan of our complex cases before a potentially risky pain medication regimen is determined, prescribed and dispensed.

Let’s help protect our most important national resource: our workers before they become statistics, by focusing on prevention as well as management of this problem.

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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 Specialty Solutions Rx. The editorial staff of Risk & Insurance had no role in its preparation.




Specialty Solutions Rx is a full service workers’ compensation PBM that was designed to proactively and effectively address opioids and other high risk medications.

Lead Story

Improving the Claims Experience

Insureds and carriers agree that more communication can address common claims complaints.
By: | January 10, 2018 • 7 min read

Carriers today often argue that buying their insurance product is about much more than financial indemnity and peace of mind.

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Many insurers include a variety of risk management services and resources in their packages to position themselves as true risk partners who help clients build resiliency and prevent losses in the first place.

That’s all well and good. No company wants to experience a loss, after all. But even with the added value of all those services, the core purpose of insurance is to reimburse loss, and policyholders pay premiums because they expect delivery on that promise.

At the end of the day, nothing else matters if your insurer can’t or won’t pay your claim, and the quality of the claims experience is ultimately the barometer by which insureds will judge their insurer.

Why, then, is the process not smoother? Insureds want more transparency and faster claims payment, but claims examiners are often overburdened and disconnected from the original policy. Where does the disconnect come from, and how can it be bridged?

Both sides of the insurer-insured equation may be responsible.

Susan Hiteshew, senior manager of global insurance and risk management, Under Armor Inc.

“One of the difficult things in our industry is that oftentimes insureds don’t call their insurer until they have a claim,” said Susan Hiteshew, senior manager of global insurance and risk management for Under Armour Inc.

“It’s important to leverage all of the other value that insurers offer through mid-term touchpoints and open communication. This can help build the insurer-insured partnership so that when a claim materializes, the relationships are already established and the claim can be resolved quickly and fairly.”

“My experience has been that claims executives are often in the background until there is an issue that needs addressing with the policyholder,” said Dan Holden, manager of corporate risk and insurance for Daimler Trucks North America.

“This is unfortunate because the claims department essentially writes the checks and they should certainly be involved in the day to day operations of the policyholders in designing polices that mitigate claims.

“By being in the shadows they often miss the opportunity to strengthen the relationship with policyholders.”

Communication Breakdown

Communication barriers may stem from internal separation between claims and underwriting teams. Prior to signing a contract and throughout a policy cycle, underwriters are often in contact with insureds to keep tabs on any changes in their risk profile and to help connect clients with risk engineering resources. Claims professionals are often left out of the loop, as if they have no proactive role to play in the insured-insurer relationship.

“Claims operates on their side of the house, ready to jump in, assist and manage when the loss occurs, and underwriting operates in their silo assessing the risk story,” Hiteshew said.
“Claims and underwriting need to be in lock-step to collectively provide maximum value to insureds, whether or not losses occur.”

Both insureds and claims professionals agree that most disputes could be solved faster or avoided completely if claims decision-makers interacted with policyholders early and often — not just when a loss occurs.

“Claims and underwriting need to be in lock-step to collectively provide maximum value to insureds, whether or not losses occur.” – Susan Hiteshew, senior manager of global insurance and risk management for Under Armour Inc.

“Communication is critically important and in my opinion, should take place prior to binding business and well before a claim comes in the door,” said David Crowe, senior vice president, claims, Berkshire Hathaway Specialty Insurance.

“In my experience, the vast majority of disputes boil down to lack of communication and most disputes ultimately are resolved when the claim decision-maker gets involved directly.”

Talent and Resource Shortage

Another contributing factor to fractured communication could be claims adjuster workload and turnover. Claims adjusting is stressful work to begin with.

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Adjusters normally deal with a high volume of cases, and each case can be emotionally draining. The customer on the other side is, after all, dealing with a loss and struggling to return to business as usual. At some TPAs, adjuster turnover can exceed 25 percent.

“This is a difficult time for claims organizations to find talent who want to be in this business long-term, and claims organizations need to invest in their employees if they’re going to have any success in retaining them,” said Patrick Walsh, executive vice president of York Risk Services Group.

The claims field — like the insurance industry as a whole — is also strained by a talent crunch. There may not be enough qualified candidates to take the place of examiners looking to retire in the next ten years.

“One of the biggest challenges facing the claims industry is a growing shortage of talent,” said Scott Rogers, president, National Accounts, Sedgwick. “This shortage is due to a combination of the number of claims professionals expected to retire in the coming years and an underdeveloped pipeline of talent in our marketplace.

“The lack of investment in ensuring a positive work environment, training, and technology for claims professionals is finally catching up to the industry.”

The pool of adjusters gets stretched even thinner in the aftermath of catastrophes — especially when a string of catastrophes occurs, as they did in the U.S in the third quarter of 2017.

“From an industry perspective, Harvey, Irma and Maria reminded us of the limitations on resources available when multiple catastrophes occur in close succession,” said Crowe.

“From independent and/or CAT adjusters to building consultants, restoration companies and contractors, resources became thin once Irma made landfall.”

Is Tech the Solution?

This is where Insurtech may help things. Automation of some processes could free up time for claims professionals, resulting in faster deployment of adjusters where they’re needed most and, ultimately, speedier claims payment.

“There is some really exciting work being done with artificial intelligence and blockchain technologies that could yield a meaningful ROI to both insureds and insurers,” Hiteshew said.

“The claim set-up process and coverage validation on some claims could be automated, which could allow adjusters to focus their work on more complex losses, expedite claim resolution and payment as well.”

Dan Holden, manager, Corporate Risk & Insurance, Daimler Trucks North America

Predictive modeling and analytics can also help claims examiners prioritize tasks and maximize productivity by flagging high-risk claims.

“We use our data to identify claims with the possibility of exceeding a specified high dollar amount in total incurred costs,” Rogers said. “If the model predicts that a claim will become a large loss, the claim is redirected to our complex claims unit. This allows us to focus appropriate resources that impact key areas like return to work.”

“York has implemented a number of models that are focused on helping the claims professional take action when it’s really required and that will have a positive impact on the claim experience,” Walsh said.

“We’ve implemented centers of excellence where our experts provide additional support and direction so claim professionals aren’t getting deluged with a bunch of predictive model alerts that they don’t understand.”

“Technology can certainly expedite the claims process, but that could also lead to even more cases being heaped on examiners.” — Dan Holden, manager, Corporate Risk & Insurance, Daimler Trucks North America

Many technology platforms focused on claims management include client portals meant to improve the customer experience by facilitating claim submission and communication with examiners.

“With convenient, easy-to-use applications, claimants can send important documents and photos to their claims professionals, thereby accelerating the claims process. They can designate their communication preferences, whether it’s email, text message, etc.,” Sedgwick’s Rogers said. “Additionally, rules can be established that direct workflow and send real time notifications when triggered by specific claim events.”

However, many in the industry don’t expect technology to revolutionize claims management any time soon, and are quick to point out its downsides. Those include even less personal interaction and deteriorating customer service.

While they acknowledge that Insurtech has the potential to simplify and speed up the claims workflow, they emphasize that insurance is a “people business” and the key to improving the claims process lies in better, more proactive communication and strengthening of the insurer-insured relationship.

Additionally, automation is often a double-edged sword in terms of making work easier for the claims examiner.

“Technology can certainly expedite the claims process, but that could also lead to even more cases being heaped on examiners,” Holden said.

“So while the intent is to make things more streamlined for claims staff, the byproduct is that management assumes that examiners can now handle more files. If management carries that assumption too far, you risk diminishing returns and examiner burnout.”

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By further taking real people out of the equation and reducing personal interaction, Holden says technology also contributes to deteriorating customer service.

“When I started more than 30 years ago as a claims examiner, I asked a few of the seasoned examiners what they felt had changed since they began their own careers 30 year earlier. Their answer was unanimous: a decline in customer service,” Holden said.

“It fell to the wayside to be replaced by faster, more impersonal methodologies.”

Insurtech may improve customer satisfaction for simpler claims, allowing policyholders to upload images with the click of a button, automating claim valuation and fast-tracking payment. But for complex claims, where the value of an insurance policy really comes into play, tech may do more harm than good.

“Technology is an important tool and allows for more timely payment and processing of claims, but it is not THE answer,” BHSI’s Crowe said. “Behind all of the technology is people.” &

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]