Medical Marijuana

Solutions Needed for Marijuana Concerns

An exploratory program may help identify answers for some of the thorny issues surrounding medical marijuana in workers' comp.
By: | October 18, 2017 • 7 min read

The steady march of medical marijuana legalization is leaving employers and workers’ comp insurers in a tricky position — especially now that courts have begun to accept the substance as a covered medication for workers’ comp patients.


For starters, marijuana remains a Schedule 1 drug on the federal level, which means payers can run afoul of the law if they purchase it for an injured worker. There’s also no concrete way for payers to control the dosage.

So far, there have been no easy answers, but some experts are actively thinking outside the box. Safety National embarked on a pilot project aiming to bring the industry closer to solutions.

The St. Louis-based workers’ comp carrier is currently participating in a pilot program with a third-party vendor that manufactures and distributes medical marijuana in the forms of patches or gel, said Sherri Hickey, Safety National’s assistant vice president of medical management.

When Safety National deems medical marijuana an appropriate treatment for an injured worker, working with this manufacturer changes the dynamic so that Safety National is not directly buying marijuana but purchasing a method of medicinal delivery — the patches or gel.

Sherri Hickey, assistant vice president of medical management, Safety National

The carrier is legally allowed to pay for this service, and the manufacturer can be paid by check, unlike dispensaries, which can only accept cash because of marijuana’s federal drug classification.

The use of patches or gel as a delivery method allows the carrier to control the amount and type prescribed. The vendor employs nurse practitioners who evaluate a patient’s height, weight, diagnoses and other medications to determine the strain and dosage most appropriate for each individual. The vendor then works with the injured worker’s personal physician on a written treatment plan.

A Viable Alternative

Hickey said the conversation about how to approach medical marijuana has been ongoing at Safety National.

“A lot of jurisdictions are requiring workers’ comp to start covering medical marijuana as an option for injured workers, and judges are saying that is reasonable and appropriate and that you’ve got to pay for that,” she said.

But in practice, most payers are still largely in uncharted territory. Hickey said Safety National noticed on one large claim a young man was taking Dronabinol, a pharmaceutical manufactured synthetic cannabis.

“While it is a generic, it was still very expensive,” Hickey said. “So we thought, what if we gave the patient the real thing — what would that cost? We had several conversations with different sources and found that it is significantly less than the generic synthesized cannabis.”

Starting with that case, Safety National obtained input from experts in the field on how the carrier could address many of his medications in this category.

“That created a huge savings, and we said to ourselves, maybe this could actually work,” she said. “That’s where we started.”

The carrier found several injured workers in its book of claims purchasing medical marijuana on their own. They had previously been on large dosages of opioids, along with a range of medications needed to counter the side effects of the opioids. These workers stopped the other medications on their own and were using medical marijuana instead.

“There are studies showing that the states that have legalized marijuana have a 25 percent lower death rate from opioids than the states that have not. Coincidence? I don’t think so — I think there’s probably some meaning there.” — Sherri Hickey, assistant vice president of medical management, Safety National

“As a result, their pharmacy bills were extremely low or zero — and they were off all of their opioids,” Hickey said. “We said to ourselves, there is something to this.”

Safety National is conducting its pilot program on a case-by-case basis in jurisdictions that allow the use of medical marijuana for the patient’s particular condition, she said. The carrier is now looking at several additional injured workers who might benefit in replacing their opioids with medical marijuana.

“There are studies showing that the states that have legalized marijuana have a 25 percent lower death rate from opioids than the states that have not,” Hickey said. “Coincidence? I don’t think so — I think there’s probably some meaning there.


“Now that medical marijuana is becoming legalized in more states, there is more research going on that will soon be telling us the outcomes and benefits of medical marijuana and not just anecdotal information.”

There are now 29 states, Washington D.C., Puerto Rico and Guam that have legalized medical marijuana and there are another dozen or so states with pending legislation, she said.

“As more and more states pass these laws and more research is done, it will just be a matter of time [until] the federal government will change marijuana from a Schedule 1 drug,” Hickey said. “I predict that will happen within the next two or three years.”

Richard Krasner, who blogs on workers’ comp topics, said the Safety National pilot program “is a positive step.”

“It’s a good sign that they are willing to put themselves out there to see if there is a scientific basis for claims that medical marijuana has benefits,” Krasner said.

“If the use of medical marijuana in workers’ comp cases helps [injured workers] to avoid using opioids that would lead to worse outcomes, then I say go ahead and start doing that,” said Krasner, noting that opioid users are increasingly going down the slippery slope to heroin and eventually overdose.

Even if workers stay on opioids alone, they can get hooked, which keeps them wanting the drugs more and more, Krasner added.

Medical marijuana, by contrast, does not have the deleterious effects of the traditional smoked marijuana, which contains THC. Moreover, medical marijuana has been shown to improve outcomes for pain management like opioids — but without developing a dependency.

Impairment Concerns

Most employers are also worried about how they can maintain a drug-free workplace even while recovering workers may be using the drug. Zero tolerance policies and drug testing programs don’t align easily with medical marijuana use.

Hickey agreed that testing for marijuana is a challenge.

“Testing for the presence of THC from recreational marijuana has been around for a long time,” she said. “However THC is metabolized through the liver and remains in the liver for days or even weeks. So when someone is tested, it is only documenting that they smoked marijuana sometime in the past couple of weeks. It does not measure a level of impairment, it is just a matter of presence or not.”


However, the standard marijuana testing does not test for the presence of cannabidiol, or CBD, which it the most common type of medical marijuana, Hickey said. CBD is metabolized through the blood stream and leaves the body within 24 hours.

“There is no impairment from CBD as it has no psychotropic effect, so there is no need for impairment testing of CBD,” she said.

Interest Is Widespread

Dr. Tom Denberg, senior medical director at Pinnacol Assurance in Denver, said the carrier would be “very interested” to see what Safety National experiences with its pilot program.

“Like other carriers across the country, we are very intrigued about other effective treatment options for injured workers who are experiencing chronic pain,” Denberg said.

Currently, Pinnacol promotes minimal and more appropriate prescribing of opioids, encourages the use of non-steroidal anti-inflammatories as first-line therapy, and makes available a variety of complementary and alternative treatments that are helpful for some patients, including therapeutic massage and acupuncture, he said.

“We do suspect that medical marijuana is more benign and less addictive than opioids, but the science and clinical experience aren’t yet at a point that make us comfortable.” — Dr. Tom Denberg, senior medical director, Pinnacol Assurance

One of the challenges within the industry is that there’s still not a high level of evidence for the use of medical marijuana, and like many carriers, Pinnacol is very focused on utilizing evidence-based treatment guidelines, Denberg said.

“The level of evidence for the use of marijuana in the treatment of chronic, non-cancer pain is probably similar to the level of evidence currently available for opioids, but many stakeholders promoted opioids too aggressively and now we’ve gotten ourselves in a big mess,” he said.

If there was stronger evidence for the use of marijuana, more knowledge about effective dosing and more understanding about which patient groups benefit the most, workers’ comp programs could minimize the risk that marijuana could adversely affect large numbers of patients “in ways we don’t yet understand.”


“We do suspect that medical marijuana is more benign and less addictive than opioids, but the science and clinical experience aren’t yet at a point that make us comfortable,” Denberg said. “We’d like to see Safety National’s experience with the gels and patches.”

Denberg said marijuana’s Schedule 1 classification remains a point of concern for now.

“This is a primary reason we’ve decided not to use medical marijuana in workers’ comp programs at this time,” he said. “If this changes, it will be easier for us to consider programs like Safety National’s.” &

Katie Kuehner-Hebert is a freelance writer based in California. She has more than two decades of journalism experience and expertise in financial writing. She can be reached at [email protected]

More from Risk & Insurance

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Risk Management

The Profession

Janet Sheiner, VP of risk management and real estate at AMN Healthcare Services Inc., sees innovation as an answer to fast-evolving and emerging risks.
By: | March 5, 2018 • 4 min read

R&I: What was your first job?

As a kid, bagging groceries. My first job out of school, part-time temp secretary.

R&I: How did you come to work in risk management?

Risk management picks you; you don’t necessarily pick it. I came into it from a regulatory compliance angle. There’s a natural evolution because a lot of your compliance activities also have the effect of managing your risk.

R&I: What is the risk management community doing right?


There’s much benefit to grounding strategic planning in an ERM framework. That’s a great innovation in the industry, to have more emphasis on ERM. I also think that risk management thought leaders are casting themselves more as enablers of business, not deterrents, a move in the right direction.

R&I: What could the risk management community be doing a better job of?

Justified or not, risk management functions are often viewed as the “Department of No.” We’ve worked hard to cultivate a reputation as the “Department of Maybe,” so partners across the organization see us as business enablers. That reputation has meant entertaining some pretty crazy ideas, but our willingness to try and find a way to “yes” tempered with good risk management has made all the difference.

Janet Sheiner, VP, Risk Management & Real Estate, AMN Healthcare Services Inc.

R&I: What was the best location and year for the RIMS conference and why?

San Diego, of course!  America’s Finest City has the infrastructure, Convention Center, hotels, airport and public transportation — plus you can’t beat our great weather! The restaurant scene is great, not to mention those beautiful coastal views.

R&I: What’s been the biggest change in the risk management and insurance industry since you’ve been in it?

The emergence of risk management as a distinct profession, with four-year degree programs and specific academic curriculum. Now I have people on my team who say their goal is to be a risk manager. I said before that risk management picks you, but we’re getting to a point where people pick it.

R&I: What emerging commercial risk most concerns you?


The commercial insurance market’s ability to innovate to meet customer demand. Businesses need to innovate to stay relevant, and the commercial market needs to innovate with us.  Carriers have to be willing to take on more risk and potentially take a loss to meet the unique and evolving risks companies are facing.

R&I: Of which insurance carrier do you have the highest opinion?

Beazley. They have been an outstanding partner to AMN. They are responsive, flexible and reasonable.  They have evolved with us. They have an appreciation for risk management practices we’ve organically woven into our business, and by extension, this makes them more comfortable with taking on new risks with us.

R&I: Are you optimistic or pessimistic about the U.S. health care industry and why?

I am very optimistic about the health care industry. We have an aging population with burgeoning health care needs, coupled with a decreasing supply of health care providers — that means we have to get smarter about how we manage health care. There’s a lot of opportunity for thought leaders to fill that gap.

R&I: Who is your mentor and why?

Professionally, AMN Healthcare General Counsel, Denise Jackson, has enabled me to do the best work I’ve ever done, and better than I thought I could do.  Personally, my husband Andrew, a second-grade teacher, who has a way of putting things into a human perspective.

R&I: What have you accomplished that you are proudest of?

In my early 20s, I set a goal for the “corner office.” I achieved that when I became vice president.  I received a ‘Values in Practice’ award for trust at AMN. The nomination came from team members I work with every day, and I was incredibly humbled and honored.

R&I: What is your favorite book or movie?

The noir genre, so anything by Raymond Chandler in books. For movies,  “Double Indemnity,” the 1944 Billy Wilder classic, with insurance at the heart of it!

R&I: What is your favorite drink?


Clean water. Check out for how to help people enjoy clean, safe water.

R&I: What’s the best restaurant at which you’ve eaten?

Liqun Roast Duck Restaurant in Beijing.

R&I: What is the most unusual/interesting place you have ever visited?

China. See favorite restaurant above. This restaurant had been open for 100 years in that location. It didn’t exactly have an “A” rating, and it was probably not a place most risk managers would go to.

R&I: What is the riskiest activity you ever engaged in?

Eating that duck at Liqun!

R&I: If the world has a modern hero, who is it and why?

Dr. Seuss who, in response to a 1954 report in Life magazine, worked to reduce illiteracy among school children by making children’s books more interesting. His work continues to educate and entertain children worldwide.

R&I: What do your friends and family think you do?

They’re not really sure!

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