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

Exclusive | Hank Greenberg on China Trade, Starr’s Rapid Growth and 100th, Spitzer, Schneiderman and More

In a robust and frank conversation, the insurance legend provides unique insights into global trade, his past battles and what the future holds for the industry and his company.
By: | October 12, 2018 • 12 min read

In 1960, Maurice “Hank” Greenberg was hired as a vice president of C.V. Starr & Co. At age 35, he had already accomplished a great deal.

He served his country as part of the Allied Forces that stormed the beaches at Normandy and liberated the Nazi death camps. He fought again during the Korean War, earning a Bronze Star. He held a law degree from New York Law School.

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Now he was ready to make his mark on the business world.

Even C.V. Starr himself — who hired Mr. Greenberg and later hand-picked him as the successor to the company he founded in Shanghai in 1919 — could not have imagined what a mark it would be.

Mr. Greenberg began to build AIG as a Starr subsidiary, then in 1969, he took it public. The company would, at its peak, achieve a market cap of some $180 billion and cement its place as the largest insurance and financial services company in history.

This month, Mr. Greenberg travels to China to celebrate the 100th anniversary of C.V. Starr & Co. That visit occurs at a prickly time in U.S.-Sino relations, as the Trump administration levies tariffs on hundreds of billions of dollars in Chinese goods and China retaliates.

In September, Risk & Insurance® sat down with Mr. Greenberg in his Park Avenue office to hear his thoughts on the centennial of C.V. Starr, the dynamics of U.S. trade relationships with China and the future of the U.S. insurance industry as it faces the challenges of technology development and talent recruitment and retention, among many others. What follows is an edited transcript of that discussion.


R&I: One hundred years is quite an impressive milestone for any company. Celebrating the anniversary in China signifies the importance and longevity of that relationship. Can you tell us more about C.V. Starr’s history with China?

Hank Greenberg: We have a long history in China. I first went there in 1975. There was little there, but I had business throughout Asia, and I stopped there all the time. I’d stop there a couple of times a year and build relationships.

When I first started visiting China, there was only one state-owned insurance company there, PICC (the People’s Insurance Company of China); it was tiny at the time. We helped them to grow.

I also received the first foreign life insurance license in China, for AIA (The American International Assurance Co.). To date, there has been no other foreign life insurance company in China. It took me 20 years of hard work to get that license.

We also introduced an agency system in China. They had none. Their life company employees would get a salary whether they sold something or not. With the agency system of course you get paid a commission if you sell something. Once that agency system was installed, it went on to create more than a million jobs.

R&I: So Starr’s success has meant success for the Chinese insurance industry as well.

Hank Greenberg: That’s partly why we’re going to be celebrating that anniversary there next month. That celebration will occur alongside that of IBLAC (International Business Leaders’ Advisory Council), an international business advisory group that was put together when Zhu Rongji was the mayor of Shanghai [Zhu is since retired from public life]. He asked me to start that to attract foreign companies to invest in Shanghai.

“It turns out that it is harder [for China] to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

Shanghai and China in general were just coming out of the doldrums then; there was a lack of foreign investment. Zhu asked me to chair IBLAC and to help get it started, which I did. I served as chairman of that group for a couple of terms. I am still a part of that board, and it will be celebrating its 30th anniversary along with our 100th anniversary.

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We have a good relationship with China, and we’re candid as you can tell from the op-ed I published in the Wall Street Journal. I’m told that my op-ed was received quite well in China, by both Chinese companies and foreign companies doing business there.

On August 29, Mr. Greenberg published an opinion piece in the WSJ reminding Chinese leaders of the productive history of U.S.-Sino relations and suggesting that Chinese leaders take pragmatic steps to ease trade tensions with the U.S.

R&I: What’s your outlook on current trade relations between the U.S. and China?

Hank Greenberg: As to the current environment, when you are in negotiations, every leader negotiates differently.

President Trump is negotiating based on his well-known approach. What’s different now is that President Xi (Jinping, General Secretary of the Communist Party of China) made himself the emperor. All the past presidents in China before the revolution had two terms. He’s there for life, which makes things much more difficult.

R&I: Sure does. You’ve got a one- or two-term president talking to somebody who can wait it out. It’s definitely unique.

Hank Greenberg: So, clearly a lot of change is going on in China. Some of it is good. But as I said in the op-ed, China needs to be treated like the second largest economy in the world, which it is. And it will be the number one economy in the world in not too many years. That means that you can’t use the same terms of trade that you did 25 or 30 years ago.

They want to have access to our market and other markets. Fine, but you have to have reciprocity, and they have not been very good at that.

R&I: What stands in the way of that happening?

Hank Greenberg: I think there are several substantial challenges. One, their structure makes it very difficult. They have a senior official, a regulator, who runs a division within the government for insurance. He keeps that job as long as he does what leadership wants him to do. He may not be sure what they want him to do.

For example, the president made a speech many months ago saying they are going to open up banking, insurance and a couple of additional sectors to foreign investment; nothing happened.

The reason was that the head of that division got changed. A new administrator came in who was not sure what the president wanted so he did nothing. Time went on and the international community said, “Wait a minute, you promised that you were going to do that and you didn’t do that.”

So the structure is such that it is very difficult. China can’t react as fast as it should. That will change, but it is going to take time.

R&I: That’s interesting, because during the financial crisis in 2008 there was talk that China, given their more centralized authority, could react more quickly, not less quickly.

Hank Greenberg: It turns out that it is harder to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.

R&I: Obviously, you have a very unique perspective and experience in China. For American companies coming to China, what are some of the current challenges?

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Hank Greenberg: Well, they very much want to do business in China. That’s due to the sheer size of the country, at 1.4 billion people. It’s a very big market and not just for insurance companies. It’s a whole range of companies that would like to have access to China as easily as Chinese companies have access to the United States. As I said previously, that has to be resolved.

It’s not going to be easy, because China has a history of not being treated well by other countries. The U.S. has been pretty good in that way. We haven’t taken advantage of China.

R&I: Your op-ed was very enlightening on that topic.

Hank Greenberg: President Xi wants to rebuild the “middle kingdom,” to what China was, a great country. Part of that was his takeover of the South China Sea rock islands during the Obama Administration; we did nothing. It’s a little late now to try and do something. They promised they would never militarize those islands. Then they did. That’s a real problem in Southern Asia. The other countries in that region are not happy about that.

R&I: One thing that has differentiated your company is that it is not a public company, and it is not a mutual company. We think you’re the only large insurance company with that structure at that scale. What advantages does that give you?

Hank Greenberg: Two things. First of all, we’re more than an insurance company. We have the traditional investment unit with the insurance company. Then we have a separate investment unit that we started, which is very successful. So we have a source of income that is diverse. We don’t have to underwrite business that is going to lose a lot of money. Not knowingly anyway.

R&I: And that’s because you are a private company?

Hank Greenberg: Yes. We attract a different type of person in a private company.

R&I: Do you think that enables you to react more quickly?

Hank Greenberg: Absolutely. When we left AIG there were three of us. Myself, Howie Smith and Ed Matthews. Howie used to run the internal financials and Ed Matthews was the investment guy coming out of Morgan Stanley when I was putting AIG together. We started with three people and now we have 3,500 and growing.

“I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

R&I:  You being forced to leave AIG in 2005 really was an injustice, by the way. AIG wouldn’t have been in the position it was in 2008 if you had still been there.

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Hank Greenberg: Absolutely not. We had all the right things in place. We met with the financial services division once a day every day to make sure they stuck to what they were supposed to do. Even Hank Paulson, the Secretary of Treasury, sat on the stand during my trial and said that if I’d been at the company, it would not have imploded the way it did.

R&I: And that fateful decision the AIG board made really affected the course of the country.

Hank Greenberg: So many people lost all of their net worth. The new management was taking on billions of dollars’ worth of risk with no collateral. They had decimated the internal risk management controls. And the government takeover of the company when the financial crisis blew up was grossly unfair.

From the time it went public, AIG’s value had increased from $300 million to $180 billion. Thanks to Eliot Spitzer, it’s now worth a fraction of that. His was a gross misuse of the Martin Act. It gives the Attorney General the power to investigate without probable cause and bring fraud charges without having to prove intent. Only in New York does the law grant the AG that much power.

R&I: It’s especially frustrating when you consider the quality of his own character, and the scandal he was involved in.

In early 2008, Spitzer was caught on a federal wiretap arranging a meeting with a prostitute at a Washington Hotel and resigned shortly thereafter.

Hank Greenberg: Yes. And it’s been successive. Look at Eric Schneiderman. He resigned earlier this year when it came out that he had abused several women. And this was after he came out so strongly against other men accused of the same thing. To me it demonstrates hypocrisy and abuse of power.

Schneiderman followed in Spitzer’s footsteps in leveraging the Martin Act against numerous corporations to generate multi-billion dollar settlements.

R&I: Starr, however, continues to thrive. You said you’re at 3,500 people and still growing. As you continue to expand, how do you deal with the challenge of attracting talent?

Hank Greenberg: We did something last week.

On September 16th, St. John’s University announced the largest gift in its 148-year history. The Starr Foundation donated $15 million to the school, establishing the Maurice R. Greenberg Leadership Initiative at St. John’s School of Risk Management, Insurance and Actuarial Science.

Hank Greenberg: We have recruited from St. John’s for many, many years. These are young people who want to be in the insurance industry. They don’t get into it by accident. They study to become proficient in this and we have recruited some very qualified individuals from that school. But we also recruit from many other universities. On the investment side, outside of the insurance industry, we also recruit from Wall Street.

R&I: We’re very interested in how you and other leaders in this industry view technology and how they’re going to use it.

Hank Greenberg: I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.

R&I: So as the pre-eminent leader of the insurance industry, what do you see in terms of where insurance is now an where it’s going?

Hank Greenberg: The country and the world will always need insurance. That doesn’t mean that what we have today is what we’re going to have 25 years from now.

How quickly the change comes and how far it will go will depend on individual companies and individual countries. Some will be more brave than others. But change will take place, there is no doubt about it.

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More will go on in space, there is no question about that. We’re involved in it right now as an insurance company, and it will get broader.

One of the things you have to worry about is it’s now a nuclear world. It’s a more dangerous world. And again, we have to find some way to deal with that.

So, change is inevitable. You need people who can deal with change.

R&I:  Is there anything else, Mr. Greenberg, you want to comment on?

Hank Greenberg: I think I’ve covered it. &

The R&I Editorial Team can be reached at [email protected]