In recent years, the workers’ compensation industry has made great strides reducing opioid prescriptions for injured workers. According to the CDC, the percentage of all workers’ comp claims with prescriptions that included at least one opioid dropped from 55% in 2012 to 44% in 2016. That number is certainly still falling thanks to stricter prescribing guidelines and more proactive patient and prescriber interventions, but it is still too high.
The industry learned the hard way that keeping opioids out of the picture altogether is the best way to avoid addiction or dependence, stalled recovery and overdose fatalities. Once this powerful painkiller is prescribed, things can unravel quickly.
“Data indicates that once opioid usage goes on beyond the 10-day mark, the chances of abuse or addiction are so much higher,” said Jill Falb, Vice President, Pharmacy Services, CorVel.
“Once someone has been on an opioid for an extended period, it becomes exponentially more difficult to wean them off. A few years ago, we put a stake in the ground and said, ‘We need to stop usage before it gets to that critical stage.’ ”
Falb and her pharmacy team at CorVel execute early opioid intervention at three key stages:
Around-the-clock access to triage nurses and telehealth physicians, can reduce the length and cost of workers’ comp claims simply by connecting injured workers to care faster. But it’s also a critical opportunity to assess pain and set appropriate expectations for pain management.
Triage nurses use a proprietary pain scale based on objective criteria such as activity level and somatic symptoms. They may ask, for example, whether pain is accompanied by nausea or sweating. Or whether it is impeding the caller’s ability to perform basic tasks like standing, turning or grasping.
The assessment also uses non-clinical adjectives that are meaningful to the caller, like “throbbing,” “dull,” “achy” and “stabbing” — rather than the traditional 1-10 scale. This helps the injured worker more accurately describe their pain so that nurses can determine an appropriate level of care.
“Depending on injury severity, the nurse may recommend self-treatment like ice, rest or compression. If further care is needed, they’ll determine whether a telehealth or an in-person visit is appropriate,” Falb said. “Currently, our telehealth physicians do not prescribe opioids through the telehealth program.”
“But from the beginning, they are setting expectations around pain, suggesting options beyond opioids,” added Charles Richards, Director of Analytics, CorVel.
“Most injured workers have never been through the workers’ comp system before, so knowing what to expect goes a long way in easing anxiety and setting that patient up for success.”
In 2016, many states began adopting more restrictive clinical guidelines for opioid prescriptions, encouraging providers to exhaust non-opioid therapies first, shrink the initial day supply and dosages, and implement more aggressive monitoring procedures.
“Our formulary is based on CDC recommendations combined with state-specific guidelines. We look to limit opioid prescriptions to a three-day supply for acute pain and require prescribers to check their state’s prescription monitoring program (PMP) database before writing a script,” Falb said.
“If a prescriber goes outside of those guidelines, we immediately reach out to find out why. We have to verify that their justification is sufficient and that they have discussed the associated risks and set clear goals and expectations with the injured worker.”
Direct outreach to the dispensing pharmacy is also critical whenever a non-formulary medication is prescribed. This is another chance to verify that the drug type, dosage and course are appropriate for the injury and to gather additional information about the patient’s medication history that may not have been captured by other records.
“We have a very restrictive formulary, because we want that phone call from the pharmacy. It creates more opportunities to discuss the implications of a particular medication — before it’s dispensed — and stop it if there is not enough evidence to support it,” Falb said.
It is critical to have total visibility into pharmacy usage, including data from both the PBM and non-PBM sources, to understand prescribing patterns and potential red flags for each patient.
Real-time updates and reports on long-term trends both help to inform interventions that could halt a substance abuse issue before it worsens. Things like the use of Narcan or opioid/muscle relaxant/benzodiazepine combinations, for example, demand immediate action.
Daily reports on these two factors enable the clinical team to initiate an intervention right away.
Less urgent but still troubling trends are captured through clinical modeling that synthesizes patient information with clinical guidelines and other benchmarking data to create a full picture of pharmacy risk.
“The primary thing we do is generate and track a pharmacy risk score for each injured worker, which is based on morphine milligram equivalents (MME),” Richards said. “Any MME above 90 will trigger an alert for intervention in our integrated platform.”
Days supply is another key data point. The goal for new injuries is to keep days supply under 10; for long-tail claims where opioids have been used continuously, anything over 120 will also trigger an alert.
Other red flags include continuous opioid usage beyond six months, more than three brand prescriptions, more than two muscle relaxers, antidepressants or antipsychotics, any fentanyl at all, methadone use, and multiple prescribers for a single patient. Most importantly, all these alerts come with clear action steps.
“With one click, the clinical team can set things in motion by alerting the case manager and the medication review team, scheduling a call, or requesting more information,” Richards said.
These proactive measures and quick interventions have positively impacted the trajectory of opioid prescriptions and overall patient safety.
“Before 2017, the average day supply of an opioid prescription was around 28 days. With implementation of 24/7 nurse triage combined with our high touch clinical pharmacy model, that average dropped to less than five days last year,” Richards said. “On new programs, we’ve seen a 12% reduction in opioid usage after one year just implementing some more proactive, hands-on controls.”
A high-touch model powered by clinical experts is the key to this success. Whether it’s the triage nurse or the call-center pharmacist communicating with prescribers, the clinical team at CorVel has the experience and credibility to drive meaningful change.
“I always look at our team as a bunch of detectives pulling information from the pharmacy, the PBM, the case manager and our own analytics team, and then packaging it in a way that makes sense for the adjuster,” Falb said. “Our mantra is to always provide the claims adjuster with what they need to make good decisions, so the clinical team has to be able to make connections and spot issues early.”
Technology plays a major role as well.
CorVel’s integrated claims management platform — CareMC Edge — provides a central location for claim-related data, bill review information, and pharmacy case management. Clinical staff and adjusters can access the latest data, interact with each other, and act on alerts all in the same place.
Streamlining the claims management process ultimately translates to quicker, higher quality care. The right intervention at the right time can help injured workers get better and back to work faster without the risk of opioid dependence.
To learn more, visit https://www.corvel.com/.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with CorVel. The editorial staff of Risk & Insurance had no role in its preparation.
Elizabeth Cunningham seemingly had it all. The daughter of two well-established professionals — her father was a personal injury attorney, her mother, also an attorney, had her own estate planning practice — she grew up in a house in Maryland horse country with lots of love and the financial security that can iron out at least some of life’s problems.
Tall, good-looking and talented, Elizabeth was moving through her junior year at the University of Pennsylvania in seemingly good order; check that, very good order, by all appearances.
Her pre-med grades were outstanding. Despite the heavy load of her course work, she’d even managed to place in the Penn Relays in the mile, in the spring of her sophomore season, in May of 2019.
But the winter of 2019/2020 brought challenges, challenges that festered below the surface, known only to her and a couple of close friends.
First came betrayal at the hands of her boyfriend, Tom, right around Thanksgiving. She saw a message pop up on his phone from Rebecca, a young woman she thought was their friend. As it turned out, Rebecca and Tom had been intimate together, and both seemed game to do it again.
Reeling, her holiday mood shattered and her relationship with Tom fractured, Elizabeth was beset by deep feelings of anxiety. As the winter gray became more dense and forbidding, the anxiety grew.
Fed up, she broke up with Tom just after Christmas. What looked like a promising start to 2020 now didn’t feel as joyous.
Right around the end of the year, she plucked a copy of her father’s New York Times from the table in his study. A budding physician, her eyes were drawn to a piece about an outbreak of a highly contagious virus in Wuhan, China.
“Sounds dreadful,” she said to herself.
Within three months, anxiety gnawed at Elizabeth daily as she sat cloistered in her family’s house in Bel Air, Maryland.
It didn’t help matters that her brother, Billy, a high school senior and a constant thorn in her side, was cloistered with her.
She felt like she was suffocating.
One night in early May, feeling shutdown and unable to bring herself to tell her parents about her true condition, Elizabeth reached out to her family physician for help.
Dr. Johnson had been Elizabeth’s doctor for a number of years and, being from a small town, Elizabeth had grown up and gone to school with Dr. Johnson’s son Evan. In fact, back in high school, Evan had asked Elizabeth out once. Not interested, Elizabeth had declined Evan’s advances and did not give this a second thought.
Dr. Johnson’s practice had recently been acquired by a Virginia-based hospital system, Medwell, so when Elizabeth called the office, she was first patched through to Medwell’s receptionist/scheduling service. Within 30 minutes, an online Telehealth consult had been arranged for her to speak directly with Dr. Johnson.
Due to the pandemic, Dr. Johnson called from the office in her home. The doctor was kind. She was practiced.
“So can you tell me what’s going on?” she said.
Elizabeth took a deep breath. She tried to fight what was happening. But she could not. Tears started streaming down her face.
“It’s just… It’s just…” she managed to stammer.
The doctor waited patiently. “It’s okay,” she said. “Just take your time.”
Elizabeth took a deep breath. “It’s like I can’t manage my own mind anymore. It’s nonstop. It won’t turn off…”
More tears streamed down her face.
Patiently, with compassion, the doctor walked Elizabeth through what she might be experiencing. The doctor recommended a follow-up with Medwell’s psychology department.
“Okay,” Elizabeth said, some semblance of relief passing through her.
Unbeknownst to Dr. Johnson, her office door had not been completely closed. During the telehealth call, Evan stopped by his mother’s office to ask her a question. Before knocking he overheard Elizabeth talking and decided to listen in.
As Elizabeth was finding the courage to open up to Dr. Johnson about her psychological condition, Evan was recording her with his smartphone through a crack in the doorway.
Spurred by who knows what — his attraction to her, his irritation at being rejected, the idleness of the COVID quarantine — it really didn’t matter. Evan posted his recording of Elizabeth to his Instagram feed.
#CantManageMyMind, #CrazyGirl, #HelpMeDoctorImBeautiful is just some of what followed.
Elizabeth and Evan were both well-liked and very well connected on social media. The posts, shares and reactions that followed Evan’s digital betrayal numbered in the hundreds. Each one of them a knife into the already troubled soul of Elizabeth Cunningham.
By noon of the following day, her well-connected father unleashed the dogs of war.
Rand Davis, the risk manager for the Medwell Health System, a 15-hospital health care company based in Alexandria, Virginia was just finishing lunch when he got a call from the company’s general counsel, Emily Vittorio.
“Yes?” Rand said. He and Emily were accustomed to being quick and blunt with each other. They didn’t have time for much else.
“I just picked up a notice of intent to sue from a personal injury attorney in Bel Air, Maryland. It seems his daughter was in a teleconference with one of our docs. She was experiencing anxiety, the daughter that is. The doctor’s son recorded the call and posted it to social media.”
“Great. Thanks, kid,” Rand said.
“His attorneys want to initiate a discovery dialogue on Monday,” Emily said.
It was Thursday. Rand’s dreams of slipping onto his fishing boat over the weekend evaporated, just like that. He closed his eyes and tilted his face up to the heavens.
Wasn’t it enough that he and the other members of the C-suite fought tooth and nail to keep thousands of people safe and treat them during the COVID-crisis?
He’d watched the explosion in the use of telemedicine with a mixture of awe and alarm. On the one hand, they were saving lives. On the other hand, they were opening themselves to exposures under the Health Insurance Portability and Accountability Act. He just knew it.
He and his colleagues tried to do the right thing. But what they were doing, overwhelmed as they were, was simply not enough.
Within the space of two weeks, the torture suffered by Elizabeth Cunningham grew into a class action against Medwell.
In addition to the violation of her privacy, the investigation by Mr. Cunningham’s attorneys revealed the following:
Medwell’s telemedicine component, as needed and well-intended as it was, lacked a viable informed consent protocol.
The consultation with Elizabeth, and as it turned out, hundreds of additional patients in Maryland, Pennsylvania and West Virginia, violated telemedicine regulations in all three states.
Numerous practitioners in the system took part in teleconferences with patients in states in which they were not credentialed to provide that service.
Even if Evan hadn’t cracked open Dr. Johnson’s door and surreptitiously recorded her conversation with Elizabeth, the Medwell telehealth system was found to be insecure — yet another violation of HIPAA.
The amount sought in the class action was $100 million. In an era of social inflation, with jury awards that were once unthinkable becoming commonplace, Medwell was standing squarely in the crosshairs of a liability jury decision that was going to devour entire towers of its insurance program.
Adding another layer of certain pain to the equation was that the case would be heard in Baltimore, a jurisdiction where plaintiffs’ attorneys tended to dance out of courtrooms with millions in their pockets.
That fall, Rand sat with his broker on a call with a specialty insurer, talking about renewals of the group’s general liability, cyber and professional liability programs.
“Yeah, we were kind of hoping to keep the increases on all three at less than 25%,” the broker said breezily.
There was a long silence from the underwriters at the other end of the phone.
“To be honest, we’re borderline about being able to offer you any cover at all,” one of the lead underwriters said.
Rand just sat silently and waited for another shoe to drop.
“Well, what can you do?” the broker said, with hope draining from his voice.
The conversation that followed would propel Rand and his broker on the difficult, next to impossible path of trying to find coverage, with general liability underwriters in full retreat, professional liability underwriters looking for double digit increases and cyber underwriters asking very pointed questions about the health system’s risk management.
Elizabeth, a strong young woman with a good support network, would eventually recover from the damage done to her.
Medwell’s relationships with the insurance markets looked like it almost never would. &
Risk & Insurance® partnered with Allied World to produce this scenario. Below are Allied World’s recommendations on how to prevent the losses presented in the scenario. This perspective is not an editorial opinion of Risk & Insurance.®.
The use of telehealth has exponentially accelerated with the advent of COVID-19. Few health care providers were prepared for this shift. Health care organizations should confirm that Telehealth coverage is included in their Medical Professional, General Liability and Cyber policies, and to what extent. Concerns around Telehealth focus on HIPAA compliance and the internal policies in place to meet the federal and state standards and best practices for privacy and quality care. As states open businesses and the crisis abates, will pre-COVID-19 telehealth policies and regulations once again be enforced?
Risk Management Considerations:
The same ethical and standard of care issues around caring for patients face-to-face in an office apply in telehealth settings:
Telehealth can create challenges around “informed consent.” It is critical to inform patients of the potential benefits and risks of telehealth (including privacy and security), ensure the use of HIPAA compliant platforms and make sure there is a good level of understanding of the scope of telehealth. Providers must be aware of the regulatory and licensure requirements in the state where the patient is located, as well as those of the state in which they are licensed.
A professional and private environment should be maintained for patient privacy and confidentiality. Best practices must be in place and followed. Medical professionals who engage in telehealth should be fully trained in operating the technology. Patients must also be instructed in its use and provided instructions on what to do if there are technical difficulties.
This case study is for illustrative purposes only and is not intended to be a summary of, and does not in any way vary, the actual coverage available to a policyholder under any insurance policy. Actual coverage for specific claims will be determined by the actual policy language and will be based on the specific facts and circumstances of the claim. Consult your insurance advisors or legal counsel for guidance on your organization’s policies and coverage matters and other issues specific to your organization.
This information is provided as a general overview for agents and brokers. Coverage will be underwritten by an insurance subsidiary of Allied World Assurance Company Holdings, Ltd, a Fairfax company (“Allied World”). Such subsidiaries currently carry an A.M. Best rating of “A” (Excellent), a Moody’s rating of “A3” (Good) and a Standard & Poor’s rating of “A-” (Strong), as applicable. Coverage is offered only through licensed agents and brokers. Actual coverage may vary and is subject to policy language as issued. Coverage may not be available in all jurisdictions. Risk management services are provided or arranged through AWAC Services Company, a member company of Allied World. © 2020 Allied World Assurance Company Holdings, Ltd. All rights reserved.