By Donna Motley, Vice President of Claims
OPIoIDs – Hydrocodone (Vicodin), Oxycodone (Oxycontin, Percocet, Norco), Tramadol (Ultram). Drugs used to control “chronic” pain. Drugs used post-surgery. Drugs used to control “any” pain. Drugs that can be highly addictive. Drugs that are talked about in the news on a regular basis in relation to an epidemic of addiction in our country. CNBC has reported that approximately 80% of global opioid supply is consumed in the United States. There is much discussion going on about how to control this situation with multiple entities stepping up to the plate to do their part.
The Michigan Workers’ Compensation Agency has made changes to the Statute and Health Care Services to address the situation and save costs in the process. And it’s working!
All medications dispensed in relation to a work related injury are to be filled in the generic form if a generic form is available.
The State of Michigan has instituted a prescription drug monitoring program called MAPS that tracks and monitors controlled substance dispensing. MAPS is utilized outside of the Workers’ Compensation arena as well. If a patient “loses” his prescription, or it is “stolen” – another order cannot be written or filled until the time has expired on the original prescription.
The Workers’ Compensation Agency added to the Statute enabling the Workers’ Compensation carrier to require the treating physician to provide written documentation of the medical necessity to prescribed opioids in excess of 90 days. The patient must be reported to MAPS. The physician must also provide a written treatment plan, to include a plan and/or attempts to wean the patient of said drugs. The physician must also point out the risks involved with continued use of the current medications. A drug screen is required every six months (to assure the patient is actually taking the prescribed medication). The report is required every 90 days. If the physician refuses to comply with supplying the Workers’ Compensation carrier with this information, the carrier can deny future medical care and treatment of the patient; however, the injured worker must be provided with a “weaning” program with alternative forms of treatment. In essence, we cannot expect the injured worker to detox “cold turkey”.
How do we manage to control this when adjudicating approximately 1,500 claims per year? We utilize the services of a Pharmacy Benefit Manager (PBM). Ideally, all prescriptions related to a Workers’ Compensation claim are processed through our PBM. Fee schedule discounts are applied to the invoices. Tracking is done on the prescribing physician, drug potency is monitored as well as refill frequency. An injured worker is assigned a “drug formulary” consistent with diagnosis and treatment. Any medications prescribed outside of the appropriate formulary requires prior authorization from the Claims Adjuster. (Or a claim can be established with ALL prescription fills requiring pre-authorization of the adjuster.) A letter of medical necessity is sent to the prescribing physician if warranted.
Prior authorization requests (and denials thereof) along with limitations imposed saved MTMIC (and our insureds) $32,979.68 last year alone! We can track which prescribed drugs are costing the most money; which drugs are most prescribed. We can see who is taking opioids and the associated costs; then follow-up with the physician.
Physicians should attempt evidence based therapies before jumping to opioid therapy. Maybe a non-steroid anti-inflammatory medication should be tried first? Opioids can be very effective when used properly; that is “short-term”. Studies have proven that the longer a patient is on an opioid, the higher the dosage required to obtain the same effect, which is counter-productive to a safe return to work!
