Tag Archives: food & drug administration

10 Strategies to Combat the Rx Abuse Epidemic – An Insurer's Perspective

The misuse and abuse of prescription drugs has taken a devastating toll on communities all across America. For insurance companies, the financial impact of rising opioid costs continues to cause concerns, as medical payments exceed indemnity payments.

In 1987, medical losses represented only 46 percent of the dollars spent on workers' compensation claims. Today, medical losses represent roughly 60 percent of the dollars spent on these claims.1 In the Winter edition of the NAMIC Mutual Insurance magazine, the article “Opioids: A Workers’ Compensation Epidemic” discussed the Accident Fund Insurance’s 60%/40% medical loss/indemnity loss split, in addition to calling opioids workers’ compensation’s current worst enemy.2

With approximately 20 percent of all medical spending going towards prescription drugs, workers' compensation, insurers have been working hard to mitigate these costs. Insurers have negotiated discounts with preferred providers, established comprehensive prescription drug networks, used advanced analytics to identify the most severe claims, promoted evidence-based pain diagnoses, leveraged utilization reviews, and invested in tort reform. All of these measures have been taken with the goal of reducing injured worker reliance on addictive prescriptions drugs and helping workers return to work sooner.

To address the opioid epidemic, a number of strategies have been developed at both the national and state levels in consultation with medical professionals, law enforcement, insurance companies, and public health and drug prevention experts. In October 2013, the Trust For America’s Health (TFAH) issued a report titled, “Prescription Drug Abuse: Strategies to Stop the Epidemic” identifying ten strategies being employed at the State level.3 In this article, we will provide a brief recap of the strategies and share our thoughts on some insurance company considerations.

Although no single strategy is a “silver bullet” that will alleviate the opioid epidemic, each strategy must be considered in the context of the unique circumstances that exist in each state. Ultimately, these efforts could play a role in helping insurance companies mitigate opioid related costs going forward.

A Recap of the 10 Strategies

1. Prescription Drug Monitoring Program: Does the state have an operational Prescription Drug Monitoring Program (PDMP)?

The TFAH report noted that 49 states have an active PDMP. These programs hold the promise of being able to quickly identify problem prescribers and individuals misusing and diverting drugs. The Prescription Drug Monitoring Program Center of Excellence at Brandeis University, the National Alliance for Model State Drug Laws, the Alliance of States with Prescription Monitoring Programs and other organizations have stressed the importance of PDMPs in fighting prescription drug abuse and misuse and improving patient safety. These organizations have also issued a variety of recommendations and leading practices for PDMPs including interstate operability, mandatory utilization, expanded access, real-time reporting, use of proactive alerts, and integration with electronic medical records.

On September 13, 2013, the American Society of Health-System Pharmacists web site discussed how PDMP programs are gaining steam.4  Specifically, they mentioned how New York became the first state to require that prescribers consult the State’s PDPM registry before prescribing Schedule II, III or IV controlled substances.   From an insurance company perspective, understanding how effective PDMP programs are with controlling physician prescriber behavior can help claim adjusters and actuaries gain a better understanding of medical costs going forward.

Of note, Missouri is currently the only state without a PDMP. From our perspective, this raises concerns that Missouri could be targeted by individuals looking to illegally sell/purchase prescription drugs and profit from their misuse and abuse. Without the tracking and monitoring of prescriptions, some patients may find it convenient to cross the border in order to fill their medications in Missouri. Not surprisingly, on November 21, 2013, KCTV News (Kansas City) published a story titled “Missouri a hot spot for 'doctor shopping' for Rx drugs” which seems to support this concern.5

2. Mandatory Use of PDMP: Does the State require mandatory use of PDMPs by providers? (i.e., any form of a mandatory use requirement).

The TFAH report found only 16 States require use of the PDMP by providers (and then only in certain situations) and of those States, only eight States require use of the PDMP before the initial dispensing of a controlled substance. From our perspective, it isn’t surprising that some professionals find the lack of enforcement troubling, especially given the recommendation from the Prescription Drug Monitoring Program Center of Excellence at Brandeis University that utilization of PDMPs be mandated for all prescribers.

Some providers have expressed genuine discontent with the mandatory use of the PDMP, since it increases their administrative burden and may reduce the time they can spend with patients.  However, this additional burden has to be weighed against the benefits of mandatory PDMP usage which can help prevent an addict from filling duplicate prescriptions, identify a stolen prescription pad, or highlight a provider who is obviously writing phony subscriptions. 

Ultimately, the majority of health-care providers rank patient health and safety as a priority, and given the undeniable prevalence of the prescription diversion and abuse, their goal can only be furthered by using the PDMP.  Lastly, from an actuarial perspective, the mandatory use of PDMP’s would increase the ability of States to measure the true value/effectiveness of PDMP efforts.

3. Doctor Shopping Law: Does the state have a doctor shopping statute?

Doctor shopping is the practice of seeing multiple physicians and pharmacies to acquire controlled substances — for a person’s own use and/or for reselling purposes. The TFAH report noted that all States have laws in place that either:

a) Make it a criminal offense to obtain drugs through fraud, deceit, misrepresentation, subterfuge, or concealment of material fact.

b) Make doctor shopping illegal.

c) Prohibit patients from withholding information that they have received either a controlled substance or prescription order from another practitioner, or the same controlled substance or one of similar therapeutic use within a specified time interval.

Doctor shopping laws are aimed at deterring individuals from one method of wrongfully obtaining prescription drugs. In Tennessee, the Office of the Inspector General has used these laws very effectively.

In the Long Island Newsday article “State’s new prescription pain pill system snags apparent doctor shoppers”, New York State’s online system discovered 200 instances of apparent doctor shopping in the first three days of use.6   With diversion and addiction on the rise, anything we can do to keep opioids out of the hands of those who shouldn’t access them is a move in the right direction. The more illegal pills taken out of circulation, the less likely an addicted injured worker will be able to further any bad habits.

4. Support for Substance Abuse Services: Has the state expanded Medicaid under the Affordable Care Act, thereby expanding coverage of substance abuse treatment?

The TFAH report noted that in 2011, 21.6 million Americans age 12 and older needed treatment for a substance abuse problem, but only 2.3 million received treatment at a substance abuse facility. This shortfall represents a “treatment gap” where treatment is not readily available for millions of Americans who are in need of assistance. The TFAH report found that 24 states and the District of Columbia have expanded Medicaid under the Patient Protection and Affordable Care Act (ACA), thereby expanding coverage of substance abuse treatment. However, it is unclear whether the remaining 26 States will expand their Medicaid coverage and substance abuse treatment efforts.

The authors have experienced firsthand the need for additional substance abuse treatment during the radio shows we host on Rx Drug abuse issues.  Several callers have expressed frustration over not being able to receive substance abuse treatment either for themselves or a loved one and want to know where they can go to find help.  Sadly, some Americans have resorted to committing a crime so they could receive free treatment while incarcerated.

Fortunately for some workers’ compensation claimants, a number of insurance companies have been proactively leveraging pain management programs to help wean injured workers off of addictive opioids.  This not only improves the quality of life of for the injured worker and his/her family, but benefits the employer through the employee’s return to work and the insurance company’s lower expenditure on medical.

5. Prescriber Education Requirement: Does the state require or recommend education for prescribers of pain medications?

The TFAH report noted it is important to educate providers about the risks of prescription drug misuse to prevent providers from prescribing incorrectly and/or to ensure they consider possible drug interactions when prescribing a new medication to a patient. The report also noted that most medical, dental, pharmacy, and other health professional schools currently do not provide in-depth training on substance abuse and students may only receive limited training on treating pain.

In July of 2012, the Food & Drug Administration (FDA) approved a Risk Evaluation and Mitigation Strategy (REMS) for extended release opioids that require manufacturers to fund voluntary painkiller training programs, at little to no cost, to all U.S. licensed prescribers. The FDA then issued a letter to prescribers, which was distributed by the American Medical Association (AMA), American Academy of Family Physicians (AAFP), the American Academy of Physician Assistants (AAPA), the American Academy of Pain Management (AAPM) and ASAM, which recommended that prescribers take advantage of those educational programs. However, the FDA did not make attendance by prescribers mandatory, a decision which drew criticism from some individuals that believed REMS should be mandatory.

How critical is the need for re-education regarding prescribing of opioids? In May of 2013, Dr. Thomas R. Frieden, the Director of the Centers for Disease Control and Prevention stated in a PBS interview: “When I went to medical school, the one thing I was told was completely wrong. The one thing I was told was if you give opioids to a patient who is in pain, they will not get addicted.  Completely wrong. Completely wrong. But a generation of doctors, a generation of us grew up being trained that these drugs aren’t risky.”7 If Dr. Frieden is correct, then the TFAH’s finding that only 22 States either require or recommend prescriber education for pain medication prescribers indicates that we have a long way to go in stemming the Rx Drug abuse problem. 

However, it is important to note that some insurance companies are doing their part in helping to educate prescribers. As noted on the Employers’ Insurance Company website, the company’s opioid program takes proactive measures to help control the flow of narcotics by involving the workers’ compensation insurance carrier, injured employees, workers’ compensation physicians and pharmacy benefit managers. The first prong of their program focuses on training physicians to recognize the signs of opioid abuse and encourages them to consider other effective pain management alternatives.8 It is insurance company efforts like this, in combination with FDA REMS, Physicians for Responsible Opioid Prescribing (PROP)9, and state and federal efforts that will help stem the Rx drug abuse problem.

6. Good Samaritan Law: Does the state have a law in place to provide a degree of immunity from criminal charges or mitigation of sentencing for an individual seeking help for themselves or others experiencing an overdose?

Per the TFAH report, 17 states and the District of Columbia have a law in place to either provide a degree of immunity from criminal charges or mitigation of sentencing for an individual seeking help for themselves or others experiencing an overdose. These laws are designed to encourage people to actually help those in danger of an overdose, as opposed to walking away or not even making the call to 911.

The TFAH report noted that a study conducted after passage of Washington’s 911 Good Samaritan Law found that 88 percent of prescription painkiller users indicated that once they were aware of the law, they would be more likely to call 911 during future overdoses. Thus, this strategy may well be critical in helping stem the toll of Rx Drug abuse until prescribing practices can be modified.

7. Support for Narcan Use: Does the state have a law in place to expand access to, and use of, Narcan (a/k/a, Naloxone) for overdosing individuals given by lay administrators?

Narcan is an FDA approved drug that can be used to counter the effects of prescription painkiller overdose. It is not a controlled substance; has no abuse potential; and, can be administered by minimally trained laypeople. The TFAH report found that 17 states and the District of Columbia have a law in place to expand access to, and the use of, Naloxone for overdosing individuals given by lay administrators. In addition, Washington and Rhode Island are currently implementing collaborative practice agreements where Narcan can be distributed by pharmacists.

As was noted in the article “Naloxone Expansion in California Will Enable Family, Friends To Save Lives At Home,” Californians are now able to reverse overdoses at home with a lifesaving injectable drug called Narcan, which can be administered through the nose or intravenously to a person suffering from an opiate overdose.10

8. Physical Exam Requirement: Does the State require a healthcare provider to either conduct a physical exam of the patient, a screening for signs of substance abuse or have a bona fide patient-physician relationship that includes a physician examination, prior to prescribing prescription medications?

Per the TFAH, 44 States and the District of Columbia have such a requirement. Unfortunately, the State laws vary regarding the circumstances under which an exam is required (for example, for all drugs or just specified prescriptions) and the consequences for prescribing without a required examination (i.e., whether there is criminal liability). While this is a promising strategy, wouldn’t unanimity between the States make this strategy even more effective?

The authors question whether “a physical exam requirement” is a better strategy than simply requiring a drug screen. While increased costs may be associated with such a strategy, a urine drug screen is the single most useful test to determine if someone is abusing controlled substances or diverting drugs they have been prescribed.

9. ID Requirement: Does the State have a law requiring or permitting a pharmacist to ask for identification prior to dispensing a controlled substance?

Pharmacists, as the dispensers of prescription drugs, play an important part in the distribution chain. Recognizing this role, the DEA took significant enforcement action in 2013 against national pharmacy chains for allegedly failing to recognize unusual sale volumes of controlled substances in several of their pharmacies.

The TFAH report found that 32 States have laws requiring or permitting a pharmacist to request an ID prior to dispensing a controlled substance. These laws vary in type from requiring presentation of an ID in all circumstances versus those where the purchasers are unknown to the pharmacist. In addition, some States require photo identification and others accept a broader range of government IDs.

The authors note that this “strategy” may represent one of the easier hurdles for drug seekers to circumvent given the ease of falsifying ID’s.  However, the battle against opioid addiction is a battle of inches, and the ID check represents one more step a possible abuser has to overcome to support their bad habit.

10. Pharmacy Lock-In Program:  Does the State’s Medicaid plan have a pharmacy lock-in program that requires individuals suspected of misusing controlled substances to use a single prescriber and pharmacy?

The TFAH report noted that in order to help healthcare providers monitor potential abuse or inappropriate utilization of controlled prescription drugs, some States have implemented programs requiring high users of certain drugs to use only one pharmacy and get prescriptions for controlled substances from only one medical office.  Lock-in programs are believed to help avoid doctor shopping while ensuring appropriate pain care for patients.

Forty-six states and the District of Columbia were noted to have a pharmacy lock-in program under the State’s Medicaid plan where individuals suspected of misusing controlled substances must use a single prescriber and pharmacy.  From discussions with pharmacists, it isn’t always easy for a pharmacist to question a treating physician about whether a prescription is valid.  From the authors’ experience, we have received a number of anecdotal reports of physicians treating pharmacists in a less than respectful manner when a pharmacist questioned whether a prescription was valid.  In these cases, the pharmacists are simply trying to do their best to help curb prescription drug diversion.  In our view, the Lock-In strategy helps strengthen the professional relationships between doctors and pharmacists.

How are the States Doing with Implementing the Strategies?

The TFAH report found that the States’ implementation of the 10 strategies vary widely. For example, 11 States have implemented at least 8 of the 10 strategies. 4 States have implement at least 9, and only New Mexico and Vermont have implemented all 10. Interestingly, in 2010 New Mexico ranked #2 in drug overdose mortality rate per 100,000 residents (which includes both prescription drug and illicit drug overdoses) while Vermont ranked 42nd. It will be interesting to see what advances, if any, New Mexico makes in the Rx drug abuse/misuse war during the next several years with all 10 strategies in place.

On the flip side, South Dakota is the only state with just 2 of the strategies in place.  However, it ranked 50th in drug overdose mortality rate per 100,000 residents in 2010, suggesting the State may not have a misuse/abuse problem of significance. However, two states, Missouri and Nebraska, have only three of the promising strategies in place. In 2010, Missouri ranked 7th in drug overdose mortality rate per 100,000 residents, while Nebraska ranked 49th. With no PDMP, it will be interesting to watch where Missouri ranks in future studies.

With over 60 percent of workers’ compensation payments going towards medical costs, it will be important for insurers to pay close attention to state specific efforts to combat prescription abuse. With the right amount of actuarial research and advanced analytics, workers’ compensation insurers can develop a better understanding of their opioid exposed population and the prescribing habits of the physicians treating their injured workers.  To the extent insurance companies can leverage the above strategies in combination with their own analytics, physician educational efforts, evidence-based pain diagnoses, utilization reviews, and tort reform efforts (e.g., In 2011, the 79th Texas Legislature adopted a closed formulary system which led to a 70 percent decrease in Schedule II narcotic costs11), we believe insurers can move the needle on reducing opioid abuse and addiction.

In the end, these opioid risk management strategies may not only generate dollar savings to workers compensation insurers as workers return to work sooner, but will help improve the quality of life for the injured worker and his/her family.

Footnotes

1 http://www.ncci.com/

2 http://www.namic.org/in/13winterpre.asp

3 http://healthyamericans.org/reports/drugabuse2013/TFAH2013RxDrugAbuseRpt12_no_embargo.pdf

4 http://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=3951

5 http://www.kctv5.com/story/24039604/missouri-a-hot-spot-for-doctor-shopping-for-rx-drugs

6 http://www.newsday.com/news/region-state/state-s-new-prescription-pain-pill-system-snags-apparent-doctor-shoppers-1.5995395

7 http://www.pbs.org/newshour/extra/daily_videos/prescription-drug-abuse-can-have-fatal-consequences/

8 http://www.employers.com/AGENTS/BLOG/post/2013/10/07/Opioid-Program-Shows-Results.aspx

9 http://www.supportprop.org/

10 http://www.huffingtonpost.com/2013/10/11/naloxone-expansion-california_n_4081044.html

11 http://www.riskandinsurance.com/story.jsp?storyId=533355286

Authors

Kevin Bingham collaborated with Alix C. Michel and David J. Ward in writing this article.

Alix C. Michel is an attorney at Michel & Ward, a firm based in Chattanooga, TN specializing in the defense of all types of healthcare professionals, hospitals, longterm care facilities, and educating society on the dangers of RX Drug Diversion and strategies to help in the fight against same.

David J. Ward is an attorney at Michel and Ward, a law firm based in Chattanooga, TN. Michel and Ward defends and advises physicians, healthcare providers, longterm care facilities, and others in professional malpractice litigation, professional licensing investigations, and healthcare practice issues.

This article first appeared on December 2, 2013 on PropertyCasualty360.com. © 2013 PropertyCasualty360, A Summit Professional Networks website.

Why Are Insurers So Slow to Adopt Superior Treatment Technologies?

Part 1 – The Issue

Picture the following scenario:

Your 17-year-old daughter is in her last semester of high school.  Last week, the letter came that announced she had been accepted on early decision to her top college choice, Stanford.  The family is riding high, and your daughter is now alternating between studying hard and floating on a cloud.  This morning at breakfast, she announces that she thinks she might need to go to the doctor because she has a lump in her right breast.  When questioned, she says she’s pretty sure she noticed it well before Christmas and perhaps even last summer, but she kept assuming it would just go away.  She stresses that she’s been busy with homework, tennis, the yearbook and all of her other activities, and she didn’t pay it much attention. This morning in the shower, however, she realized that it is larger and is now sore to the touch.  You keep asking her gentle questions, trying to be sensitive and not freak her out.  Inside, you are freaking out.  You tell her you’ll make an appointment with the doctor today. 

Ten weeks later, a lot of progress has been made, but many questions and issues still remain.  A gynecologist has examined her, performed an ultrasound and referred her to an imaging center for a mammogram in preparation for a biopsy.  The mammogram confirmed that she had a 1.9mm tumor in her right breast. Two weeks later, she went back for a needle biopsy of the lesion.  Her doctor called her three days later to tell her that she had a benign fibroadenoma and suggested she see a breast surgeon to discuss treatment options.  You and your daughter immediately start searching the internet to gain more knowledge and look at all possible treatments for this fibroadenoma.

You then both went to the breast surgeon’s office to discuss what happens next.  The doctor explained that fibroadenoma is a disease of adolescent girls and women of child-bearing age, that while the lesion is benign and not malignant it will most likely continue to grow, and that women who have a fibroadenoma tend to have multiple tumors develop over their lifetime.  In many cases, no treatment is necessary, but most women choose to have their fibroadenomas treated for their comfort and peace of mind. About 75% of women have their fibroadenoma treated within 5 years of diagnosis.   The doctor outlined a choice of treatment alternatives:

  1. Watch and wait – The doctor explained that many women choose to simply watch the tumor, returning to the doctor at 6-month intervals to evaluate the progress of the fibroadenoma.  In your daughter’s case, because the site of her lesion is very tender, this would likely not be an option.
  2. Surgical excision – The next option is to remove the tumor with a surgical procedure.  This option would be 100% effective in removing the tumor but would leave a ½-1” scar and may result in a slight dimpling in her breast because of the tissue removal.
  3. Va cuum-assisted “debulking” – This option would involve placing a vacuum probe through a small incision in her breast and sucking out much of the fibroadenoma in small pieces.  The procedure would take 40-60 minutes under local anesthesia, but there is a 30-40% recurrence rate in tumors larger than 1.5mm.  

Your daughter brings up a fourth option she read about online, a process called cryoablation, which freezes and destroys the tumor without any tissue removal and with only a 1/8” skin nick instead of a larger scar.  She says that she understands the procedure takes 10-15 minutes in a doctor’s office instead of an operating room, needs only local anesthesia, is minimally invasive, and is 100% effective in the destruction of the tumor without removing any breast tissue or changing the shape or appearance of her breast—obviously a higher priority for her.  After some discussion with the doctor, she is referred to a doctor who can perform the cryoablation. [In the interests of full disclosure, I should note that my company makes equipment used in cryoablation. But the issue about insurance companies and new technologies is much broader; cryoablation is just an example.]

You both then visited the new doctor and were informed that your daughter was an excellent candidate for cryoablation.  You learned that cryoablation unleashes the body’s natural healing process, that it’s been used in other parts of the body for more than two decades, that cryoablation for the breast was developed by a company in California in 2000 and that their systems had successfully been used to treat more than 4,000 cases of breast tumors. You also learned that the procedure had been cleared by the FDA since 2001 for the  treatment of fibroadenoma as well as for the treatment of cancerous and malignant tissue, and that the American Society of Breast Surgeons had issued a consensus statement in 2005 that stated, “Several multi-institutional trials have demonstrated cryoablation to be a successful option for the resolution of fibroadenomas without surgical excision.  The FDA has approved the use of cryoablation as a safe and effective therapy for fibroadenomas.  Results of cryoablation have been followed out to 4 years and demonstrate the procedure to be safe, efficacious and durable.”  There has also been a breast cancer trial using the cryoablation system, and results for breast cancer cryoablation treatment would be published next year.  The doctor also stated that while your daughter would still be able to feel a palpable lump in her breast for a number of months after the treatment while her body reabsorbed the treated tissue, 69% of cryoablated fibroadenomas ≤ 2 cm were non-palpable within 6 months and nearly all would resolve within 2 1/2 years, with a 97% patient satisfaction rate.  You are both convinced that this sounds like the treatment of choice.

You stopped at the front desk to make sure the doctor’s office has all the necessary insurance information. You were told that they would have to get a pre-authorization.  Your daughter is leaving for college in five weeks, so time is of the essence.  Then the waiting began; a week later you called the doctor, but no approval yet.

On day 13, you feel like you stepped into the Twilight Zone.  You receive a call from the doctor’s office telling you your insurer has denied coverage for the cryoablation.  When, in disbelief, you ask why, you are told that the insurer considers the procedure “investigational.”  You immediately call your insurer, who politely repeats the investigational mantra, and talking to the supervisor gets you no further.  You call the doctor’s office and are told that you could appeal the denial with the insurance company and with an Independent Medical Review, or pay cash for the treatment.  Because all of the family’s cash is going into the college fund, paying cash is not an option.

You are both left questioning why a safe and effective, minimally invasive treatment wouldn’t immediately be embraced by the insurance company.  You head back to the internet and find that United Healthcare, some of the Blue Cross plans and numerous smaller insurers around the U.S. had been covering the procedure for nearly eight years, but your insurance plan does not.  You are blowing a gasket at this point. You could change plans but not in time to get the cryoablation treatment before your daughter left for college.  You could choose another treatment option, but she has her heart set on preserving the look and shape of her breast.  Why, you wonder, if women can get free birth control pills and men can get Viagra covered by all insurers, why couldn’t you get a breast-saving procedure for your daughter paid by your healthcare insurer? 

It just doesn’t make sense. Finally, in anger and disgust, you write a letter to your insurer protesting the denial of coverage and resolve to follow the path of Independent Medical Review to get the denial overturned.  Your daughter leaves for college with the increasingly painful fibroadenoma untreated.

Unfortunately, this scenario and many more like it play out in the U.S far too frequently.  In the U.S., 700,000 cases of benign fibroadenoma are diagnosed annually.  These fibroadenomas will continue to grow, are frequently unsightly, and often cause pain and considerable emotional trauma and suffering for the affected women.  More than 500,000 cases are treated within five years, often at a larger size and with more physical damage and disruption to the breast.  Cryoablation is FDA 510k-cleared and has been a safe and effective treatment for more than a dozen years, yet many health insurers continue to deny their insureds a superior treatment option for a frequently disfiguring disease.  One wonders why?  Why are many insurance companies so slow to adopt new technologies?

NEXT:  This is the first of a 3-part series.  Next, we will look at the technology and treatment process, and Part 3 will examine the economics of various treatment options.

25 Axioms Of Medical Care In The Workers Compensation System

  1. The right medical care at the right time is always in the best interest of the injured worker and almost always will result in the lowest claims costs.
  2. The right medical care at the right time will (almost always) result in an earlier return to work with less permanent residual disability.
  3. Evidence-based medicine is the right care for the legitimately injured workers. (There is a hierarchy on how to apply evidence-based medicine).
  4. To control worker's compensation medical costs requires both a fee schedule and an ability to control the frequency and the appropriateness of treatment. One without the others usually results in massive increase in medical costs for the system.
  5. The medical treatment fee schedule should be clear, easy to use, accurate and reflect the latest technology.
  6. A fee-for-service system may result in incentives for physicians to over-treat, inappropriately.
  7. In many jurisdictions Worker's Compensation is generally the last fee-for-service system.
  1. As long as workers compensation uses a fee-for-service system, medical utilization review is needed to make sure that the physicians will treat adhering to evidence-based medicine.
  2. Pharmacy utilization is problematic because of the “Medicalization” of the general population. (Medicalization is the direct advertising of symptoms and diagnoses to the general population by drug manufacturers, resulting in an overuse and/or misuse of some types of drugs and therapies).
  3. There is a significant problem with “off label use” of drugs in the worker's compensation system. (Off Label is the use of a drug for treatment that was not the reason for its approval from the FDA).
  4. Medical decisions should be made by medical professionals. Most Workers' Compensation judges, attorneys, and claims adjusters have little to no formal medical training and are not medical professionals.
  5. Poorly (inappropriate) placed incentives will result in poor medical outcomes. (There are several studies that demonstrate that allowing physicians to do self-referrals or to dispense pharmacy goods from their offices will usually result in a utilization of unnecessary services or inappropriate usage of drugs).
  6. Even if the doctor is not dispensing the drugs, opiates require regular visits to the doctor for renewal of the prescription and also may involve expensive drug testing; so there is a financial interest on the part of some doctors to prescribe opiates.
  7. Some physicians who prescribe opiates do not fully appreciate the addictive power of the drugs that they are using or the difficulty in detoxing the patients.
  8. There are currently enough treating physicians and specialty physicians in most urban areas; however there are not enough physicians (treating, orthopedic or neurosurgeons, etc.) in the rural areas to meet the demand. This problem will only get worse as the population ages and more doctors retire. It will also get worse if physicians leave workers' compensation due to the demand for their services due to the implementation of the federal universal health care programs.
  9. Many surgeons and other physicians want to perform their craft (do surgery, provide injections, etc.). They truly believe that their surgery or injections will work even if the prior treatments have not been successful or if current evidence-based medicine says surgery is not appropriate.
  10. Every patient looks like a good candidate for an MRI when there is an MRI machine in the doctor's office.
  11. Not every person with a surgical or potentially surgical condition is a good surgical candidate. Though pre-surgical psychiatric evaluations are required for spinal cord stimulators (post spine surgery), the same is not true for many other surgeries.
  12. It is difficult for a patient who is in intractable pain to believe that strong medications (including opiates) are not appropriate or are not good.
  13. It is difficult for a patient who is in intractable pain to believe that not having back surgery will have the same ultimate result as having surgery when the surgeon is saying (with confidence) that the surgery will cure all. Even though current evidence-based medicine says differently.
  14. Because “doing something is better than doing nothing” when the patient is in intractable pain, if the surgeon says surgery will not be successful, the injured worker will attempt to find someone who will say that the surgery “will be more successful than not having surgery,” and will then attempt to have the surgery.
  15. Patient advocacy is the application of appropriate treatment and patient encouragement that allows the patient to remain as functional and productive as possible.
  16. Patient advocacy does not always mean the pursuit of treatment a patient desires.
  17. Patient advocacy may require the physician to decline to do the treatment sought by the patient when that treatment is inappropriate.
  18. In Workers'Compensation, there are many (known and unknown) underlying non-industrial, psyche/social issues that may hinder or completely stop optimum medical recovery.