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How to Think About the Zika Virus

Employers may be considering the risk posed by the recent spread of the Zika virus and potential claims filed by employees who contract the disease. The Zika virus is transmitted to people primarily through the bite of an infected Aedes aegypti species mosquito. These are the same mosquitos that spread dengue and chikungunya viruses. Mosquitos become infected when they feed on a person already infected with the virus. Infected mosquitos spread the virus to other people through bites. The virus can also be spread through blood transfusion or be sexually transmitted.

Where Is Zika Spreading?

Prior to 2015, Zika virus outbreaks occurred in areas of Africa, Southeast Asia and the Pacific Islands. In May 2015, the Pan American Health Organization issued an alert regarding the first confirmed Zika virus infections in Brazil. Locally transmitted cases were also reported in the Commonwealth of Puerto Rico. As of March 16, 2016, no mosquito-transmitted Zika cases had been reported in the continental U.S., but cases have been reported in returning travelers. Outbreaks are occurring in many countries, and the virus will continue to spread, but it is difficult to determine how and where. However, researchers who tracked dengue fever outbreaks in the past predict small local outbreaks of the Zika virus in Florida and Texas.

What Are the Symptoms?

About one in five people infected with the Zika virus become ill. Symptoms include fever, rash, joint pain, conjunctivitis (red eyes), muscle pain and headache. The exact incubation period (the time from exposure to symptoms) is not known, but is likely to be a few days to a week. The illness is usually mild, with symptoms lasting for several days to a week. The Zika virus usually remains in the blood of an infected person for a few days, but it can be found longer in some people. Severe disease requiring hospitalization is uncommon. Deaths are rare. Cases are identified by the symptoms, confirmation of recent travel to locales with confirmed infections and blood tests.

See also: Healthcare Case on Cutting Corners

How Is Zika Treated?

No vaccine or medications are available to prevent or treat Zika infections. An infected individual showing symptoms should get plenty of rest, drink fluids to prevent dehydration and take medicine such as acetaminophen to relieve fever and pain. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS), like ibuprofen and naproxen, should not be taken until dengue can be ruled out to reduce the risk of hemorrhage (bleeding). An individual taking medicine for another medical condition should consult a healthcare provider before taking additional medication.

What Special Precautions Should Be Taken by Pregnant Women?

A mother already infected with the Zika virus near the time of delivery can pass the virus to her newborn around the time of birth, but it is rare. It is possible that the virus could be passed from mother to fetus during pregnancy. This mode of transmission is being investigated and is not yet understood. To date, there are no reports of infants getting the Zika virus through breastfeeding. The Centers for Disease Control and Prevention (CDC) recommends that women who are pregnant or trying to become pregnant use special precautions including avoiding travel to affected areas and using protective clothing and insect repellant. Women who are trying to become pregnant or thinking about becoming pregnant should consult with their healthcare providers before traveling to these areas and strictly follow steps to prevent mosquito bites during the trip. There have been reports in Brazil of microcephaly and other poor pregnancy outcomes in babies of mothers who were infected with the Zika virus while pregnant. Microcephaly is a medical condition in which the circumference of the head is smaller than normal because the brain has not developed properly. Additional studies are planned to learn more about the risks of Zika virus infection during pregnancy.

See also: Healthcare Quality: How to Define It

What Should Employers Do?

Businesses with employees traveling to areas of infection should follow the precautions outlined by the CDC, including preventative measures to avoid mosquito bites. If a workers’ compensation claim is filed for Zika virus exposure, it should be handled the same as any disease or exposure claim would be handled. A thorough investigation of the claim and circumstances involved should be conducted, and medical tests and evaluations should be done to confirm a diagnosis. Compensability determination would follow applicable regulatory standards for determining whether exposure occurred within the course and scope of employment.

Physician Dispensing: Costs, Consequences

At WCRI 2015, the panel of Vennela Thumula (Workers Compensation Research Institute), Dongchun Wang (WCRI) Alex Swedlow (California Workers’ Compensation Institute) and Artemis Emsilie (myMatrixx) tackled physician dispensing.

Eighteen states have made changes to their rules regarding physician dispensing, with a focus on pricing. Four states (Pennsylvania, North Carolina, Tennessee and Florida) also put limits on the timeframe in which physicians could dispense.

According to WCRI studies, the prices paid for medications dispensed by physicians decreased significantly after regulations were reformed. However, the prices paid after reforms were still significantly higher than for the same drug from a retail pharmacy.

The exception was Ilinois, which saw the costs of physician-dispensed medications increase after reforms. This appears to be because of a change in prescribing patterns as physicians shifted to reformulated medications, which reimbursed at a much higher rate. So, it was this change in prescribing patterns that caused the cost increase, not the reform bill.

Another study focused on whether physician dispensing increased opioid use. The results were somewhat inconsistent. There was an increase in pharmacy-dispensed stronger opioids, but overall the number of prescriptions for stronger opioids dropped. However, the frequency of physician-dispensed nonsteroidal anti-inflammatory drugs (NSAIDs) and weaker opioids increased slightly post-reform. Overall, there appears to be a drop in the total opioid prescriptions after physician-dispensing reforms, but not as significant as you would expect.

A study by CWCI focused on whether injured workers had adequate access to retail pharmacies. Access was clearly not an issue, as almost all injured workers had multiple pharmacies within a short distance of their homes. The CWCI study also showed a greater delay in return to work and an increase in overall claims costs when there were physician-dispensed medications. This increase in costs was not simply the increased cost of medications but also increased disability and more frequent office visits.

The final speaker focused on differences between workers’ compensation and the commercial marketplace with regard to physician dispensing. The biggest difference is that on the group health side the process is integrated. The focus is on speeding the care to the patient, not increasing the overall costs. The group health physician checks the insurance formulary and drug utilization protocols prior to dispensing. In workers’ comp, these different processes are siloed. The main reason for physician dispensing in workers’ compensation is the increased profits to the physicians, not integrated speed of patient care.

Audience members reminded everyone that the focus around management of opioids needs to be mostly on the appropriateness of the medication, not who is doing the dispensing.

There was a recent New York Times article on this subject that I encourage readers of this blog to review.

Understanding the Challenges in Narcotic Management

At a cost of more than $1.4 billion annually, narcotics and opioids have rapidly become one of the highest-cost therapeutic categories for workers’ compensation injuries.* They are also among the most difficult to manage. No employer wants to have injured workers in undue pain or discomfort – and narcotics do alleviate pain. However, there are serious issues to consider with regard to prescription abuse and misuse, especially for opioids such as Oxycontin and Vicodin.

How can employers help injured workers while ensuring appropriate use of narcotics and reducing unnecessary costs? Comprehensive, clinically based narcotic management programs can help.

Over the past 10 years, opioids, a type of narcotic, have become more commonly used to treat chronic to severe pain associated with workers’ compensation injuries. Known by the generic names of morphine or codeine, and now more frequently by the brand names Oxycontin and Vicodin, opioids are powerful pain relievers.

However, many of these medications were initially intended for end-stage cancer, not for common workplace injuries. While there is likely some benefit in some cases for the use of such medications to treat workers’ compensation injuries, clinicians note that those benefits are typically seen by just a small percentage of patients. There is little evidence to support their long-term or widespread use in standard workers’ compensation injuries. In fact, a study reported by the American Insurance Association found that only a minority of workers with back injuries improved their level of pain (26%) and function (16%) with the use of opioids.** What’s more, there is a high risk for abuse, dependency, and overutilization with this classification of drugs. Indeed, the strongest predictor of long-term opioid use was when it was prescribed within the first 90 days post-injury; that means that every prescription – especially the first one – must be scrutinized to ensure appropriate utilization and optimal benefit. Employers are also concerned about the cost of narcotics. While narcotic use is concentrated among a small percentage of claimants, per-claim costs for narcotics have increased more than 50% over the past decade

Key statistics

  • From 1997 to 2007, the milligram per person use of prescription opioids in the U.S. increased from 74 milligrams to 369 milligrams – that’s an increase of 400%.
  • In 2000, retail pharmacies dispensed 174 million prescriptions for opioids; by 2009, 257 million prescriptions were dispensed – an increase of more than 40%.
  • Opioid overdoses, once almost always because of heroin use, are now increasing because of abuse of prescription painkillers.

White House Office of National Drug Control Policy

Managing narcotics is not about removing viable medications for mitigating pain from the therapies available to providers – it is about ensuring the best possible medications for workers’ compensation injuries are used.

As a result, claims examiners should be trained to look for red flags, such as:

  • Higher-than-normal physician dispensing.
  • Lower-than-average generic dispensing.
  • Higher-than-average prescribing of opioids such as Fentanyl Citrate.

But prescribing medications is a complex issue – reports and percentages alone don’t tell the whole story. So, it’s crucial to look beyond simple prescribing reports to uncover additional information that could indicate why prescribers’ patterns are outside the norm. For example, use of amphetamines could indicate that a patient has a traumatic brain injury, where such medications are a standard treatment protocol.

Drugs that are not suitable for the injury type and the age of the claim need to be identified at the point-of-sale, so claims examiners or nurses are alerted before a prescription that is outside the formulary is filled at the retail pharmacy and can intercede with drug management, if needed. This is particularly useful in the acute injury stage to eliminate early narcotic use where it is not appropriate. If a narcotic is prescribed, the injured worker’s entire medical history needs to be reviewed, using both in-network and out-of-network transactions and non-occupational associated medications to evaluate actual medication use and ensure appropriate utilization.

Follow-up appointments should be required, and only a few days of treatment should be authorized initially. This helps determine whether the medication has improved pain control and function.

Another critical step to managing narcotics is to thoroughly educate employees as to the benefits, dangers, and alternatives for narcotics. The education should include:

  • Training the injured workers about their medication, adverse side effects, and alternative medication options.
  • Required screenings for risk of addiction or abuse (history of drug or alcohol abuse, or regular use of sedatives).
  • Opioid use agreement/contract with urine drug screenings and avoidance of other sources for medication, such as emergency rooms.

A number of factors should trigger a review:

  • Narcotic-class medications for the treatment of pain (Oxycontin, Demerol, etc.).
  • Use of multiple medications excessively or from multiple therapeutic classes.
  • Using medications not typical for the treatment of workers’ compensation injuries.
  • High-cost medications.
  • Receiving high doses of morphine equivalents daily for treatment of chronic pain.
  • Using three or more narcotic analgesics.
  • Receiving duplicate therapy with NSAIDs, muscle relaxants or sedatives.
  • Using both sedatives and stimulants concurrently.
  • Using compounded medications instead of commercially available products.

* “Narcotics in Workers Compensation,” NCCI Research Brief, Dec. 2009

** http://www.aiadc.org/AIAdotNET/docHandler.aspx?DocID=351901