The American workplace has changed dramatically since Illinois created its workers’ compensation system in 1911. But the workers’ compensation system, especially in Illinois, has not kept pace. Not only does the current system do a poor job of serving the majority of workers, especially parents and other workers who need flexibility to work hours outside the traditional workday and in off-site locations such as their own homes, but it also prioritizes the financial interests of groups such as lawyers and workers’ compensation doctors over the needs of both workers and employers.
The system needs to be reformed. Illinois policymakers should allow workers and employers to opt out of the state-run workers’ compensation system and to craft their own agreements around their particular circumstances – rather than forcing all workers and employers to adhere to rigid regulations that often no longer serve their purpose.
The early 20th century origins of workers’ compensation
At the turn of the 20th century, increasing numbers of Americans found themselves in new, hazardous working conditions in the jobs created by the Industrial Revolution. But few protections existed for workers who might be unable to support their families if they became injured at work. Workers’ compensation was designed to remedy that situation by providing medical care and income replacement to injured workers. The system, however, has not evolved to meet the needs of today’s workers and employers and is ill-suited to address the problems of the modern workplace.
Changes in the modern workplace
Far fewer people work in inherently risky jobs today. The industrial sector employed nearly a third of the workforce in 1900, but employed just 19% in 1999. And even today’s dangerous jobs have become less hazardous. Deaths per 100,000 workers fell more than 93% to just four by the end of the 20th century, down from 61 deaths per 100,000 workers at the start.
But workers also face new challenges. In the middle of the 20th century, just 30% of women were part of the workforce. That number has risen to nearly 60%. Increasing numbers of Americans must now balance work responsibilities with caring for a child or elderly relative: 82% of parents are in families where both parents work. Many employers have met those challenges by offering more flexible work environments such as telecommuting and flexible schedules. But workers’ compensation – a system supposed to protect workers – increasingly stands in the way of new work arrangements to meet workers’ needs.
Workers’ compensation was designed for an industrial workplace. Yet, it applies equally to a telecommuter working from home. A professor who slips on papers in his home office or an interior designer who trips on her dog can claim workers’ compensation.
That makes businesses less likely to give workers flexibility to work at home or, when employers do, to let workers set their own hours. A worker who answers email at night, after taking time to pick up children from school and prepare dinner, could still be considered in the workplace as though the distinction between work and home could be drawn as simply as when workers punched a time card. Employers have little control over possible costs if the employee is injured at home, and the broken workers’ compensation system gives employers an incentive to take away flexible working arrangements for fear of legal liability.
These problems are not unique to Illinois, but the Prairie State is unusual both in having one of the most costly workers’ compensation systems in America and in not having exemptions for small businesses or domestic workers. The absence of an exemption for domestic employees hurts increasing numbers of workers who must balance work with child or elder care. As with telecommuting, this can affect all workers, but it disproportionately affects women, who tend to spend more time caring for children. And, while not everyone can afford a live-in nanny, reducing impediments to hiring domestic help makes it easier for women to hold more senior positions.
Opting out of the state-run workers’ compensation system
While Illinois has one of the most restrictive workers’ compensation systems, Texas has one of the least restrictive, even allowing employers to opt out entirely. Critics of the Texas system allege this has led employers to cut services, but the evidence suggests employers prefer to save money by cutting areas prone to fraud, while often increasing benefits that employees value. Employers often provide better benefits than required for the same reason they offer flextime: to recruit the best employees at the lowest cost.
Special interests benefit from the current workers’ compensation system to the detriment of workers and employers
The government-imposed workers’ compensation system has also been far more susceptible to co-option by special interests. While workers and employers use the workers’ compensation system only when there is an injury, lawyers interact with workers’ compensation every day. As a result, although the workers’ compensation system is supposed to provide quick resolution to workers’ claims, the powerful lawyers’ lobby helped create a system that can stretch claims out over years. This costs businesses money and denies injured workers rapid settlement of their medical bills.
Medical providers, too, have benefited from a system that unnecessarily prolongs treatment and facilitates the overprescription of certain medications, including addictive opioids.
Employers and workers both have an incentive to design a better system, but the false presumption that the government-run system is better prevents them from doing so. Interestingly, Texas employers who opted out of the state-run workers’ compensation system have all but eliminated opioid overprescription.
Fixing Illinois’ workers’ compensation system means government must step back and allow workers and employers to reach agreements that make sense in their specific situations – arrangements that suit the needs of workers and employers, rather than line the pockets of special interest groups benefiting financially from the current system.
One day in 2014, before most people could even spell “opioids” (two “i’s), the CEO of a company named Healthentic asked me to review a white paper based on the output of its new analytics tool. Healthentic’s tool is far more focused on the “80” of the “80-20” rule than competing tools are. So, rather than drowning readers in data, the tool is supposed to help certain figures jump off the pages and lead to action.
As my role in life appears to be the thankless task of finding errors in other people’s work, I was pleasantly surprised that Healthentic called me to plausibility-check the tool early in the process, rather than disseminate it and wait for me to publish “highlights” of my analysis after the fact, as I am wont to do.
As usual, I noticed some highly suspect information. In this case, it was prescriptions for Tramadol, Oxycontin and Hydrocodone. With my usual charm, grace and humility, I said: “These figures can’t possibly be right. This isn’t an NFL team in constant pain. If these figures were correct, it would mean that 40% of their employees filled a prescription for a synthetic opioid in a single year.” We rechecked the figure and the raw data several times. And yet the original statistic refused to bend. It was accurate.
Ironically, the particular Healthentic customer profiled in the white paper was obsessed with employee health. Its staff could recite how many employees had high blood pressure or high cholesterol, participated in the “steps challenge” or the “biggest loser contest” or didn’t buckle their seat belts. But opiates and synthetic opioids — the elephant in the room capable of magnitudes more damage to employee health and productivity than any of the wellness vendor siren songs — had been completely overlooked.
In the days that followed, we talked through four possible scenarios and ruled out three:
Employees were being injured due to safety hazards and accidents — but the company’s OSHA reports were clean and, in any event, those prescriptions would have shown up in workers’ compensation, not group benefits;
Certain local doctors were prescribing way too many of these pills — but the prescriptions seemed to be coming from many different doctors;
Employees were reselling their prescription meds — but if that were the case they’d have enough sense not to purchase these pills through the PBM;
A sizable number of employees were at-risk or already addicted to opiates.
It was definitely the last. Little did we know this was the leading edge of the belatedly discovered synthetic opioid epidemic.
Healthentic analysis consistently finds that opioids are some of the most prescribed drugs for all employers. “Take two aspirin and call me in the morning” has become: “Take some Oxy and text me in the morning.” It wasn’t hard for a person with a few dental or medical procedures to have several months’ supply of the drug.
Pain is no laughing matter. It is human nature to ease suffering. But the cost and consequences of treating chronic pain so freely with opioids is shockingly high. Not a week goes by without more national news being made on the topic, such as Prince’s death. Of course it isn’t just famous people who are susceptible. Opioids — synthetically designed cousins of heroin — are so addictive there’s a Super Bowl commercial for another drug to treat constipation from chronic use. Obviously a market has to be quite sizable to merit a Super Bowl ad.
The good news is that it doesn’t have to be this way. Pursuing early detection of a large supply of opioids and putting treatment goals in place will help a great deal in avoiding chronic use and addiction. Employers can help to head off chronic use before it turns into addiction. Independent analysis of your data should identify the three key risk factors for this population:
a 45-day or greater supply;
10 or more prescription refills; or
overlapping synthetic opioid and benzodiazepine prescriptions.
As brokers and employers, you can flag this population to the medical carriers and providers. You yourselves won’t be aware who is at risk, in conformance with the new CDC guidelines.
I emphasize the word “independent” because of how far behind the curve the payers are. One insurance carrier told an employer not to worry about the 150 people Healthentic had tagged for being at risk for chronic opioid use. “We know about these people. They are in our medication compliance program. Most are on palliative care.” That would be an obvious whopper even if these employees had worked at Chernobyl, and a quick analysis confirmed there wasn’t a single palliative care referral in the group.
Employers’ obsession with wellness, and carriers’ unwillingness to run the data, is great for my business, and for Healthentic’s. Unfortunately, it is not so great for employees at risk for opioid addiction. The only good news is that at least they won’t be constipated.
Across the U.S., the number of reported events exemplifying the opioid and heroin epidemics continues to skyrocket. U.S. Government Publishing Office data shows that the usage of both prescribed stimulants and prescribed opiates increased by a factor of 19 in just two decades since 1994(1). On Dec. 18, 2015, the U.S. Centers for Disease Control and Prevention (CDC) released a report showing drug overdose deaths reached record highs in 2014, fueled in large part by the abuse of narcotic painkillers and heroin. In 2014, more than 47,000 Americans died from drug overdoses, an increase of more than 14% from 2013. About 61% of those deaths involved the use of opioids. From 2000 to 2014, the report noted that nearly half a million people have died from overdoses in the U.S. In 2014, there were approximately one and a half times more drug overdose deaths than deaths from motor vehicle crashes!(2)
A very worrisome statistic and trend…
For workers’ compensation insurers, opioid use in treating chronic pain has also exploded over the past two decades. Although there appear to be some signs that opioid use is finally cresting, insurers still have a long way to go in helping to ensure that physicians and the injured workers they treat are fully educated on the pros and cons of using opioids with various types of injuries and pain. As the Risk & Insurance article “Paying for Detox – The Opioid Epidemic Is Addressed by Detoxification Programs” notes, some workers’ compensation insurers have been funding tapering and detoxification programs to help dependent or addicted patients wean themselves off the very medications that were designed to ease their pain(3). Unfortunately, recidivism is common, with experts noting that it can take several attempts to wean someone off narcotics.
This article will highlight some of the challenges in front of us and share some innovative ideas on potential ways to help prevent opioid dependency and addiction before the habits requiring tapering and detoxification programs are ever formed.
The Challenge in Front of Us
In January 2011, USA Today shared a powerful story about David Fridovich, a three-star Green Beret general who has become an advocate for warning soldiers about the epidemic of chronic pain and the use of narcotic pain relievers sweeping through the U.S. military(4). Much like others across the country who have suffered a severe back injury, the general began taking narcotics for chronic pain in 2006. Over time, the general became addicted to narcotics. During one 24-hour period the general took five dozen pain pills. After going through a detoxification program, the general has been helping other soldiers avoid the complications he faced because he was unaware of the addictive nature of the pills he was taking.
In a recent book about the opioid and heroin epidemic in the U.S., Dream Land author Sam Quinones shares his research on the history of how we ended up where we are today. From a workers’ compensation perspective, the author shared a story about a prison guard who had injured his back during a fight with an inmate. The doctor, who took the guard off of work for six months, also prescribed opioids to be taken twice a day for 30 days. After becoming severely addicted, the guard said, “It really humbles you. You think you’re doing stuff the way it’s supposed to be done. You’re trusting the doctor. After a while, you realize this isn’t right, but there really isn’t anything you can do about it. You’re stuck. You’re addicted.”
Both stories illustrate how the use of painkillers can lead to dependency and addiction without warning. They also highlight the critical role prescribing physicians play in educating patients about the warning signs and addictive nature of opioid prescriptions. As part of this education process, prescribing guidelines and analytics can play an important role in driving better outcomes.
Opioid Prescribing Guidelines
For workers’ compensation insurers, it is critical to understand the opioid prescribing guidelines that underlie the way physicians are treating injured workers. The more the insurers can help educate physicians on best practices, the better off insurance companies may be in helping to prevent any issues that may arise because of unnecessary or excessive opioid prescribing.
The CDC worked with the National Drug Institute, Substance Abuse and Mental Health Services Administration and the Office of the National Coordinator for Health Information Technology to review existing opioid prescribing guidelines for chronic pain. Their review and analysis of eight prescribing guidelines highlighted a number of important provider actions, such as the review of pain history, medical and family history, pregnancy, prescription drug monitoring programs (PDMP), urine drug screening, evaluations of alternatives to opioids, rational documentation, tapering plans, referrals for medication assisted treatment, evidence review, conflicts of interest and more(5). In January, Kentucky Attorney General Andy Beshear announced his support for national guidelines for prescribing opiates for chronic pain, stating: “In Kentucky, we face a crushing epidemic of addiction. One of my core missions as attorney general is to better address the drug problem faced by our Kentucky families and workforce.”(6) In his speech, the attorney general mentions that he is joining other state attorneys general in voicing support for the CDC guidelines for prescribing opiates for chronic pain.
California’s “Division of Workers’ Compensation Guideline for the Use of Opioids to Treat Work-Related Injuries” documented treatment protocols for three specific pain categories:
Opioids for acute pain (pain lasting as much as four weeks from onset)
Opioids for subacute pain (one to three months)
Opioids for chronic pain and chronic opioid treatment (three months or more)(7)
The guidelines state that, in general, opioids are not indicated for mild injuries such as acute strains, sprains, tendinitis, myofascial pain and repetitive strain injuries. Just as important, the guidelines clearly warn physicians to consider and document relative contraindications (e.g., depression, anxiety, past substance abuse, etc.). The document provides an abbreviated treatment protocol for the three pain categories that address important topics like prescribing a limited supply of opioids, documentation, accessing California’s PDMP, monitoring opioid use, evaluating the use of non-opioid treatments, completing opioid use, educating patients on opioid usage and potential adverse effects, responsibly storing and disposing of opioids, tracking pain level, screening for the risk of addiction, testing urine for drugs and more.
At the end of the day, it is important for workers’ compensation insurers and physician employees to clearly understand the opioid prescribing guidelines that help physicians achieve a proper balance between treating workers’ pain and keeping them safe from any adverse impacts of excessive opioid usage. With more insurance companies leveraging early physician peer-to-peer outreach to open a dialogue between the insurance company physician and the treating physician, knowing prescribing guidelines and sharing that knowledge will be more important than ever in improving outcomes and return to work.
The Inspiration for Using Analytics
For more than a decade, Deloitte Consulting’s Advanced Analytics & Modeling practice has been developing claim predictive solutions designed to help insurance companies, self-insureds and third-party administrators better segment and triage predicted high-severity from low-severity claims, enabling business decisions and actions that can help drive loss cost savings of as much as 10% of an organization’s annual claims spending. (See Claims Magazine articles “Analytics on the Cloud: Transforming the Way Claims Leverages Advanced Analytics “(2011)(8), “Enhancing Workers’ Comp Predictive Modeling With Injury Groupings” (2012)(9), “Reaping the Financial Rewards of End-to-End Claims Analytics” (2014)(10) and “The Challenges of Implementing Advanced Analytics “(2014).(11) A large part of the claims modeling success is attributed to gaining actionable insights as early as first notice of loss before adverse chain reactions can set in, and shortly thereafter with the three-point contact investigation where additional information is learned about the patient’s history and co-morbidities.
The authors, having observed the success of predicting claims complexity outcomes early in the claim’s lifecycle, became excited about the application of similar models to help identify early warning signs of future excessive opioid usage by injured workers. With as much as 60% of workers’ compensation spending going toward medical costs, one-fifth of that related to prescription drugs(12), we believed the use of predictive models… combined with physician peer-to-peer outreach and proper prescribing guidelines… could help workers’ compensation insurers improve the lives of the injured workers while significantly reducing medical expenditures. The following sections explain the analytics journey undertaken to help move the needle on this issue.
Defining the Target Variable: Predicting Future Excess
An important part of any analytics journey is defining the target variable (i.e., what we are trying to understand and predict). Excessive opiates usage is difficult to ascertain, as higher consumption may indeed be necessary for the most severe injuries. Therefore, various tests on the most appropriate target variables were conducted to probe these hypotheses. Many versions of opioid supply days were tested (i.e., ultimate total supply days across all opiates drugs prescribed to, and consumed by, the injured worker). Variations of opiates prescription counts were also considered (i.e., ultimate count of opiates prescriptions through the lifecycle of the claims). Similarly, supply units were analyzed (i.e., ultimate sum of all individual opiates pills prescribed to, and consumed by, the injured worker from the day of the injury until the claim closure). Figure 1 illustrates the calculation of total supply days for three different opiates that were prescribed to, and consumed by, the injured worker over the duration of his workers’ compensation claim:
Figure 1. Supply Day Illustration
Methodology and Data Considered
Using predictive analytics and data science, a number of algorithms were built, tested, iterated and fine-tuned to better understand those like-injury cohorts (i.e., same injury sustained) that consumed more opiates than their corresponding peers who managed to consume a lower amount. Various thresholds of “excess” were analyzed by injury and venues, thus controlling for differences that affect the prescription base.
By testing these algorithms, it was determined that segmentation was similar across the different target variables. However, total supply days seemed to exhibit the most robustness from a modeling perspective and had intuitive interpretability (i.e., number of days an injured worker consumes opioids).
The algorithms used more than eight years of lost time workers’ compensation claims to accumulate enough data credibility. Claims were selected for various injury groups where opiates were prescribed and consumed for at least one prescription. The data was organized for a longitudinal study observing a claimant over time and quantifying her consumption of opiates. The comparison to this usage to like-injury counterparts over thousands of cases and using hundreds of attributes is what helped the model shed light on claimants who consumed excessive amounts of opioids relative to the entire population.
Over the years, Deloitte healthcare practitioners and claims professionals used ICD-9 codes that describe a disease or condition, as well as National Council on Compensation (NCCI) nature of injury and body part codes, to create more than 70 proprietary injury groups that are factored into the model to provide enhanced segmentation within like injury claims.(13) For illustration purposes in this article, we presented results for the injury group representing medium- and high-complexity spinal disorders (e.g., ICD-9 codes 722.0 – displacement of cervical intervertebral disc without myelopathy, 722.10 – displacement of lumbar intervertebral disc without myelopathy, 724.9 – other unspecified back disorders, etc.). We selected medium- and high-complexity spinal disorder claims because they are significantly more severe than the average workers’ compensation claim, and, as expected, these claimants typically have more prescriptions filled by their physicians. In addition, the models aren’t run on just any injury group. For example, an injury group containing low-complexity injuries such as finger cuts and minor open wounds would not be part of our analysis. Claimants with these types of low-complexity injuries do not require opioids, given the nature of injury, so it would not make sense to include these injury groups in the model.
The information attributes used to understand excessive consumption were sourced from similar data sources used in developing our claim-severity models. They are large in number and varied in terms of coverage. They include claimant data (e.g., claimant age, gender, job classification, years of employment, wage, claim filing lag, cause and nature of injury, etc.), prior claims data (e.g., prior frequency and type of claims), employer information (e.g., financial characteristics, years in business, etc.), injury circumstance (e.g. location, type, body part injured), three-point contact information (e.g., co-morbidities, early medical services) as well as other standard external third-party data sources (e.g. lifestyle, behavioral, geo-demographic).
The lift curves shown in Figure 2 illustrate the segmentation achieved by using multivariate equations to predict total supply days. Each claim below was scored using the model, which generated scores from 1 to 100, with lower scores corresponding to smaller predicted supply days and higher scores corresponding to larger predicted supply days. This score is represented on the x-axis of Figure 2, where each “decile” refers to a group of claims that compose 10% of the data. The actual supply days are tracked and plotted on the y-axis in the appropriate decile.
Figure 2. Lift Curve – GLM model
As one can see from Figure 2, injured workers studied who are predicted to fall in decile 10 have more than 18 times the supply days as workers predicted to fall in decile 1. Injured workers studied who scored in decile 10 consume, on average, more than three and a half years of opioid supply days! This very large and widespread segmentation suggests that individuals sustaining the same injury can still vary significantly in their future consumption of opioids… and this variation ranges from a couple months to more than three and a half years.
In Figure 3, we compare two 24-year-old male claimants with very similar injuries but drastically different predicted outcomes.
Figure 3. Similar Injuries, Drastically Different Outcomes
As one can see from Figure 3, the claimant scoring in decile 10 has a number of variables that correlate with the potential for excessive opioid use. Given the combination of co-morbidities, worker health, reporting lags, employer business conditions and additional attributes collected on the individual from external sources (e.g. lifestyle and behavioral data), it is possible for the insurance company to identify and analyze the early drivers that may lead to future excessive opioid the first few days after receiving notice of the claim.
With more than 60 predictive variables in the model (e.g., co-morbidities, prior claims history, job classes, injury causes, business characteristics, claim characteristics, etc.), the most influential categories and reason codes driving the score represent “eyeglasses” for the insurance company physician. The model helps the insurance company physician weigh together multiple pieces of information but doesn’t replace his judgement. Analogously, many of us wear eyeglasses to read a dinner menu, but those eyeglasses do not order the food for us.
Armed with a plethora of facts and the opioid prescribing guidelines, a physician can open a dialogue with the treating physician to help guide the discussion in a direction that best benefits the injured worker. The physician, using the prediction from the model, can tailor appropriate decisions and actions – from low touch or regular prognosis for the first claimant above, to a much more closely managed case for the second individual.
Figure 4 provides a drill-down into the actual versus predicted supply days achieved in the highest-scoring 30% of medium- to high-complexity spinal disorder claims for the train/test data and validation data. Using the train/test/validation approach, the models were trained and enhanced using approximately 70% of the claims data. The validation results shown below were derived from the remaining 30% of the claims data that was held in “cold storage.” Using this kind of blind-test validation data helps ensure that the model’s estimated “lift” (i.e., segmentation power) is true and unbiased.
Figure 4. Highest Score Drill-Down
Approximately 60% of claims scoring in deciles 8, 9 and 10 exceed one year in supply days. For a quarter of the claims, the injured workers take in excess of four years in supply days of opioids. At the far end of the spectrum, roughly 4% of medium- to high-complexity spinal disorder claims scoring in deciles 8, 9 and 10 will exceed a decade’s worth of opioids in supply days.
One Last Check
In addition to the generalized linear models (GLMs) discussed above, focused on predicting the actual supply days, we also ran a logistic regression model focused on predicting which claimants would take more than a year’s supply of opioids. Using classical statistical measures of precision (i.e., how many of the positively classified results are relevant), recall (i.e., how accurate the model is at detecting the positives) and specificity (i.e., how good the model is at avoiding false alarms), we achieved the following results: a precision of 59%, a recall of 64% and a specificity of 72%.(14) As one last test of the logistic regression model’s segmentation power, we calculated the receiver operating characteristic (ROC) curve. At almost 80%, it represented a good model from a statistical perspective. Although illustrative, we prefer the GLM model presented above.
Behavioral Economics and Nudges
All across the country, physicians and medical boards are spreading the word about the responsible prescribing of opioids. State and federal agencies are toughening criminal and administrative penalties for doctors and clinics that traffic in prescription drugs. Governors across the country are forming opioid working groups that include senior Health and Human Services professionals, attorneys general, drug courts, hospital professionals, elected officials and more.
Research shows that a number of factors can help insurance companies better understand the severity of claims early on in the life cycle of a claim. Two studies by the National Council on Compensation Insurance, Inc. (NCCI) highlight the effect of obesity on workers’ compensation claims. According to “Reserving in the Age of Obesity,” a Nov. 1, 2010, NCCI study by Chris Laws and Frank Schmid, the ratio in the medical costs per claim of obese to nonobese claimants deteriorates over time from a ratio of 2.8 at the end of one year, to 4.5 at the end of three years, to 5.3 at the end of five years.(15) In a following study from May 29, 2012, “Indemnity Benefit Duration and Obesity,” authors Frank Schmid, Chris Laws and Mathew Montero found the duration of obese claimants is more than five times the duration of nonobese claimants, after controlling for primary International Classification of Diseases (ICD)-9 code, injury year, state, industry, gender and age for temporary total and permanent total indemnity benefit payments.(16) Deloitte’s claim predictive models have shown that the number of medical conditions at the time of injury plays a significant role in determining the ultimate severity and potential for excess opioid usage (e.g., claims with three or more existing medical conditions are 12 times more costly than claims with no existing medical conditions).
With energy and momentum building around addressing the opioid epidemic, insurance companies can leverage behavioral economics and data-driven nudges to help treating physicians improve outcomes and return to work. Leveraging prescribing guidelines and the model results and reason codes that help explain the top five drivers behind the model prediction, insurance company physicians can be more strategic in shaping the discussions they have with treating physicians. For the highest-scoring claims, the insurance company may want to use a mix of peer-to-peer contact and data-driven nudges (e.g., “did you know that 95% of physicians we work with follow the state prescribing guidelines and only prescribe 30 days of opioids for this type of claim,” ”for injuries of this type, physicians we work with usually prescribe less than x milligrams of strength,” etc.). For lower-scoring claims, the insurance company may touch base with the treating physician but skip any reference to data-driven nudges.
In the end, it is important for workers’ compensation insurers and their medical professionals to clearly understand opioid prescribing guidelines and the internal and external factors that could affect the opioid usage and habits of their injured workers. A Business Insurance white paper titled “Opioid Abuse and Workers’ Comp – How to Tackle a Growing Problem,” described the challenge well: “Monitoring or managing opioid abuse is another key step for workers’ comp managers. It’s not enough to simply dive into the data and look for claimants who appear to be using lots of opioids. Nor is preventing doctors from prescribing opioids a desirable action. The goal is to find claimants who are struggling with a problem they never intended to have, and support those claimants in solving that problem.”(17)
However, our hope is that through the use of predictive analytics (i.e., the ability to identify, in the first few days of receiving a claim, individuals most likely to become high consumers of opioids), prescribing guidelines and physician peer-to-peer outreach, we can help increase insurers’ and treating physicians’ awareness as they work to help prevent injured workers from struggling with dependency and addiction before the behaviors or habits ever form.
As former British Prime Minister Benjamin Disraeli once said, “What we anticipate seldom occurs; what we least expect generally happens.” The science and passion exists today to better anticipate opioid trends and help prevent opioid dependency and addiction before it happens.
As used in this document, “Deloitte” means Deloitte Consulting LLP, a subsidiary of Deloitte LLP. Please see www.deloitte.com/us/about for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting.
This communication contains general information only, and none of Deloitte Touche Tohmatsu Limited, its member firms, or their related entities (collectively, the “Deloitte Network”) is, by means of this communication, rendering professional advice or services. Before making any decision or taking any action that may affect your finances or your business, you should consult a qualified professional adviser. No entity in the Deloitte Network shall be responsible for any loss whatsoever sustained by any person who relies on this communication.
 Precision measures the ratio of true predicted positives to the ratio of true predictive positives plus false predicted positives. Recall, also referred to as sensitivity, measures the ratio of true predicted positives to the ratio of true predicted positives plus false predicted negatives. Specificity measures the ratio of true predicted negatives to the ratio of true predicted negatives plus false predicted positives.
At the 2015 Harbor Health MPN Medical Directors Meeting, a panel discussed current issues affecting workers’ compensation. The panel consisted of:
Dr. Tedd Blatt (moderator)
Dr. Craig Uejo
Dr. Don Dinwoodie
Dr. Minh Nguyen
Dr. Kayvon Yadidi
Question: What are the things physicians can do or should do to improve workers comp?
Physicians need to assist in training their peers. There is inadequate training of occupational medicine physicians on the nuances of the workers’ compensation system. This is something other stakeholders in the system could also assist with.
Physicians need to be considering psycho-social issues in the treatment of patients. These can have a significant impact on claim outcomes.
There is not enough training for physicians on how to properly write medical reports, especially in the workers’ compensation arena.
It is imperative that physicians are responsive to questions from the payers. Failure to respond in a timely way to questions causes delays in reimbursement and creates animosity.
Question: How should physicians be approaching the issues of opioids, and are payers willing to consider alternatives?
This is something that needs to be considered from the initial visit forward. These drugs can lead to long-term issues, and prescribing them cannot be taken lightly. Too many physicians just prescribe these to make the patient happy.
There are inadequate detox programs to wean people off these drugs. Patients tend to bounce from one pain clinic to the next, which just continues the cycle of using these drugs.
Payers are often hesitant to authorize detox programs or non-pharmaceutical pain management alternatives because they view these things as experimental.
Physicians will soon be required to utilize CURES, the California prescription drug monitoring program, prior to prescribing opioids. This is intended to identify people who are doctor-shopping to abuse the opioids.
If you don’t prescribe the opioids, the patient will find someone else who does. Until there is a consistent approach to how these drugs are prescribed, this will continue to be a problem.
This is the greatest physician-created public health crisis in the history of the U.S. These drugs are massively overprescribed and should only be used for a very short term for post-operative care. They should never be used for long-term treatment.
Question: What do you think about utilization review? Are there things that you feel should always be subject to utilization review?
All surgeries should be subject to mandatory utilization review. Too many physicians are conducting unnecessary surgeries, which cause harm to their patients.
Compound medications and medications not usually prescribed in workers’ comp should be subject to utilization review.
There needs to be a level of common sense in UR. It should not be used if the recommended treatment is part of the normal course of care for an injury. Payers also are sometimes paying more for the UR review than the actual service requested costs.
If you have quantified that a physician is producing better outcomes for injured workers, these physicians should be subject to less utilization review.
The UR process needs to be more selective and focus on the outliers, not routine care. The perception from providers is that UR is being grossly overused. Physicians view this as punitive.
Question: More physicians are becoming part of larger health systems. Is this a positive change?
This is a positive change because the physicians have a better support structure to assist in writing reports and navigating the nuances of the workers’ compensation system.
Question: Is the Affordable Care Act going to affect workers’ compensation?
We will see an increased focus on outcomes, and, if a physician does not deliver superior outcomes, then payers will not refer patients to them for treatment.
Many of the policies under the exchanges have high deductibles and, because of this, it is likely we will continue to see pressure to push treatment into the workers’ compensation space.
Question: What changes would you recommend on the claims administrator side?
There needs to be more focus on better internal communication within claims organizations. Physicians end up sending reports and responding to requests multiple times because the claims organization does not have good internal communication.
The fee structure is affecting the number of physicians willing to treat workers’ compensation patients. Many specialists have stopped treating workers’ compensation patients because they do not feel adequately compensated for the amount of work required.
By now, most of you have read the series of articles published by ProPublica on “The Demolition of the Workers’ Comp.” These well-written articles touched on some very important issues faced by our industry. For example, caps to the wage-replacement benefits provided under workers’ compensation can devastate employees earning higher wages. In addition, there is wide variation in the total-loss-of-use benefits provided under the various state systems. Legislators around the nation and people in the workers’ compensation industry would do well to carefully consider some of the issues raised by ProPublica.
As someone who has been in the workers’ compensation industry for more than 25 years, I also found there were several shortcomings in the ProPublica stories. For example, ProPublica failed to touch on what is often the biggest reason behind an injured workers’ poor recovery, and that is the secondary-gain motivation of unscrupulous medical providers and attorneys. I remember years ago, when I first started handling claims, Texas had the worst workers’ compensation system in the nation. Plaintiff attorneys would refer injured workers to physicians who had been sued so many times that they had lost privileges at every hospital in the state. But that didn’t discourage these physicians, who had set up operating rooms in their offices and continued ruining the lives of so many injured workers. Many of the injured workers who were treated by these physicians were left in ruin both physically and financially. But this harm to injured workers was not being done by insurance companies or employers or the state systems. This harm to injured workers was being done by the attorneys those injured workers trusted and the doctors who worked with those attorneys. These attorneys and doctors were not motivated by what was best for the injured worker. They simply wanted a payday.
Today, Texas has one of the best workers’ compensation systems in the nation. What changed? The legislators and regulators realized that they had to stop those who put their self-interests ahead of injured workers. Legislators instituted treatment guidelines, mandatory second opinions, attorney fee caps and approved physician panels. Over time, those doctors who put their financial interests ahead of the health of injured workers were removed from the system. Texas is a remarkable success story that illustrates how the workers’ compensation system can be improved to provide better outcomes for both injured workers and employers.
ProPublica also noted that insurance premium rates are at a 25-year low. While this may be true, it is an extremely misleading statistic. Over time, there have been significant advances in loss prevention and safety. Workplaces are safer than they were 25 years ago. Lower “rates” reflect both safer workplaces and more competition among carriers. However, lower “rates” do NOT mean employers are paying lower premiums than they were 25 years ago. I would challenge you to find any employer that is paying lower premiums than 25 years ago. For most employers, premiums have increased steadily over time, and they continue to increase. Rate is but a single element in the calculation of premiums, so looking at rate alone as a performance measurement does not provide an accurate reflection of the true picture. Also, based on National Council on Compensation Insurance (NCCI) data, claims costs have risen pretty steadily over the last 20 years, as well. So, premiums and claim costs are significantly higher than 25 years ago. Those data elements are a better reflection on the actual state of the workers’ compensation industry than rate.
Many choose to use the ProPublica articles as an indictment on the entire workers’ compensation system. While I agree the system is far from perfect, the system functions quite well most of the time. The vast majority of injured workers receive medical treatment and return to work in their pre-injury job without any conflict or complications. Those workers do not retain attorneys, suffer financial hardship or have significant lasting physical effects from their work injury. For these workers, the system does exactly what it is intended to do.
There will always be examples of injured workers for whom the workers’ compensation system produced an undesired result. It is impossible to design a perfect system. However, for every example that can be provided where the system didn’t work, I can provide you examples where it worked very well. In the workers’ compensation industry, we are in the business of helping people recover from injury and resume their place as a productive member of our society. For the most part, this is something the industry does very well.
My company deals with catastrophic injuries and other high-dollar claims. Our caseloads are literally the “worst of the worst” in the workers’ compensation industry. We see horrible, life-changing, devastating injuries every day. Yet, in spite of this, I can provide countless examples of how the efforts of our staff, the employers we insure and the claims adjusters and service providers we work with went above and beyond what was required under the workers’ compensation statutes. For example:
A paraplegic worker lived with his family in a dilapidated mobile home that was insufficient for his wheelchair. We were obligated to provide him with comparable housing, which would have been a new mobile home. Instead, we purchased a house that was large enough for him and his family, complete with all the necessary modifications needed to make the home handicap-accessible.
A paraplegic worker used to enjoy hunting with his family. We purchased an all-terrain wheelchair in addition to his regular wheelchair so he could continue to enjoy this activity with his family.
We recently purchased experimental motorized leg braces for a paraplegic worker. Because of these braces, he is able to walk again.
I have seen numerous injured workers whom we have assisted in recovering from an addiction to opioid pain medications. When these injured workers are free of this addiction, their quality of life and their relationship with their families is significantly improved. We have had both injured workers and their family members thank us for helping them overcome this addiction.
I’m sure every workers’ compensation carrier or third-party administrator has similar examples they could share. My point is, for everything wrong that people can identify about the workers’ compensation system, there are also a lot of good things about it. There are also many good people in this industry who work very hard to assist injured workers in their recovery. At the end of the day, claims adjusting is about helping people. Perhaps we, as an industry, need to do a better job sharing the positive stories of what we do every day to make the lives of injured workers better.