Tag Archives: opioids

Optimizing Surgical Outcomes


Does the word “surgery” make you cringe as you consider the negative thoughts associated with the realities of surgical procedures? Despite advances in modern medicine, being on the receiving end of surgery is not without significant risk. This is why the concept of informed consent is embedded in every medical consent form patients are required to sign as a means of acknowledging and accepting the known or potential risks of the procedure. 

Even when the surgical outcome appears to have been successful, there is a risk of experiencing complications. Unfortunately, the outcomes of surgical procedures vary for many different reasons. Traditional methods of surgery achieve only average results in total when compared with the universe of surgical procedures profiled in MDGuidelines from the Reed Group, which provides average healing times for most procedures. The healing times are expressed in the expected duration of days of disability following the procedure. 

Traditional approaches will never achieve better-than-average outcomes in this model. The rising complexity of medical research and medical technologies offer the promise of improving surgical outcomes. However, without changing preoperative education and care, this promise will not materialize, and costs of surgical procedures will likely outpace medical cost inflationary trends. There is a need for innovation and breakthrough solutions to achieve cost containment in the way in which patients, employers, health insurance and primary care physicians and surgeons approach surgery differently. 

How Surgeries Affect the Workplace 

Surgery affects 5% to 10% of the population in any given year. Virtually 100% of employers have one or more employees undergo a surgical procedure each year and, thus, experience the costs related to outdated surgical approaches. In one estimate, over 50% of healthcare expenditures were the result of surgical procedures. And that analysis did not include the cost of common surgical complications, including opioid painkiller addiction, which affects 9% of post-surgery patients.

Employers are not immune from the complications and risks when employers choose elective surgical procedures outside the sponsored health benefit plan. Employers have a vested interest in employees receiving the best care when surgery is required for musculoskeletal, women’s health, cancer or other health reasons. The incentives may vary somewhat depending on the setting of healthcare benefits. Yet, the end goal remains the same: helping employees to navigate a scary, expensive time and to get back to life as soon as possible. 

The Impact of Suboptimal Surgical Outcomes

Suboptimal surgical outcomes have consequences that are borne by both patients and their family members, as well as their employer organizations. The major adverse impacts from suboptimal surgical procedures include the following representative examples summarized below:  

What Are Enhanced Recovery After Surgery (ERAS) Protocols? 

In the field of surgery, over the last decade advanced, innovative providers have separated themselves from their peers by implementing minimally invasive surgery as part of broader Enhanced Recovery After Surgery (ERAS) protocols. Such protocols can take many forms and include interventions before, during and after surgery. ERAS represents the entire surgical experience re-imagined with patients and their recovery front and center.

See also: 2021: The Great Reset in Insurance

Enhanced Recovery emerged in Europe over a decade ago. Since then, over 4,000 journal articles have been published enumerating the benefits of this approach across nearly every procedure type. ERAS protocols often include:  

  • tailored nutrition pre-surgery rather than lengthy fasting
  • multiple, non-addictive pain medications to get — and stay — ahead of surgery pain
  • techniques to prevent common surgical complications
  • strategies to improve the patient’s ability to return to normal life function sooner

Patients experiencing ERAS-based care demonstrate:

  • 30% shorter hospital stays
  • 50% fewer complications
  • 90% reduced opioid use
  • Thousands of dollars in savings per surgery
  • Faster return to normal life, including work

At a time when our society desperately needs solutions to the opioid crisis, ERAS provides one. In fact, it changes the picture entirely. What if you could change the underlying dynamic and prevent the first dose exposure to opioids? That’s exactly what ERAS does.

Surgeons, anesthesiologists and surgical teams have come together across disciplines to implement these care pathways in countries around the world, including the U.S. However, the adoption has been inconsistent. 

As the writer William Gibson once said, “The future is already here—it’s just not evenly distributed.”

Three primary systemic barriers explain the lagging levels of adoption for ERAS protocols:

  1. The reluctance of patients to ask their doctors hard questions about alternative treatments, less invasive surgical procedures and non-opioid pain management strategies
  2. Conventional wisdom and long-standing industry orthodoxy
  3. Slow adoption of innovation in many organizations, especially smaller and rural healthcare centers

SIDEBAR:  Opioid First-Dose Prevention 

A major benefit of the ERAS procedures has been the measured reduction in the amount of opioid pain medication both prescribed by surgeons and consumed by patients. In fact, adherents to ERAS protocols have shown verified reductions of up to 90% when compared with surgeries performed using standard/traditional pre-operative procedures. These evidence-based clinical findings are significant in that ERAS provides a direct pathway to reducing exposure to prolonged use of opioid pain medications. In turn, ERAS can reduce the probability of patients developing an addiction. Moreover, the potential downstream ripple effect of opioids being consumed by other family members is likewise reduced. ERAS protocols are a proven strategy for effectively preventing the first dose of highly addictive opioid pain medications and all the resultant potential side-effects, complications, misuse and addiction. 

Consider the Benefits of Surgical Quality Analysis

Through a surgery quality analysis, Goldfinch Health processes medical (including pharmacy) claims for one to three years and produces a summary of areas to watch and opportunities for improvement in one of the highest-cost areas of healthcare and employee productivity: surgery. 

The picture that often emerges is one of not only opportunity but urgency. For example, Goldfinch recently reviewed a population that showed during COVID-19:

  • 18% reduction in major musculoskeletal procedures (back, hips, knees, shoulders)
  • And a 25% increase in steroid injections into joints

Of course, this means members in this population have put off surgery. But, in the end, most of those cases are inevitable. There will be a knee replacement or shoulder procedure needed. Due to the time, stress and treatments that have occurred in the meantime, those members will report for surgery with diminished physical and mental health. It truly is a powder keg waiting to blow. 

Another group believed strides had been made related to opioid use. A deeper look at the data revealed progress had been made—but not in post-surgery opioid use, where painkiller use remained three times higher than national guidelines recommend. 

Considering surgery often touches more than 60% of high-cost claimant cases, these insights provide the vision to act before healthcare and productivity costs overwhelm your budget. 

See also: Mental Health in Post-COVID Era

SIDEBAR: Representative Insights Derived from Surgical Quality Analysis 

This surgery quality assessment by Goldfinch Health includes assessment of:

  • Outpatient vs. inpatient procedures (highlighting the potential for 40% (or greater) cost savings with outpatient procedures, and the formula for getting there)
  • Large incision (“open”) surgery vs. minimally invasive surgery approaches
  • Post-surgery opioid use  
  • Surgical complications benchmarked against industry standards

Conclusion: Who Can Benefit from a Surgical Quality Analysis? 

Surgical quality analysis is a proven strategy for self-funded employee benefit plans for private and public employers as well as union-sponsored health plans. Employee benefits administrators and trustees will gain insights from engaging in a surgical quality analysis. A surgical quality analysis of self-funded claims data will offer key insights as to instituting modern medical case management strategies to optimize healing and achieve cost containment strategies. In short, self-funded organizations seeking to improve the outcomes of surgical procedures to reduce patient safety risks, promote faster healing, expedite return to work, decrease lost work time and associated lost productivity and achieve cost containment can expect to find value in a surgical quality analysis.

Addressing the Rise in Topical Prescriptions

Across the country, healthcare providers are shifting their prescribing practices in response to the opioid epidemic. According to IQVIA Institute’s Medicine Use and Spending in the U.S. — A Review of 2018 and Outlook for 2023, prescription opioid volume declined 43%, from 246 billion morphine milligram equivalents in 2011 to 141 billion in 2018. Many factors have driven the decline, including news media coverage, state and federal initiatives (e.g., prevention, intervention, treatment and recovery support), the Center for Disease Control and Prevention’s 2016 guidelines for prescribing opioids for chronic pain, healthcare provider education, lawsuits against companies that manufacture and distribute opioids, the arrest and prosecution of healthcare providers and efforts taken by insurers to reduce opioid prescribing.

Although there has been significant progress in some ways, unintended consequences periodically emerge in the fight to reduce opioid dependency and addiction. For example, in early efforts to address the emerging opioid epidemic, law enforcement officials aggressively targeted and shut down opioid pill mills overnight. This abruptly left many opioid-dependent patients without access to opioids, resulting in a spike in heroin use. As another example, several states and private companies have successfully implemented policies to limit opioid prescriptions on initial fills to seven days or less under specific circumstances. In response, some healthcare providers have avoided these limitations by prescribing 30 days (or more) of pills in the shortened time frame. Lastly, as prescribers look for alternatives to opioids, the healthcare industry has seen a dramatic increase in the use of topical and compounded pain relievers. This has increased the cost of providing care in a healthcare system already struggling to contain medical costs. Despite the increased spending, these options often fail to demonstrate a corresponding desired therapeutic outcome.

This article will share some strategies being used by insurance companies to help injured workers receive cost-effective and therapeutically effective pain management drugs, with the ultimate goal of returning them to work and more productive lives.

Topical vs. Compounded Pain Reliever

By definition, a topical medication is a medication administered externally. Commercially available topical pain relievers usually contain one or more of the following ingredients: lidocaine, menthol, methyl salicylate, capsaicin and camphor.

The Food and Drug Administration (FDA) defines drug compounding as “combining, mixing or altering ingredients to create a medication tailored to the needs of an individual patient.” It notes: “[c]ompounded drugs are not FDA-approved.” Compounded medications can be made into a variety of dosage forms (e.g., oral, injectable, topical, etc.), but the majority of compounded medications we have seen in workers’ compensation are topical (i.e., applied to your skin).

Coventry and First Scripts 2018 Drug Trend Series Report noted that topicals represent 5.1% of high-impact drug classes by volume but 14% of costs. 68 of every 1,000 workers were using topical prescription analgesics, and nearly eight of every 1,000 workers were using private label topical analgesics. As Coventry’s Director of Pharmacy Product Development Nikki Wilson noted, retail, mail-order and out-of-network prescriptions for compounds costs and use decreased while topical costs and use increased in 2018. Topical costs increased due to the use of private label topical analgesics (PLTA), some of “[w]hich add little to no value clinically but increase costs exponentially” according to Wilson.

Studies Making News

In November 2016, CVSHealth published The Rise and Fall of Compound Spend – Ongoing Monitoring Enables Early Identification of Lidocaine Spend, which noted that gross costs per compounded claim “increased nearly 1,700 percent for employer clients” from January 2011 to March 2014, while the “[a]verage gross cost per 30-day script increased more than 10-fold over a three-year period.” Leveraging a multidisciplinary team that included pharmacists and physicians, CVSHealth developed criteria to provide “coverage consistent with labeling, FDA guidance, standards of medical practice and evidence-based drug information to help ensure patient safety and appropriate utilization.” Their strategies drove the use of lidocaine products down on average by more than 80%.

In the August 2018 Office of Inspector General (OIG) report, Questionable Billing for Compounded Topical Drugs in Medicare Part D, OIG found that about 550 pharmacies and 124 prescribers had questionable Part D billing for compounded topical drugs in 2016 based on five measures that OIG has developed as indicators of possible fraud, waste and abuse. The study was driven by the 625% increase in compounded drugs from 2006 through 2015. OIG made several recommendations, including clarifying Part D coverage policies, conducting training for Part D sponsors on fraud schemes and safety concerns related to compounded topical drugs, clarifying that sponsors may apply utilization management tools, and following up with the pharmacies and prescribers identified in the report.

Workers Compensation Efforts

Several insurance companies have been monitoring and addressing compound spending across the country. The Connecticut Interlocal Risk Management Agency (CIRMA) has achieved success curtailing prescription costs and opioid use by adopting a comprehensive managed care program that combines communication, education, collaboration and data. Through nurse collaboration, prior authorizations, managing the use of compound drugs, excluding long-acting opioids, discussing best practices with prescribers, addressing claims with high morphine equivalent doses and using generic drugs over brand drugs, CIRMA significantly lowered utilization of opioids and compounds. For compound drugs, CIRMA and Coventry created a dedicated drug evaluation team that managed compound drugs and prevented processing of such medications without adjuster approval and clinical input. The effort included providing adjusters with recommendations for appropriate management of compound prescriptions, which “led to a decrease in both compound spending and utilization,” where “the percentage of compound costs dropped 42% from 4.0% in 2015 to 2.3% in 2017.” 

According to CompPharma’s 15th Annual Survey Prescription Drug Management in Workers’ Compensation, the survey of 29 state funds, insurers, TPAs and self-insureds showed that there has been a 49% reduction in compound usage among survey respondents with data for 2016 and 2017. Of the respondents who provided figures, only one had an increase in total compounds reimbursed. A number of reasons were cited for the decline in total drug costs, including a continued focus on improving clinical management programs, expanding utilization review and prior authorization, dramatic reductions in compounds, changes in prescribing patterns driven by physician awareness of opioid risk, state formularies and more structured drug alerts and alert management processes.

Effective July 1, 2018, the Texas Division of Workers Compensation revised Title 28 Texas Administrative Code, amending the definition of the closed formulary to exclude “any prescription drug created through compounding” and “required pre-authorization for all prescription drugs created through compounding.” The background section stated that reimbursements per compounded drug increased 141% from calendar year 2010 to 2015, with ingredient costs for a selected group of 10 commonly compounded drugs increasing between 82% and 1,474% from 2010 to 2014.

Chesapeake Employers’ History with Opioids

For more than a decade, Chesapeake Employers has been trying to turn the tide against the opioid epidemic. In 2009, a dedicated pain management review nursing position was established within the Health Services department to identify and monitor concerning claims. Since that time, the scope of the internal pain management program has evolved and expanded greatly. Now, in addition to a dedicated pain management nurse, Chesapeake Employers’ leverages the data analytics from its Pharmacy Benefit Manager (PBM) Express Scripts and the expertise of an in-house pharmacist, physicians and nurses to stay cutting edge in the approach to care. While there are many indicators of success, the above efforts have helped reduce the dollars spent on dispensing opioids by almost 76% over a five-year period and seen the number of injured workers receiving opioids decrease by 66%. 

Some of the most notable initiatives provide necessary resources to raise awareness for providers, the public and our employees. In 2016, Chesapeake Employers gave $750,000 to the Department of Health to be used for the state’s prescription drug monitoring program (PDMP), which allows prescribers and pharmacists to review opioid fills from all sources within the state. In 2017, Chesapeake Employers launched the STOPIOID addiction campaign via radio ads, safety kits and online safety posters to help educate Maryland about the dangers of opioid abuse and addiction. The Chesapeake Employers’ Communication Department won four awards from the Public Relations of America – Maryland Chapter, including “Best in Show” for our Let’s Work to Stop Opioid Addiction Now campaign in 2018.

See also: Access to Care, Return to Work in a Pandemic  

A final highlight was the 2019 rollout of the Opioid Overdose Response Naloxone (Narcan) training authorized by the Maryland Department of Health, which teaches employees and the public about opioids and overdose and provides materials and training to save lives. 

Chesapeake Employer’s Compound and Topical Strategy

As stated earlier, a costly effect of reduced opioid prescribing seen throughout the industry has been a proliferation of prescribing for topical and compounded pain medications. A recent analysis of Chesapeake data reveals hundreds of thousands of dollars, a larger share of annual drug expenditures, is spent on compounded or topical medications. Similar to trends seen in the industry, Chesapeake Employers’ has observed an increase in cost and use of these medications. Since 2016, pharmacy-dispensed topicals have increased from 2.8% of scripts to 4.4% and from 6.1% to 9.3% of total costs in 2019. This does not include costs for compounded medications and physician-office dispensed topical medications, which further inflate costs. 

Chesapeake Employers leverages a multi-disciplinary team approach when managing pharmacy cost and utilization. This includes the in-house pharmacist, physicians, nurses, claims and legal professionals. The goal is to facilitate rapid injured worker recovery by using cost-effective and therapeutically effective drugs and appropriate means. 

In 2011, Chesapeake Employers’ began researching and educating our claims and health services professionals on compounded medications. The research included documenting the available medical literature and outlining the circumstances under which the use and payment for a compounded medication may be considered reasonable. The research is updated periodically and peer-reviewed by an external independent medical expert.

Closed formulary states, such as Texas, Arizona and Tennessee, only cover drugs on the adopted Official Disability Guidelines (ODG) Workers’ Compensation Drug Formulary list. According to the NCCI’s June 2019 Research Brief Formulary Implementations and Initial Impacts on Workers Compensation, use of topical and compound drugs in Tennessee decreased 35% following the requirement of pre-authorization for all topicals and compound drugs, regardless of the ODG Formulary status. By contrast, Maryland is an open formulary state, which allows physicians to prescribe any medication available on the market. In an effort to address the use of costly topicals and compounds, Chesapeake Employers leverages established medical policy supported by evidence-based medicine and guidelines to help educate healthcare providers. Assessment of the topical’s therapeutic value becomes necessary in continuing its use with our injured workers. Research shared from the American Medical Association (AMA) Opioid Task Force, medical journals and the Federal Drug Administration’s Opioid Analgesic REMS Educational Blueprint shows healthcare providers are less likely to prescribe medication when educated about the risk, especially when guidance is supported by medical guidelines and continuing medical educational training focused on opioid prescribing, non-opioid alternatives and pain management. An educated prescriber provides another layer of protection to the process, because providers are asked to provide the rationale that supports medical necessity and appropriateness. 

In addition to discussions with providers, Chesapeake Employers has implemented other successful initiatives. The company partners with a local compounding pharmacy to meet the prescription needs of injured workers at a lower cost. The company also provides educational letters to prescribers for high-cost topicals for which there are therapeutically equivalent alternatives at a much lower cost. Some individual claim recommendations generate cost savings of greater than 85% without compromise of the desired clinical outcomes.


Educating patients, educating prescribers, using a multi-disciplinary team, enhancing data analysis and reporting, in addition to using peer reviews and independent medical evaluations (IMEs), offer a cohesive approach to evaluating the medical necessity and therapeutic effectiveness of compounds and topicals.

In the face of rising use and cost, insurance companies must help injured workers receive cost-effective and therapeutically effective drugs so they can receive the care they deserve and ultimately return to work and more productive lives. 

See also: Can AI Solve Health Insurance Fraud?  

However, there is still a lot of work to be done when it comes to taking care of our injured workers. It is strongly believed that healthcare professionals are conscious of prescription costs when they are educated about the cost ramifications of their prescribing habits. Greater awareness and transparency about topical pain medications results in better, informed patient care decisions. As Larry Winget said in his book “It’s Called Work for A Reason,” “Knowledge is not power. The implementation of that knowledge is power.”

When all parties involved in the workers’ compensation system understand the therapeutic equivalence, effectiveness and cost savings from using alternatives; and the importance of only prescribing drugs when it is medically necessary for the injured worker, everyone wins.

Potential Risks of Illicit Drug Residue

As we continue to face a national opioid crisis, insurance adjusters need to keep their safety top of mind during the inspection of a drug-related claim. It is essential to be aware of the potential health risks you could be facing, especially if the property or vehicle you are dealing with may be contaminated with an illicit drug. When you first step on the scene, remember to think whether the property could have been contaminated by the insured, a third party involved in the claim or an unknown party.

Take a situation where an adjuster is inspecting a property damaged by the renter, and a mysterious white powder is discovered. This powder could be a number of substances –flour, drywall compound, cocaine or even fentanyl. It is important to treat it with caution while identifying the substance, as this will affect the claim and your safety. Another example is water damage that has occurred to a home where recreational drug use or pill pressing occurs. Adjusters must ask themselves and their teams what the contents or mixture of those pills were. Moreover, what if a car is stolen and damaged by individuals high on drugs? What is the risk is to the repair facility?

It’s important to mitigate and manage these types of losses. How do we protect ourselves and our sub trades and rehabilitate the risk? Start by asking yourself, do I really know what the risks are and who can help assess and clean it up? Next, think about the risks by asking yourself, how can we best manage the salvage? As the fentanyl crisis continues, these questions are all crucial.

Fentanyl and carfentanil are both now being cut into to illicit drugs like cocaine, heroin and counterfeit pills, which are made to look like prescription opioids. For this reason, there is no easy way to know if carfentanil was used in the making of a drug – especially because you can’t see, smell or taste it. This causes additional problems, as it is essential to know if there is even a very small amount of fentanyl when handling a substance because of its danger due to the high level of toxicity.

See also: Better Treatments for Opioid Addiction  

What level of exposure from opioids increases health risks? The answer isn’t clear-cut, as it depends on the types of drug that are present – scenes are highly variable if inspections are uncontrolled and unregulated. With fentanyl being 50 to 100 times more potent than morphine, and carfentanil approximately 100 times more potent than fentanyl, the risk is apparent. As little as a grain of salt of carfentanil could be lethal.

If faced with a situation possibly involving illicit drugs, it is important to do your homework and make sure that qualified and experienced firms are used for the testing and decontaminating of fentanyl or carfentanil. Cleaning can create hazardous wastes or other issues if not done properly. Documenting the work and results by designated professionals is another way to limit a potential liability.

In any case, next time you’re walking through a property and notice a strange powder on your clothes, think twice before simply brushing it off. The results could be fatal, not only to you but to whomever you may come in contact with.

Better Treatments for Opioid Addiction

The opioid epidemic is a moral hazard of existential proportions.

A test of the moral health of the insurance industry in which the question is, Will insurers acknowledge the severity of this threat by subsidizing better ways to treat this threat?

Will insurers accept what patients concede and even cynics confess, that specific treatments for opioid addiction outside the U.S. are more effective than the many but mostly unsuccessful treatment options in the U.S.?

Will insurers admit that it is more expensive to cover what does not work than it is to underwrite what returns people—healthy and strong—to the workforce?

To ask these questions is to know that it is smarter to insure domestic tranquility by experiencing it abroad, that it is easier to promote the general welfare by supporting programs that lessen dependency on welfare, not because these programs are wrong, but because it is wrong to abandon tens of millions of people—including mothers and military veterans—to short, nasty and brutish lives of addiction.

The answers to these questions are available to all.

See also: Alternatives to Opioids for Pain Management  

The answers, thanks to my correspondence with staffers at Clear Sky Recovery, raise the ultimate question of whether we will exist half-slave or half-free, whether we will succumb to the ravages of opioid addiction or avoid this descent altogether, whether we will cause our health to worsen or rally to the cause of health and wellness.

What I ask of insurers is no different than what insurers should ask of themselves: help.

Let us be unafraid to seek help.

Let us also be aware that help is achievable, that help is available, that help is accessible.

Let us free ourselves from the false promises of what is a racket rather than a legitimate means of rehabilitation, what with the bombardment of ads and commercials, what with the inundation of junk mail and junk science—an audiovisual overdose of empty words and meaningless slogans.

Let us wake up to the reality of this situation, that we face a do-or-die decision; a dire choice, indeed.

Either we do what is necessary, either we do what is right, or we plead guilty to the fast death of minds and the slow loss of bodies: a sight too painful to witness but too profound to ignore, a sight too traumatic to forget but sometimes too awful to recall.

Either we unite against opioid addiction, or we allow our divisions to destroy us.

Either we encourage patients to get treatment abroad, or we stop demanding that insurers pay for treatment whose efficacy is questionable and whose rate of failure is so high as to be unquestionable.

We must choose what is just, in lieu of what is popular or convenient.

See also: Is There an Answer to Opioid Crisis?  

That standard should determine not only treatment for opioid addiction but how insurers treat all matters of health and wellness.

With truth as our guide, we can stop the advance of opioid addiction.

With insurers on our side, we can win this war.

Maine Says: Buy Your Own Marijuana

Bourgoin v. Twin Rivers Paper Co. (SJC Maine, June 14, 2018)

Maine has just joined the list of states that preclude worker’s compensation coverage for the cost of medical marijuana used to treat a workplace injury.

Bourgoin sustained a workplace injury that caused him to suffer chronic back pain and total disability. After receiving a certification to use medical marijuana, he obtained an order from the Worker’s Compensation Board directing Twin Rivers, his former employer, to pay for the cost of the marijuana. He found that marijuana was more effective and had fewer side effects than the opioid drugs he had been prescribed.

Twin Rivers appealed, arguing that the federal Controlled Substances Act (“CSA”) prevented an employer from paying for marijuana even when it is legal under state law. The Maine Supreme Court acknowledged that the CSA expressly disclaimed “field preemption” but held that there was an inevitable conflict between state law that ordered an employer to pay for marijuana and the CSA, which criminalizes marijuana.

The court concluded that, if Twin Rivers subsidized the cost of marijuana as a worker’s compensation benefit, it would inevitably be aiding and abetting a federal crime, which is itself criminal activity. The court emphasized that “the magnitude of the risk of criminal prosecution is immaterial in this case. Prosecuted or not, Twin Rivers would be forced to commit a federal crime if it complied with the directive of the Worker’s Compensation Board.” Two justices dissented.

This article was written with Meghan Shiner.