Claims involving chronic pain can be challenging for workers’ compensation insurers due to the nuances of each claim. Chronic pain cases are complex in nature—involving multiple symptoms, chronic anxiety or depression, changes in anger control, various lifestyle changes and increased tolerance for pain medication, just to name a few. Workers’ compensation insurers must take steps to appropriately monitor prescription drug utilization for these claims on a case-by-case basis.

Within chronic pain cases in workers’ compensation, as within healthcare in general, medications are typically an effective and cost-saving form of therapy. According to a NCCI Winter 2009 study, prescriptions account for 19 percent of workers’ compensation expenses on average. However, according to recent industry statistics, prescriptions associated with chronic pain may comprise 30 to 40 percent of a workers’ compensation claim. Containing these costs is critical for workers’ compensation insurers as costs can rise quickly over the lifecycle of a claim.

Many of these long-term claims involving chronic pain (and their often associated higher utilization of pain medications) lead to increased costs over time. According to a 2007 NCCI report, prescription drugs typically accounted for 3 percent of costs on the claim in the first year; but after a seven year lifespan of the claim, the percentage jumps to 31 percent.

In addition to the challenges of heightened medication costs, overuse of pain medication, and specifically opioid use, have shown adverse effects on injured parties’ overall well-being and treatment. A June 2008 study by the California Workers’ Compensation Institute (CWCI) on workers with back injuries found that high levels of opioid use, were associated with a high prevalence of adverse outcomes, increased lost time from work, and delayed recovery. This analysis added to other literature suggesting that at higher levels of use opioids can have an adverse impact on both activity levels and on self-sufficiency. Prolonged administration may impede, rather than facilitate, injured workers' recovery from occupational injuries.

Drug costs associated with chronic pain in workers’ compensation claims may be decreased using a variety of methods, including substituting generic equivalents for brand-name medications and leveraging pharmacy network discounts. Savings from these two methods are irrelevant if the medication should not have been dispensed in the first place. It is important to ensure that all medications dispensed are appropriate for each chronic pain case. This can be accomplished by having medical professionals review the injured worker’s therapy.

One solution that payers should take a closer look at is medication therapy management (MTM), which enables a pharmacist to optimize an injured party’s medications, minimizing complications or interactions. The purpose of the concept, which was originally established by the Medicare Modernization Act of 2003, is to ensure that medication therapy is individualized to meet the unique needs of the injured party in workers’ compensation.

The initial steps of effective MTM are:

• Analysis of injured party’s medical history
• Comprehensive medication review
• Detection of adverse drug events
• Monitoring of drug therapy outcomes

Based on this review, the pharmacist makes recommendations for modifying medication therapy and communicates these potential treatment plans to other providers including insurers, physicians and retail pharmacists, to improve on injured party medication outcomes.

Recently we conducted a study that examined MTM reports completed between July 2007 and July 2008 for a group of workers’ compensation claims in one jurisdiction. The study found that 90 percent of the reviewed claims had at least one inappropriate medication approved on the claim and 56 percent had prescription dosages that required modification. What’s more, if every clinical pharmacist’s recommendation was followed, as reviewed and approved by the treating physician, the average per claim savings could amount to more than $6,000 annually.

In chronic pain cases, not only will the recommendations of pharmacists result in reduced costs, they may also improve the therapeutic outcome for injured parties who experience adverse effects from pain medications. A recent study listed in the March 25, 2009 issue of the Journal of the American Medical Association noted that collaborative strategy for chronic pain management—including patient and primary care doctor education as well as frequent reevaluation of the pain plan—provided better relief of pain compared to standard care.

An MTM strategy should effectively meet an insurer’s cost containment objectives. This type of program is generally appropriate for claims that involve chronic pain treatment resulting from injury, have excessive medications, or are more than three years old and show a history of more than one prescribing physician. In these types of chronic pain cases it becomes increasingly important for all parties to note changes in behavior to identify red flags. It is also important for claims professionals, pharmacists providing MTM and prescribing physicians to have direct communication regarding recommendations for treatment.

Here’s an example of how a chronic pain claim works. A woman suffered a right-elbow injury on the job and filed a workers’ compensation claim. After undergoing multiple surgeries, she still has chronic pain in her elbow and shoulder as well as limited elbow movement. She was prescribed five medications which caused subsequent conditions of depression and anxiety.

After a comprehensive review of the injured party’s medical records and prescription history by a clinical pharmacist, it was determined that the injured party was inappropriately being treated for insomnia. The clinical pharmacist and physician recommended the elimination of a drug from her regimen and that she might benefit from being treated for insomnia and depression with a non-drug therapy. As a result, by reducing a medication and incorporating non-pharmacologic therapy, the insurer reduced its annual cost significantly for this injured party.

With more than 4 million workers injured on the job each year (U.S. Bureau of Labor Statistics), payers are looking for ways to reduce costs. Engaging in a medical therapy management program that includes clinical review by a pharmacist can often result in cost savings of tens of thousands of dollars. This approach also ensures that injured parties receive appropriate medications to help them get back to work more quickly.

About the Author
Tron Emptage, RPh, MA, is Executive Vice President of Business Development at Progressive Medical, Inc. He oversees Progressive Medical’s Clinical Services Department, which provides drug formulary design and management, clinical review by a pharmacist and/or physician, drug utilization review and Ask-a-Pharmacist and Ask a PMI Nurse call-in hotlines for answering pharmacy-related questions. He can be reached at Tron.Emptage@progressive-medical.com or 800.777.3574.