All posts tagged injured workers

Measure Aims to Reduce Unnecessary Opioid Prescriptions

Pharmacist in pharmacy (Digital Composite)

Employers and insurers in California are enthusiastic about the prospects of legislation that aims to reduce the chances of injured workers getting hooked on opioids when they are recovering from workplace injuries.

Senate Bill 482, which is sailing the through the Legislature, would require doctors to first check the state’s prescription drug monitoring system before writing a prescription for opioids.

The bill is moving through the state Legislature after a new study found that doctors have been seriously curtailing the amount of opioid prescriptions they write to injured workers. The study found that stronger laws on prescription drug monitoring were likely a main reason for opioid prescriptions having waned during the study period.

SB 482 aims to further tackle the opioid scourge that has hit injured workers hard, leading to addictions that reduce the chances of them returning to their at-injury employer. California has already seen a decrease in the opioid prescriptions for injured workers, but if this legislation passes, it would strengthen safeguards even further.

SB 482, authored by Sen. Ricardo Lara, a Democrat from Bell Gardens, aims to force doctors to use the Controlled Substance and Utilization Review and Evaluation System (CURES) database.

Even though CURES is the oldest such system in the nation, legislators believe that few doctors consult it before writing prescriptions for opioids, which are highly addictive and are often associated with slower recovery periods for injured workers.

Under the measure, doctors authorized to prescribe, order, administer, furnish or dispense a controlled substance, would be required to check CURES no earlier than 24 before writing a prescription for a Schedule II, Schedule III or Schedule IV controlled substance for the first time – and at least annually thereafter.

Doctors who knowingly fail to check the database before writing a prescription would be referred to their licensing board for administrative sanctions.

The measure has already been passed by the State Senate and two committees in the Assembly (in unanimous votes) and looks like it will have a smooth ride on the Assembly floor thanks to amendments that were made in June.

Employers and insurers are encouraging passage of the bill.

The American Insurance Association says that CURES and other prescription drug monitoring programs have been shown to be effective in controlling the practice of “doctor shopping”, whereby patients will visit different doctors to obtain prescriptions for addictive medications. The association also said it will protect patients and improve outcomes.

Additionally, the California Chamber of Commerce says that SB 482 would discourage doctor shopping and identify the handful of physicians who write the majority of inappropriate prescriptions for opioids.


Addictive Medications

Schedule II: Substances that have a high potential for abuse which may lead to severe psychological or physical dependence.

Types: : Methadone, meperidine (brand name Demerol), oxycodone (brand names OxyContin, Percocet), fentanyl, morphine and high-strength codeine.

Schedule III: : Substances with a potential for abuse less than substances in Schedule II, and abuse of which may lead to moderate or low physical dependence or high psychological dependence.

Types: : Hydrocodone (brand name Vicodin), codeine (Tylenol with Codeine).

Schedule IV: Substances in this schedule have a lower potential for abuse than schedule III drugs.

Types: : Brand names Xanax, Soma and Valium.


The study

The study, released in June by the Workers’ Compensation Research Institute, found “significant” decreases in the amount of opioid prescriptions being written for injured workers.

Fourteen of the 25 states examined by the institute recorded decreases in opioid prescriptions of between 11% and 31% in the study period, which measured 24-month periods ending in March 2012 and March 2014.

Michigan saw the biggest drop (31%), followed by Oklahoma (29%) and Massachusetts (24%). Texas saw a drop of 19%; Connecticut, 17%; California, 12%; and Pennsylvania, 4%. Just four states saw increases.

The institute noted that the decreases coincided with various states enacting legislation aimed at reducing the abuse of opioids by improving prescription drug monitoring programs and adopting more stringent treatment guidelines and drug formularies.


Pharmacist in pharmacy (Digital Composite)

Pharmacist in pharmacy (Digital Composite)

Cumulative Trauma Claims Rising Fast

carpal tunnel

A new and costly trend is affecting workers’ compensation as more cases involve what’s known as “cumulative trauma” – or injuries that develop over an extended period of time from repetitive or continuous motions.

Often these injuries are due to excessive wear and tear on tendons, muscles and sensitive nerve tissue that can leave a worker unable to perform their job due to pain. They can arise in any profession where a worker performs the same motion over and over again.

Interestingly though, many of the new cases are being filed after employees are fired and they are primarily being filed in Southern California.

A report by the Workers’ Compensation Insurance Rating Bureau of California, the “Analysis of Changes in Indemnity Claim Frequency – January 2016 Updated Report,” found that cumulative trauma cases accounted for 18% of indemnity claims in 2014, up from less than 8% in 2005. The percentage has steadily increased over the past decade, the Rating Bureau found.

According to the agency, the growth in cumulative injury claims beginning in 2009 has been concentrated in claims involving more serious injuries and multiple injured body parts.

The WCIRB, in its “Cumulative Injury Claim Survey” in 2015, noted that the median time before a claim is reported is 79 days from the date of injury.

Also, according to the WCIRB, 40% of cumulative trauma claims are filed after a worker is terminated. Of those cases, a whopping 98% are litigated and 90% are in Southern California.

These post-termination cumulative injury claims were much more likely to involve multiple insurers, psychiatric injuries or multiple body parts, according to the Rating Bureau.

The Bureau also noted that insurers denied 63% of cumulative trauma claims as to all issues (multiple body parts, for example), and an additional 9% were denied in part.

Another sobering bit of news is that most cumulative injury claims involve attorney representation or multiple body parts, and these proportions have increased over the last several years, while the proportion involving a specific claim component, psychiatric injury or sleep disorder has declined.

Approximately 10% of claims that involve some time away from work are estimated to be reported late (up to 18 months after an insurance policy inception), compared to less than 2% for 2007. A significant proportion of these late-reported claims are for cumulative injury claims, which are approximately four times as likely to be reported late as non-cumulative injury claims.

According to the study:

  • 30% of cumulative trauma claims involve multiple body parts
  • 7% involve the lower back
  • 2% involve body systems
  • 7% involve the wrist
  • 1% involve a shoulder
  • 9 % involve multiple upper extremities
  • 9% involve the hand
  • 4% percent involve hand and wrist
  • 6% involve knees


What you can do

Ergonomics – the science of adjusting the job to fit the body’s needs – can prevent cumulative trauma, also known as repetitive stress injuries (RSIs) in workplace safety parlance.

While in some cases redesigning the workplace is the best way to prevent RSIs, often many simple and inexpensive remedies will eliminate a significant portion of the problem.

For instance, providing knives with curved handles to poultry workers, so they won’t have to unnaturally bend their wrists; taking more frequent short breaks to rest muscles; providing lifting equipment, so nursing home workers won’t strain their backs lifting patients by themselves; or varying tasks to break up the routine of activities.

One large airline’s flight reservation facility, with 650 employees, had 250 cases of RSIs over a two-year period. An alarming 30% of these cases resulted in surgery.

The company took some simple steps to reduce the number of RSIs, including hiring an ergonomist to redesign the workstations, developing work/rest regimens, and eliminating electronic monitoring that included disciplinary action based on productivity, among other actions. Since then, the incidence of RSIs has dropped, underscoring the lesson that ergonomics can prevent RSIs.

A nationally known poultry producer instituted an ergonomics program and after two years its workers’ compensation claims had fallen to $1 million a year, compared to $4 million prior to the program.

In one facility, days missed due to cumulative trauma disorders declined from 552 to 24 per year, and days of restricted work went from 1,717 per year to just 48.

Identifying Problem Workers’ Comp Claims, Fraud with Predictive Modeling


With decades of information in their databases, many insurers have started using those statistics to their advantage to intervene earlier in problem claims and to identify potential fraud.

With years of data to rely on, insurers have identified certain triggers that can indicate that a claim may require additional intervention and more hands-on management. The predictive modeling program will alert a claims adjuster when it identifies certain parameters or events.

This early identification of problem claims is helping employers and insurers achieve better outcomes for injured workers, as well as save money and time. As the trend continues, it should help reduce claims costs by eliminating more fraud and also lower the cost of some claims and reduce the time some injured employees are away from work recovering.

Conventional wisdom in workers’ comp is that 20% of the claims account for 80% of the losses. Efforts such as early claims reporting, medical case management and return to work have long proved essential for reducing claims.

Predictive modeling aims to improve the ability of insurers to identify claims that require early intervention.

Insurance predictive modeling applies statistical techniques and algorithms on insurance and claims data to develop variables that predict the likelihood of a particular situation (like a worker staying off work for longer than average).

While predictive modeling has been successful used for years by automobile insurers, it’s been slower to catch on in workers’ comp, particularly because it requires multiple data sets for which data availability can be scarce.

Predictive modeling begins with the first notice of loss and then continues to monitor for certain trigger points and specific actions during a claim’s lifecycle.

In the case of a potentially fraudulent claim, some of these could include the number of prior injury claims submitted by a claimant and the amount of time that an allegedly injured claimant is out of work.


Employer tackles medical costs

Supermarket chain Ahold USA, a self-insured employer, started using predictive modeling in early 2012.

Ahold’s model uses claim characteristics, medical transaction details, and other data sources to identify factors that are predictive of higher claims costs.

Some of the indicators the company uses include multiple visits to doctors and the use of certain prescription drugs.

The model then prioritizes claims that need special handling and medical case management. This helps injured employees receive appropriate medical care to reach maximum medical improvement and return to work sooner.

The company’s predictive modeling can indicate whether a claim has the propensity to develop adversely. It can also be used to evaluate the likelihood that a claim will result in litigation.

It may also provide the ability to identify workers’ compensation claims with a greater likelihood of surgery. Such tools allow adjusters to develop case strategies at first notice and gain control over the claim as it progresses.

The results for Ahold have been positive, resulting in a lower workers’ comp expenditures in “low seven digits.”


Insurer birddogs fraud faster

National insurance company Chubb Corp. has been using predictive modeling for both its workers’ comp and automobile claims.

At Chubb, predictive modeling begins with the first notice of loss and then continues to monitor for certain trigger points and specific actions during a claim’s lifecycle, such as the number of prior injury claims submitted by a claimant and the amount of time that an allegedly injured claimant is out of work.

The model flags claims based on patterns that have historically proven fraudulent and patterns that the claims adjuster may not detect.

If a claim is flagged, the adjuster can investigate further and/or monitor the claim. If certain warning signs appear, the claim is referred to Chubb’s insurer’s special investigation unit. At that point the SIU can work with the claims adjuster to investigate further.

Before predictive modeling at Chubb, it could take up to 180 days to spot potentially fraudulent workers’ comp claims and assign them to the SIU. Now that number is down to six days.

Also, predictive modeling has led to a significant increase in accepted referrals to the insurer’s SIU. As a result, the number of investigation days has decreased, and the company has achieved significant cost savings.


Workers’ Comp Medical Costs Fall in Wake of Reforms

workers comp construction

The workers’ comp reforms in 2013 have generated surprising cost savings in treating injured workers in California, with overall medical costs per claim falling 8% over a three-year period.

That’s in contrast to the years of inflation before the reforms, when the average medical costs per claim were increasing by an average of 6.5% a year. The new study by the Workers’ Compensation Insurance Rating Bureau of California dissected claims costs between July 2012 and June 2015, finding the medical cost savings were greater than originally anticipated.

SB 863 increased benefits effective January 1, 2013 and January 1, 2014 and provided for a number of structural changes to the California workers’ compensation benefit delivery system.

In total, based on the most current information available, the WCIRB estimates the impact of SB 863 is an annual net savings of $770 million, or 4.1%, of total system costs.

The new study, released in early December, looked at the effects of the legislation on the medical costs associated with treating injured workers. The Rating Bureau had anticipated that reforms would cut medical costs, but it underestimated the effects.

These cumulative savings were primarily driven by changes to the physician fee schedule and pharmacy services, which collectively represent around 61% of all medical service payments. The use of medical services also dropped, due to a more stringent regimen of independent medical review (IMR) of claims.

Additional savings were generated by outpatient facilities and medical equipment providers, which when combined, represent roughly 16% of all medical service payments.

Medical-legal and inpatient hospital services, when taken together, represent approximately 23% of all payments and were the only services to register increases in costs per claim over the three-year period.


Other findings of the study include:

  • Payments per claim via the physician fee schedule (46% of all medical costs) decreased by 9% over the three-year study period. This decline was due in part to the introduction a new and more accurate fee schedule that is widely used in many states. That fee schedule took effect on Jan. 1, 2014.
  • Costs per claim for pharmaceuticals (which account for 15% of all medical costs) declined by 22% during the study period. But the legislation did not address drug costs, and the decline was largely the result of a drop in medical service usage – or utilization – due to the increased use of IMR.
    This reduction in utilization had a particular effect on the prescriptions of highly addictive drugs called opiates, such as OxyContin, the outlays for which fell 48% during the study period.
  • Inpatient hospital costs (12% of all medical costs) increased by 14% on a cost-per-claim basis over the study period. The costs declined in the first half of 2013 likely due to the elimination of payments for duplicate surgical hardware enacted by SB 863.
  • Costs per claim for outpatient facilities (7% of all medical costs) dropped 7% during the study period. Since the majority of these payments are to ambulatory surgical centers (ASCs), the primary driver of the savings was the reduction in reimbursements to ASCs enacted by SB 863.
    That said, outpatient facility cost payments started inching higher in 2015 due to upward adjustments in the Medicare ASC fee schedule as well as changes in the types of outpatient services these facilities provide.
  • Costs under another fee schedule for a variety of services like durable medical equipment, prosthetics and orthotics, fell 12% over the study period. The reforms had nothing to do with this, but rather, the costs were affected by changes to Medicare fee schedules.


Despite these results, the Rating Bureau noted that the trend may be reversing. It said payments per claim for all medical services increased 4% in the first half of 2015 from the same period the year prior.


Drug Testing in Workers’ Comp Skyrockets

Drug testing of injured workers by treating doctors has skyrocketed over the past seven years as painkiller abuse continues and physicians want to monitor their patients for staying with their prescribed drug regimen.

The use of urine drug testing on injured workers in California increased 2,431% between 2007 and 2014, according to the California Workers’ Compensation Institute (CWCI).

During that period, urine drug tests grew from 10% to 59% of all California workers’ compensation laboratory services, while drug testing reimbursements increased from 23% to 77% of all lab payments in the system.

The rapid increase reflects the growing concern among workers’ comp insurers and employers about workers getting hooked on high-strength pain medications known as opioids, and similar pain drugs.

Other studies by the institute have found that adding opioids into the picture can greatly increase the time an injured worker is away from work recovering, as well as the cost of the claim.

Also, doctors are increasingly using the tests to ensure injured workers are taking the medicines they prescribe. The downside is that the cost of the testing continues to increase and can easily be a few thousand dollars, adding significantly to the cost of claims.

And the trend is not unique to California. In a recent multi-state study by the Workers’ Compensation Research Institute on injured workers with long-term opioid use, the percentage of workers who received at least one drug test increased from 16% to 25%.

Not only are more injured workers being tested, but workers themselves are being tested more, as well.


Here are some other significant findings from the study:

  • Between 2003 and 2012, the average number of drug testing service dates for injured workers who received these services increased by 9% at 12 months post-injury; 35% at 24 months post-injury; and 350% at 36 months post-injury.
  • Among the injured workers who were drug tested, the average number of tests per employee more than tripled from 4.5 in 2007 to 14.9 in 2014, driving the average amount paid per date of service from $96 in 2007 to $307 in 2014 – a 220% increase.
  • The number of providers who were paid for testing injured workers climbed from 428 in 2008 to 876 in 2014. Much of that growth is attributed to a migration towards physician in-office testing, because testing equipment has drastically come down in price.
  • The amount paid for drug tests in California workers’ comp are based on Medicare billing rules. These rules were revised in 2010 and 2011, after Medicare determined there were questionable billing practices for drug tests taking place.
    The CWCI study found that after those changes were made, the mix of tests used on injured workers changed. Drug screens, which are used to identify the presence or absence of a drug, accounted for a smaller share of tests.
    Meanwhile, quantitative tests, which are used to measure the amount of a drug sample, increased sharply. The CWCI notes quantitative tests are not subject to the tighter Medicare billing rules, perhaps explaining the increase.


Is it necessary?

Drug testing is in part related to the increasing costs and prescriptions for drugs in the workers’ comp system, as well as the fact that testing has shifted from labs to doctors’ offices, which can now afford testing equipment that was too expensive in the past.

Several medical treatment guidelines do call for doctors prescribing opioids to also test for illicit drug use under certain circumstances, such as when addiction or abuse is detected or when patients are at risk for overdose and death, sources said.

Doctors need to identify patients abusing drugs because it is inappropriate to provide them opioids and it can change the treatment required for them.

Proponents of drug testing say it helps keep injured workers’ medicinal intake in check to ensure they are sticking with their drug regimens and also not abusing prescription pain medications.

Tests revealing that patients are using drugs for other than “clinical health” can also help workers’ comp payers arguing before a judge or hearing officer regarding their responsibility for the claimant.

The purpose of testing is to assist in medical management. Still, testing should be done based on medical necessity related to a claimant’s medical presentation, dispensed drugs and evidence-based medicine protocols.


Medical Marijuana Complicating Workers’ Comp

While insurers and employers have expressed concern over the rise of medical marijuana in the context of workers’ compensation, some experts and new research suggest it could reduce the use of controversial and highly addictive opioids to treat pain.

There is a growing consensus in the workers’ comp community that any treatment that can reduce the use of opioids is worth considering. Several studies have found that long-term use of opioids to treat pain associated with workplace injuries often ends up increasing the cost of claims, as well as keeping many workers off the job longer than usual.

But there are also concerns about using marijuana to treat injured workers: It’s still illegal under federal law, and it may be detrimental to a worker’s efforts to return to work after the injury has healed.

In August, the Minnesota Department of Labor and Industry adopted a rule establishing criteria for long-term opioid treatment that also said medical marijuana is not an “illegal substance” for injured workers under state law. It remains illegal under federal law, however.

The U.S. Food and Drug Administration has not approved marijuana for any medical condition, so it’s difficult to compare its effects with other drugs used in workers’ comp. Also, there have been few studies looking at the efficacy of marijuana in treating pain.

Insurers are often loath to pay for a prescription for a drug that’s illegal under federal law.

So for now, state courts seem to be the battleground over the use of medical marijuana to treat injured workers.

In New Mexico, the state Court of Appeals has ruled three times since 2014 that medical marijuana is “reasonable and necessary” for injured workers, and that it should be covered under workers’ comp.

In each New Mexico case, physicians supported the use of medical marijuana when opioids and other medications failed to relieve injured workers’ chronic pain.

In the most recent case, Sandra Lewis vs. American General Media and Gallagher Bassett, the injured worker’s health care provider opined that the “benefits of medical marijuana outweigh the risk of hyper doses of narcotic medications.”

There have been no similar cases brought in other states with medical marijuana laws in place, but it’s reasonable to assume that the courts would side with injured workers in light of state law.


Do employers, insurers have to pay for claimant’s medical marijuana?

It has yet to be determined whether the answer is affected by state or federal regulations. Even in states in which marijuana use is legal for medical purposes, laws may not require insurers to pay for it.

In a situation in which the employer or insurance provider is located in a state that does not allow for medical marijuana and chooses to pay for its use for an employee in a state in which it is allowed, the employer may find themselves in violation of their own state’s laws, as well as federal law.

In the states in which it is currently legal to use marijuana for medical purposes, legal protection is afforded to patients diagnosed with a variety of illnesses. Generally, these include pain relief, particularly of neuropathic pain, nausea, spasticity, glaucoma, and movement disorders.

Marijuana is also a powerful appetite stimulant, specifically for patients suffering from HIV, the AIDS wasting syndrome, or dementia. Legislation varies widely, and can be as vague as that in California, which reads, “Any debilitating illness where the medical use of marijuana has been ‘deemed appropriate and has been recommended by a physician.’ ”

Scientists have confirmed that the cannabis plant contains active ingredients with therapeutic potential for relieving pain, controlling nausea and stimulating appetite, and in the workers’ comp arena, chronic – and especially neuropathic – pain stands out as an issue that insurers must address.

On the other hand, “Marijuana has the potential to cause or exacerbate problems in daily life, including increased absences, tardiness, accidents, workers’ compensation claims and job turnover,” according to the National Institute on Drug Abuse.

Marijuana is classified as a Schedule I drug, meaning it has a high potential for abuse and no currently accepted medical use in treatment in the United States.


What Employers Can Do

  • All employers should have a drug policy in place, which must be re-evaluated on a consistent basis to ensure compliancy with state and federal laws.
  • Paying for medical marijuana under workers’ compensation is a gray area and could have repercussions. Until the laws are clarified, payment should be under the direction of the state board. In addition, each case must be reviewed individually.
  • When an employee returns to work after being treated with marijuana, keeping them and other employees safe should be the primary concern. Although this should also be considered when an employee is treated with any medication, extra caution is needed due to the fact that marijuana use is still illegal under federal law.
  • Employers should review their workplace and employment policies to incorporate changes as they occur.