Medical Management Strategies for Cost Containment

Sedgwick © 2013 Confidential – Do not disclose or distribute.
Medical Management
Strategies for Cost
Containment

Sedgwick © 2013 Confidential – Do not disclose or distribute.
Jackie Pierce
Teresa Bartlett, MD
February 13, 2013

Sedgwick © 2013 Confidential – Do not disclose or distribute. 3
Objectives
This presentation will explain the practical application of medical
management strategies and how they play a role in lowering the
ultimate cost of risk for employers.
It will include both the employer and TPA perspective. The various
disciplines of medical management will be discussed from a risk
insurance perspective, with emphasis on medication strategies as a
primary cost driver in workers’ compensation.

Value your mature workers
Knowledgemanagement
• Perceptions
• Health risks
• Treatment impact
• Care coordination
• Outcome data
• Generational
considerations
Modelconsiderations
• Nurse navigators
• Medical literacy
• Physician scheduling
services
• Sound technology
solutions
• Key stakeholder
awareness
• Consumer driven plans
Accesstoinformation
• Political
component
• Media
• Direct advertising
• Technology
• Provider marketing
• Payer
communication

The focus has changed
From managed care to
health care
From managing
transactions to
ensuring and driving
quality results

Importance of capturing great medical
information early in the claim process
• Captures:
 what
 when
 how
• Quantifies the
initial injury
details
• Improves morale
• Improves
penetration
• Quality health
care experience
Employer
onsite
medical
Clinical
resources
on the
front line
24 x 7
nurse call
line

Clinical consultation process
Injury occurs and employee advises supervisor
Supervisor calls clinical consultation and the employee speaks
confidentially with the nurse
Nurse reviews symptoms & recommends appropriate care. If
provider care appropriate, nurse schedules appointment
Follow up survey within 24-36 hours of triage
Report is transmitted to examiner. Supervisor transferred to intake
to report incident

Claim examiner role
• Be the quarterback of the file
• Rely on the clinical team to help with medical decisions
• Focus on quality providers
• Be fair
• Use all team members wisely
• Aggressively advance the file
• Be an extension of the employer culturally
• Recognize potential risks
• Work to develop an actionable plan
• Make decisions in a way that will ultimately lower risk for the employer
• Check the box
• Real strategic impact!

Telephonic case management
• Support claim examiners
• Aggressively advance claim
• Answer injured worker questions
• Apply evidence-based standards
HOW DOES IT WORK?
• Business rules driven referrals based on client-specific data
• Integrated file approach with claim examiners
• Custom model development for each client

Nurses interact with injured worker
Advocate for best-in-class care
Expedite most appropriate treatment
Encourage and coach injured worker
Identify medical red flags
Look for psycho-social barriers to recovery
Telephonic case management

Utilization review
• Addresses
 frequency
 duration
 appropriateness of medical services reasonably required to
cure and relieve the injury effects
 setting (inpatient vs. outpatient)
• Nurses use evidence-based guidelines
• Involve physician peer discussions

Utilization review
• Applies the latest evidence-based medical guidelines to proposed
treatment
• Physicians may be stuck in a pattern of how they have always
approached treatment
• Physicians have difficulty digesting and implementing the latest
studies and technology
• Not intended to reduce or limit treatment
• QUALITY medical care is the goal
• Very impactful especially when applied to medication strategies in
Washington

Vocational rehabilitation
Required in
Washington
Vocational
rehab plan
Need more
Washington
details

Bill Review
• Efficiency
• Process driven
• Cost savings
• Negotiation

Focused approach to bill review
• Best-in-class approach to fee schedule and UCR application
• NCCI and clinical edits applied as part of the standard process eliminating unbundling
costs as part of bill review
• Systematic application of up-coding rules
• UR/TCM treatment plans are integrated into the system, allowing us to reject
treatment denied by UR on a consistent basis
• Thorough and just-in-time clinical review
• Systemic referral to clinical resources based on dollar level and service type
• Nurse review of medical documentation for appropriateness and level of care
• Discussions with claim team to ensure all areas are covered regarding treatment
• Surgeries reviewed for duplicate billing practices and the proper application of the
multiple surgical procedures rules
• Hospital line level review for proper billing practices

Specialty partners
Durable medical equipment
Physical therapy
Pharmacy
Linked to system for desk level efficiencies
Paperless

Provider benchmarking
• Quality
• Considers many data points to evaluate a provider
 claim cost
 medical cost
 litigation rates
 recidivism rates
 return to work success rate
• Feedback loop
• Objective: share the positive characteristics of 5 star providers
• Medical director meetings

Sedgwick © 2012 Confidential– Do not disclose or distribute. 18
Medication Management
Strategies

Background: How did we get to this place?
• In late 2000, Congress passed into law a provision, which the
President signed, that declared the ten-year period that began
January 1, 2001, as the Decade of Pain Control and Research
• The American Pain Society has actively supported the Decade of Pain
Control and Research and it has been a focal point for the
development of numerous programs to advance awareness and
treatment of pain and funding for research
From the American Pain Society Website

Narcotic utilization
• Since 1990, the medical use of opioids has increased by a factor of
10
• According to the CDC, enough opioids were prescribed last year to
medicate every American adult with a standard pain treatment dose
of hydrocodone every 4 hours for a month
• Fatal overdoses involving prescribed opioids tripled in the United
States between 1999 and 2006
• A recent government study determined that opioid poisoning was the
leading cause of death for people aged 35-54
• This rate was higher than motor vehicle or firearm
related deaths for that age group

Narcotic medication management
• Creates issues for:
Patients Physicians Employers

Prescription drug diversion as a national issue

Background: How did we get to this place?
• cross the country, there is an
increase in the number of ER visits
due to non-medical use of
narcotics
• Up to 89% of abused prescription
drugs are diverted from legally
written prescriptions
• Problem isn’t just with narcotic
prescribing, but how they are
used once in the hands of the
public

• The way the brain reacts facilitates the process of addiction/abuse:
Biochemical physiology of narcotic use
Endorphins are naturally occurring chemicals that work on the
nervous system to reduce pain
The endorphins can act on certain parts of the brain to produce
euphoria or a natural “high”
Addiction shuts the endorphin system down
This leads to hyperalgia (increased pain perception) and
hypersensitivity
The abuser then seeks higher doses or stronger drugs

Opioid guideline for chronic pain
• Use opioid only after other pain relief therapies have been exhausted
• Before prescribing a risk assessment screening should be conducted
• Opioids should be started at the lowest possible dose
• If a patients dosage has increased to 120mg MED without substantial
improvement in function or pain relief a chronic pain specialist should
be consulted
• Long acting or controlled release opioids should not be used for acute
pain
• Fentanyl patches, OxyContin and Methadone are examples

Recommend using a patient agreement
Washington agreement

Follow up care
Failure to progress or demonstrate functional progress or any signs of
compliance should lead to prompt discontinuance of medication
Dosage may need to be increased to maximize therapeutic value not to
exceed 120mg Morphine/day
Random urine drug screen
Weaning should involve a mental health professional who specializes in
addiction
PT, exercise and other medications such as NSAIDS are important in this
process

An electronic dose calculator can be found
and downloaded
WWW.agencymeddirectors.wa.gov/wa/guidelines.asp
Morphine 120mg/day is the MAXIMUM
MORPHINE (reference) 30 mg
Codeine 200 mg
Fentanyl Transdermal 12.5mcg/hr
Hydrocodone (Vicodin) 30 mg
Hydromorphone 7.5mg
Oxycodone 20mg
Oxymorphone 10mg
Methadone 4mgj *BE CAUTIOUS

Opioid risk tool (ORT)
1
Date ______
Patient Name
OPIOID RISK TOOL
Mark each
box that applies
Item Score
If Female
Item Score
If Male
1. Family History of Substance Abuse Alcohol [ ] 1 3
Illegal Drugs [ ] 2 3
Prescription Drugs [ ] 4 4
2. Personal History of Substance Abuse Alcohol [ ] 3 3
Illegal Drugs [ ] 4 4
Prescription Drugs [ ] 5 5
3. Age (Mark box if 16 – 45) [ ] 1 1
4. History of Preadolescent Sexual Abuse [ ] 3 0
5. Psychological Disease Attention Deficit
Disorder [ ] 2 2
Obsessive Compulsive
Disorder
Bipolar
Schizophrenia
Depression [ ] 1 1
TOTAL [ ]
Total Score Risk Category Low Risk 0 – 3 Moderate Risk 4 – 7 High Risk > 8

Urine drug testing
• Purpose
 Identify aberrant behavior
 Undisclosed drug use and/or abuse
 Verify compliance with treatment
• Frequency
 Based on risk assessment for drug abuse
 Low risk once/year
 Moderate risk twice/year
 High risk three to four times/year
 Unusual or suspicious behavior at time of visit
• Losing prescription, requesting early refills, multiple prescribers, demonstrating intoxication,
slurred and/or slow speech

Urine drug testing result interpretation
• The following UDT results should be viewed as a “red flag” requiring
confirmation and intervention:
 Negative for opioid(s) prescribed
 Positive for drug (benzodiazepines, opioids, etc.) NOT prescribed
 Positive for amphetamine or methamphetamine
 Positive for alcohol
 Positive for cocaine or metabolites

Urine drug testing result interpretation
• If a confirmatory drug test (MRO) substantiates a “red flag” result
AND is:
 Positive for prescribed opioid(s)
• a controlled taper and a referral to an addiction specialist or drug
treatment program should be considered
 Negative for prescribed opioid(s)
• The physician should stop prescribing opioid(s) and consider a referral to
an addiction specialist or drug treatment program

Assessment of function
Overall pain
management
How well if the
pain being
managed?
Pain rating when asked to
consider the past month
Should indicate pain is overall
better and able to function at
a higher level
Function
Daily activities should be
listed; even in WC
activities that are healthy
should be encouraged

Progress
report

Suggested weaning process
Reduce Morphine mg by 10% each week
Add Clonopine to help with withdrawal symptom
Addiction or pain management specialist should be consulted
May require short inpatient stay to assist with initial phase
May require drug rehab program (inpatient and outpatient)

Examiner Role
• Help the physician stay on track
• Ask for the Risk assessment (ORT) and provide tool if necessary
• Make sure other therapies are tried first
• That first RX for opioids should be small doses and improvements should be
documented in function and pain
• Request follow up assessment of patient to see if medication is working
(allergic reaction) Does not have to be office visit
• Set next appointment with treating physician for 10 to 14 days for next
assessment
• Provide State of Washington Opioid agreement for any physician prescribing
these drugs
• Ask for copies of screening, opioid agreement, drug test results and board of
pharmacy report

Integration Opportunities

Integration of available programs
Wellness
Health
and
Safety
Industrial
Athlete

QUESTIONS?

Teresa Bartlett, MD
Senior Vice President, Medical Quality
Sedgwick
Phone: 248-637-3120
teresa.bartlett@sedgwickcms.com

Medical Management Strategies for Cost Containment

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