Physician-dispensed Veterans Affairs Legislative update ... · accidents involving addictive...

Workers’ Compensation and Disability Management News / 1

An Inside Look at Medication Safety2

Yoga as an Alternative to Pain MedsPage 8

Anesthesiologist Wins Disability Benefits for AddictionPage 7

Physician-dispensed medication by the numbers Page 5

Veterans Affairs overpays vets for disabilities Page 6

Legislative update on California Senate Bill 863 Page 9

Workers’ Compensation and Disability Management News

Spring 2013

A Message from Peter Madeja, President and CEO, GENEX Services, Inc.

Welcome to the Spring 2013 edition of the GENEX Pyramid publication.

In 2013, GENEX is celebrating its 35-year anniversary as a company. As we all know, the world was a different place when GENEX opened its doors more than three decades ago. This was on the cusp of the technology boom, before we knew the term managed care, and in advance of any understanding of what a global economy truly means.

There has been a dramatic evolution in the world, in business, and even in our specific industry. The challenges of evolving and adapting as a company to meet the needs of employees and the expectations of clients while maintaining, enhancing, and expanding your products or services can be a formidable undertaking.

The path to success has not always been easy. However, one of the great early strengths of the company was building a strong culture that fostered an environment of high performance, regard for employees, outstanding service to customers, and a view that we could continue to grow as a company and be more tomorrow than we are today. That culture and spirit has remained a cornerstone of GENEX as we have grown, expanded geographically, and diversified our service portfolio.

Knowing what should never change about your company while understanding the evolution you must pursue in order to remain relevant and competitive in the market is a hallmark of a strong business. In many ways, GENEX today remains the same service-focused business that we were in 1978, providing creative solutions to controlling disability and medical costs. Yet for those employees and clients that have witnessed a great deal of our journey, they hopefully see that today we are much, much more.

In closing, I want to extend my deepest appreciation to all my GENEX colleagues for their contributions to our ongoing success, and to our business partners and clients for their trust and confidence.

Best regards,

Peter C. Madeja

A news magazine for GENEX clients

EditorMichele Ritchie

DesignMelissa Lapid

Correspondence440 East Swedesford Road

Suite 1000Wayne, PA 19087888.GO.GENEX

[email protected]

Websitewww.genexservices.com

Material discussed herein is meant to provide information and should not be construed as legal or professional advice. Unless otherwise noted, the articles are written by independent authors and the opinions expressed in them are not necessarily those of

GENEX Services, Inc.

All articles are reprinted with permission from the noted

publication.

PYRAMID

2 / PYRAMID / Spring 2013

L E T T E R S

In the Fall 2012 issue of Pyramid, we announced

the names of the five schools who were winners

in GENEX’s 2012 Case Manager Scholarship Award

Program.

The program was developed to strengthen the

awareness of the case management profession,

and to invest in a new generation of future

graduates.

“I wanted to thank you for providing a scholarship

to the Rehabilitation Counseling and Psychology

students at UNC-Chapel Hill,” wrote one scholarship

recipient. “It allowed me to be a full-time student

and give my time and commitment to working with

those with disabilities.”

“Thank you, thank you, thank you!” wrote one

of the school administrators. “I can’t tell you how

“The scholarship...allowed me to be a full-time

student and give my time and commitment to

working with those with disabilities.”

grateful we are for this amazing gift you gave us.

I think we will be able to give four or five students

scholarships this fall. It will mean so much to them.”

One student wrote, “Thanks again for your

generosity this year. I have officially passed Nursing

300 and am looking forward to next semester.”

Our second annual scholarship award program

is now underway, and we will be

announcing this year’s winning

schools in the next few months.

For updates on this program and

for other GENEX news, be sure

to follow us by clicking the social

media icons on our website at

www.genexservices.com.

“I can’t tell you how

grateful we are for this

amazing gift you gave us.”

Scholarship Recipients Offer Resounding Thanks


T R E N D S

Lindsey Tanner, Associated Press

CHICAGO — Drug overdose deaths rose for the 11th straight year, federal data show, and most of them were accidents involving addictive painkillers despite growing attention to risks from these medicines.

“The big picture is that this is a big problem that has got-ten much worse quickly,” said Thomas Frieden, head of the Centers for Disease Control and Prevention, which gathered and analyzed the data.

In 2010, the CDC reported, there were 38,329 drug overdose deaths nationwide. Medicines, mostly prescription drugs, were involved in nearly 60% of overdose deaths that year, overshadowing deaths from illicit narcotics.

The report appears in Tuesday’s Journal of the American Medical Association.

It details which drugs were at play in most of the fatalities. As in previous recent years, opioid drugs — which include OxyContin and Vicodin — were the biggest problem, con-tributing to 3 out of 4 medication overdose deaths.

Frieden said many doctors and patients don’t realize how addictive these drugs can be, and that they’re too often pre-scribed for pain that can be managed with less risky drugs.

They’re useful for cancer, “but if you’ve got terrible back pain or terrible migraines,” using these addictive drugs can be dangerous, he said.

Medication-related deaths accounted for 22,134 of the drug overdose deaths in 2010.

Anti-anxiety drugs including Valium were among common causes of medication-related deaths, involved in almost 30% of them. Among the medication-related deaths, 17% were suicides.

The report’s data came from death certificates, which aren’t always clear on whether a death was a suicide or a tragic attempt at getting high. But it does seem like most serious painkiller overdoses were accidental, said Rich Zane, chair of emergency medicine at the University of Colorado School of Medicine.

The study’s findings are no surprise, he added. “The results are consistent with what we experience” in ERs, he said, add-ing that the statistics no doubt have gotten worse since 2010.

Frieden said the data show a need for more prescription drug monitoring programs at the state level, and more laws shutting down “pill mills” — doctor offices and pharmacies that over-prescribe addictive medicines.

Last month, a federal panel of drug safety specialists rec-ommended that Vicodin and dozens of other medicines be subjected to the same restrictions as other narcotic drugs like oxycodone and morphine. Meanwhile, more and more hospi-tals have been establishing tougher restrictions on painkiller prescriptions and refills.

One example: The University of Colorado Hospital in Aurora is considering a rule that would ban emergency doctors from prescribing more medicine for patients who say they lost their pain meds, Zane said.

Writer Mike Stobbe in Atlanta contributed to this report. Copyright 2012 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Drug overdose deaths up for 11th straight yearMedicines were involved in nearly 60% of overdose deaths in 2010.


T R E N D S

Physician-Dispensed MedicationWorkers’ compensation is experiencing a national year-over-year increase in the cost of prescription drugs. Physician-dispensed medications are driving a significant portion of that trend. A number of states, such as California and Georgia, have passed legislation to curb physician dispensing, but in many states it is still under-regulated. Here we point out a few examples of the impact of this trend.

The top five states where physicians

dispense medication

53% ..................California

45% .......................Florida

43% ........................Illinois

36% ..................... Georgia

35% ...................Maryland

PAYMENTS FOR

MEDICATIONDISPENSED

BY PHYSICIANS IN SOME STATES

ACCOUNT FOR

MORE ThAN 50%OF ALL PRESCRIPTIONS

DISPENSED TOINjURED WORkERS

IN FLORIDA, THE PRICE FOR

vICODIN® AT THE:

PHARMACY

$0.43PHYSICIAN

$1.08

IN MARYLAND, THE PRICE FOR

PRILOSEC® AT THE:

PHARMACY

$0.64PHYSICIAN

$5.27

Source: WCRI Study, Physician Dispensing in Workers’ Compensation. Dongchun Wang. July 2012.

Price Per Pill Percent Change for Physician- and Pharmacy-Dispensed Medication in Illinois

Over a four-year period the price per pill decreased when dispensed at a pharmacy, but there was a drastic increase in the price for the same medication when dispensed by a physician. -20%

0%

20%

40%

60%

80%

IBU

PRO

FEN

CYC

LOBE

NZA

PRIN

E

TRA

MA

DO

L

MEL

OXI

CA

M

HYD

ROC

OD

ON

E-A

CET

AM

INO

PHEN

PHYSICIAN DISPENSED

PHARMACY DISPENSED


Inspectors say the most stubborn, chronic mistake made by Veterans Affairs claims examiners while trying to dig their way out of a growing backlog of cases is overcom-

pensating some veterans with too much money.The Department of Veterans Affairs overpaid 12,800 vets

$943 million from 1993 to 2009, according to projections by the VA’s Office of Inspector General. And if the error isn’t corrected, inspector general auditors said an additional $1.1 billion could be wasted by 2016.

The House Veterans Affairs Committee plans to hold a hearing on the issue in February.

The mistakes occur in a narrow batch of cases in which vets temporarily receive a 100% disability rating while undergoing surgery or debilitating treatments and convalescing.

Claims examiners have repeatedly failed—often in two out of three sampled cases—to seek a follow-up exam to deter-mine whether the veteran’s condition has improved and the temporary 100% disability rating should be reduced, inspectors said. The error results in veterans who improve or recover receiving hundreds of thousands of dollars in compen-sation over years for a level of disability level they no longer have, inspectors said.

“That (rating) will run forever until some-body like us stumbles upon it,” said Brent Arronte, a director of inspections.

The 100% rating legally bars the VA from recouping overpayments, the department said.

A common error involves cancer treat-ment where the disease stabilizes or goes into remission, according to inspector general reports. In one case, a veteran who improved after being treated for non-Hodgkin lym-phoma was overpaid $237,000 over 71/2 years until the mistake at a Cleveland VA office was caught, according to a September report.

Inspectors said that claims examiners either fail to schedule follow-up exams when the disability rating is put in place or fail to act when alerted that one is necessary.

The VA said fixes were put in place last July to help ensure follow-up exams are scheduled. In addition, the claims process is to become automated this year and claims examiners will automatically be alerted that

exams may be necessary, said Lois Mittelstaedt, VA benefits administration chief of staff.

A January 2011 inspector general audit first projected more than $1 billion would be lost over five years if the temporary disability problem was not fixed, and all 42 regional office inspections since then still show errors.

“When you’re projecting $1.1 billion over the next five years could be spent on inaccurate benefits,” said Linda Halliday, assistant inspector general for audits and evalua-tions, “That’s a lot of money...(that) could potentially be used to serve other veterans’ benefits.”

From USA Today, January 24 © 2013 Gannett. All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribution, or retransmission of this Content without express written permission is prohibited.

Audit: Veterans Affairs overpays vets for disabilitiesLack of follow-up exams, errors could mean $1.1B loss by 2016

Gregg Zoroya, USA Today

WhERE ERRORS WERE FOUNDInspections at 42 Department of Veterans Affairs regional offices over the past two years found errors at every facility in processing veterans’ claims for temporary 100% disability ratings. At each facility, 30 sample cases were received.

THE FIVE OFFICES WITH THE LOWEST ACCURACY RATES

THE FIVE OFFICES WITH THE HIGHEST ACCURACY RATES

Source: Dept. of Veterans Affairs Office of Inspector General

Des Moines

Lincoln, NE

Sioux Falls, SD

Fort Harrison, MT

Chicago

73.3%

73.3%

70%

66.7%

56.7%

Los Angeles

Houston

Pittsburgh

Honolulu

Phoenix

3.3%

10%

10%

13.3%

13.3%


Roberto Ceniceros, Business Insurance

A group insurer must provide long- term disability benefits for a hospital staff anesthesiologist addicted to an

opioid pain medication commonly used in her anesthesia practice, a federal court ruled on Thursday.

In the case of Julie Colby v. Union Security Insurance Co., the 1st U.S. Circuit Court of Appeals in Boston considered whether the risk of a relapse into drug use can be so significant as to be considered a current dis-ability. In 2004, a colleague found Dr. Colby sleeping or unconscious on a hospital table, and she tested positive for fentanyl. “As mat-ters turned out, she had for some time been self-administering opioids and had become addicted,” the court’s opinion states. She later entered an inpatient substance abuse treat-ment program and was diagnosed as having an opioid dependence, a dysthymic disorder, and obsessive-compulsive personality traits. The exam also revealed severe back pain associated with de-generative disc disease and a history of major depression. Her employer’s group disability insurer, USIC provided benefits until the end of Dr. Colby’s inpatient stay. But USIC refused to pay benefits beyond that point. It argued that Dr. Colby had been discharged and, even though she remained under a doctor’s care and feared a relapse, the risk of relapse is not the same as a current disability.

No exclusion for risk of relapseAfter Dr. Colby exhausted her access to administrative

appeals, she sued in federal district court, and the district court deemed USIC’s categorical exclusion of the risk of drug abuse relapse an unreasonable interpretation of the insurance plan’s coverage.

On further appeal, the 1st U.S. Circuit Court of Appeals considered a number of factors, including Dr. Colby’s medical conditions and medical expert testimony that “to a reasonable degree of medical certainty,” she was at high risk of relapse if she returned to a job where she could easily access opioids.USIC then asserted that “a doctor’s opinion that there is a high probability of relapse is not objective or even reliable evidence of a current disability,” and therefore not grounds

for an LTD benefits claim under its policy. But the appeals court said the insurance plan’s language “admits of no such categorical bar. It does not mention risk of relapse, let alone exclude risk of relapse as a potential basis for a finding of disability.” USIC could have written an exclusion for risk of relapse into the plan, but did not do so, the appeals court found. “Without such a written exclusion in place, we believe that USIC acted arbitrarily and capriciously in refusing to consider whether the plaintiff ’s risk of relapse swelled to the level of a disability,” the court said in its ruling. The court also said that “a risk of relapse into substance dependence — like a risk of relapse into cardiac distress or a risk of relapse into orthopedic complications — can swell to so significant a level as to constitute a current disability.” It upheld the district court’s finding.

Reprinted with permission, Business Insurance January 18, 2013. Copyright Crain Communications, Inc.

Anesthesiologist wins disability benefits for opioid addiction


Yoga may become an alternative to pain meds in workers comp claimsPractice used in functional restoration programs

Roberto Ceniceros, Business Insurance

Yoga is flexing its way into the workers compensation world.

Industry experts say yoga, which combines stretch-ing and strengthening exercises with meditation, even could help address a formidable workers comp problem: how to resolve complex claims involving patients with chronic pain treated with addictive narcotics.

Yoga’s potential benefits for other work-related injuries are already documented in several evidence-based medical treat-ment guidelines that workers comp payers and state regula-tors expect treating doctors to consult.

The American College of Occupational and Environmental Medicine’s guidelines say yoga can help address chronic lower back pain, persistent pain and arthritic hands, said Christo-pher Wolfkiel, director of ACOEM’s practice guidelines in Elk Grove Village, Ill.

In workers comp cases, yoga is being incorporated into functional-restoration programs, said Mark Pew, senior vice president of business development for Prium, a Duluth, Ga.-based workers comp utilization review company.

Businesses providing the functional restoration programs aim to help patients, including those who have struggled with chronic pain from workplace injuries, Mr. Pew said. Often, such patients’ conditions have deteriorated following their injuries because they took increasing quantities of pain medi-cations such as opioid drugs.

Functional restoration programs often provide differing combinations of physical therapy, counseling for psycho-social issues, occupational therapy, addiction education and physical fitness activities such as yoga.

Rehabilitation service providers say their goals include helping patients improve their ability to cope with pain, increasing physical functioning and addressing emotional conditions to promote a more productive lifestyle.

The programs can cost workers comp payers tens of thou-sands of dollars for sessions that patients attend daily over several weeks. Yet their results, like their offerings, are mixed, several sources said.

There is a lack of quality outcomes data showing what works and what doesn’t, said Eunhee Kim, CEO at EK Health Services Inc., a San Jose, Calif.-based workers com-pensation managed care company.

Patients might report health improvements and regaining lost physical abilities immediately after completing a func-tional restoration program, only to relapse months later with their pain and narcotic use increasing, Ms. Kim said. There could be several physical or social reasons for that.

Payers may close a claim immediately after claimants complete such programs or they may offer follow-up care.

To help injured workers suffering from multiple complica-tions requires treatment with “interdisciplinary themes,” such as cognitive behavioral therapy blended with occupational or physical therapy, said Dr. Kathryn Mueller, a medical profes-sor at the University of Colorado in Denver.

Overall, increasing functional outcomes that are measur-able should be the goal of all medical treatment, said Dr. Mueller, who is also medical director for the Colorado Division of Workers’ Compensation.


California SB 863GENEX regulatory compliance staff is always monitoring the leg-islative landscape to ensure we stay apprised of any activity that may impact the products and services we offer our clients. Senate Bill 863 was signed into law by Governor Brown on September 18, 2012. The bill makes wide-ranging changes to California’s workers’ compensation system, including increased benefits to injured workers and cost-saving efficiencies. The bill took effect on january 1, 2013, although not all of its provisions will be effective immediately.

Since the passing of CA SB 863, GENEX has been reviewing the legislative changes and systematically developing and implement-ing operational workflows, policies, and processes to incorporate the new legislative requirements into our products and services. GENEX is currently compliant with all applicable regulations impacting our service offerings, especially to the requirements impacting Utilization Review/Independent Medical Review and Independent Bill Review. MPN changes are not effective until 1/1/2014.

Utilization Review/Independent Medical Review

Independent Medical Review (IMR) is a new procedure adopted to deal with Utilization Review (UR) disputes to modify, delay, or deny a request for treatment. IMR is the exclusive process to challenge a UR decision once the UR process/appeal has been exhausted. Disputes may not be referred to an Agreed Medical Evaluator (AME), a Qualified Medical Evaluator (QME), or any other doctor. GENEX has fully reviewed all regulatory changes and is compliant with the changes as applicable.

Independent Bill Review

For Independent Bill Review (IBR), CA SB 863 created a process to resolve disputes regarding the amount to be paid to healthcare providers, if the doctors continue to dispute the reimbursement after one bill review appeal. California workers’ compensation medical treatment bills and medical-legal bills with dates of service on or after january 1, 2013, are subject to the new IBR rules for processing provider disputes (i.e., reconsiderations/provider appeals). The regulation implements the “Second Review” and “Independent Bill Review” procedures. While the IBR process is run by the state, GENEX is versed on the entirety of the IBR pro-cess, but is more focused on the “Second Review” process due to the demands of processing timeframes and penalty structure.

Continued, page 15.

LegisLAtiVe updAte

“That is particularly true with opioid man-agement, but it is true” for all care, she said. “In workers comp, we think of that as return to work or at least increasing job tasks” that an injured worker is capable of performing.

Without a strict definition of functional restoration, providers can assert that they offer such programs while providing nothing more than physical therapy, sources said.

Some are even “fly-by-night” operations, Mr. Pew said.

To recommend which functional restora-tion programs provide good outcomes, Mr. Pew said he is attempting to score them based on a set of questions he developed for the service providers.

The goal is to help work comp payers decide what action to take after utilization review and peer-to-peer discussions with a treating physician have concluded that an injured worker is consuming too many drugs without showing improvement.

While scoring functional restoration pro-grams, Mr. Pew said he found that those that appear to have the best practices are making yoga part of their offerings.

Yoga “helps with flexibility, which obviously is part of trying to get (patients suffering from chronic-pain issues) beyond the “I can’t move stage,” Mr. Pew said.

Yoga also appears particularly suited for helping patients, such as workers who have experienced failed back surgeries, focus on something other than their pain, Mr. Pew said.

“However you came to chronic pain, you have to figure out some way to not let it drive you,” Mr. Pew said. “That is really what func-tional restoration is trying to do — improve your function, which improves your quality of life.”

But several experts said patients must be interested in the functional restoration program’s offerings and motivated to make lifestyle changes to achieve positive results. Better programs properly screen participants for their motivation before admitting them, sources said.

Motivated patients can find yoga to be beneficial, Dr. Mueller said.

Reprinted with permission, Business Insurance February 10, 2013. Copyright Crain Communica-tions, Inc.


industrial Hearing LossBy Don StevensHarmony Hearing

how does the ear process sound?

The outer ear and the ear canal constitute the outer ear which funnels sound to the ear drum. The middle ear begins at the ear drum (tympanic membrane). In the middle ear, three small bones called the hammer, the anvil, and the stirrup help to transmit and amplify the vibrations generated by the sound, such that it travels through the middle ear to the inner ear. The inner ear, besides having the functions that relate to the perception of sound, is also responsible for the perception of balance/orientation and acceleration.

Our greater concern in this article is specifically that unwanted sound that we call “noise.” The inner ear has a snail-like object called the cochlea, that is filled with fluid and lined by cells with very fine hairs. This sequence of sensitive cells is somewhat like the keys of a piano. In the inner ear, one end of the sensitive cells in the cochlea discerns high frequency sounds and the other end discerns low frequency sounds, with a continuous spectrum in between the two.

how do you measure noise?

Sound can be measured scientifically in terms of intensity, but also specifically related to particular frequency bands. Pitch or frequency is measured in cycles per second, or Hertz (Hz). The higher the pitch of sound, the higher the frequency. It is reported that in young children, even frequencies as low as 20Hz and up to 1000 times greater, as in a dog whistle, can be detected.

Sound intensity is measured in decibels (dB). By definition, the faintest level of hearing detected by the human ear is set at zero decibels (though some people can hear levels lower than this).

Potential for industrial hearing loss

Workers at special risk of hearing damage (industrial deafness) are usually those in heavy productive industry, such as metal work, drilling and quarrying, stone cutting, or the use of noisy machinery, as in textiles, printing, wood cutting, transportation, and agricul-ture. Noises above 90 dB, as measured with special instruments that are electronically weighted to mimic loudness functions of the human ear, are likely to cause damage to a proportion of the exposed population with continued exposure. Very high levels may cause damage after relatively short periods, even when the noise is intermittent. This may be illustrated by the frequent finding of hearing loss in people who have fired guns as an occasional hobby,

as well as in people who are exposed to noise of lower levels but more constantly, such as those working on construction sites or in other industrial locations such as mines.

The harmful effects of noise are cumulative and not, of course, confined to the workplace. The use of personal iPods and fre-quenting of clubs has resulted in young people having some early damage to hearing before they even start work.

how does noise damage the ear? What is NIhL?

The answer to this is not completely known. However, we do know that the damage is caused to the sensitive cells in the cochlea. For reasons which are not entirely clear, some of the cells part of the way along the sensory organ in the cochlea are more sensitive than others. Hence, noise-induced hearing loss (NIHL) will begin to affect hearing of certain frequencies. This results in a ‘dip’ in an audiogram predominately in the high frequencies.

The effects of hearing loss

The first symptom of noise-induced hearing loss is usually difficul-ty hearing a conversation against a noisy background. The sufferer comes to avoid parties where everyone is apparently chattering away happily, yet he or she hears just a jumble of noise. Conso-nants seem to be lost first. Often he or she will mention intermit-

CLINICAL PERSPECTIVE

CHOICE PROVIDER NETWORK

Anatomy of the Ear

Medical Illustration Copyright © 2013 Nucleus Medical Media, All rights reserved. www.nucleusinc.com


tent high-pitched ringing in the ears, though this is rarely sufficient to be more than an irritant. By the time these symptoms have become sufficient to prompt a medical consultation, the damage as measured by audiometry will be severe, and even with cessation of noise exposure, progressive hearing loss can continue.

how can NIhL be prevented?

The following measures can and should be taken: Assessment of exposure, using tools and equipment which generate a lower level of noise, segregation and insulation, appropriate work practices and personal protection, such as ear muffs and ear plugs. Additionally, steps should be taken to protect workers from noise.

The most reasonable way to protect the ears is to generate less noise in the first place, by better design of machinery and equip-ment.

Secondly, steps should be taken to insulate the machinery to reduce the noise that it emits and to segregate people from it.

People should work in areas where they are not exposed to high levels of noise. The same goes for leisure activities.

At a personal level, it is possible to protect the ears with ear muffs and/or ear plugs. If you must work in an excessively noisy environ-ment, you should wear protectors.

Hearing protection may attenuate noise by between 15 and 30 dBA. As with all personal protection, this is the last line in protec-tion. Appropriate low noise machinery/ processes must be in place, then followed by insulation and segregation to attenuate the workers’ exposure to noise.

Research:

Raymond Agius 2006

“Noise-Induced Hearing Loss; Scientific Advances”: Colleen G. Le Prell (Editor), Donald Henderson (Editor)

Richard R. Fay (Editor), Arthur N. Propper (Editor)

“Medical-Legal Evaluation of Hearing Loss”: Robert A Dobie (author)

“Occupational Hearing Loss”: Robert Thayer Sataloff (Editor), joseph Sataloff (Editor)

It’s Time to Talk to GENEX about Comprehensive Pharmacy Review!GENEX has the solution to your workers’ comp prescription drug costs. Our Comprehensive Pharmacy Review (CPR) program is a detailed analysis of a claimant’s pharmacy utilization and prescribing provider’s treatment plan followed by peer-to-peer outreach.

GENEX has a dedicated service unit which handles all CPR referrals. Our experienced staff coordinates the peer-to-peer consultation, negotiation, agreement, and Concurrence letter. Our case management follow-up and intervention is a key component to a successful outcome. And, with the comprehensive pharmacy review report and cost savings analysis, you can better track your medical spend on prescription drugs.

For more information email us at [email protected]

888.GO.GENEX | GENEXSERVICES.COM

Prescriptiondrugs make upabout

19%of workers’ compmedical costs


Medication safety:An Inside Look


Michele Ritchie, Marketing Communications Manager, GENEX Services

Nine Years, 17 Surgeries, 17 MedicationsIt was 1996. Dan Smith* was working 60-70 hours

a week using air sanders, drills, and other vibrational tools. The numbness and pain started in both hands and wrists. By 1997, he was feeling the pain in both shoulders and upper extremities and had already injured his back lifting heavy equipment.

Over the next nine years, Smith had 17 surgeries, includ-ing several bilateral carpal tunnel release procedures, bilateral shoulder arthroscopy, wrist arthroscopy, thumb reconstruc-tion, elbow arthroscopy, and a right elbow release procedure. At this point, Smith was taking 17 medications, including:

• 4 pain medications

• 3 depression/anxiety medications

• 1 sleep aid medication

• 4 reflux medications

• 1 blood pressure medication

• 3 constipation medications

• 1 nausea/vomiting medication

By 2011, Smith had undergone several independent medi-cal evaluations, with doctors recommending that no further surgery be performed, and that he be admitted to a drug rehab program. Heavy opioid use had caused him to become irrational, which led to despair and depression, which led to medications to combat his depression. When he wasn’t happy with one doctor or couldn’t get medications from them, he would see another doctor, complaining that his pain was a “9” on a scale of 1-10.

Dan Smith’s case was complicated, involving second-, third-, and even fourth-opinion doctors. In late 2012,

GENEX became involved, and a Peer-to-Peer Review and Assessment was requested, the results of which revealed three major issues with Smith’s case:

• An underlying overuse injury that caused pain to both hands and wrists

• Significant psychiatric issues, ranging from severe depression to suicidal thoughts, de-spite extensive psychotherapy and cognitive behavioral therapy

• A clear need for inpatient detox or a simi-lar program that included an outpatient program with a strong psychological/ psychiatric follow-up plan.

Based on the review, Smith’s medications were reduced from 17 down to seven. Smith needed to sign an opioid treatment agree-ment, and has to undergo random urine drug

monitoring at least twice a year. To put cost in perspective, monthly savings totaled $3,683; annual savings are $44,206; and $1.4 million is the projected savings over the claimant’s expected lifetime. At this time, Smith remains out of work on permanent long-term disability, due to the injuries in his shoulders and wrists. However, he has significantly reduced his dependency on opioids.

Medication Safety — Where Do You Start?In workers’ compensation, there is a big focus on opioid

abuse, medication misuse, tolerance, and dependence, as well as physicians prescribing opioids at the wrong point clini-cally for the injury. Therefore, the earlier the case is managed, the better the opportunity to impact the case with a positive result, such as a return to work and management of pain without medication.

A GENEX Telephonic Case Manager who receives a new injury case has a window of opportunity to impact the medi-cation usage issue. However, GENEX Field Case Managers frequently receive cases that are quite old, and treatment and medication plans, as well as the lack of progress towards recovery, have already been established. These are the types of cases that are often “red-flagged,” like Dan Smith’s, because of the likelihood of opioid abuse.

“Our case managers are required to complete our CCM, CRC, and CDMS-approved Medication Safety Train-ing CEU Program and New Hire Training Module,” said Mariellen Blue, RN, CCM, CDMS, National Director, Case Management Services. “They know that they cannot impact case outcomes without considering all medications the per-son is taking and whether those medications are helping or hindering the individual’s recovery.”

Medication plays a key role in the individual’s return to wellness — along with surgery, conservative care such as physical therapy, and the healing properties of time. By recognizing potential issues, GENEX Case Managers are able to intervene for the safety of the patient.

Opioid use is a national crisis. According to the National Council on Compensation

Insurance (NCCI), narcotic prescriptions account for

$1.4 billion of workers’ compensation medication

spending annually. It is such a hot topic with workers’

compensation carriers that many states have enacted

laws or guidelines to deal with the issues surrounding

opioids. In this issue, we look at how GENEX Case

Managers consider all medications the person is taking,

and whether those medications are helping or hindering

the individual’s recovery process.


don’t miss an issue!Subscribe to Pyramid by sending your email address to: [email protected] is offered free of charge and produced by the GENEX Corporate Marketing department.


States Must

Decide if

Workers’ Comp

Benefits Extend

to Illegal

Workers

Scrutiny on

Police Disability

Program

Top 10 highest

cost workers’ comp

states

Line-of-duty

fatalities rise in

2010

Message from

GENEX CEO

Peter Madeja

Workers’ Compensation and Disability Management News

Spring 2011

When a telephonic or field case manager receives a new case, a complete medication and pain assessment is con-ducted to determine if the appropriate diagnostic tests were completed in accordance with clinical guidelines for the injury. They also need to know if the diagnosis supports the current clinical symptoms and medications. If the diagnosis is incorrect, the medications prescribed may not lead to re-covery for the claimant. Or, worse yet, they could contribute to an opioid addiction further into treatment.

Part of the assessment includes a discussion with the claimant to determine their treatment plan, to make sure they fully understand the purpose of the medications, and how to properly take them. The case manager asks pointed questions regarding the claimant’s quality of sleep, appetite, perspec-tive, and motivation to return to work. They spend time with the person and educate him/her about the choices the person makes as they proceed through the claims and case manage-ment process.

GENEX’s Case Managers are often the only educational resource for the individual, as the provider frequently does not spend the time on educating and explaining. “We train our case managers to empower the person by educating and coaching them,” said Blue. “It is crucial that the claimant knows how to navigate the medical system and become edu-cated about their injury. They play a vital role in maximizing their own recovery.”

GENEX’s Solutions

Medical costs, including the rising costs of prescription medications, are increasingly the biggest part of workers’ compensation claims. Case managers are a key part in helping to control those costs. But GENEX’s Medication Safety Program also includes:

• Quality Medical Provider Networks

• Customized Provider Panels

• Utilization Review

• Medical Bill Review

• Pharmacy Benefit Management

• Independent Medical Examinations

• Comprehensive Pharmacy Review

Using these tools in tandem with medical case management can substantially decrease the medical spend and improve the patient outcomes, especially on cases involving claimants with issues such as chronic pain, catastrophic injuries, and other debilitating injuries.

Educating and coaching the claimant can include such topics as:

• Discuss and share drug interaction issues if appropriate

• Answer questions about treatment and possible outcomes

• Encourage return to productivity and work

• Discuss what the person can do on his/her own to manage how they feel and cope

“Our goal is to help the person return as close as possible to their pre-injury/illness state,” said Blue. “Physical medicine is a big part of that, but so is medication. Education and information can help the individual stay

informed during the process that often leaves many injured people feeling overwhelmed.”

The claimant must own the process of medication compli-ance (taking the medication as ordered), reporting on the medication results to his/her provider, and medication safety (keeping the medication safely out of the hands of other people), just as the person owns the process of complying with treatment like physical therapy.

*Not the person’s real name.

For more information on GENEX’s Medication Safety Program or any of the services and products mentioned, please contact your GENEX Account Representative, or call 1.888.GO.GENEX.

geNeX’s Case Managers are often the only educational resource for the individual, as the provider frequently does not spend the time on educating.


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3eVeNts CALeNdArGENEX will be attending these upcoming industry events. We look forward to seeing you!

South Dakota Workers’ Compensation SummitApril 17–18, 2013Sioux Falls, SD

RIMS Annual Conference and ExhibitApril 21–24, 2013Los Angeles, CA

Wisconsin Safety Council ConferenceApril 22–24, 2013Wisconsin Dells, WI

Alabama Workers’ Compensation Organization May 1–3, 2013Birmingham, AL

The 83rd Annual North Carolina Statewide Safety ConferenceMay 14–16, 2013Greensboro, NC

West virginia Workers’ Comp Educational ConferenceMay 17, 2013Charleston, WV

PRIMA’s 2013 Annual Conferencejune 2–5, 2013Tampa, FL

The Association of Workers’ Compensation Claims Professionals (WCCP) 22nd Annual Claims Management & Leadership Conferencejune 9, 2013Naples, FL

Pennsylvania Bureau of Workers’ Compensation 12th Annual Workers’ Compensation Conference june 10–11, 2013Hershey, PA

Oregon Self-Insurers Association july 10–12, 2013Gleneden Beach, OR

Kansas Department of Labor 39th Annual Workers’ Compensation SeminarAugust 6–7, 2013Wichita, kS

Maryland Workers’ Compensation Educational AssociationSeptember 15–18, 2013Ocean City, MD

Legislative Updates, continued from page 9:

Medical Provider Networks

The administrative rulemaking process for Medical Provider Networks (MPNs) is currently underway, with most effective dates not occurring until january 1, 2014. GENEX files MPN Applications on behalf of those clients desiring California MPNs. We have thoroughly reviewed the MPN changes out-lined in SB 863, and we are closely monitoring the rulemaking process for the MPN changes that are occurring this year. We are also in direct contact with state regulators regarding the MPN changes.

Compliance and GENEX

GENEX is fully compliant with the requirements set forth in California SB 863 as it relates to the products and services we offer our customers.

The scope and impact of this workers’ compensation reform is too large to outline in this summary. We encourage you to refer to http://www.dir.ca.gov/dwc/dwc_home_page.htm for more comprehensive information on all components of SB 863. The California Department of Workers’ Compensation provides detailed legislative information along with frequently asked questions that address each component of the rule.

Specific questions involving more detail on any component of SB 863 can be directed to your GENEX Account Manager.

ICD-10 is coming 10.1.2014

Are You Ready?here is a list of some action items to consider in preparation for the conversion to ICD-10:

33 Identify ICD-10 impact on your business processes, systems and trading partners

33 Develop your company’s ICD-10 project plan and mapping strategy

33 Develop an ICD-10 communication plan for staff and business partners

33 Implement changes to integrate ICD-10 into all systems that currently use ICD-9

33 Provide ICD-10 training

GENEX is gearing up for ICD-10! visit www.genexservices.com for more information and periodic updates.


http://www.dir.ca.gov/dwc/dwc_home_page.htm

http://www.genexservices.com

SOlVING the cost/care equation for our customers

Visit us at RIMS booth 1009

GENEX is the nation’s leading provider of integrated managed care services, focused on controlling health care costs and reducing disability expenses. Only GENEX offers the market experience, proven products, customized solutions, unique service integration, and technical expertise to solve your cost/care equation.

Workers’ Compensation & Disability ManagementMedical Cost Containment

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To learn more about our products and services:• Visit us at genexservices.com • Call us at 888.GO.GENEX• Email us at [email protected]

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