Long-term opioid use is the single biggest concern identified by workers’ compensation payers.
This continues to be a major issue – it’s not new. We’ve talked about it for years. The industry has talked about it for years.
What is new is the breadth and depth of proactive solutions to combat the issue from every angle.
Payers’ Role in Managing Narcotics
Express Scripts’ Morphine Equivalent Dose (MED) management program is a real-time approach to managing opioid utilization in workers’ compensation. When an opioid prescription is presented at the pharmacy, Express Scripts’ proprietary prescription processing system calculates the MED value for the individual prescription, as well as the cumulative level for all opioids the injured worker has on hand. If the prescription does not exceed the client-specified MED threshold, the prescription is filled. If either the individual or cumulative MED values are too high, the prescription is submitted to the payer to review for appropriateness prior to filling. The MED threshold is established by each client in consultation with the Express Scripts clinical pharmacy team. By implementing and leveraging the MED management program, payers can aggressively prevent abuse or misuse of opioids.
Automated Benefits for Adjusters and Nurse Case Manager
OASIS, Express Scripts’ automated technology for handling prior authorizations, provides the claims adjuster or nurse case manager with critical information needed to make an informed decision about whether to approve an opioid prescription that exceeds the payer’s MED threshold. This threshold includes information for both the individual opioid prescription in question, as well as the cumulative MED for the patient for all opioid prescriptions at that time. Adjusters and nurse case managers can then make a determination whether to approve the medication, and can even proactively modify the MED limit at the injured worker level as needed.
Engaging Injured Workers
As many as 35% of patients with chronic pain have become addicted to their pain medication. This is why Express Scripts has a program in place to communicate directly with the injured worker upon their first opioid fill. The communication educates the injured worker on side effects, risk of addiction and overall treatment information for safely taking opioid pain medication.
By opening the lines of communication among injured workers, Express Scripts educates the worker about potential safety concerns to ensure a safe and effective treatment plan.
Collaborating With Prescribing Physicians
The most recent enhancement to the MED management program engages the prescribing physician.
When an injured worker fills an opioid with an MED over the client-designated MED threshold, the physician will receive a reminder about the guidelines that should be used when prescribing opioids for non-cancer pain.
Because the MED management program totals the cumulative MED levels for all current opioid prescriptions, if an injured worker is receiving opioid prescriptions from multiple physicians, each prescriber will receive this communication.
Firing on All Cylinders
While there’s no silver bullet to manage the safety and cost concerns associated with opioid use, payers can arm themselves with proactive tools to prevent to ensure safe and cost-effective treatment and leverage these tools against the current evidence-based guidelines and treatment protocols.
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