Medical Management Strategies for Cost Containment

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Jackie Pierce and Teresa Bartlett, MD

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Medical Management Strategies for Cost Containment

  1. 1. Sedgwick © 2013 Confidential – Do not disclose or distribute.Medical ManagementStrategies for CostContainment
  2. 2. Sedgwick © 2013 Confidential – Do not disclose or distribute.Jackie PierceTeresa Bartlett, MDFebruary 13, 2013
  3. 3. Sedgwick © 2013 Confidential – Do not disclose or distribute. 3ObjectivesThis presentation will explain the practical application of medicalmanagement strategies and how they play a role in lowering theultimate cost of risk for employers.It will include both the employer and TPA perspective. The variousdisciplines of medical management will be discussed from a riskinsurance perspective, with emphasis on medication strategies as aprimary cost driver in workers’ compensation.
  4. 4. Sedgwick © 2013 Confidential – Do not disclose or distribute. 4Value your mature workersKnowledgemanagement• Perceptions• Health risks• Treatment impact• Care coordination• Outcome data• GenerationalconsiderationsModelconsiderations• Nurse navigators• Medical literacy• Physician schedulingservices• Sound technologysolutions• Key stakeholderawareness• Consumer driven plansAccesstoinformation• Politicalcomponent• Media• Direct advertising• Technology• Provider marketing• Payercommunication
  5. 5. Sedgwick © 2013 Confidential – Do not disclose or distribute. 5The focus has changedFrom managed care tohealth careFrom managingtransactions toensuring and drivingquality results
  6. 6. Sedgwick © 2013 Confidential – Do not disclose or distribute. 6Importance of capturing great medicalinformation early in the claim process• Captures: what when how• Quantifies theinitial injurydetails• Improves morale• Improvespenetration• Quality healthcare experienceEmployeronsitemedicalClinicalresourceson thefront line24 x 7nurse callline
  7. 7. Sedgwick © 2013 Confidential – Do not disclose or distribute. 7Clinical consultation processInjury occurs and employee advises supervisorSupervisor calls clinical consultation and the employee speaksconfidentially with the nurseNurse reviews symptoms & recommends appropriate care. Ifprovider care appropriate, nurse schedules appointmentFollow up survey within 24-36 hours of triageReport is transmitted to examiner. Supervisor transferred to intaketo report incident
  8. 8. Sedgwick © 2013 Confidential – Do not disclose or distribute. 8Claim 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!
  9. 9. Sedgwick © 2013 Confidential – Do not disclose or distribute. 9Telephonic case management• Support claim examiners• Aggressively advance claim• Answer injured worker questions• Apply evidence-based standardsHOW DOES IT WORK?• Business rules driven referrals based on client-specific data• Integrated file approach with claim examiners• Custom model development for each client
  10. 10. Sedgwick © 2013 Confidential – Do not disclose or distribute. 10Nurses interact with injured workerAdvocate for best-in-class careExpedite most appropriate treatmentEncourage and coach injured workerIdentify medical red flagsLook for psycho-social barriers to recoveryTelephonic case management
  11. 11. Sedgwick © 2013 Confidential – Do not disclose or distribute. 11Utilization review• Addresses frequency duration appropriateness of medical services reasonably required tocure and relieve the injury effects setting (inpatient vs. outpatient)• Nurses use evidence-based guidelines• Involve physician peer discussions
  12. 12. Sedgwick © 2013 Confidential – Do not disclose or distribute. 12Utilization review• Applies the latest evidence-based medical guidelines to proposedtreatment• Physicians may be stuck in a pattern of how they have alwaysapproached treatment• Physicians have difficulty digesting and implementing the lateststudies and technology• Not intended to reduce or limit treatment• QUALITY medical care is the goal• Very impactful especially when applied to medication strategies inWashington
  13. 13. Sedgwick © 2013 Confidential – Do not disclose or distribute. 13Vocational rehabilitationRequired inWashingtonVocationalrehab planNeed moreWashingtondetails
  14. 14. Sedgwick © 2013 Confidential – Do not disclose or distribute. 14Bill Review• Efficiency• Process driven• Cost savings• Negotiation
  15. 15. Sedgwick © 2013 Confidential – Do not disclose or distribute. 15Focused 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 unbundlingcosts as part of bill review• Systematic application of up-coding rules• UR/TCM treatment plans are integrated into the system, allowing us to rejecttreatment 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 themultiple surgical procedures rules• Hospital line level review for proper billing practices
  16. 16. Sedgwick © 2013 Confidential – Do not disclose or distribute. 16Specialty partnersDurable medical equipmentPhysical therapyPharmacyLinked to system for desk level efficienciesPaperless
  17. 17. Sedgwick © 2013 Confidential – Do not disclose or distribute. 17Provider 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
  18. 18. Sedgwick © 2012 Confidential– Do not disclose or distribute. 18Medication ManagementStrategies
  19. 19. Sedgwick © 2013 Confidential – Do not disclose or distribute. 19Background: How did we get to this place?• In late 2000, Congress passed into law a provision, which thePresident signed, that declared the ten-year period that beganJanuary 1, 2001, as the Decade of Pain Control and Research• The American Pain Society has actively supported the Decade of PainControl and Research and it has been a focal point for thedevelopment of numerous programs to advance awareness andtreatment of pain and funding for researchFrom the American Pain Society Website
  20. 20. Sedgwick © 2013 Confidential – Do not disclose or distribute. 20Narcotic utilization• Since 1990, the medical use of opioids has increased by a factor of10• According to the CDC, enough opioids were prescribed last year tomedicate every American adult with a standard pain treatment doseof hydrocodone every 4 hours for a month• Fatal overdoses involving prescribed opioids tripled in the UnitedStates between 1999 and 2006• A recent government study determined that opioid poisoning was theleading cause of death for people aged 35-54• This rate was higher than motor vehicle or firearmrelated deaths for that age group
  21. 21. Sedgwick © 2012 Confidential– Do not disclose or distribute. 21
  22. 22. Sedgwick © 2013 Confidential – Do not disclose or distribute. 22Narcotic medication management• Creates issues for:Patients Physicians Employers
  23. 23. Sedgwick © 2013 Confidential – Do not disclose or distribute. 23Prescription drug diversion as a national issue
  24. 24. Sedgwick © 2013 Confidential – Do not disclose or distribute. 24Background: How did we get to this place?• cross the country, there is anincrease in the number of ER visitsdue to non-medical use ofnarcotics• Up to 89% of abused prescriptiondrugs are diverted from legallywritten prescriptions• Problem isn’t just with narcoticprescribing, but how they areused once in the hands of thepublic
  25. 25. Sedgwick © 2013 Confidential – Do not disclose or distribute. 25• The way the brain reacts facilitates the process of addiction/abuse:Biochemical physiology of narcotic useEndorphins are naturally occurring chemicals that work on thenervous system to reduce painThe endorphins can act on certain parts of the brain to produceeuphoria or a natural “high”Addiction shuts the endorphin system downThis leads to hyperalgia (increased pain perception) andhypersensitivityThe abuser then seeks higher doses or stronger drugs
  26. 26. Sedgwick © 2013 Confidential – Do not disclose or distribute. 26Opioid 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 substantialimprovement in function or pain relief a chronic pain specialist shouldbe consulted• Long acting or controlled release opioids should not be used for acutepain• Fentanyl patches, OxyContin and Methadone are examples
  27. 27. Sedgwick © 2013 Confidential – Do not disclose or distribute. 27Recommend using a patient agreementWashington agreement
  28. 28. Sedgwick © 2013 Confidential – Do not disclose or distribute. 28Follow up careFailure to progress or demonstrate functional progress or any signs ofcompliance should lead to prompt discontinuance of medicationDosage may need to be increased to maximize therapeutic value not toexceed 120mg Morphine/dayRandom urine drug screenWeaning should involve a mental health professional who specializes inaddictionPT, exercise and other medications such as NSAIDS are important in thisprocess
  29. 29. Sedgwick © 2013 Confidential – Do not disclose or distribute. 29An electronic dose calculator can be foundand downloadedWWW.agencymeddirectors.wa.gov/wa/guidelines.aspMorphine 120mg/day is the MAXIMUMMORPHINE (reference) 30 mgCodeine 200 mgFentanyl Transdermal 12.5mcg/hrHydrocodone (Vicodin) 30 mgHydromorphone 7.5mgOxycodone 20mgOxymorphone 10mgMethadone 4mgj *BE CAUTIOUS
  30. 30. Sedgwick © 2013 Confidential – Do not disclose or distribute. 30Opioid risk tool (ORT)1Date ______Patient NameOPIOID RISK TOOLMark eachbox that appliesItem ScoreIf FemaleItem ScoreIf Male1. Family History of Substance Abuse Alcohol [ ] 1 3Illegal Drugs [ ] 2 3Prescription Drugs [ ] 4 42. Personal History of Substance Abuse Alcohol [ ] 3 3Illegal Drugs [ ] 4 4Prescription Drugs [ ] 5 53. Age (Mark box if 16 – 45) [ ] 1 14. History of Preadolescent Sexual Abuse [ ] 3 05. Psychological Disease Attention DeficitDisorder [ ] 2 2Obsessive CompulsiveDisorderBipolarSchizophreniaDepression [ ] 1 1TOTAL [ ]Total Score Risk Category Low Risk 0 – 3 Moderate Risk 4 – 7 High Risk > 8
  31. 31. Sedgwick © 2013 Confidential – Do not disclose or distribute. 31Urine 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
  32. 32. Sedgwick © 2013 Confidential – Do not disclose or distribute. 32Urine drug testing result interpretation• The following UDT results should be viewed as a “red flag” requiringconfirmation 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
  33. 33. Sedgwick © 2013 Confidential – Do not disclose or distribute. 33Urine drug testing result interpretation• If a confirmatory drug test (MRO) substantiates a “red flag” resultAND is: Positive for prescribed opioid(s)• a controlled taper and a referral to an addiction specialist or drugtreatment program should be considered Negative for prescribed opioid(s)• The physician should stop prescribing opioid(s) and consider a referral toan addiction specialist or drug treatment program
  34. 34. Sedgwick © 2013 Confidential – Do not disclose or distribute. 34Assessment of functionOverall painmanagementHow well if thepain beingmanaged?Pain rating when asked toconsider the past monthShould indicate pain is overallbetter and able to function ata higher levelFunctionDaily activities should belisted; even in WCactivities that are healthyshould be encouraged
  35. 35. Sedgwick © 2013 Confidential – Do not disclose or distribute. 35Progressreport
  36. 36. Sedgwick © 2013 Confidential – Do not disclose or distribute. 36Suggested weaning processReduce Morphine mg by 10% each weekAdd Clonopine to help with withdrawal symptomAddiction or pain management specialist should be consultedMay require short inpatient stay to assist with initial phaseMay require drug rehab program (inpatient and outpatient)
  37. 37. Sedgwick © 2013 Confidential – Do not disclose or distribute. 37Examiner 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 bedocumented 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 nextassessment• Provide State of Washington Opioid agreement for any physician prescribingthese drugs• Ask for copies of screening, opioid agreement, drug test results and board ofpharmacy report
  38. 38. Sedgwick © 2012 Confidential– Do not disclose or distribute. 38Integration Opportunities
  39. 39. Sedgwick © 2013 Confidential – Do not disclose or distribute. 39Integration of available programsWellnessHealthandSafetyIndustrialAthlete
  40. 40. Sedgwick © 2012 Confidential– Do not disclose or distribute. 40QUESTIONS?
  41. 41. Sedgwick © 2012 Confidential– Do not disclose or distribute. 41Teresa Bartlett, MDSenior Vice President, Medical QualitySedgwickPhone: 248-637-3120teresa.bartlett@sedgwickcms.com

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