Delayed Recovery

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Functional Restoration Programs The Workers’ Compensation Payor Perspective

Steven Moskowitz, MD, Senior Medical Director © Paradigm Outcomes, Proprietary

Our Case Where is he now? ■ 8/10 pain; not returned to work ■ Escalated Medications –

Norco 10/325, 8 per day

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Oxycontin 40 mg TID

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Cyclobenzaprine 10 mg q day

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Escitalopram 10 mg per day

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Alprazolam 1.0 mg TID

■ Morphine Equivalent Daily Dose = 300 mg ■ Poor Functional Recovery ■ Past Medical History

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Tobacco dependence

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Alcoholism

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Anxiety disorder

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The Worker’s Compensation Perspective: 50 States/50 Regs Goal is a closed claim (or less spend).

■ The carrier pays the medical costs for life

■ Workers’ Compensation interest in FRP varies:

■ These costs are estimated in medical reserves

– Good functional outcome

– the claims reserve is money that is earmarked for the eventual claim payment.

– Return to work, if IW has not already settled indemnity portion of claim – Decreased medical costs

■ Some states allow them to settle medical costs

• Pharmacy • Procedures

■ Payor has no incentive to settle high medical reserves

• Durability

■ Medicare Set-Aside rules have further complicated settlement

– Medicare July 2001 guidance formally introduced the term

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How Chronic Pain Emerges This phenomenon can come on gradually, but has markers at each stage.

atrophy

depression atrophy

insomnia

insomnia

PAIN

PAIN

PAIN

weight gain

fear of movement medical issues

addiction life roles Acute Pain (0-3 months)

Transitional (3-6 months)

Chronic Pain Syndrome (greater than 6 months)

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The Costs Add Up The costs on these cases may be moderate in any one year, but they represent significant expense over time. Pharmacy costs, while important, typically represent less than one-third of total costs.

Typical Complex Pain Case Spend Breakdown of Case Costs

Cumulative Spend Pattern on Illustrative Case

Other Medical 17% DME and Home Health 22%

Pharmacy (Non Opioid) 15% Pharmacy (Opioid) 13% Surgery/ Facility/ Physician 33%

Incurred Medical ($000)

$250 $200 $150 $100 $50 $-

Injury

Year Year Year Year Year Year Year Year 1 2 3 4 5 6 7 8 Source: Paradigm Analytics, based on 10,000 open lost time claims

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Current State of Workers’ Compensation Medical Losses All Claims – NCCI States

1988

Medical 46%

Indemnity 54%

Indemnity 47%

2008 Indemnity 42%

1998

Medical 53%

2018 - Projected Indemnity 30% Medical 58%

Medical 70%

Accident Year. Based on the states where NCCI provides ratemaking services, including state funds. Excludes high deductible policies. 6

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Let’s Assume You Can Improve Someone's Function It’s also essential to decrease the medical costs of the case.

■ MMI and P and S determinations are no longer enough

■ To settle a case, you need to decrease long-term medical costs as measured by:

■ New factors have complicated case settlement

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Reserves

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Medicare set-aside

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Statutory rules on settling medical costs

■ Major determinants

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Cost of settlement needs to be realistic

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Pharmacy

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Medicare set-aside rules have upped the ante on settlement

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Procedures

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Case Conceptualization How did this worker get here?

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Case Assessment Biopsychosocial, not biomedical assessment.

■ Clarify the diagnosis: Post-Laminectomy syndrome? “Radiculopathy”? Chronic pain syndrome? ■ Psychological: Substance use disorder? Cognitive distortions? ■ Social issue: Secondary gain? Family issues? Litigation?

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Best Predictors of Acute Injury Progressing to Chronic Pain These factors increase the risk of delayed recovery.

1. Filing a WC claim1 2. Substantial pain disability2 3. Radiculopathy2 __Add other diagnoses : TOS, CRPS 4. Catastrophic behavior, high pain intensity1 5. Litigation1 6. Previous work injury with extended lost time2 7. History of substance abuse 8. Family history of being on compensation 9. Geographic factors/providers 2

1. Compensation and chronic pain; Teasell RW., Journal; Clin J Pain. 2001 Dec;17(4, Suppl):S46-64 2. Early Predictors of Chronic Work Disability, A Prospective, Population-Based Study of Workers, With Back Injuries 10

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Chronic Widespread Pain Risk factors associated with the transition to CWP (chronic widespread pain).

■ Moderate to severe pain complaint ■ Female gender ■ History of abuse

■ Family history of chronic widespread pain ■ Severe interference with general activity ■ One or more central sensitivity syndromes

■ Using multiple (“more”) pain strategies

Ref. Risk factors predicting the development of widespread pain from chronic back or neck pain; J Pain. 2010 December ; 11(12): 1320–1328

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This Injured Worker Is A High Risk for Chronic Pain Opioid Risk

Risk of Chronicity  Substantial pain disability, severe pain complaint  Radiculopathy __Add other diagnoses : TOS, CRPS,  Catastrophic behavior, high pain intensity1

 Litigation  Previous work injury with extended lost time2  History of substance abuse  Smoking + prescription opioids, benzos  Family history of being on compensation  Geographic factors/providers  History of abuse

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Claims View Of An Effective FRP Outcome Case closure is the holy grail. ■ Case closure determinants – Full medical recovery – Medical stability: MMI / P and S • Maximal medical improvement (MMI): Your condition is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Once you reach MMI, a doctor can assess how much, if any, permanent disability resulted from your work injury. http://www.dir.ca.gov/dwc/WCGlossary.htmFunctional improvement – Return to work

– Settlement • Indemnity • Workers' Compensation Medicare Set-aside : allocates a portion of the WC settlement for future medical expenses. The amount of the set aside is determined on a case-by-case basis and should be reviewed by CMS

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Looking for in a CP program Look for a “center of excellence” for chronic pain.

■ Good outcomes –

■ Strong Physician leadership

Restoration of function/therapeutic exercise

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Objective measures

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Durability of outcome

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Capacity for detoxification, manage addiction

■ Interdisciplinary –

Cognitive Behavioral Therapy

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Mental health capacity

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Non-interventional

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Clarification of pain diagnosis

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Medication weaning

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Detoxification off controlled substances (opioids, benzos)

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Eye on medical costs • Avoids replacement of costly care with costly care

■ Good communication –

Easy to reach

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Responsiveness

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Our Outcome Needs To Include Decreasing The Cost of Care The costs of these services are multiplied over life expectancy.

■ Our 39 year old worker, life expectancy is 39.6 years. ■ Medication list is : Norco 10mg/325, 8 per day

$621/month

Oxycontin 40mg TID

$550/month

cyclobenzaprine 10 mg TID PRN

$175/month

Escitalopram 10mg Q day

$140/month

Alprazolam 1.0mg TID

$308/month

Monthly total Lifetime estimate

FRP Return on Investment

$1, 619

$50,000 program

$769,348

ROI in 30.8 months

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Pitfalls Lost financial outcomes

■ Replacing a high cost med with a new high cost med –

Ex. Suboxone, compound creams

■ Program durability/recidivism

■ Not planning for post-discharge set-back –

Return to prior MD

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Drug seeking

■ Opening a psych claim

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