Thursday, January 5, 2012

Moving from Diagnosis to Treatment

Quick… rattle off the stats regarding chronic (over)use of prescription narcotics in work comp. 
Let’s see, there’s the spend ($1.4 billion a year and rising).  There’s the risk (more people dying of accidental opioid overdoses than cocaine and heroin combined).  There’s the clear lack of medical necessity (no evidence-based guidelines suggest that long term use of these drugs is a good thing for common work injuries). 
Imagine going to the doctor.  The doctor says, “I have a bad news.  You have a tumor.  It’s growing.  Let me tell you everything there is to know about this tumor.  We’re going to look at some pictures of it.  We’re going to look at a historical chart of its growth.  We’re going to talk about how much it’s going to hurt as it continues to grow.”
What would you say?  I would guess something like, “Enough talk, already… WHAT ARE WE GOING TO DO ABOUT IT?!?!?”
That’s how I’m feeling about the issue of chronic opioid abuse in work comp.  We get that there’s a problem.  Now what are we going to do about it?  I’ve heard this question asked in a few different forums now and the answers generally come down to:
1)   Education and awareness (i.e., let’s keep talking about that tumor in the hope that by talking endlessly about the diagnosis, the treatment miraculously reveals itself)
2)   Statutory change (i.e., the only way to get doctors and patients to start thinking differently about this issue is to legislate our way to solutions)
3)   Early intervention (i.e., let’s stop the train from going off the tracks in the first place)
I’m tired of #1 (the way it’s currently done).  I’m leery of #2.  I’m a big fan of #3, but only if it’s done right – and it still leaves the open question regarding what to do with existing legacy claims that have already gone off the track.
Here’s my take: We need education and awareness, but it needs to occur claim by claim, doctor by doctor, via a physician-led peer review model with consistent nurse oversight and follow up, coordinated with the PBM to exchange data on the front end and back end of the intervention.  This entire process needs to be supported by compliance advice and legal counsel to ensure that, if a physician refuses to participate, the appropriate rules are followed in each jurisdiction to attempt to fix the claim (and, we would argue, give the patient a fighting shot at a functional and enjoyable life, even if it’s not 100% pain free). 
If your solution to this problem doesn’t look like that, our view is that you’re missing something. 

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