The Toxic Balloon
Nancy Strolich, a workers’ compensation claims professional for a carrier, is doing what she feels is a diligent job in tracking the pharmacy intake and quality of care for an injured emergency medical technician. But the case spins out of control when the injured worker displays a voracious appetite for narcotic pain killers. While this Risk Scenario depicts a case example that could be considered an outlier type of scenario, there are several significant situations and opportunities illustrated that are very common.
Video Insights: Cyril Tuohy sat down with Daryl Corr, President of Healthesystems who is the sponsor of this scenario, for an in-depth discussion of “The Toxic Balloon”. Highlights of their conversation are integrated into the summary below.
1. Establish a comprehensive pharmacy management process: In this scenario, Nancy is blindsided by bills that come to her through different mediums and from different billing sources and she isn’t provided with any alerts or visibility about the escalating prescription activity until it is too late. Nancy needed much greater transparency into the number of prescriptions Rick was getting filled, who was prescribing them and where they were being filled. In addition, she needed more tools that would have enforced prior authorizations of certain retail dispensed scripts while providing her with the capability to deny payments of scripts being received on paper.
2. Screen for addiction predisposition: The fact that Rick was a smoker, combined with his brother Petey and his father both being smokers and excessive drinkers was valuable information that could have helped alert Nancy to about Rick’s potential for becoming addicted to opioids. Had Nancy’s claims best practices included processes such as monitoring whether prescribing physicians were screening injured employees for risks of opioid addiction, it could have provided earlier warning sings to intervene and challenge the appropriateness and safety of certain prescriptions being used in Rick’s therapy much sooner.
3. Aggressive intervention and treatment analysis: The prescribing activity occurring in Rick’s case escalated over a period of time and Nancy was ill-equipped to slow it down or reverse course. Several prescribing physicians were writing scripts, many of which made the combined therapies excessive if not potentially lethal.
4. Monitor jurisdictional trends and new legislation: Cases based in a state like Florida, which has become a hot bed of physician drug dispensation and drug repackaging, should warrant extra attention. States that allow the proliferation of such pill mills are a dangerous environment for an injured worker and for the payer who is paying for their prescriptions. Prescription costs for physician-dispensed drugs can dwarf those of drugs obtained at a pharmacy. Legislation is one of the key areas of focus that can help regain control over challenges such as physician dispensing and repackaged drugs.
5. Consider urine drug monitoring: Had Nancy been able to get a chemical picture of what was going on inside Rick she would have been shocked and perhaps motivated to intervene in his case much sooner. Monitoring bills is one thing, but getting biological evidence of the state of an injured employee can go a long way in determining whether the worker is taking too many drugs, or in some cases, obtaining the lucrative drugs, not taking them and selling them on the black market.
6. Assess the mind set: In many cases, assessing the mind set of an injured employee can be just as important as monitoring the injured employee’s physical recovery process. In Rick’s case, his depression over his brother’s death led him to seek additional physicians and additionally prescriptions, greatly complicating his workers’ compensation case and negatively impacting his recovery.
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