Medical Management Strategies for Improved Claims Results

At the 2015 National Workers’ Compensation & Disability Conference, Adam L. Seidner, M.D., Global Medical Director, Travelers Insurance Co. and Silvia Sacalis, PharmD, VP Clinical Services, Healthesystems presented how a comprehensive view of an injured worker’s medical history and treatment course ensures appropriate claims decisions, resulting in optimal care and functional restoration.

Silvia started the session by giving a few stats regarding prescriptions. 20%-30% of prescriptions are never filled and 50% are never taken as prescribed. Many patients have comorbidities that hinder their recovery. The more medicines that are added to their treatment the more that they are not taken correctly. The patient is not just an injured worker but is a patient and might have several other comorbidities that need to be addressed.

Isolated complexities include psychosocial factors, multiple providers, comorbidities, complex medication regimen, adherence to therapy and patient medical history. Integrated complexities include power in collaboration and to focus on how we can tackle this collaboratively. Having the data helps drives the medical decision making, need to track and measure the outcomes. Stakeholders complexities include partnering together to share data to achieve best possible care for the injured worker. The patient should be involved with their care.

Case Study- Doe, John

Age/sex:68 year old male

DOI: 9/11/2001

Injury:large box fell on worker while working in warehouse, injuries sustained in neck, back and knees. Lower back pain and occasional pain right leg.

This case is lacking so much necessary information. For a case to be handled properly you need very detailed information of event, how heavy was the box, did he fall onto something else and how high was the box when it fell.

Diagnosis within claim-PTSD, sprain thoracic regin, lumbar disc disease, spasm of muscle, and displacement of lumbar intervertebral disc without myelopathy

Diagnosis outside of claim- sleep apnea, diabetes, heart murmur, hypertension and hypercholesterolemia

Medications processed through workers’ comp- opana, oxycodone, miralax, cialis, citalopram, amitriptyline (so many medications create problems, high risk medication combinations, drug interactions) multiple prescribers are prescribing too many meds, one might not know what the other is prescribing. Patient is probably not taking the medicines correctly since they are prescribed so many. Medications processed through other means-lipitor, lisinopril, glucophage (high cholesterol and lipitor can causes muscle pain this might not be associated with the injury could be associated with the medicine) Diabetes can cause nerve pain so is the nerve pain caused by the injury or the Diabetes, work together to gather as much data as possible. Other medical and diagnostics include physical therapy, electrical nerve stimulator, imaging, injections, discogram, and physiatry. Comprehensive patient management includes complete access to data, John Doe is on several medications which can make it difficult to decide on the correct care for each patient.

Continuum of care emcompasses 3 phases including acute pain, sub-acute pain and chronic pain.

Acute pain is up to 4 weeks post injury. During this phase opioids are not recommended for acute pain, John was prescribed two different opioids, John had high blood pressure and diabetes so this causes problems with the prescribed medicines for each of these items. For the injured worker it’s important to attack the pain in the acute phase and get rid of it as soon as possible. Multiple subscribers could cause issues. Medications are added because of other medicines that are recommended. Stop and take a look at the pain and which medications the injured worker is on, maybe start to eliminate medications rather than add medications.

Sub-acute pain is pain lasting between 1 – 3 months, lack of coordination of care which can cause prolonged pain. Again medications prescribed by different physicians can cause life threatening issues. Crucial to have coordination of care. Injured worker could be abusing substances.

Chronic pain is pain lasting greater than 3 months, work together to take action if this patient is still on too many pain medications and figure out how to decrease this, need to take control of the claim so that it does not get out of control any longer, pain characteristics are more complicated, pay attention and make changes now, some patients just want to treat the symptoms not the actual problem

You have to look at the measurements and analyze the data to make sure you are reaching the desired outcomes. Measurements include the following:

• improvement in pain
• improvement in adherence/compliance
• reduction in pain meds
• psychosocial improvements
• care coordination/optimization
• medication regimen optimization
• quality of life