Opioid and narcotic abuses are plaguing the workers’ compensation system. According to the Center for Disease Control, “42 percent of workers with back injuries got an opioid prescription in the first year after injury… one year after the injury, 16 percent of those workers were still getting opioids.” Accident Fund found that when opioids are prescribed, claims are “four times as likely to have a total cost of $100,000 or more compared with claims without any prescriptions.” The WCRI study from 2011 concluded that Opioids represent “15 and 20 percent of all medical costs on longer term claims.”
It seems like all of the PBMs in the workers’ comp space have some form of service marketed to reduce opioid abuse. The challenge with these “solutions” is that there is an innate disincentive for the PBMs to truly limited these high cost drugs because it runs contrary to their revenue stream. We grew frustrated with our national PBM vendor so we built a unique collegial model with a nurse-driven enforcement process to transform the outcomes on these older cases.
RTW’s Complex Claims Solution targets older work comp claims that have chronic pain or narcotic abuse. The service helps eliminate unnecessary future medical costs through a unique collegial intervention and management model. The Complex Claims Solution brings together clinical expertise and a laser-like managed care oversight process to reduce reserves through:
- Evidence-based clinical necessity
- Drug price
- Utilization control
RTW’s Complex Claims Solution reduces the medical reserves on claims that have been open anywhere from 6 months to 30 years. We ensure that injured workers only receive appropriate medications and medical treatment. The service can be integrated into the ID15 Care Management process, or utilized on an unbundled basis. Our holistic approach of bringing clinical expertise and managed care together leads to an average reduction of 23% on the medical reserves.