LANSING, Mich., April 12, 2012 /PRNewswire/ -- Accident Fund Holdings, Inc. (AFHI) recently created a comprehensive narcotics program to help reduce the health risks of these drugs on injured workers and ultimately provide a mechanism for them to get back to work sooner.
AFHI's program incorporates data analytics, case management and peer-to-peer physician pharmaceutical review. Unique to this program is the integration of pharmacy and claims data with an early detection software solution called Care Analytics™. The software uses predictive analytics and pre-determined rules to optimize care and identify injured workers at risk for narcotics abuse. Alerts from the software are escalated to internal medical resources and when specialized expertise are needed they turn to PRIUM, a utilization review company specializing in opioid abuse.
"Realizing the problem was half the battle; developing the technology to detect injured workers at risk was the critical next step; successfully intervening on every claim that involves narcotics abuse remains an elusive final goal," Jeffrey Austin White, Accident Fund's Holdings, Inc. director of medical management practice and strategies, said.
Paul Kauffman, director of medical programs, for Accident Fund Holdings feels the narcotics program works because PRIUM specializes in managing drugs, particularly opioids, and its doctors have backgrounds in toxicology, pain management and addiction.
"Utilization review with drugs is tricky," Kauffman said. "In standard UR processes, the review of the requested service is either approved or unapproved. However, with medications involved you cannot simply discontinue the approval. It takes a lot of physician and claimant education, and typically there's a long weaning process to reduce dependency on opioids. In many cases, the use of opioids is indicated however standards for monitoring long-term usage and controls are often not utilized."
Doctors talking to doctors seems to be more effective than pharmacists, nurses or other medical professionals contacting the treating physician.
"When a doctor calls, the treating physician is more likely to pick up the phone," Michael Gavin, Chief Marketing Officer of PRIUM, said. "The approach is to have a collegial discussion to ensure that the claimant receives the most appropriate care, and that treatment focuses on return to work."
PRIUM's preliminary results from working with AFHI shows that their peer physician "discussion rate" is as high as 89 percent and PRIUM's "success rate" in getting treating physicians to change the opioid therapy is currently almost 70 percent. Gavin stressed that the peer-to-peer discussion is rooted in evidence-based medicine, using treatment guidelines that are accepted in the claim's jurisdiction.
"Every case is different," he said. "There may be a treating doctor who doesn't have much experience in safely prescribing opioids or one who inherited a patient taking a lot of narcotics and needs help weaning the patient off them. In certain cases, after we've done all we can do through peer review, nurse oversight, and coordination with the PBM, we're left with what we call 'the last clinical mile' of care delivery that's needed to get the patient better and, hopefully, back to work. So we're beginning to develop relationships with data-driven, outcomes-oriented centers of excellence throughout the country so that we can advise individual adjusters of the best possible clinical path forward. These centers will provide multidisciplinary, multimodal care focused on addiction recovery and functional restoration."
For more information about Accident Fund Holdings, visit www.afhi.com.
Accident Fund Holdings, Inc. Accident Fund Holdings, Inc. is a workers compensation insurance holding company conducting business through four operating units: Accident Fund Companies, located in Lansing, Michigan; United Heartland, located in New Berlin, Wisconsin; CompWest, located in San Francisco, California; and Third Coast Underwriters, located in Chicago, Illinois. Its insurance company subsidiaries are rated "A-" (Excellent) by A.M. Best. Accident Fund Holdings is a wholly-owned subsidiary of Blue Cross Blue Shield of Michigan. For more information, visit Accident Fund Holdings' website at www.afhi.com.
PRIUM Based in Duluth, Ga., PRIUM is a medical cost management company providing prospective, concurrent and retrospective reviews that facilitate the management of clinical resources to the workers' compensation industry. Among its services is a comprehensive narcotics control program rooted in the core principles of peer-to-peer discussion, enforcement through pharmacy benefit management and oversight via PRIUM's nurse oversight. To reach PRIUM, call 888-588-4964 or visit www.prium.net. For insight and commentary on medical management issues in workers' compensation, please visit PRIUM's blog at http://prium-evidencebased.blogspot.com.