NEWS FOR SUMMIT S MANAGED-CARE COMMUNITY NOVEMBER Help your patients manage the cost of prescription drugs

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1 The Heritage NEWS FOR SUMMIT S MANAGED-CARE COMMUNITY NOVEMBER 2008 Help your patients manage the cost of prescription drugs Prescription costs don t just affect employers when they have a workers comp claim they affect everyone. Though we re all aware that health care costs have risen dramatically over the past 10 years, and prescription drugs are a major driver of this trend, the statistics might surprise you. The facts In 2006, 10 percent of U.S. health spending went to pay for prescription drugs 1 and it s estimated that the rising cost of medicine accounts for 14.3 percent of the total growth in health care expenditures in the U.S. 2 Public trends are even more disturbing. According to a USA Today poll 3 in January 2008: 79 percent of Americans believe the cost of prescription drugs is unreasonable. In the last 2 years, 29 percent have not filled a prescription due to cost. Also in the last 2 years, 23 percent have skipped doses or cut pills in half to make the prescription last longer. More than 4 in 10 Americans report problems paying for needed prescription medications for themselves or their family, with 16 percent saying it is a serious problem. The good news In many cases, you can help control the cost of prescription drugs for your patients. Summit medical director, Dr. Karen Olson, shares how. We as physicians can really affect this disturbing cost trend. Our prescribing patterns make a huge difference in the price of medications for our patients. In medical school, we re taught what drugs do, but usually not what they cost. But, that information is out there. With a little research, we can learn to use our resources responsibly. Taking action Insurance carriers and medical providers can work together to affect positive change. In that spirit, we ve packed this issue of Heritage News with prescription drug information. You ll find helpful data on painkillers, compliance testing and our upcoming new online formulary. And, in future issues we ll continue to provide information on prescription drug costs to keep you updated. Remember, this information can be applied to all of your patients, not just our injured workers. So take a look, and take action for your patients today! The price of painkillers.. 2 MD Speak...4 Back2Work...7

2 For Your INFORMATION Pain management: a minefield of misconceptions Today, there are more options than ever when it comes to pain management medications. So it s no wonder that there are some major misconceptions out there about certain drugs. Below, we help clear up a few confusing points. Opioid Analgesics One of the most difficult choices a physician can make is when to stop prescribing a painkiller, especially one with strong addictive properties like a narcotic. End the prescription too soon, and it can lose its effectiveness. Continue it for too long, and there s a risk of creating an addiction. Misconceptions are rampant about the appropriate time to discontinue a narcotic prescription. According to the Official Disability Guidelines, any of the following are indications that it s time to stop prescribing a narcotic. (Of course, a slow weaning process is recommended in all but extreme cases.) 4 There is no overall improvement in function. Pain continues, with evidence of intolerable side effects. A decrease in function. Resolution of pain. Serious prescription non-adherence. The patient requests discontinuing. Immediate discontinuation is recommended when there is evidence of illegal activity, such as drug diversion, prescription forgery, stealing, or driving under the influence of opioids, illegal drugs or alcohol. Aggressive behavior or suicide attempts are also signs that you should stop the prescription. Lidocaine (Lidoderm patches) This often-prescribed drug is a favorite among physicians, and as a company, Summit spends more on Lidocaine each year than on almost any other drug. However, many physicians are surprised to find that it is actually only FDA-approved to treat post-herpetic neuralgia (shingles). Studies have shown that it is not effective for nociceptive pain (an indication of damage to the body in general). It has been shown to be somewhat effective for neuropathic pain (where there is damage to the nerves). For this reason, ODG suggests its use only as a second-line treatment. 4 NSAIDs There is an interesting misconception about the use of non-steroidal anti-inflammatory drugs (NSAIDs). In the past, there have been various viewpoints about whether acetaminophen should be prescribed before or after an NSAID. After reviewing several studies, ODG recommends acetaminophen as the first choice for acute pain relief. 4 The price of painkillers While your first priority is to give the medications that are most effective, remember, effectiveness and cost don t always go hand in hand. It is important to be aware of the cost of the drugs you prescribe, understanding that prescription costs impact the healthcare system for workers comp and as a whole. Just like there are many choices among painkillers, there are also a wide range of prices. To the right you ll find a table of pain-management drugs and their national average wholesale prices (AWP) for a quantity of 30, broken down by category. 5 One of the most exciting, cost-saving opportunities on this table is Percocet (oxycodone/ APAP)*. In a 10-milligram tablet, Percocet costs $53.32 per prescription. However, by simply prescribing two five-milligram tablets per dose instead of one 10-milligram tablet, you can lower the 30-day cost to $18.64, a savings of almost 65 percent! 2

3 NATIONAL AWP FOR COMMONLY PRESCRIBED MEDICATIONS MEDICATION CATEGORY & NAME NSAIDs what about for type of quote here as a filler? COST FOR A QTY. OF 30 Celebrex 200mg capsule $ Ibuprofen 800mg tablet $8.71 Naproxen 500mg tablet $35.78 Meloxicam 15mg tablet $ NARCOTICS Hydrocodone/APAP 5-500mg tablet $5.91 Hydrocodone/APAP mg tablet $15.45 Hydrocodone/APAP mg tablet $15.18 Propo-N/APAP mg tablet $17.16 *Oxycodone/APAP 5-325mg tablet $9.32 *Oxycodone/APAP mg tablet $53.32 Hydrocodone/APAP mg tablet $15.96 Hydrocodone/APAP mg tablet $20.24 Hydrocodone/APAP mg tablet $13.42 MUSCLE RELAXANTS Cyclobenzaprine 10mg tablet $30.92 Carisoprodol 350mg tablet $17.18 Skelaxin 800mg tablet $ Tizanidine 4mg tablet $43.95 ANTI-SEIZURE PAIN MEDICATIONS Lyrica 75mg capsule $73.69 Gabapentin 300mg capsule $39.93 TOPICAL PAIN MEDICATIONS Coming Soon Summit s new online formulary Summit s website, is about to get a physician-friendly makeover. Currently, employers and injured workers can find you through our online provider search tool, and can download medical forms and information. But, we recognize that you need online resources as well. With that in mind, our new website (due to debut in early 2009) will include a section specifically for medical providers. You ll be able to find forms, review issues of Heritage News, and most exciting, use our new formulary. Just like the website, the formulary is undergoing a major overhaul, and we re confident you ll like the results. We share the goal of the most effective and efficient treatment for injured workers, and this formulary will be a great tool to help you find that balance. By using the formulary, you can: Save time. The formulary provides comprehensive information and is designed to cover virtually every treatment situation you may encounter. Trust the information you see. It will be based largely on the Official Disability Guidelines (ODG) formulary, which is based on expert research. Improve communications with our claims adjustors. The new formulary will clarify a particular drug s usages, creating more consistent dialogue. Help to keep employers claims costs down. It takes cost into consideration. Working together, we can provide quality treatment while responsibly managing medication expenses. Your suggestions are what help us improve. If you would like to see a particular medication added to our formulary, please contact a Summit medical director. Lidoderm 5% DIS $

4 MD SPEAK by Dr. Karen Olson, Summit Medical Director Establishing causality In workers comp, one of the questions you probably hear most often is that of causality. In other words, what caused an injury or illness? Sometimes it s easy to pinpoint the source of an injury (as in, I dropped the box on my foot ). But, sometimes it s more difficult ( my back just started hurting ). Causality is an important question, because it often determines the patient s workers comp benefits. So how do you decide if an injury is work-related? First, remember that the question is as much legal as it is medical. Many doctors simply ask whether the job could have contributed to the injury. However, legally, this is the wrong approach. In Florida, the work situation must be more than 50 percent responsible for the injury in order for workers comp benefits to apply. Next, it s always a smart idea to use scientific rules to determine causality, not just intuition. Thanks to British statistician Austin Bradford Hill, we have a well-accepted, systematic way to approach the question of causality. He developed these questions, commonly referred to as Hill s Criteria 6, as a framework to evaluate this issue. Temporal Relationship: Does the timing of the development of symptoms correlate with the time of the reported injury? Dose-Response Relationship: Does the severity of the injury correlate with the mechanism of injury? Plausibility: Does the history of the injury or illness make sense? Experimental Repeatability: If the circumstances repeated themselves, would a similar outcome occur? Ever? Some of the time? All of the time? Coherence: Is there research that supports a causal relationship? Consideration of Alternate Explanations: Is there something more here than meets the eye? None of these questions alone can prove or disprove causality, but they can help you approach the issue methodically. They also provide a framework to express why you believe there is NETWORK expansion on the way We re expanding our provider network statewide and we need your help! Injured workers need access to quality primary care physicians, hospitals, clinics and medical specialists, and they need to find those providers close to home or work. With your help, we hope to fill in some of the geographic gaps in our network. No one knows doctors quite like other doctors, and that s why we re looking to you for recommendations. If you know a highly skilled candidate who you believe would make a great addition to our network, please let us know. Physicians to whom you often refer your patients are a great place to start. To give us your recommendations, please give us a call and ask for the PPO Help Desk, or send an to provider.leads@summitholdings.com. (or is not) a causal relationship, lending further credibility to your opinion. If you have more questions about causality and its legal ramifications, please call Summit and speak to a medical director. 4

5 Prescription COMPLIANCE TESTING You may have received several letters from Summit about prescription compliance testing. We re encouraging all of our providers who prescribe narcotics to monitor their patients. Below are the answers to some of the most common questions we ve received about this process. If you have others, please give us a call. Why does Summit ask physicians to administer urine screenings for prescription compliance? Between 1990 and 2002, accidental drug-related deaths increased by 218 percent nationwide. According to a national study published in the 2006 American Journal of Preventative Medicine, Dr. Leonard J. Paulozzi and Dr. George W. Ryan found a strong correlation between this trend and the increase in opioid analgesic sales in the U.S. 7 This indicates that many patients are not taking their medications as prescribed and, even more disturbing, raises suspicions that medications are being diverted onto the street. In an effort to prevent misuse among our injured workers, Summit recommends that patients who are taking controlled substances for pain management be monitored for prescription compliance. What medications are most often misused? Both natural and synthetic opioid analgesics are in high demand as street drugs. Of drugs in this category, oxycodone and methadone are most frequently linked to accidental drug-related deaths. Slow-release formulations, such as OxyContin, can be particularly dangerous because many users dose themselves too often, or crush the pills to enhance the high. Vicodin is a popular choice among young people. Is the problem really that big? In April 2006, the U.S. Department of Health and Human Services issued a memorandum on prescription drug abuse. Below are a few statistics from that release. 8 The 2002 National Survey on Drug Use and Health (formerly known as the National Household Survey on Drug Abuse) reports that 6.2 million Americans age 12 and older are current users of prescription drugs for nonmedical purposes. An estimated 4.4 million used pain relievers specifically. Alcohol and prescription drug misuse may affect as many as 17 percent of older adults. In 2007, a study was conducted using urine screen data from 470 patients at an urban teaching hospital. 9 Of the patients tested, 45 percent had abnormal test results. Most of these patients had unexpected drugs in their systems, with 14.4 percent taking prescription drugs of which the treating physician was unaware percent were using illegal drugs percent of those tested were not taking the appropriate prescription drug. How do I start the testing process? Summit has contracted with Ameritox to perform toxicology tests for our injured workers. If you would like to use Ameritox, call Cathy Gibson at (214) or visit Note: If you already have a prescription monitoring system in place, we appreciate your diligence and support your efforts to provide the best quality care for your patients. What happens if a test shows that a patient is not taking medication as prescribed? You have several options. At the very least, the patient should be counseled and continue to be monitored. You may choose to discontinue prescribing narcotics and other addictive medications. Summit discourages discharging non-compliant patients from your practice whenever possible. If you have a case you would like to discuss, please call us. Other than investigational purposes, is there a benefit to testing? Testing can offer excellent guidance for treatment. For instance, if the patient is shown to be taking the medication as prescribed, but yet shows no improvement, you can be confident in changing the course of therapy. Is testing a requirement? No. You may periodically receive reminders from Summit about testing recommendations, but compliance monitoring is always administered at your discretion. 5

6 Official Disability Guidelines Attorneys are embracing ODG The discussion centered on real-life applications of ODG in court. Several interesting observations came from the group discussion. ODG training will aid communication during physician depositions, as the attorneys will have a better understanding of medical protocol. ODG directly links users to medical evidence for the treatments they recommend, which is often invaluable in litigated cases. ODG s duration guidelines provide statistical data to support return-to-work timeframes set by the treating physician. Expert medical advisors who testify in court may need to be trained on ODG as it becomes a more prevalent tool in legal situations. If you have questions about ODG or its uses, please give us a call. One of the greatest benefits of the Official Disability Guidelines is that it provides medical expertise and a decision-making framework for the non-medical professionals involved in workers comp. Summit claims adjustors have long used this tool as a reference guide. Now, ODG is finding popularity among another group of worker s comp professionals attorneys. Until recently, Florida attorneys have had little opportunity for formal ODG training, so it hasn t been used often in legal settings. Now, more defense attorneys are becoming familiar with the guidelines, and excitement is growing about potential uses in court. On August 20, 2008, Summit s Mitch St. Jean presented the ODG concept to defense attorneys from across the state at the annual Florida Workers Compensation Convention. The presentation covered the basics what ODG offers, how to purchase access to the guidelines, training opportunities and the relationship between the guidelines and Florida statutes. Once Mitch presented the fundamentals, Summit medical director Dr. Ken Phillips opened the floor for a panel discussion, with the help of attorneys Robert Rodriguez, David Beach and Sean O Connor.* SPECIAL THANKS to these gentlemen for facilitating our August 20, 2008, panel discussion: Robert Rodriguez Miller, Kagan, Rodriguez and Silver, P.A. David Beach Rissman, Barrett, Hurt, Donahue and McLain, P.A. Sean O Connor McConnaughhay, Duffy, Coonrod, Pope & Weaver, P.A. Becoming an ODG-trained provider opens doors for you and your practice and makes working with Summit even easier. Learning how to use ODG is quick and simple! Just visit com/odgtraining.htm to view an online presentation from Summit about ODG, its benefits to you and how to find the training resources you need. 6

7 BACK2WORK Summit s Return-to-Work Program George Shaw of the Sheraton PGA Vacation Resort is just one of many Back2Work success stories. With clear communication and appropriate activity restrictions from you, your patients can return to the workforce without hindering the healing process. To make sure you re communicating restrictions effectively, follow the guidelines below. Be sure you have a clear understanding of your patient s job. Use the DWC-25 form correctly. (Please call us if you need help.) Focus on what your patients can do, instead of what they can t. Remind your patients that restrictions apply everywhere, at home or work. Take advantage of ODG. For more information on transitional duty, the DWC-25 form, or setting physical restrictions, call Summit and ask to speak with a return-to-work coordinator. Examples of Transitional Duty Tasks Filing Driving Answering phones Cashier Cleaning Supervising/training Entering data Collating Folding Inspecting parts/products Delivering parts Painting Copying Security Recording inventory Sorting mail Delivering messages The Sheraton treats us like a team. We all pitch in and do whatever we can to help the other fellow do a better job. So when I busted up my ankle, I just came on back as soon as I could, and they made a place for me. I used the golf cart to get around for a while. I might have slowed down for a day or two, but being busy makes you heal faster. Now, I m as good as new. George Shaw, injured employee 7

8 References 1 Kaiser Family Foundation: Kaiser Slides: Distribution of National Health Expenditures, by type of service, 1996 and 2006, Oct < > 2 Kaiser Family Foundation: Kaiser Slides: Relative Contributions of Different Types of Health Services to Total Growth in National Health Expenditures, Oct < 3 Kaiser Family Foundation: The Public on Prescription Drugs and Pharmaceutical Companies. 10 Oct < > 4 All references to ODG or the Official Disability Guidelines in this newsletter: Official Disability Guidelines. Work Loss Data Institute. 10 Oct < 5 Medical Service Company, Jacksonville, Florida (September 26, 2008) 9 Michna, et al. Urine Toxicology Screening Among Chronic Pain Patients on Opioid Therapy: Frequency and Predictability of Abnormal Findings. The Clinical Journal of Pain. Volume 23, Number 6. (February 2007): How to Contact Us Heritage Summit HealthCare Inc. P.O. Box 3623 Lakeland, FL Claims Center P.O. Box 2928 Lakeland, FL Austin Bradford Hill, The Environment and Disease: Association or Causation?, Proceedings of the Royal Society of Medicine, 58 (1965), Leonard J. Paulozzi, MD, MPH, George W. Ryan, PhD. Opioid Analgesics and Rates of Fatal Drug Poisoning in the United States. American Journal of Preventative Medicine Volume 31, Number 6 (2006): Prescription Drug Abuse, National Institutes of Health (9000 Rockville Pike Bethesda, Maryland; April 10, 2006). 24-hour hotline to report injuries If you know of a provider who may be interested in joining our network, please give us a call or send an to provider.leads@summitholdings.com. If you have any questions or comments about the content of this newsletter, please send an to heritagenews@ summitholdings.com. Bridgefield Casualty Insurance Company, a Summit affiliate Bridgefield Employers Insurance Company, a Summit affiliate BusinessFirst Insurance Company, managed by Summit Louisiana Retailers Mutual Insurance Company, managed by Summit Florida Retail Federation Self Insurers Fund, administered by Summit Who is Summit? With more than 30 years of experience, Summit is a leading provider of workers compensation insurance products and services to employers throughout the Southeast. 11/08 (08-348) Summit includes Summit Consulting Inc. and its affiliate companies of Heritage Summit HealthCare Inc., Summit Consulting Inc. of Louisiana, Bridgefield Casualty Insurance Company and Bridgefield Employers Insurance Company. Summit is also the managing general agent of BusinessFirst Insurance Company and Louisiana Retailers Mutual Insurance Company, and is the third-party administrator of the Florida Retail Federation Self Insurers Fund. Summit includes Summit Consulting Inc. and its subsidiaries Summit Consulting Inc. 8