Sometimes we aren't always treating the work environment to impact Return To Work. There are many pieces of the puzzle that affect RTW, but it's the sum of all parts pushing towards the same common goal that creates success. In this case our outcome was getting someone to a healthier state, the by-product of that was some cost savings.
This case was talked about internally, and I thought it would be interesting to share the "behind the scenes" analysis that went into not only reducing Rx spend by 495%, but more importantly getting a yes from the provider and IW, (injured worker) to begin the process of being weaned from oxycodone.
This started as a Pharmacy Review, then quickly shifted to a Peer Review with the treating Physician in agreement to at least attempt to wean medications (opioids had been prescribed for several years for a work injury without any changes ). The injured worker's lawyer became involved so the provider decided that an attempt to wean was no longer possible. We were able to overcome these barriers from every angle.
The Same Old Same Old
An old work injury that the carrier had settled but was still paying for medications was referred to us to see if we could examine the medication regimen with the goal of reducing usage or gather data to substantiate the medications prescribed.
Our initial review of case notes found years of monthly fills of Percocet and Flexeril. Nowhere did we find supporting documentation that this course of treatment resulted in a reduction in pain scores, Return To Work or any functional improvement.
The case was sent for Peer Review to see if there have been any changes in pain or functional improvement attributable to the medications. The prescribing Provider was the injured worker's PCP (primary care physician). The PCP inherited the case several years ago and continued with what was working (Percocet and Flexeril).
Don't always do what you've always done
The Provider indicated that the IW had said the meds do not help very much. Peer Review suggested trying to wean the IW from medications. The Peer Review report was sent to the treating Physician to review and respond to. The Provider responded in writing agreeing with the report and a plan was made to try to wean medications and reduce Flexeril to "as needed" as chronic use of muscle relaxants is not supported by evidence based literature and guidelines.
The IW was very unhappy with this plan, and got a lawyer involved. The Provider suddenly would not even try to wean medications. We worked with the Provider to develop a plan of care that satisfied everyone.
- We started with transitioning the generic Percocet (oxycodone/acetaminophen combo) to just oxycodone without reducing the daily intake of oxycodone. Then we provided the IW with a separate script for acetaminophen to potentiate the effects of oxycodone. There were significant cost savings here. The combination of Oxy/Tylenol can cost 5x as much as oxycodone alone. Costs dropped from $539.38 to $108.81, for 240 pills.
- At the IW's following office visit more data was gathered as we requested the Provider to submit data to prescribe Flexeril outside the treatment guidelines. Further investigation found Flexeril was being used as a sleep aid and in relation to nocturnal leg cramps, a condition in existence prior to the work injury.
- The plan shifted to very slowly wean oxycodone and provide the IW with resources such as PT to help with pain. They were offered consultation with a pain management specialist who had a great deal of experience with weaning opioids.
A Successful Outcome
Our goal was to be able to wean medications through education and support. We accomplished not only cost savings, but enhanced clarity of medication usage goals, and a plan that would ultimately achieve zero opioid consumption by the IW.
1. American Society of Addiction Medicine (ASAM). (2016). Opioid Addiction 2016 Facts & Figures. Available at http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf