Screening With Meaning

Sophisticated urine analysis of employees on workers’ comp could become a bulwark in the fight to control the epidemic use and abuse of narcotics.

As a method to detect whether an injured worker is taking the medications prescribed to them, the use of quantitative clinical urine analysis hasn’t really come into vogue just yet.

According to some experts, it’s only been in the last 18 months to 24 months that a more widespread use of the technique known as tandem mass spectrometry has come into play to determine whether an injured worker is taking the drugs they’ve been prescribed, and not coupling them with illicit drugs, or not taking them at all and instead selling medications on the street.

The technology shows promise as a valuable tool in not only saving money on prescription medication, but as a method of determining whether a worker is following their workers’ compensation treatment plan in good faith.

“Patients not taking medications as the doctors prescribe them has been an issue not just in comp but in our overall healthcare industry,” says Jim Andrews, the senior vice president of pharmacy services for Atlanta-based Healthcare Solutions, a worker’s compensation claims management company.

“There is a significant disconnect from the time the doctor writes a prescription and the way the patient gets it filled at the pharmacy and takes the medication,” Andrews says.

For Bob Steggert, the Bethesda, Md.-based vice president of casualty claims, for Marriott International Inc., the information his claims department has been able to gather from drug testing has shown him beyond any reasonable doubt that many workers who are prescribed medications aren’t taking them properly, if at all.

Marriott rolled out the use of high-level urine analysis nationwide in 2010, according to Steggert, and he says some of the statistics produced by such testing are very much worth noting.

Only 36 percent of patients who underwent urine analysis were found to be taking medications in the manner in which they were prescribed, Steggert says. In addition, 52 percent of patients had “not expected” results, which meant that they either didn’t have all of the drug in their system or they had other drugs in their system which hadn’t been prescribed.

“So what we are looking at as a payer and especially as a payer who is paying for expensive drugs that are designed to cure and relieve, and it is not completely in their system it raises questions that we think are bona fide questions to address,” Steggert says.

Health Solutions’ Andrews says there could be one of at least three things going on when a urine test reveals that a worker isn’t taking a medication properly.

One, the worker may want the drug as a benefit extension but doesn’t really need it. Two, the worker could be taking too much or too little of the drug and getting results that are different from what the prescriber expects. And three, the worker could be taking illicit drugs on top of the prescribed drug “and all three of those things could contribute to less-than-predictable outcomes,” Andrews says.

Sophisticated drug testing has value and has more recently become more affordable.

According to Frank Fornari, the CEO of Dominion Diagnostics, the lab that Steggert and Marriott use, a thorough test costs between $300 and $500. And with prescription medications sometimes costing hundreds of dollars per pill, there are savings to be realized.

“The drug test can cost less than the one pill that you’re not taking,” Fornari says.

But Fornari and others say that for sophisticated urine analysis to really gain traction there is a lot of ground to be made up between treating physicians and the companies and carriers who might be paying for drugs that workers are not taking at all or not taking properly.

One big issue, according to Fornari and others, is the issue of physician reimbursement.

“You’ve got to attack this a number of ways,” says Fornari. “You’ve got to incentivize physicians for actually being pharma vigilant.”

Fornari says physicians who work with companies and carriers to carry out urine testing that reveals that prescribed medications aren’t being taken should be rewarded for the savings they help create for the company.

“Say I test you and you are getting eight prescriptions from me and you are only taking three of them. I take five away from you and I don’t fill them anymore and the savings I just made for the company, I get paid for that,” Fornari says.

Historically, Fornari says, physicians who were inclined to participate in urine analysis as a workers’ comp cost and care-management technique may have become dispirited when they weren’t reimbursed for their labor and time in collecting specimens and reporting data.

Also, historically, the techniques that could produce bankable results weren’t yet developed or affordable says Jerry Fogel, founder of Imagine Clinical, a healthcare and workers’ compensation consultancy based in Coral Springs, Fla.

“If you are going to try and hold doctors accountable for practically managing their patients or if you are going to try and hold patients accountable for complying with their treatment protocols, you better have some good information to hold people accountable,” Fogel says.

Marriott’s Steggert says solid clinical evidence is something that will hold sway in court when a judge is determining what a settlement or benefit level should be in a workers’ compensation case.

“It depends on the complexion of the case and the degree of noncompliance and the precise findings,” Steggert says. “But there are not too many judges that want to hear that a patient is not compliant with a care plan, particularly if it involves drugs that are not in their system.”

“It means that they are not taken as prescribed or they are being diverted,” he says.

Drug testing for evidence of diversion is not solely in the interest of companies trying to protect their bottom line or even the health of their patients.

The United States is in the grip of a national epidemic around Schedule II narcotics, such medications sold under the brands Oxycontin and Actiq, highly addictive drugs that are worth a lot of money on the street. Oxycontin is worth $1 per milligram in illicit trade, according to a recent report in the New York Times.

According to the quarterly magazine Physician Pain News, published by the American Society of Interventional Pain Physicians, 80 percent of all narcotic medications consumed globally are consumed in the United States. And that’s in a country the population of which comprises only 4.5 percent of the world’s population.

“There is no exact roadmap, but bottom line, these are long-tail expensive cases,” Steggert says. “But with the known problems with drug diversion and dependency and frankly worsening conditions we think it makes eminent sense to stay on top of it. The only way you can do that for something like these drugs is periodic testing.”

“As a primary payer in the workers’ comp arena, we feel that we have an obligation not only from a fiduciary standpoint but to the broader social good to do what we can to root out diversion and pay only for what patients are taking as prescribed,” he says.

March 10, 2011

Copyright 2011© LRP Publications