Archive for August, 2013

Curbing Claim Related Opioid Abuse

Chris Tidball, Senior Director-Casualty Solutions Consultant, Mitchell International

Keith Peterson, Vice President-Advanced Analytics and Consulting, Mitchell International



We have heard the terms before; pill mills, oxy, perc, and other such slang for opioid drugs and their distributors.   Each year, opioids kill more people than cocaine and heroin combined.   In fact, nearly three out of four drug overdoses are caused by prescription pain killers, also called opioid pain relievers. 

The unprecedented rise in overdose deaths in the United States parallels a 300% increase since 1999 in the sale of these strong painkillers.  The highly lucrative U.S. market for opioids reached $1.5 Billion in 2012 and opioids account for almost 30% of all prescription costs in the work comp claims.  These opioids are derived from opium poppy, or synthetic versions of it, and used for pain relief.  Examples include hydrocodone (Vicodin), oxycodone (OxyContin) and fentanyl (Duragesic), methadone and codeine.  

Opioid abuse drives a myriad of other healthcare costs. Between 2004 and 2009, misuse and abuse of prescription painkillers resulted in a doubling of emergency room visits, to 475,000 annually.  

As a claims organization, what steps can we take to reign in the epidemic of misuse and over-prescribing?  After all, pain is a fact of injury claims and medical providers legally prescribe what they perceive as the best treatment regimen for their patients.  Perhaps.  But according to the CDC, most prescription painkillers are being prescribed by primary care and internal medicine doctors and dentists, not specialists.  And significantly, 80% of all prescription painkillers are coming from just 20% of prescribers.  This means that a small number of generalists are driving enormous costs for payers and exposing their policyholders to significant addiction and injury risk.  Given the statistically demonstrated risk posed by opioid pain relievers, how do payers facilitate the best health outcomes for their injured insureds? 

A big part of the problem lies with the states.  Currently,  only eight restrict pain-clinic ownership to medical professionals.  While 42 states track prescription drugs, they don’t all monitor the same information and only 10 share data with other states.  This makes it difficult to detect issues and investigate problem prescribers. Florida, once a haven for pill mills, has seen a drastic reduction after laws were enacted to curb the practice of virtually unfettered access to these narcotics.  According to the Florida Department of Health, the number of pill mills has plummeted from over 900 in 2009 to just over 400 today.    Unfortunately, the tougher laws in the Sunshine state have pushed purveyors of these drugs to states such as Georgia, where one need not be a physician to operate clinics prescribing opioids.  

One of the biggest opportunities for insurers to overcome these current challenges is the leveraging of both existing medical bill data and predictive analytics.  Companies such as Mitchell International have developed databases and scoring algorithms to enable customers to better manage prescription claims with tools that predict the likely risk of opioid drug abuse developing over the course of a claim. These tools enable better interventions that both reduce costs and save lives.  Claims can be targeted effectively as early as the First Report of Injury.  And, as the claim develops, more powerful diagnosis and treatment indicators help improve those predictions, creating a dynamic view of which claimants may need more assistance to achieve the fastest return to health and work.

Similarly, Progressive Medical, a PBM company, reports that their early pharmacy statistical model intervention program has resulted in a 26% reduction in prescription costs per claim for their clients.   This is critical when considering that the average annual drug cost per patient for abusers is 4.5 times that of non abusers ($3918.00 versus $877.00).   Even more astonishing is the total average per patient health care payer cost for opioid abusers of $24,193, or 6.6 times higher than the $3,467 paid out for non abusers. 

By leveraging analytical tools, carriers gain the ability to access real time indicators and calculate severity scores on both work comp and auto no fault claims, enabling adjusters and case managers to monitor utilization while proactively identifying situations of potential addiction, abuse or misuse. 

A claims-based opioid monitoring program involves five components:

1)       Assessment of the prevalence and incidence of potential opioid abuse within the insured population

2)      Development of a method to score claims in a dynamic fashion

3)      Implementation of a workflow to apply the most appropriate action to the claim given the current phase of the claim and assessed risk

4)      Monitoring of providers to understand where risk is greatest

5)      Measurement of cost and health outcomes including prescription costs, emergency room visits, readmissions, lost work time and claimant satisfaction







Helpful indicators to detect opioid abuse risk


  •     Income level
  •     Urbanicity
  •     Medicaid enrollment
  •     History of mental illness
  •     Prior substance abuse,
  •     Daily dosage and type
  •     Use of known pill mills
  •     Doctor shopping strategies. 



While the medical community is awakening to the enormous risks posed by opioid pain relievers, insurance companies and their policyholders face enormous health risks and financial costs today.  In the absence of coordinated public or medical policies to protect consumers, insurers can take a leading role by managing risk at the point of the claim.  Progress in the use of data and analytics make this type of intervention cost-effective.  By flagging claims based upon a predictive model, claims professionals can intervene earlier and engage the assistance of independent medical reviews through an integrated system strategy. 




August 14, 2013 at 1:51 pm Leave a comment

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Chris Tidball is a claims and revenue management consultant and author of the "20 Essential Rules" series of self and organizational improvement books. You can ask him a question at

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