ProviderPulse

Current Pharmacy Initiatives

From Pinnacol's Medical Director

June 2015
Current Pharmacy Initiatives and Resources for Physicians

Pharmacy utilization continues to be a major contributor to medical spend for the healthcare industry and workers’ compensation. The most recent data from the 2014 IMS Institute for Healthcare Informatics report documents that the healthcare industry experienced pharmaceutical expenditure of $373.9 billion in 2014.

This rate of increase is 13.1 percent and is the highest since 2001. There is a distinction in the most highly utilized drug categories between general healthcare (cancer, asthma, COPD, dyslipidemia, diabetes, and behavioral health) versus workers’ compensation (analgesics, anti-inflammatory, skeletal muscle relaxants, anticonvulsants, and antidepressants). In workers’ compensation, opioid analgesics continue to be the highest utilized therapeutic class. There is increasing recognition of the necessity to address this problem, and in the Helios 2015 Workers’ Compensation Drug Trends Report, a very slight 1.6 percent decline in opioid utilization is noted. In Colorado, our efforts have produced some minimal improvement in Colorado’s ranking changing from the second-worst state for inappropriate opioid utilization down to the eleventh-worst state. However, clearly the need continues for the development of new initiatives.

Pinnacol Assurance is currently working with Helios – our pharmacy benefits management company – to identify opportunities to help physicians and injured workers with prescription medications. There are two initiatives at present, Clinical Escalation Alert (CEA) and Targeted Intervention Letter (TIL).

Helios will send a CEA to the assigned claims representative (CR) and/or medical case manager (MCM) when one or more of the following occurs: prescriptions for new claims include long-acting opioids, long-acting Tramadol, and/or Fentanyl Citrate; opioid use is in effect for more than 90 days; daily opioid use is greater than 120 morphine equivalents; or daily Acetaminophen doses exceed 4,000 mg. The CR and/or MCM then plan what additional action will be taken (e.g., sending a letter to the prescribing physician or initiating a physician advisor peer review). If you, as a treating physician, receive a CEA letter, please respond as quickly as possible.

The second initiative is the use of a Targeted Intervention Letter. This initiative addresses situations that could involve generic versus brand-name medications, multiple opioid usage, and/or multiple providers prescribing opioid medications. Helios provides Pinnacol claims and MCM specialists a monthly report that identifies injured workers who potentially may be in need of an intervention. The claims and MCM specialists share this information with the assigned CR and MCM and request that they consider sending a TIL to the injured worker’s medical providers. Some of you may already have received a TIL. Attached to the letter is a form for the medical providers to complete and return to Pinnacol. The claims and MCM specialists are compiling responses from medical providers and the results. We would appreciate your assistance with this initiative. If you receive a TIL from Pinnacol, please complete the form and fax it to the number indicated on the form as quickly as possible.

If you identify situations of inappropriate use of prescription medications in your practice through the Colorado Prescription Drug Monitoring Program, please be aware that you have Pinnacol and Helios resources to assist you in medication management for your patients. Pinnacol has physician advisors whose practices specialize in treating patients with complex medication utilization. Please contact the nurse assigned to the injured worker claim if you would like to have a physician advisor review and provide recommendations or if you would like a peer-to-peer discussion.

Helios has clinical pharmacists with considerable experience in workers’ compensation and pain management. This clinical pharmacist team is knowledgeable in guidelines for workers’ compensation, including the Colorado Division of Workers’ Compensation Medical Treatment Guidelines and the American College of Occupational and Environmental Medicine Guidelines. This pharmacist team is a resource to assist with appropriate use of pharmaceutical therapy and treatment guidelines by offering actionable recommendations. You can request a medication review by contacting the Pinnacol nurse assigned to the injured worker claim so that she/he can forward your request to Helios. Please inform the Pinnacol MCM if you want a discussion with a Helios Pharm.D. in addition to a written report.

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Case Law Review

Featured Story

June 2015
A Former IME (But Not DIME) Physician May Become The ATP

Contributed by Harvey Flewelling, Pinnacol Assurance Appeals Counsel

The recent case of Lopez v. Scott Contractors involved a worker who injured both of his legs, including a fractured left tibia, while trying to extricate one of his employer’s trucks from snow on December 6, 2011. He underwent two surgeries, including the insertion of two metal plates through the use of six screws placed into the tibia. The authorized treating physician (ATP) providing primary care for the injury subsequently recommended conservative therapy, but the worker continued to complain of pain in his left leg. In 2013, two surgeons recommended that the surgical hardware be removed from the worker’s left leg. The ATP recommended against the procedure, and the employer declined to authorize the surgery.

The injured worker requested a hearing before an administrative law judge (ALJ). The worker sought authorization for the surgery and for a change of ATP under § 8-43-404(5)(a)(VI), Colorado Revised Statutes, which states that an employee may, upon making a “proper showing,” procure permission to have a physician of the employee’s selection treat the employee. The ALJ found that the hardware removal surgery was reasonable and necessary, and he ordered it authorized. The ALJ also found that the injured worker had made an appropriate showing that he had lost confidence in the ATP and that a change in primary care physician would facilitate his recovery. Therefore, the ALJ authorized a new ATP.

The employer appealed the ALJ’s decision. The employer did not dispute that the injured worker made a “proper showing” to secure permission to have a change of physician, but argued that once the ALJ determined a change of physician was required, he was obligated to either direct the former ATP to make a referral to a new doctor or allow the employer to designate a substitute physician. The employer also contended that the ALJ erred in authorizing the new ATP because the injured worker had previously used that physician to provide an independent medical examination (IME) opinion pertinent to the hardware removal surgery.

The Industrial Claim Appeals Office (ICAO) affirmed the ALJ’s decision. ICAO rejected the employer’s first argument, noting that the statute allows the ALJ to authorize only a change to “a physician of the employee’s selection,” and thus under such circumstance neither the former ATP nor the employer has the right to designate a new ATP. ICAO also held that while a treating physician would not qualify as an “independent” examiner, a former IME physician is not precluded from undertaking direct care of the injured worker. ICAO noted that a former Division of Workers’ Compensation IME (DIME) physician may not become a treating physician, but a DIME was not involved here. ICAO concluded that the employer failed to show that the ALJ abused his discretion in ordering the change of physician.

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Nineteen PCPs Receive Summit Elite Designations

Corporate News

June 2015
This spring, Pinnacol Assurance awarded our Clinic Performance Initiative (CPI) Summit Elite designation to 19 SelectNet primary care clinics for their superior performance, as demonstrated by their maintenance of a five-star rating for two or more consecutive metric periods.

Taking a proactive approach is the key to success, said Dave Balak, lead case manager at St. Mary’s Occupational Medicine.

“Achieving Summit Elite status within the Pinnacol Assurance CPI program was truly a team effort,” Balak added. “St. Mary’s Occupational Medicine uses an education component and a follow up a process wherein we cross-checked one another to ensure we were sharing the information in a complete and timely fashion. Ultimately, our goal was to ensure injured workers received quality care and understood they are part of the treatment team along with their doctor, their insurance carrier and their employer.”

Linda Torres of Premier Occupational Medicine, which also received the designation, said, “We are proud to be a Summit Elite provider ― combining the very best in medical care with strong communication to patients, our partner companies and Pinnacol Assurance.”

Congratulations to the current Summit Elite designees:
Aviation & Occupational Medicine
CCOM Durango
Colorado Mountain Medical – Eagle
Colorado Mountain Medical – Edwards
Colorado Mountain Medical – Vail
Colorado Occupational Medicine Physicians
EmergiCare Medical Clinic – Bijou
HealthONE Occupational Medicine & Rehabilitation - Aurora
High Country Occupational and Travel Medicine, LLC
Longmont Clinic – Primary Care
Occupational Health Services – Boulder
Premier Occupational Medicine
SCL Physicians – Broomfield
SCL Physicians – Green Mountain
SCL Physicians – Larkridge
SCL Physicians – Southwest
St. Mary’s Occupational Medicine
Steamboat Medical Group
WORKPartners

If you have any questions about Summit Elite designation or Pinnacol’s CPI program, please contact Ken Crane, SelectNet network operations lead, at 303.361.4950.

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Pinnacol Celebrates 100 Years

In The News

June 2015
Protecting Coloradans on the job never gets old.

Over the next six-eight months, we’ll be celebrating 100 years of supporting Colorado’s commitment to keeping the state’s businesses safe, healthy and doing what they do best. But this 100 year anniversary isn’t about us – it’s about the people, places and passions we have the great honor to protect.

So it is with great appreciation that we say thank you. Thank you for helping us to care for Colorado’s injured workers, getting them well and back to work.

We look forward to another century together.

Over the next six-eight months, we’ll be celebrating 100 years of supporting Colorado’s commitment to keeping the state’s businesses safe, healthy and doing what they do best. But this 100 year anniversary isn’t about us – it’s about the people, places and passions we have the great honor to protect.

So it is with great appreciation that we say thank you. Thank you for helping us to care for Colorado’s injured workers, getting them well and back to work.

We look forward to another century together.

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New QuitLine Partnership

Workers' Comp Coordination

June 2015
Partnership Offers Free Tobacco Cessation Help

We are pleased to announce a new partnership with Colorado QuitLine that allows any employee of a Pinnacol Assurance policyholder to receive complimentary tobacco cessation or nicotine replacement therapy, whether or not the employee has been injured on the job.

Colorado QuitLine is provided by National Jewish Health and administered by the Colorado Department of Public Health and Environment. The QuitLine partnership is part of our overall health and wellness effort to help us take better care of injured workers before, during and after an injury.

About QuitLine

Colorado QuitLine is a telephone-based program that provides services tailored to each individual’s needs. Trained coaches work closely with each individual to help develop coping skills to quit using tobacco and remain tobacco-free. The program consists of:

If you are treating an injured worker who uses tobacco, please refer them to the Colorado Quitline at 800.784.8669 (1.800.Quit.Now) or online at COquitline.org.

When asked about their health or workers’ compensation insurance, your patients should indicate that Pinnacol Assurance is their workers’ compensation provider. This ensures they will receive all services free of charge. Participation in the program is entirely voluntary and confidential.

Colorado Quitline referral pads are available for your use. Contact your provider relations specialists at 303.361.4945 to request a referral pad or for additional information.

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Wellness Research at Pinnacol

From the Desk of Karyn Gonzales

March 2015
New Research Confirms Value of Pinnacol’s Worksite Wellness Program

As you know, Pinnacol has offered a worksite wellness program since 2010. This wellness program was part of a study with the Colorado School of Public Health, Johns Hopkins University and Truven Health Analytics and featured in the January issue of the Journal of Occupational and Environmental Medicine (JOEM).

Key findings include:

Pinnacol’s health and wellness strategy supports our companywide focus on finding new and innovative ways to serve and bring enhanced value to our stakeholders, while remaining committed to making Colorado a great place to live, work and grow a business.

Our emphasis on health and wellness is an extension of our core business model. One way we can help our policyholders minimize the frequency and cost of workplace injuries is by helping keep their employees healthy.

As part of this strategy, we’re pleased to announce we have selected Virgin Pulse, a market leader in worksite wellness programs, to be our partner for our new worksite wellness program.

A part of Sir Richard Branson’s Virgin Group, Virgin Pulse helps employers create worksite wellness programs with an engaging, award-winning online platform to foster healthy habits and sustainable behavior change to help employees thrive at work and across all aspects of their lives.

We’re working closely with Virgin Pulse to customize the program for Pinnacol. In April, we will be rolling out a “soft launch” of the program to policyholders that have participated in our health risk management wellness program. The program will be available to all policyholders later in 2015.

If you would like more information about our worksite wellness program, please contact Karen Curran, worksite wellness director, at 303.361.4784 or Danielle Nieto, health and wellness promotion specialist, at 303.361.4768.

Karyn Piché Gonzales is the vice president of medical operations and healthcare strategy for Pinnacol Assurance.

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What Is Vestibular Rehabilitation?

Featured Story

March 2015
Submitted by Nancy Bonifer, PT, DPT, MS

Physical therapy can play an important role in the rehabilitation of symptoms of dizziness, vertigo, headache and disequilibrium. After an auto accident, whiplash-associated injury, work-related accident or fall, or concussion or blow to the head, individuals may complain of symptoms including vertigo, dizziness, motion sensitivity, nausea, headaches, poor balance and/or disequilibrium. Such symptoms can arise from an injury to the central nervous system (brain), peripheral vestibular system (inner ear), or neck and spine (cervicogenic origin).

Vestibular dysfunction can limit a person’s ability to perform work-related tasks, drive, perform head and neck motions, or walk. In addition, vestibular issues can result in problems with postural control and balance reactions and increase the risk of falls.

A physical therapist with specialized training and certification in vestibular rehabilitation therapy (VRT) can perform a comprehensive evaluation to determine the cause of the symptoms as well as develop an individualized treatment and patient education program for rehabilitation.

VRT is an exercise-based program designed to promote central nervous system habituation or compensation. Vestibular rehabilitation is an evidence-based approach that has been shown to help in a number of conditions that may result from an on-the-job injury, including benign paroxysmal positional vertigo (BPPV), unilateral or bilateral vestibular hypofunction (reduced inner-ear function on one or both sides), complications from a brain injury or concussion, cervicogenic dizziness (dizziness arising from neck dysfunction), and falls or unsteadiness.

Repositioning maneuvers are used to treat the altered biomechanics involved in BPPV, a condition in which calcium carbonate crystals within the inner ear become detached and displaced, leading to symptoms of vertigo and nausea and difficulty with balance. BPPV commonly occurs after an accident involving the head or neck. Habituation exercises repetitively expose the client to sensory inputs that cause a moderate level of symptoms with a resulting minimization of symptoms. Habituation exercises may be necessary after concussion or whiplash-type injuries. Adaptation exercises strengthen intact sensorimotor pathways to help a client compensate for a permanent loss of vestibular functioning. In addition, exercises can be prescribed to maximize postural control and normal balance reactions, thus decreasing the risk of falls and further injury.

Manual therapy techniques, postural education and exercise prescription can address issues of head and neck pain as well as cervicogenic dizziness after an injury. Since the neck has approximately 400% more sensory receptors than other areas of the body, accidents involving this region can result in significant impairment if not addressed.

Physical therapy for vestibular rehabilitation should also include client education. Many of the symptoms associated with head and neck injuries can be very frightening and upsetting. Educating the client regarding the cause of their symptoms as well as the normal course of rehabilitation can reassure the person that functional progress and a return to work duties can occur.

For further information, feel free to contact Nancy Bonifer, PT, DPT, MS, or visit her clinic website dynamicrecoverypt.com. Nancy has over 20 years of experience treating physical therapy clients for orthopedic, neurologic and vestibular disorders. She has a specialty certification in vestibular rehabilitation and has successfully assisted individuals with significant dizziness and vestibular issues in decreasing their disability and returning to work.

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New Provider Choice Law

Workers' Compensation Coordination

March 2015
During the 2014 Colorado Legislative Session, state lawmakers passed House Bill 1383, which requires employers to increase the number of physicians or corporate medical providers they designate to treat their injured workers from two to four. The new law goes into effect April 1, 2015.

We are encouraging our policyholders to designate their additional medical providers now. However, if they do not designate their four providers, Pinnacol will designate SelectNet providers for their policy by the April 1 deadline. To be compliant with the law, employers will still need to provide the Designated Providers List Notification Letter to their employees at the time of injury.

For more details on this new law, including details on the rural exemption, visit www.pinnacol.com/1383.

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Friendly Reminder on Protection of Medical Records

Corporate News

March 2015
Pinnacol receives many injured worker medical records, and we do send out medical records to parties on the claims. We have policies and procedures in place to safeguard these records and ensure that they are distributed appropriately. We also want to do our best to protect the injured workers’ medical records once they leave our office. As such, this is a friendly reminder so that physicians who treat injured workers and consult on their claims do their part in the safekeeping and disposal of injured workers’ medical records.

Physicians are ultimately responsible for ensuring that medical records are stored and maintained according to federal and state legal requirements and the principles related to the protection of medical records. Under Colorado Medical Board Policy, physicians must develop a written plan to ensure the security of patient medical records, addressing at least the storage and proper disposal (if appropriate) of medical records, and the method by which patients may access or obtain their medical records promptly.

Colorado Medical Board recommends retaining all patient records for a minimum of seven years. In cases of litigation, records must be retained until resolution. For injured workers, the medical records must be retained until the claims are closed and the period for request of reopening of a claim has passed. The period for a request of reopening of a claim is two years from the last date of treatment, which may be treatment by any of the medical practitioners on record for that claim.

All patient records and data must be kept in a safe and secure environment - restricted access areas or locked filing cabinets - to protect against loss of information and damage. These same precautions apply regardless of whether the information is stored on premises within the physician’s control or otherwise. Physicians who take records out of the clinic or receive medical records outside the clinic must take appropriate measures to prevent loss, restrict access, and maintain the privacy of patients’ personal health information. This is especially true in cases where an independent medical evaluation (IME) is arranged.

Physicians must not dispose of a record of personal health information unless their obligation to retain the record has come to an end. Records must be disposed of in a secure manner such that the reconstruction of the record is not reasonably foreseeable in the circumstances. In cases of IMEs, the physician must either return the medical records to Pinnacol for proper disposal or acknowledge on the Pinnacol IME form that the records have been properly disposed of.

Physicians must notify Pinnacol should there be a loss or breach of injured workers’ medical records so we can assist in mitigating any adverse impacts to the injured workers involved. If you have questions, please contact your provider relations specialist at 303.361.4945.

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