What we're doing

This is our objective at QBE North America and Sedgwick, in working with industry-leading PBM partner Optum. Our collective goal is to effectively and efficiently manage opioid use on behalf of workers' compensation policyholders. Like other parties engaged in workers' compensation, we realize that historical and real-time claims data is crucial in addressing adverse outcomes. Sedgwick's pharmacy program, which is staffed with pharmacists, nurses, and physicians, works with Optum to access real-time pharmacy data. Using customized clinical tools to analyze Sedgwick's vast storehouse of claims data and Optum's real-time point-of-sale pharmacy data, we can identify potential pharmacy issues early in the life of the claim.

Once flagged, we trigger a high-risk alert. A standard trigger is an injured worker who receives six weeks of an opioid or a morphine equivalent dose of 80mg per day or more. Once triggered, a Sedgwick nurse will work in collaboration with the claims examiner to address the issue with the prescriber. Other alerts trigger when specific high-risk drug combinations occur and ensure that outreach is made to the prescriber(s) to advocate for better, safer prescribing.

During the claims review process, evidence of potential prescription abuse like early and/or consistent drug refills are flagged, as are inconsistent urine drug screens and overuse of PRN opioids (PRN is a Latin term, pro re nata, meaning "as the thing is needed"). Such medications essentially are taken for intermittent pain but can lead to overuse and abuse.

We have also developed customized drug formularies with our PBM partner that align with each type of workplace injury and related phases of pain, such as an injury with acute pain that can last for up to six weeks. We further require prior authorization for medications generally considered inappropriate in a workers' compensation context. For example, if an injured worker submits a diabetes prescription request through the workers' compensation pharmacy benefit, our point-of-sale prior authorization process reviews the prescription to ensure it is related to the claim before the medication is dispensed. When possible instances of prescription abuse are identified, the prescriber is contacted to discuss the clinical issues, including the expanded potential for an opioid use disorder.

If a claim is flagged for intervention with an injured worker for drug rehabilitation purposes, the claims examiner is contacted to evaluate if the use of a treatment facility is appropriate. This patient-centered approach to opioid use disorders also encourages such non-pharmacologic interventions as cognitive behavioral therapy, meditation, yoga and stress and anxiety counseling.

Lastly, the clinical dashboard's comprehensive view of all data concerning client workers' compensation claims serves another purpose, flagging physicians who prescribe opioid pain medications more than other healthcare providers.

Although every workers' compensation claim is different, this partnering approach to opioid abuse is making a difference. In many cases, we have succeeded in helping to wean injured employees off pain medications before this use turned into an obdurate addiction. We've also intervened with physicians to reduce prescriptions of opioids for consistent pain management, encouraging the use of other medications like ibuprofen and non-pharmacologic pain management therapies.

As gatekeepers in the medical care of injured employees, our role in addressing this public health crisis is a very serious matter. We believe we are striking a delicate balance between much-needed pain relief for injured workers and averting adverse health outcomes from opioid abuse. As a nation, we are not yet out of the woods, but there is a reason for hope.

Special Reports /

Turning the tide in employee opioid abuse

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