Meet ​Jim

A few years ago, Marjorie, an adjuster for a large insurance company, worked with a claimant, Jim, who suffered a debilitating back injury while lifting items out of a freezer. The injury resulted in lumbar disc herniation, and a spinal fusion surgery was performed at L5-S1. Post-surgery, Jim still had chronic back pain radiating to both legs, which affected his mobility and activities of daily living.

Neither his extensive medication treatment regimen, nor back surgery, nor a spinal cord stimulator (SCS) helped control his pain. The claimant – a Medicare beneficiary – advised Marjorie he wanted to settle the case. (Full diagnosis and complete medications list noted below)

Problem with “unrealistic” Medicare Set Aside

When Medicare beneficiaries, like Jim, want to settle their case, obtaining a Medicare Set Aside (MSA) is recommended to ensure that the burden of future medical care for the workers’ compensation injury is not shifted to the Centers for Medicare and Medicaid Services (CMS).

An MSA was completed for Jim, which allocated a total future therapy cost that was unrealistic for settlement due to the medication regimen and the possibility of another SCS trial and an intrathecal pain pump (ITP). So, Jim’s case was referred to Optum Settlement Solutions to review the treatment plan and determine if there were opportunities for clinical, as well as cost containment improvements.

Clinical Cost Containment Review (CCCR) requested from Optum

The CCCR process involves a comprehensive case analysis by a clinical pharmacist and a nurse reviewer. The pharmacist reviews current medication therapy for both therapeutic appropriateness and cost-effectiveness to align with current clinical practice guidelines. The nurse reviews medical treatments that are in use, planned or suggested for medical necessity and appropriateness to align with current clinical practice guidelines.

CCCR finds multiple concerns with claimant’s treatment regimen

Identified medication issues included: non-compliance, inappropriate dosing, duplication of therapy and drug interactions. His multiple prescribed medications were costly but had safe, cost-effective alternatives available. In addition, the SCS and ITP therapies that were discussed for the claimant were not supported by clinical practice guidelines.

Case proceeds to peer outreach

During the Peer Outreach process, a specialty-matched physician discusses the pharmacist’s and nurse’s analysis with the treating prescriber(s). Peer Outreach increases the likelihood that recommended changes will be implemented by the prescriber(s) and promotes safer, more effective care.

Nurse progress monitoring ensures plans are followed

After Peer Outreach, Nurse Progress Monitoring (NPM) was initiated to follow up with the treating prescriber(s) for up to six months to ensure agreed-upon changes were successfully implemented and sustained. Intervention by Optum nurse produces results:

• The SCS and ITP were formally documented as no longer recommended.
• Diclofenac solution, Terocin patches, New Terocin lotion, senna, and tadalafil were discontinued.
• Sildenafil use was reduced from once daily (30 tablets per month) to as-needed (10 tablets per month).
• Carisoprodol was replaced with tizanidine to be used as needed.

Clinical mitigation generates almost $2 million in savings and a better treatment plan for the claimant

The medication regimen was simplified and clinical concerns identified by Optum were addressed. In addition to benefitting the claimant, the overall claim costs and the projected MSA costs were significantly reduced, which will ultimately help Jim settle this claim.

Claimant diagnosis and medication list

Jim was diagnosed with a lumbosacral disc herniation, lumbar degenerative disc disease, lumbar spondylosis, spinal stenosis, and lumbar facet arthropathy. He had L5-S1 fusion surgery the year after his injury and was later diagnosed with failed back surgery syndrome and lumbar radiculopathy. A spinal cord stimulator (SCS) was implanted in 2013 but was removed two years later because it no longer provided any pain relief. Jim was also diagnosed with erectile dysfunction (ED) and anxiety secondary to his injury.

Jim was prescribed the following medications:

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