Winter 2020/2021

Side Effects: COVID-19-Related Healthcare and Pharmacy Trends Impacting Workers’ Comp

Fast Focus

The COVID-19 pandemic has had a profound impact on the American healthcare system, causing disruptions and driving rapid adaptations to care delivery. Workers’ comp is affected in multiple ways, including patient access to care, medication adherences, and behavioral health issues. Employers and insurers can help to mitigate adverse effects on injured workers.

The COVID-19 pandemic has had a profound impact on the American healthcare system, causing disruptions and driving rapid adaptations to care delivery. Whether these changes will be temporary or permanent remains to be seen. In the meantime, repercussions are being realized – from the patient experience to ultimate health outcomes – by all healthcare consumers, including injured workers.

The degree to which patients are affected by the transforming healthcare landscape can vary, depending on factors such as geography, disease/condition, etc. But some changes are likely to impact most, if not all, workers’ compensation patients.

Almost 20% of primary care physicians chose to close their practices and 40% furloughed workers1

Hindered Access to Care

Receiving care in a timely manner is essential for injured workers to recover fully and return to work as quickly as possible. Even before COVID-19, physician shortages and the administrative requirements of the highly regulated workers’ compensation healthcare environment were contributing to longer wait times for injured workers in some areas, and the risk of delayed care has been exacerbated by pandemic-induced changes, including:

Medical practice closures during lockdowns
Ambulatory surgery center closures preventing non-emergency surgeries during lockdown
Permanent practice closures due to financial pressure
Limited appointment availability resulting from social distancing requirements
Backups at labs and diagnostic imaging facilities due to COVID-19 testing
Reluctant injured workers avoiding medical attention for fear of contracting the virus
In workers’ compensation, where a high number of injuries require orthopedic care, a delay in personal office visits, diagnostic tests, and surgeries can have serious consequences for claims duration and health outcomes for injured workers. At the peak of the pandemic, orthopedic surgeries declined by 82% worldwide and one workers’ compensation care management company reported a 64% decline in surgical dates.2 Both surgeries and physician office visits have increased as states reduced or eliminated restrictions, but the number of out-patient physician visits is still one third lower than pre-pandemic levels.1
Orthopedic surgeries declined 82% at the pandemic’s peak

Unfortunately, the patients who most need to see their physicians – those with chronic conditions – are also the most likely to delay care. These patients are particularly wary of medical environments because their conditions make them susceptible to severe illness and death from COVID-19.

Nearly half of Americans have delayed medical care due to the pandemic4

In fact, death rates are 12 times higher for patients with chronic conditions, regardless of age.3 However, it is also crucial that these patients receive consistent care to manage these conditions, which can lead to a host of serious complications unrelated to COVID-19.

National telehealth claim lines increased by over 8,000% from April 2019 – April 20206

One way to mitigate care access issues is by using telemedicine, which makes it possible for more patients to avoid unnecessary exposure by consulting with physicians virtually. Since the pandemic began, 5% of the U.S. population, or 16.5 million people, has used telehealth services.5 This includes workers’ comp patients in at least 24 states7 where legislators have rushed to pass laws removing or relaxing restrictions on telehealth visits.

Patients with these chronic conditions are at (higher) risk of severe illness from COVID-19:3
Cancer
Kidney Disease
COPD
Obesity
Heart Disease
Type 2 Diabetes
Sickle Cell Disease
Immunocompromised State

Telemedicine has also been helpful in allowing patients to continue physical and behavioral therapies. One service provider reported a 650% increase in telerehab referrals,8 and a large insurer reported telemedicine use for behavioral health has increased by 56 times, as compared to pre-COVID-19 levels.9 For workers’ comp patients, such remote services can be indispensable to keeping a full and timely recovery on course. At Healthesystems, we saw a nearly 20-fold increase in telerehab appointments from March to April of this year for our workers’ comp patients.22

For all of its benefits, when it comes to medication management, telemedicine can be a double-edged sword, posing both risk and opportunity.

States With Relaxed Telehealth Restrictions

Easier Access to Rx Medications

In response to the pandemic, federal and state regulators amended policies regarding prescription drugs, generally loosening restrictions to allow the following practices:

90-day, rather than 30-day, refills, except for controlled substances
Early refills, including for controlled substances
Waiver of test requirements and imaging studies as prerequisites for treatment
Renewal of prescriptions without seeing patients
Controlled substances prescribed via telehealth
Out-of-state prescribing of opioids and other controlled substances

Ensuring that patients receive their medications without exposing them to unnecessary risk is a laudable goal, which can and should be achieved while exercising appropriate oversight, particularly for high-risk drugs.

Although we have made tremendous progress against the opioid epidemic, especially in workers’ comp, signs of a relapse in the general population is cause for concern. In 2019, deaths from drug overdose rose to nearly 71,000, which was an increase of 4.6% over 2018.10 Approximately 70% of drug overdose deaths in recent years have been from opioids, which brings the 2019 opioid death rate to almost 50,000,11 and all indications point to a situation made even worse by the pandemic.

Thus far in 2020, total drug deaths (including prescription and illicit drugs) are 13% higher than last year,12 an increase that is largely attributed to emotional and economic despair caused by the pandemic. When comparing suspected overdose data in the weeks before and after mandatory lockdowns, the national Overdose Detection Mapping Application Program reported an increase of 18%.13

Deaths from all drugs are tracking 13% higher in 2020

Demand for antidepressants and anti-anxiety drugs has also increased due to the pressures of the pandemic, with new prescriptions for the month of March rising 9.2% and 10.2%, respectively.14 (Healthesystems has also seen an increase in prescriptions for antidepressants and anti-anxiety drugs among its patient population). Both antidepressants and anti-anxiety drugs pose high risks when combined with opioids, and a serious concern for workers’ comp is the possibility that these drugs are being prescribed to patients outside of their workers’ comp treatment. In addition, abuse of other drugs that are dangerous in combination with opioids, such as alcohol and methamphetamines, is also on the rise.15 All of which combines to make this a time for extra vigilance in monitoring the prescription activity of injured workers.

Antidepressant Rx’s ↑ 9.2%

Anti-anxiety Rx’s ↑ 10.2%

And this is where telehealth technology provides a valuable opportunity. In a short period of time, more patients have become familiar with and accepting of telehealth technology, which can be used to enhance patient engagement and medication management services. Connecting with patients virtually creates a safe and personal environment for pharmacists to monitor and counsel patients who may be at risk for adverse drug reactions and other complications. This type of personal connection can also help patients to feel they have a trusted healthcare resource with whom they can share any psychosocial stressors or obstacles they may experience with their current treatment regimen.

Other Pharmacy Impacts

Drug shortages: A persistent issue in healthcare for the past several years, drug shortages have been made worse by the pandemic. In the first six months of 2020, medication shortages reached 87% of the total shortages seen in 2019.16 Some of the drugs in short supply are related to the treatment of COVID-19, such as injectable sedatives and Remdesivir, but drugs commonly used in workers’ comp, including analgesics and anti-anxiety medications, are also in short supply.17
Physician Dispensing: Because patients who visit their physicians in person are anxious to avoid further risk of exposure at the pharmacy, physician dispensing of prescription drugs may be on the rise during this time. At Healthesystems, we helped our customers manage and mitigate this issue, keeping some customers' increases as low as 1%.18 While it is understandable that physicians and patients would want to minimize exposure to others during a pandemic, physician-dispensed drugs have been shown to cost as much as 60% – 300% more for workers’ comp patients19 and can pose challenges for medication management and patient safety.
Rx Delivery: A less expensive and safer alternative to retail pharmacy pick up, mail order delivery is also on the rise. To encourage the use of mail order, some states have eliminated the need for a signature to prove receipt of a prescription.20 Full results are not yet available, but mail order activity increased by 21% nationally during the month of March.21 At Healthesystems, we have worked with our clients to increase safe delivery of prescription medications, and increased 90-day refills for appropriate medications by more than 130% since March.22 Patients can also take advantage of delivery service from retail pharmacy chains, such as CVS and Walgreens, who agreed to waive delivery fees during the pandemic.23 And digital pharmacy start-ups, such as NowRx and Alto Pharmacy, are experiencing accelerated interest and investment as a result of COVID-19-related safety concerns.24
More patients want medications delivered to their homes due to COVID-19 safety concerns
Medication Adherence: It is unclear whether this pandemic will ultimately have a positive or negative effect on medication adherence. As noted earlier, fear of contracting COVID-19 causes patients to delay, or entirely avoid, medical care, which can lead to a failure in taking needed medications, either because they are not renewed or not being prescribed in the first place. On the other hand, the increase in 90-day refills makes it easier for patients to obtain their medications, which could positively influence adherence. Unfortunately, adherence for the highest risk patients may not be improving very much. One study has shown that since the pandemic began, late medication fills for low-risk patients decreased by 33%, but for high-risk patients, the decrease in late fills was only 13%,25 indicating that adherence improved the least among the patients who need it the most.

Late Refills

Low-risk patient ↓ 33%

High-risk patients ↓ 13%

Monitoring medication adherence during this time is extremely important, keeping in mind that standard methods of measurement may need to be re-evaluated because both medication possession ration (MPR) and proportion of days covered (PDC) could be skewed due to early refills. For high risk patients26, individual medication reviews by a pharmacist may be advisable.

The More Things Change . . .

As significant as the changes in healthcare and pharmacy have been, there are undoubtedly more to come in today’s dynamic environment. However, the fundamentals of patient care have not changed. Whatever the circumstances, case managers and claims professionals can still rely on tried and true best practices, such as being alert to risk factors and working with PBM partners to execute intervention strategies and actively engage patients to ensure their safe and appropriate care.

references

  1. Shah SA, Chernew ME, Beaulieu N. Supporting health care delivery in low-income areas during COVID-19. July 17, 2020. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20200715.332672/full/
  2. Raneri F. How ambulatory surgery centers responded to the COVID-19 pandemic and are uniquely poised for this crisis. July 21, 2020. WorkCompWire.com. https://www.workcompwire.com/2020/07/frank-raneri-how-ambulatory-surgery-centers-responded-to-the-covid-19-pandemic-and-are-uniquely-poised-for-this-crisis/
  3. Centers for Disease Control. Coronavirus Disease 2019: People with Certain Medical Conditions. Updated August 14, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
  4. Hamel L, Kearney A, Kirzinger A, et al. Impact of coronavirus on personal health, economic and food security, and Medicaid. May 27, 2020. Kaiser Family Foundation. https://www.kff.org/report-section/kff-health-tracking-poll-may-2020-health-and-economic-impacts/
  5. PwC Health Research Institute. The COVID-19 pandemic is influencing consumer health behavior. Are the changes here to stay? A consumer survey from PwC’s Health Research Institute. April 2020. https://www.pwc.com/us/en/library/covid-19/covid-19-consumer-behavior.html#content-free-1-fe80
  6. Gelburd R. Telehealth continues rapid growth tied to COVID-19: insurance claims data shows use of virtual health services continues to surge. July 13, 2020. https://www.usnews.com/news/healthiest-communities/articles/2020-07-13/telehealth-continues-rapid-growth-amid-coronavirus-pandemic
  7. Healthesystems data. http://medmonitor.healthesystems.com/regulatory-developments/covid-19-telehealth-updates/
  8. Despres M. COVID-19 serves as catalyst for telerehab adoption. One Call. July 2020. https://onecallcm.com/about/news-blog/covid-19-serves-as-catalyst-for-telerehab-adoption
  9. Minemyer P. Anthem seeing massive spike in use of telemedicine for behavioral health. Jul 29, 2020. Fierce Healthcare. https://www.fiercehealthcare.com/payer/anthem-earns-2-2b-q2-profit-as-payers-continue-to-see-massive-financial-gains-amid-covid-19
  10. Centers for Disease Control, National Center for Health Statistics. Provisional drug overdose death counts. August 2, 2020. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
  11. National Institutes of Health. Overdose Death Rates. January 2020. https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates#:~:text=Drug%20overdose%20deaths%20involving%20any%20opioid%E2%80%95prescription%20opioids%20(including%20methadone,among%20males%20(Figure%203).
  12. Katz J, Goodnough A, Sanger-Katz M. In shadow of pandemic, U.S. drug overdose deaths resurge to record. July 15, 2020. New York Times. https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html
  13. Alter A, Yeager C. COVID-19 Impact on US National Overdose Crisis. July 2020. Overdose Detection Mapping Application Program (ODMAP). University of Baltimore. http://www.odmap.org/Content/docs/news/2020/ODMAP-Report-June-2020.pdf
  14. Petersen A. More people are taking drugs for anxiety and insomnia, and doctors are worried. May 25. 2020. Wall Street Journal. https://www.wsj.com/articles/more-people-are-taking-drugs-for-anxiety-and-insomnia-and-doctors-are-worried-11590411600
  15. Weiner S. COVID-19 and the opioid crisis: When a pandemic and an epidemic collide. July 27, 2020. Association of American Medical Colleges. https://www.aamc.org/news-insights/covid-19-and-opioid-crisis-when-pandemic-and-epidemic-collide
  16. Sen-Crowe B, McKenney M, Elkbuli A. Medication shortages during the COVID-19 pandemic: Saving more than COVID lives. The American Journal of Emergency Medicine. July 23, 2020. https://www.ajemjournal.com/article/S0735-6757(20)30638-0/fulltext
  17. U.S. Food and Drug Administration. Current and Resolved Drug Shortages and Discontinuations Reported to FDA. Updated August 2020. https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm
  18. Healthesystems data
  19. Wong D. Physician Dispensing in Workers’ Compensation. July 1, 2012. Workers Compensation Research Institute. https://www.wcrinet.org/reports/physician-dispensing-in-workers-compensation
  20. Dolan R. States are Shifting How They Cover Prescription Drugs in Response to COVID-19. April 30, 2020. Kaiser Family Foundation. https://www.kff.org/policy-watch/states-are-shifting-how-they-cover-prescription-drugs-in-response-to-covid-19/
  21. Hopkins JS. Mail-Order Drug Delivery Rises During Coronavirus Lockdowns. May 12, 2020. Wall Street Journal. https://www.wsj.com/articles/mail-order-drug-delivery-rises-during-coronavirus-lockdowns-11589281203
  22. Healthesystems data
  23. Jaspen B. Walgreens joins CVS to waive drug delivery fees amid coronavirus crisis. March 12, 2020. Forbes. https://www.forbes.com/sites/brucejapsen/2020/03/12/walgreens-joins-cvs-waiving-drug-delivery-fees-amid-coronavirus-crisis/#3012c7751e35
  24. Landi H. NowRx, Medly Pharmacy land new funding as demand for digital pharmacies grows. July 17, 2020. https://www.fiercehealthcare.com/tech/nowrx-medly-pharmacy-land-new-funding-as-demand-for-digital-pharmacies-grows
  25. Allazo Health. COVID-19 widens disparities in medication adherence between patient populations. 2020. https://allazohealth.com/resources/covid-19-adherence/
  26. Crowe M. Do you know the difference between these adherence measures?. July 6, 2015. Pharmacy Times. https://www.pharmacytimes.com/contributor/michael-crowe-pharmd-mba-csp-fmpa/2015/07/do-you-know-the-difference-between-these-adherence-measures

RxInformer

Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.
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