Prescription medications - considerations in workers' comp claims 
By Lance Watkins, VP, client services, Sedgwick MCO

Over the past decade, prescription medication has emerged as one of the hottest topics in medical management, and within the workers’ compensation system in particular. The state of Ohio and the Ohio Bureau of Workers’ Compensation have amplified efforts to bring accountability to medical providers on this issue and have addressed several egregious cases of over-prescribing and “pill mill” operations.  But beyond these extreme situations that make the news, there are several factors that make scrutiny of an employee’s prescribed medication through a workers’ compensation claim not only reasonable, but essential. 

Cost is one obvious factor.  Everyone has become familiar with direct consumer advertising of name-brand prescription medications that encourages the audience to ask their physician about these drugs.  While that patient-initiated dynamic can be somewhat concerning, these name-brand drugs typically come with much higher price tag.  There are often far more cost-effective generic alternatives available, or even over-the-counter options that accomplish the essential goal. 

It is also important to weigh the effect a prescribed medication has an injured employee’s duration of disability.  For example, an injured employee could be functionally able to perform the essential elements of their job but remain off work due to a prescribed drug impairing their ability to drive a car and travel to work. Exploring alternative pain management options, flexibility in dosage and timing of taking the medication, or arranging for commute assistance can facilitate a resolution to the claim.

When an injured employee does return to work, it is still worthwhile to pay attention to medications involved in their continued treatment of the workers’ compensation injury.  If daily work involves driving or operating heavy machinery, prescribed medication can be a safety concern.  A thoughtful discussion between the injured employee and their treating and/or prescribing physician about specific job duties should be a part of every office visit, but these details can be occasionally overlooked.  Providing a detailed job description to the treating physician is a great way to facilitate early return-to-work and modified duty but can also assist with clarity on the job duties that should influence medication options. 

An employer’s ability to be aware of an employee’s prescribed medication is not always guaranteed.  HIPPA-related restrictions may prevent employers from accessing this information for employees who are prescribed medication through private healthcare.  But within the context of a workers’ compensation claim, an employer does have the right to information regarding an injured worker’s medications because the employer is a “party to the claim”.  Whether or not medication is prescribed through a workers’ compensation claim or through private healthcare and insurance, employers should consider the value of a prescription drug policy that specifically outlines an employee’s responsibility to inform the employer of any medications that could impair their ability to safely perform their job duties.

Within the scope of our medical management function as a MCO, we examine prescription medications from the standpoint of appropriate treatment for the allowed conditions of a workers’ compensation claim.  Is the type of drug appropriate for the nature of injury and active treatment?  Does the combination of medications make sense or pose concerns for the recovery and return-to-work process?  Does the timing and duration of the medication seem reasonable?  We routinely discuss these issues with both injured workers and their treating physicians to make sure that prescriptions are contributing to a recovery and return- to-work rather than delaying a resolution to the claim and creating unwarranted cost and liability.  An option that we have available to address questionable medications is the “Drug Utilization Review” process (DUR).  We are frequently able to have questionable prescriptions either modified or removed from reimbursement in the claim.