Lack of guidelines complicates COVID-19 care

Evidence-based medicine is a mainstay in the workers compensation industry, and those aiming to treat workers with COVID-19 are relying on an ever-changing list of experimental and unproven treatments. 

Yet experts say that, anecdotally, the infections among workers whose COVID-19 claims are accepted as being work-connected are generally not serious, and few require hospitalization, where more expensive treatments are approved on a case-by-case basis as needed. 

The anti-viral infusion of the drug remdesivir, which became a household name when President Donald Trump received the treatment while hospitalized for COVID-19, can only be provided to a hospitalized patient — and few comp claimants are hospitalized, according to experts. While figures are not available, at least two third-party administrators in July reported COVID-19 hospitalizations among workers at 2% to 5%. 

“The large majority of the claims are the ones where they do not need treatment but need to quarantine at home with a mild illness,” said Jennifer Mason, Tampa, Florida-based vice president of claims for third-party administrator Broadspire, a subsidiary of claims firm Crawford & Co. 

“These are minor claims, minimal lost time, maybe one doctor visit and a few medications to help support the patient,” said Dr. Teresa Bartlett, Troy, Michigan-based senior vice president of medical quality for third-party administrator Sedgwick Claims Management Services Inc.

Yet which medications to prescribe, and cover, is somewhat of a moving target for workers compensation stakeholders, who for years have adhered to evidence-based care, of which, when it comes to COVID-19, there is little to go on. 

“The short answer is there are no clinical treatment guidelines for COVID-19 specifically,” said Joe Paduda, Skaneateles, New York-based principal for the comp consulting firm Health Strategy Associates LLC. “There’s no adequate science behind it,” he said, adding that a major concern is that statements from the federal government on treating the virus “appear to be inconsistent from time to time.” 

“As far as treatment goes, we are following evidence-based guidelines … that change on a regular basis weekly,” said Dr. Lisa Shaw O’Connor, Freemont, California-based associate clinical director of utilization review for Genex Services LLC. 

To date, 15 states have in place law-enacted workers comp formularies, or drug lists of approved medications for certain conditions; insurers, third-party administrators and pharmacy benefits managers have adhered to their own independent formularies, or drug treatment guidelines, for several years. As of October, not all state formularies had addressed COVID-19 care. 

For the most part, both states and comp payers rely on the Official Disability Guidelines drug list developed by Austin, Texas-based MCG Health LLC or the American College of Occupational and Environmental Medicine to manage and update their formularies. Both entities have addressed COVID-19. 

However, the guidelines are fluid and the workers comp industry is traditionally unused to treating widespread infectious diseases, according to experts. 

“Unfortunately we don’t know what works and what doesn’t,” Mr. Paduda said.  

“Comp has historically dealt with injuries and not disease,” said Mark Pew, Atlanta-based senior vice president of product development and marketing for pharmacy benefits manager Preferred Medical. “Comp is learning as they go.” 

The drug hydroxychloroquine, for example, was in the early weeks of the pandemic touted as a therapy to suppress the immune system response to COVID-19 and was at the time approved by the Food and Drug Administration for emergency use authorization. In June, the FDA issued a warning against the drug outside of the hospital setting due to side-effects. 

Meanwhile, both ODG and ACOEM guidelines have listed the drug as a COVID-19 treatment. The ACOEM guidelines, updated in August, do not recommend the drug after the first three days of COVID-19 symptoms. Both organizations declined to comment. 

Phil Walls, Tampa, Florida-based chief clinical officer for myMatrixx, an Express Scripts company, said the question of formularies, guidelines and recommendations comes up frequently among clients. That some treatments were made political muddied the issue, he said, adding that myMatrixx does not recommend the drug. 

Most of the treatments MyMatrixx is promoting are those that provide “supportive care,” such as steroids. “They make sense,” Mr. Walls said. “If it assists a patient with symptoms, I have no objection.” 

Dr. Bartlett said that in addition to drugs that suppress symptoms of the virus, such as cough suppressants, steroids and inhalers, antibiotics to treat secondary bacterial infections are also commonly approved for workers who contract COVID-19. She said the typical drug spend for a COVID-19 patient is “way under” $500. 

“It is a lot of symptom mitigation and requests for over-the-counter symptom relief. If anything (for prescriptions) we are seeing a request for a short term of steroids,” Dr. Shaw O’Connor said.

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Experimental COVID-19 treatments present employers with dilemma?

Prescribing experimental drugs for COVID-19 workers comp treatments carries the potential for long-term complications and high costs, as adverse side-effects of any treatment in the comp scheme fall under the original injury claim, legal experts say.

“There’s a general principal in workers comp that any medical malpractice or adverse reaction that is part of the treatment for an injury falls on the employer covering the injury,” said Carin Burford, a Birmingham, Alabama-based shareholder with Ogletree, Deakins, Nash, Smoak & Stewart P.C.

“That’s one reason why an employer might want to question, is this reasonable and medically necessary?” said Ms. Burford, who is also an adjunct professor at the University of Alabama School of Law.

Michael Sullivan, El Segundo, California-based general managing partner of the workers comp defense firm Michael Sullivan & Associates LLC, said whether to opt for experimental treatments depends on the employer.

“What do they want to authorize? There aren’t going to be (workers comp treatment guidelines) on the new treatments coming out, and how far do you want to go in paying for a treatment that may just be emerging?” Mr. Sullivan said.

“If you provide meds that cause an additional negative impact, the work comp payer owns that injury too,” said Joe Paduda, Skaneateles, New York-based principal of the comp consulting firm Health Strategy Associates LLC. “It’s you’re damned if you do, damned if you don’t.” 

That conundrum for payers could create legal issues later on, Ms. Burford said. “I think litigation is possible. We are not just dealing with whether (COVID-19) is compensable. The next question is, are we on the hook for experimental treatments? That is going to be an open question.”