Ohio's New Rules: A Good Start (with a Potential Gap)

The Ohio Bureau of Workers’ Compensation formally adopted new rules intended to control the inappropriate use of prescription narcotics within the state-controlled work comp system.  The rules are known collectively as the “coordinated services program” and they’re being referred to colloquially as the “lock in” program. 

At first pass, I thought the program appeared cumbersome and difficult to understand.  Now that I’ve studied the rules and had a chance to discuss them with clinicians and claims people, I’m quite impressed with the new rules and I’m hopeful they’ll have a significant impact (for now, BWC estimates savings to the system of $15 million just by the end of this year). 

In summary, claimants that receive certain combinations of drugs from certain combinations of either prescribers or pharmacies are potentially subject to being placed in the “coordinated services program” by the BWC.  This means the claimant must:

1)      Choose a single prescriber from a list of BWC pre-qualified physicians

2)      Choose a single pharmacy from a list of BWC pre-qualified pharmacies

3)      Be subject to a physician review of the most recent 12 months of prescription history to assess the medical necessity of the drug regimen. 

From here, the path to successfully weaning and/or discontinuing unnecessary medications isn’t exactly clear.  There are no clear cut statements in the new rules that disallow payment for medically unnecessary drugs – the rules simply stipulate that drugs must be prescribed by a single physician and dispensed by a single pharmacy.  Perhaps the assumption is that because these physicians and pharmacies are pre-qualified by BWC for participation in the “coordinated services program,” they will do the right thing and get the drug regimen under control.  Appears logical, but if the new rules have a gap, this is it.   

So, a decent start for Ohio.  But as I said about Washington State’s new rules, for employers and insurers in other, non-monopolistic states waiting for legislation to fix the problem of opioid abuse in work comp, don’t hold your breath.  Get to work on a market-driven solution. 

Michael
On Twitter @PRIUM1

Utilization Review in Illinois: Missing an Opportunity

PRIUM’s General Counsel recently happened upon a post on a work comp law blog out of Illinois published by Eugene Keefe at Keefe, Campbell & Associates, LLP in Chicago.  The post was both fascinating and disappointing. 

Mr. Keefe’s extensive research on the application of new utilization review (UR) rules for the state work comp system shines a light on what happens when UR isn’t well understood (or perhaps what happens when UR is, in fact, well understood, but where the Work Comp Commission clearly leans in favor of claimants instead of the employer community.)  Despite the fact that the new rules were intended to give UR more weight and credibility in the process, it appears the Illinois Work Comp Commission (IWCC) is more interested in pleasing the plaintiffs’ bar.

During 2011, there were 32 UR decisions for which the dispute resolution process led all the way to a decision by IWCC.  In 23 of those 32 cases, the UR non-certification was overturned.  This doesn’t exactly inspire confidence amongst the employer/insurer community. 

Maybe there’s good reason those 23 decisions were overturned?  Not exactly.  In one case examined by Mr. Keefe, the reason for disregarding the UR determination was because “the utilization review doctor did not examine the Petitioner and his findings are based solely on record and diagnostic reviews.”  To this, Mr. Keefe responds appropriately, “Well, duh.”  The fundamental approach of UR is to examine records in search of documented, objective medical evidence that suggests a particular test, procedure, or therapy is medically appropriate.  And nowhere in the IL statute governing work comp is there even a suggestion that UR should require actual examination of the patient. 

So what’s an employer/insurer to do?  Do the right thing anyway.  Three reasons:

1)      A well structured UR non-certification may provide for a more informed Independent Medical Examination down the road;

2)      A UR non-certification may still have value in the settlement process, should the case progress to that point.

3)      Even if the odds don’t appear very attractive, engaging UR is still better than not engaging UR (and passively allowing inappropriate medical care to be rendered). 

In March of last year, the Chairman of Caterpillar (which employs 23,000 people in Illinois),  Doug Oberhelman, sent a letter to Illinois Governor Patrick Quinn which stated, in part, “The direction that this state is headed in is not favorable to business, and I'd like to work with you to change that.”   

Governor Quinn (and Governors everywhere) – are you listening? 

Michael
On Twitter @PRIUM1

Texas Closed Formulary – Just Do It

So, to recap, the first Phase of TCF has apparently been successful already, and the second Phase has been well defined by the DWC.  So now it just comes down to the willingness of all the stakeholders to proactively start addressing the legacy claims and utilize the element of time to deal with these very difficult claims (and, most importantly, the health and well-being of many injured workers).  The issues have been identified, the table has been set, and now it comes down to execution.

Do I have a business reason for pushing this forward?  Yes, because our methodology matches very closely to the DWC’s intended process.  And our outcomes (high discussion rate, high agreement rate, actual savings by facilitating the discontinuance of inappropriate drugs) exceed those of the industry.  However, after having spent over almost 8 years focused on the prescription drug issue in Work Comp, my passion is personal.

This process works.  I have observed patients go from an egregiously inappropriate drug regimen to one that has a lucid clinical rationale, and even to no drugs at all with a better way to cope with the pain while being more cognitively aware and satisfied.  I have heard a thankful phone call from a patient who initially resisted changes to his drug regimen, but after many discussions with him and his wife and his treating physician about the effect the drugs were having on his life and life expectancy, went through detoxification and now has a much happier existence.  I have overheard conversations with treating physicians who were thankful for the peer dialogue that initiated a personal epiphany for them in how they managed chronic pain.  For this process to work, all stakeholders need to understand the risks associated with maintaining the status quo and have a desire and will to change.

So, now it’s time to just “do it”.  If you're ready to get started, call me.

In this together – Mark

On Twitter @PRIUM1

Florida Doctors Push Back on CVS

Last November, CVS sent letters to certain Florida doctors informing them that “CVS will not be able to fill prescriptions that you write for Schedule II narcotic controlled substances.” 

Today, we learned that some of those doctors are pushing back.  CVS is being sued by several doctors for a host of reasons ranging from “emotional distress” to “damage of [medical] practice.”  CVS has filed a motion to dismiss the suit.  Most of us saw this coming.

The headline on workcompcentral, though, is what caught my attention: “Doctors Say ‘Pill Mill’ Ban Impacting Patients.”  And embedded in the article is this nonspecific, anecdotal nugget from the Florida Society of Pain Management Providers: “Some patients are having trouble filling prescriptions.”  

I don’t have a window into the process CVS utilized to identify these doctors (none of us do – CVS has been tightlipped on that front).  But I imagine the folks at CVS are smart enough to know that these actions were going to start quite the brouhaha.  And I’m betting they’re prepared for the backlash.    

To the patients not able to fill their scripts at CVS, I offer this advice: While it seems it would be (incredibly) easy to find another pharmacy, don’t do that.  Instead, find another doctor.   

Michael
On Twitter @PRIUM1

Texas Closed Formulary – 9/1/13, Legacy Claim Cleanup

Given the apparent success to-date of the TCF Phase 1, now the focus shifts to Phase 2 for cleaning up the “legacy claims” (those with a Date of Injury prior to 9/1/11).

Every jurisdiction has the issue of longstanding claims that have accrued large medical costs (and continue to do so), involved failed treatment regimens over time, and included various attempts at mitigating the cost / treatment scope that for the most part have not succeeded.  These claims are called various things - legacy, high exposure, old dog, trainwreck - but the bottom line is they have cost a lot of money yet provided unsatisfactory improvement in health.

The TCF Phase 2 is an interesting take.  The DWC has essentially granted 2 years for payers and physicians to work collegially and bring the drug regimens into compliance with ODG or face preauthorization (and likely denial) of drugs at the pharmacies starting on 9/1/13.  Everyone knows that this process is going to be complicated (several stakeholders with different motivations), there likely will not be 100% compliance (some physicians, even with the mandate, still might not cooperate), and it will take a long time to accomplish (ODG classified these as “N” drugs because they are addictive and have long-term negative consequences).  Hence, the strategy should be to get started ASAP while time is our friend.

Our suggestion, after reading the rules and talking with experts, is to use 2012 as the “handshake” and reserving 2013 for the “hammer”:

• The 2012 handshake is a collegial outreach to cooperative physicians, reaching consensus on any necessary changes, and implementing those changes so the patient is clinically stable with an appropriate treatment plan
• The 2013 hammer is the second pass through where those that chose not to cooperate have more assertive pressure applied with the impending 9/1/13 deadline

I remember Y2K as an IT professional, and the months of effort to prepare, and the anxiety I felt as the clock struck midnight and then 4 hours later when we turned all of the mainframe computers back on to see if they actually would.  You might be of the opinion that Y2K was a made-up crisis by the technology industry - I know the amount of effort and planning that was required.  The DWC has ensured, with punitive measures for non-compliance, that 9/1/13 is a deadline that cannot be ignored.  For those proactive in the process, 9/1/13 will be just another day.

In this together – Mark

On Twitter @PRIUM1

Texas Closed Formulary – 9/1/11, Phase 1

The first phase of the Texas Closed Formulary was made effective 9/1/11 and required the preauthorization of all Official Disability Guidelines (ODG) “N” drugs for new Work Comp claims.  This was a prudent approach for three different reasons:

1. Stopping the drugs from being dispensed at the Point of Sale (POS, aka the pharmacy) is the most reliable way to enforce change
2. Texas physicians were familiar with the preauthorization process after years of seeking approval for treatment such as physical therapy and spinal surgery
3. ODG is the most reliably updated reference on the appropriate use of drug therapy available and is the standard of care in Texas

This first phase certainly had its detours and obstacles over the past several years as the content of the rules were hashed and rehashed by the various stakeholders.  Implementing something this dramatic is not easy, and the negotiation process was sometimes controversial and messy.  To everyone’s credit, a consensus was reached and implementation completed.  And it is obvious after 3 months the new requirement is having an effect.

In my whitepaper, “Legacy Cleanup, Texas Style”, I document the fact that the use of “N” drugs within the first 90 days after Date of Injury (DOI) has been reduced by more than 50% because of Phase One.  For DOI’s 9/1/10 thru 8/31/11, the proportion of “N” drugs to all dispensed drugs was 7.38%.  For DOI’s 9/1/11 thru 12/22/11, that proportion dropped to 3.51%.  This is real data from a major Pharmacy Benefit Manager (PBM) operating in Texas.

This analysis is corroborated by the DWC, who mentioned while I was in Austin last week that preliminary analysis shows a two-thirds reduction in the use of “N” drugs since 9/1/11 (across all claims, year over year).

Time will tell whether this is an anomaly during the first few days or a permanent trend.  Regardless, this is REAL impact and REAL progress.  But this is only the first phase, as I will discuss more tomorrow.

In this together – Mark

On Twitter @PRIUM1

Texas Closed Formulary - Prelude

I was in Austin last week in follow-up to my whitepaper, “Legacy Cleanup, Texas Style”.  I participated in the inaugural Alliance Against Prescription Drug Abuse that is sponsored by the Texas Association of Business and was pleased to see more than 50 in attendance representing a variety of stakeholders in medical care (government, law enforcement, businesses, carriers, medical associations, pharmacy associations, alliances and lobbyists, media).  In addition, I was able to speak with several well-connected individuals in Work Comp, two customers and a well renowned clinician.  As I had anticipated, there was a consensus among all that prescription drug over-utilization is a huge issue that is increasing healthcare costs, reducing the quality of life (and life expectancy and functionality) of patients, and using law enforcement resources best suited for other purposes.  Additionally, it was commonly recognized as a societal issue in America, that it is multi-dimensional in its genesis and impact, and any attempt at stemming the tide of this epidemic must be multi-faceted and coordinated.  My colleague and fellow blogger, Michael Gavin, will be speaking at the National Prescription Drug Abuse Summit in mid-April because we strongly believe this issue is bigger than Work Comp.

Even though I am visiting customers in California this week, my blogs will be focused on how the Texas Department of Workers’ Compensation (DWC) is addressing their part of the pie.  They decided to take a two phased approach.  First was reducing the introduction of Official Disability Guidelines (ODG) “N” drugs for new WC claims effective 9/1/11, and as I will note tomorrow this already has had a positive effect.  The second phase will be fully implemented on 9/1/13 but really should start now - evaluating the ongoing medical appropriateness of ODG “N” drugs for all “legacy claims” (those with a Date of Injury prior to 9/1/11). 

As you can imagine from a state the size of Texas, and the dependence and addiction these “N” drugs often cause, this process will be time consuming and likely not easy.  Which is why, in all of my discussions this week, I tried to push forward a sense of urgency to get started now, as the overall success of this program will be closely linked to how assertive and proactive each of the stakeholders are given the 2 year window the DWC has provided.

From my research of the various plans across the country, I am convinced that Texas has designed a process that can be a game changer and possibly a model for other states.  The issue now is not recognition of the problem, but rather in the execution of solutions.  And, to leverage a famous phrase from the Space Center in Houston in 1970, "failure is not an option".

In this together – Mark

On Twitter @PRIUM1

Doing Well by Doing Good

Back when I was in graduate school, I was constantly (some would suggest obnoxiously) talking about health care.  I was surrounded by fellow classmates that had come from a multitude of different backgrounds, careers, cultures, and countries, and each of them had a different perspective on business problems and how we should go about solving them.  For those that wondered why I related so much of what we studied and discussed back to health care, I would routinely offer two reasons:

1)      Health care is everyone’s problem.  “Do you think that health care is a top 3 issue for the CEOs of Wal-Mart, IBM, Google?” I would ask, rhetorically.  “It absolutely is!” I would answer, predictably.  Whether from an internal human resources perspective or an external market solutions perspective, health care is on the agenda for nearly every corporation and the executives that lead them.     

2)      In health care, one can do well by doing good.  I had classmates that were focused on careers leading non-profits.  They will do a lot of good in the world, but it’s questionable whether or not they’ll do well for themselves financially.  I had other classmates that went on to careers in investment banking.  They’ll do quite well for themselves, but it’s questionable as to how much good they’ll do in the world.  I chose health care because I get the best of both.

Every day at PRIUM we work hard to ensure that the right care is delivered to the right claimant at the right time for the right reasons.  And we’re particularly focused on the over-utilization of prescription drugs to treat injured workers.  By no means is it easy to come to work every day prepared for the inevitable fights with doctors, lawyers, claimants, and others that would rather take the path of least resistance and continue with medically unnecessary and potentially damaging treatment.  We come to work every day with our proverbial boxing gloves on. 

But it’s worth it.  We’re on the right side of a major public health issue.  And we’re giving injured workers their lives back, one claim at a time. 

Whether or not we do well may, in fact, be determined by how much good we’re able to do.  And we’re working hard to do good every day. 

Michael
On Twitter @PRIUM1

Washington State: The Fine Print

Much has been made of the public policy initiatives of the state of Washington in the area of prescription narcotics.  To quote from a workcompcentral article (subscription required) this week: “The CDC held out Washington as an example of a state that is aggressively tackling problems with excessive opioid prescriptions.  Five medical boards and commissions passed measures requiring a provider to perform a full assessment of a patient’s health history and past treatment of pain when prescribing opioids.  Doctors are required to prepare a treatment plan, and also seek a consultation for any prescription that exceeds the equivalent of a 120 mg dose of orally administered morphine per day.”

And another article appears to indicate that the state’s 2007 dosage guidelines may, in fact, have led to a drop in both the dosage levels and overdose deaths associated with opioids. 

I applaud these efforts as a necessary step toward mitigating the public health crisis of prescription drug over-utilization.  In particular, I’m appreciative of the efforts of Dr. Gary Franklin, Medical Director for the Washington State Department of Labor and Industries, who has served as a voice of reason on this issue. 

But I also want to make sure we collectively understand the fine print on the new rules, effective January 2, 2012.  For instance:

• Washington is a single payer state (i.e., the state essentially operates as a monopolistic work comp carrier).  This is a well-known fact and not exactly “fine print”, but it’s important to note because this makes translating public policy initiatives to other, non-monopolistic states a potentially more complicated proposition. 
• The rules provide for an exemption from the mandatory consultation requirement for the following: pain management specialists, doctors who have completed at least 12 hours of CE in chronic pain management (with at least 2 hours focused on long acting opioids), physicians who are “pain management practitioners” working in a multidisciplinary pain program or academic medical center, or any physician with at least 3 years of experience in a chronic pain management setting with at least 30% of current care being delivered in the area of chronic pain management.  Did you get all that?  In our experience, the presumption that “pain management specialists know better” is a dangerous one. 
• The rules do not require doctor/patient narcotics contracts unless the patient is deemed “at high risk for medication abuse, or has a history of substance abuse, or psychiatric comorbidities.”  This conflicts with the ACOEM guidelines, which suggest initiation of such a contract for any patient being prescribed an opioid for chronic non-cancer pain.      
• And what happens if a doctor doesn’t follow these rules?  The commission goes out of its way to state, within rule set itself (WAC 246-919-850), that “physicians should not fear disciplinary action from the commission for ordering, prescribing, dispensing, or administering controlled substances, including opioid analgesics, for a legitimate medical purpose…”  Until the commission intervenes with punitive action for non-compliant physicians, I’m not convinced the rules will have their intended (and much needed) effect. 

I don’t mean to be overly critical.  These rules are an excellent start and a good step in the right direction.  But for employers and insurers in other states waiting for legislation to fix the problem of opioid abuse in work comp, don’t hold your breath.  Get to work on a market-driven solution. 

Michael
On Twitter @PRIUM1

Predictive Modeling: Prioritizing Vision Over Execution

When Lou Gerstner took over a struggling IBM in the summer of 1993, he famously commented, “‘There’s been a  lot of speculation as to when I’m going to deliver a vision of IBM, and what I’d like to say to all of you is that the last thing IBM needs right now is a vision.  What IBM needs right now is a series of very tough-minded, market driven, highly effective strategies for each of its businesses.”

Well said.

I gave an interview last week and the topic of discussion was predictive modeling and its ability to help “fix” the problem of prescription drug abuse in work comp.  Could sophisticated software that identifies potentially problematic claims before the patient becomes tolerant, dependent, or addicted really help mitigate this difficult, multi-billion dollar issue? 

As the discussion unfolded, I couldn’t help but think of Mr. Gerstner.  The essence of his early days at IBM was a focus on execution.  He recognized that spending time and money on developing a “vision” created a built-in organizational excuse for lack of execution. When it comes to problem solving, the practical should always trump the theoretical. 

I absolutely believe there is a place in worker’s comp for predictive modeling.  Smart people are finding ever smarter ways to more effectively manage claims.  But when it comes to the issue of prescription drug over-utilization, let’s not let the theoretical trump the practical.  I talk to claims executives constantly and, for the most part, there exists a clear understanding regarding the identification of complicated claims and an intuition regarding claims that may end up being complicated. 

So we can talk about how predictive modeling can help.  We can even wonder aloud about whether, in the future, these models will be the best possible means by which to manage claims. 

But first, let’s put some prescription data in a spreadsheet, pick all the claims with Actiq, and get on the phone with the treating physician to figure out how to fix it. 

We don’t need a vision for that.  We just need to execute.

Michael 
On Twitter @PRIUM1

Obesity: CHOA Makes a Stand

NCCI published an excellent study about a year ago regarding the increased risk of disabling injuries as a result of obesity.  According to NCCI, “the study concludes that there are systematic differences in the outcomes for obese and non-obese claimants with comparable demographic characteristics. The study also concludes that there is greater risk that injuries will create permanent disabilities if the injured worker is obese.”

Based on the cases in which PRIUM has intervened with our clinical review services for complex claims, it’s clear obesity is the most common (and most complicating) co-morbidity, particularly among those struggling with tolerance, dependence, or addiction to prescription narcotics.  The frustrations we encounter in trying to deal with the condition among injured adults are for another post.  The best long term solution to the problem lies in prevention, namely a focus on rectifying childhood obesity. 

Children’s Healthcare of Atlanta (CHOA) has developed an ad campaign around the issue of childhood obesity that is, let’s just say, pointed.  (Full disclosure: Children’s is a former consulting client of mine and there are precious few organizations on the planet that I think more highly of than CHOA).  The organization is breaking new ground with this campaign, however, and it’s ruffled a few feathers both locally and nationally.  Georgia has the second highest rate of childhood obesity in the nation and the Children’s hospital that takes care of these children has decided to hit the issue head on.

Some notable taglines from the print and television ads:

“Being fat takes the fun out of being a kid”

“Stop sugar-coating it, Georgia”

“It’s hard to be a little girl… if you’re not”

Gut wrenching stuff.  My view: I’m supportive.  I think this is the kind of direct, tough talk that’s needed to begin to fix the problem. 

What do you think?  And will the ads make a difference in the long run?   

Michael
On Twitter @PRIUM1

How Concerned? Very, Very Concerned.

Like a lot of other people in our industry, I’m a regular reader of Joe Paduda’s blog, Managed Care Matters.  Like him or not (and I acknowledge that opinions vary), Joe is an informed guy, a smart consultant, and an entertaining read.    

A post on MCM from the middle of last week caught my eye.  In the midst of compiling the results from the most recent survey of pharmacy management in workers’ comp, Joe felt compelled to stop and share one specific data point.

The survey question: “How much of an issue are opioids in worker’s comp?”

The average response was a 4.8 on a 1 to 5 scale with 5 meaning “extremely significant.”  Joe noted that this is the highest score for any question in the eight year history of the survey.

He closed the post by noting, “next step is to put solutions in place.”

From his lips to God’s ears.  Some have interpreted my post regarding the need for our industry to move away from the diagnosis of an obvious issue (over-utilization of prescription narcotics in work comp) and toward a meaningful and efficacious solution as overly ambitious and lacking in the patience required to mitigate such an intractable problem. 

To that I say… nonsense. 

To even begin to fix this problem, our industry needs levels of commitment, transparency, communication, and fortitude that don’t exist today.  We need to identify solutions that work and then have the courage to implement them, even if it creates some noise and awkwardness as we do so. 

An example:  Occasionally, PRIUM’s services rendered on an individual claim file lead to the point that another vendor should be involved – perhaps a utilization review vendor.  PRIUM happens to provide those services, but contracts sometimes don’t allow for PRIUM’s UR services to be utilized.  In essence, we’re handing business to a competitor.  And you know what?  That's ok.  We care more about fixing the claim than we do about getting our hands on one more UR case.   

Those of us who want to see the right care delivered to the right patient at the right time and for the right reasons… well, we’re on the right side of this fight.  Let’s work together, do the right thing… and not apologize for it. 

Michael
On Twitter @PRIUM1

Getting past cynicism

For my younger readers who did not understand the Star Trek references in my introductory blog, I will footnote this time!

Objectivity and logic is very important when making medical and financial decisions.  Obviously the TV commercials that give you not one, but two, of the widgets if you buy in the next 10 minutes count on your impulsive nature overriding your logical assessment as to whether you really need the widget.  But the last thing a patient, or Payer, needs is for a treatment plan to be based on the impulse of treating a subjective complaint without thoroughly, logically, and objectively evaluating every potential option available, starting with (and possibly returning to repeatedly) the plan that has the best outcomes with the least side effects.  In this case, you need the capacity of Mr. Spock's dispassionate assessment.

But, on the other hand, a passionate approach to decisions and the way one lives life is also very important.  Not to the extent that some sports fans go, like the Giants fan that was beaten up by Dodgers fans after the baseball season opener in 2011.  But the intense desire to do the right thing, sometimes when the right thing is not logical or easy.  In this case, you need the ability to move forward against all odds, like Captain James T. Kirk.

In our Work Comp industry, the easy claims (slight injury, patients motivated to return to health and work quickly) are not the ones that occupy the time of the various stakeholders.  Instead, the claims where the patient is unmotivated, or the treating physician is a “bad actor”, or the plaintiff’s attorney is litigating everything … those are the ones that occupy the most time, create the most frustration, and can create an attitude of cynicism or ambivalence.  That makes it easy to lose both objectivity and passion, which reduces the ability to make good decisions.

Our organization received a compliment (at least from my perspective) yesterday from one of our customers.  When asked why he was impressed (and he does not impress easily), the immediate response was “because you care”.  Our passion to do the right thing, clinical for the patient and financial for the Payer, was evident to him during our interactions.  The challenge, for all of us, is to maintain both objectivity and passion even though our daily circumstances might try to steal that away.

In this together – Mark Pew

On Twitter @PRIUM1

Redefining “stable”

One of the ways dictionary.com defines stable is “firmly established”.

A Workers’ Compensation definition of “stable” is Maximum Medical Improvement (MMI), a rather self-defining term that means the patient’s condition cannot be improved any further.  Keep in mind this doesn’t necessarily mean they have reached a point where the patient is satisfied with their health, or that the injury is fully healed with no pain, just that there is no further improvement expected in the patient’s health.  This implies that a variety of treatments have been tried (conservative, surgical, pharmacological, psycho-social), and with varying degrees of success they have delivered the patient to a certain plateau of wellbeing.  In California, the term Permanent and Stationary (P&S) is the legal term for “the point when the employee has reached maximum medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment.”

So why, when a Payer (or a Peer Reviewer) asks a treating physician for their clinical rationale of a treatment plan that has remained the same for many months/years but the patient still has low Activities of Daily Living (ADL) and high levels of pain (7+ out of 10), is their response that they have “stabilized” their care?  In its purest definition that is probably true because nothing substantial has changed from month to month except the date of the office visit.  However, if there is no objective proof that functionality has increased over time and that pain is becoming better controlled, repeating the same treatment from month to month is having no effect in moving the patient towards MMI.  Using Albert Einstein’s definition of insanity, doing the same thing over and over again and expecting different results, it is fair to say that continuing the same treatment (including the drug regimen) but yet having low function and high pain is insane.

CMS prefers the WCMSA proposal not be sent until the “individual’s condition has stabilized so that it can be determined, based on past experience, what the future medical expenses may be.”  That is a completely reasonable expectation, and we should expect no less during the management of claims.

So let common sense prevail and do not allow a clinically inappropriate regimen with no track record of success be classified as “stable”.  Per the great sage Hank Haney (Tiger Woods’ golf swing coach), if you’re not getting better you’re getting worse.

In this together – Mark Pew

On Twitter @PRIUM1

Opioid over-utilization and WC death benefits

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There is a massive amount of unintended consequences from treating the symptoms of pain and not necessarily the source of pain.  The most obvious is cost – to the Payer, to the medical delivery system, and to society (the National Drug Intelligence Center estimates that drug abuse costs the U.S. more than $120B in lost productivity each year).  The clinical consequences may be even greater, and ultimately more costly.  From the unmet expectations by the patient of total pain control, to dealing with subjective rather than objective complaints, to masking other illnesses whose symptoms cannot be identified due to sedation, to drug side effects that often require other drugs and often create co-morbidities, to over-sedation that turns them into zombies … they all have a negative effect on a patient, their family and friends and their treating physician.  However, recent reports indicate the ultimate cost, death, is gaining momentum.

First, the statistics: Research from the CDC’s Morbidity and Mortality Weekly Report from 11/1/11 (Volume 60) showed that the death rate from drug overdoses in the U.S. has tripled from 1991 to 2007.  Per their research, the death rate in 2007 was 11.8 per 100,000 (or almost 100 people per day), and prescription drugs have accounted for most of that increase.  In 2009, 1.2M emergency department visits (an increase of 98.4% from 2004) were related to misuse or abuse of pharmaceuticals (compared to 1.0M visits due to illicit drugs).  The biggest driver of these increases was due to opioid pain relievers.  In 2008, drug overdoses were responsible for 36,540 deaths.  Opioids were involved in 14,800 deaths, or 73.8% of the total 20,044 overdoses related to overdoses that included one or more prescription drug.  Just think what 14,800 people means – 40 per day, or the entire city of Taos NM.

And then the effect: Recent court decisions indicate this is a burgeoning problem for Work Comp.  On 11/30/11 the Tennessee Supreme Court Special Workers’ Compensation Appeals Panel ruled that death benefits should be allowed for a claimant who overdosed on oxycodone.  The Commonwealth Court of Pennsylvania confirmed on 12/2/11 that a claimant’s fatal overdose from fentanyl was compensable because even though a Utilization Review report concluded the drugs were not reasonable and the Payer refused to fill the prescriptions, the claimant’s treating physician prescribed them anyway.  The North Carolina Court of Appeals affirmed on 12/20/11 that the widow of a claimant is due death benefits because her husband died from a methadone overdose that was part of his WC treatment regimen.

Our industry, and society in general, has created zombies who are unfortunately marching to their graves.  That is a trend we need to reverse.

In this together – Mark Pew

On Twitter @PRIUM1

Curative vs. Palliative

Curative care is focused on healing disease.  Palliative care is directed at alleviating symptoms.  We get into trouble as a society (clinically, ethically, and legally) when we confuse the two.

Typically, the discussion of curative vs. palliative methods is reserved for issues related to end-of-life care for terminally ill patients.  This is a critical component of the overarching health care debate in which we’re currently engaged in this country, though it’s a hot-button issue to say the least.  If Social Security is the “third rail” of American politics, end-of-life care is the “third rail” of the health care debate (“death panels” being my own favorite rhetorical lowlight of the past few years.) 

According to the New England Journal of Medicine, approximately 5% of Medicare beneficiaries die each year, though this group consumes 27% of the Medicare budget.  As a society, we’re simply not comfortable with the concept of death.  And while many of us acknowledge the economic impact of acting more rationally with regard to end-of-life care decisions, when those decisions become personal in nature, rationality is tossed aside (understandably so).  Until we decide to grapple with this most intransigent of bio-medical-ethical debates, very little is likely to change. 

The distinction between curative and palliative care, though, is also extremely relevant to the workers’ compensation medical cost management space, albeit for entirely different reasons.  I am consistently shocked at the number of injured workers that believe their chronic opioid therapy (COT) is, in fact, curative.  I have sufficient faith in the medical community to believe that the source of this ignorance is lack of clear and complete communication between provider and patient regarding “curing disease” and “alleviating symptoms” (and not, presumably, from doctors that don’t understand the difference).

COT should be placed in its proper context as merely palliative care that might be necessary to alleviate symptoms, but will never be sufficient, in and of itself, to fix the underlying problem.  I’m the first to acknowledge there are exceptional cases in which COT is indicated, but we’ve seen too many minor low back sprains turn into tolerance, dependence, addiction, hyperalgesia, and a host of other adverse effects of COT for the current clinical approach to be deemed acceptable.

I wish more doctors, when writing the first script (or the fiftieth script) for opioid therapy had the courage to say, “At best, this is only going to make you feel better for a short time.  This is not going to heal your pain.” 

Michael
On Twitter @PRIUM1

Moving from Diagnosis to Treatment

Quick… rattle off the stats regarding chronic (over)use of prescription narcotics in work comp. 

Let’s see, there’s the spend ($1.4 billion a year and rising).  There’s the risk (more people dying of accidental opioid overdoses than cocaine and heroin combined).  There’s the clear lack of medical necessity (no evidence-based guidelines suggest that long term use of these drugs is a good thing for common work injuries). 

Imagine going to the doctor.  The doctor says, “I have a bad news.  You have a tumor.  It’s growing.  Let me tell you everything there is to know about this tumor.  We’re going to look at some pictures of it.  We’re going to look at a historical chart of its growth.  We’re going to talk about how much it’s going to hurt as it continues to grow.”

What would you say?  I would guess something like, “Enough talk, already… WHAT ARE WE GOING TO DO ABOUT IT?!?!?”

That’s how I’m feeling about the issue of chronic opioid abuse in work comp.  We get that there’s a problem.  Now what are we going to do about it?  I’ve heard this question asked in a few different forums now and the answers generally come down to:

1)   Education and awareness (i.e., let’s keep talking about that tumor in the hope that by talking endlessly about the diagnosis, the treatment miraculously reveals itself)

2)   Statutory change (i.e., the only way to get doctors and patients to start thinking differently about this issue is to legislate our way to solutions)

3)   Early intervention (i.e., let’s stop the train from going off the tracks in the first place)

I’m tired of #1 (the way it’s currently done).  I’m leery of #2.  I’m a big fan of #3, but only if it’s done right – and it still leaves the open question regarding what to do with existing legacy claims that have already gone off the track.

Here’s my take: We need education and awareness, but it needs to occur claim by claim, doctor by doctor, via a physician-led peer review model with consistent nurse oversight and follow up, coordinated with the PBM to exchange data on the front end and back end of the intervention.  This entire process needs to be supported by compliance advice and legal counsel to ensure that, if a physician refuses to participate, the appropriate rules are followed in each jurisdiction to attempt to fix the claim (and, we would argue, give the patient a fighting shot at a functional and enjoyable life, even if it’s not 100% pain free). 

If your solution to this problem doesn’t look like that, our view is that you’re missing something. 

Michael
On Twitter @PRIUM1

What Happened? Follow the Money.

The stated philosophy of the workers’ compensation system, while the words vary from state to state and program to program, is to expeditiously return the injured worker back to the workplace.  Among my many observations of the work comp space thus far:  nearly every economic incentive that exists within the “system” today runs counter to the philosophical goal of returning the injured worker to work.  Doctors have clear economic incentives to over-treat.  Attorneys have clear economic incentives to create the perception of disability and, in many cases, prolong litigation matters that should otherwise be settled.  And as Richard Victor of WCRI has adroitly pointed out, the injured employee has economic incentives to prolong lost time – there may not be a job to which the employee can return. 

Like most social and political issues through the ages, many of the problems inherent in the work comp system are a result of rational economic behavior.  Given the incentives that exist, it’s little wonder we find ourselves in our current state.  Doesn’t make it right, but it does make it logical. 

I don’t have a clear view on how to fix the medical/legal aspect of work comp claims management – I’ll defer to the likes of David DePaolo on those issues (David’s blog, by the way, is an absolutely essential tool for ramping up and staying informed).   

I do have a view on the health care provider component of work comp – we must align the economic incentives for care delivery with the desired outcomes of that care (a view, by the way, shared by David and many others in the industry).  Once upon a time, I worked for the management consulting firm founded by a pretty smart guy named Michael Porter (The Monitor Group).  When Porter shifted his attention to the health care space (particularly in his 2006 book “Redefining Health Care”), I studied his views closely.  When he teamed up with Robert Kaplan (his fellow Harvard Business School professor and father of modern cost accounting), I became convinced.

I co-authored an article on this back in my consulting days (“Value Management: Optimizing Service, Quality, and Cost,” Journal for Healthcare Quality, January 2010).  To quote from that article:

“Because of the nature of services provided in the healthcare industry, our belief is that quality (i.e., clinical outcomes and patient safety) will become the most visible indicator of value.  Health care organizations will not be seen as leaders unless they go beyond what is mandated, and make it an organizational mission to demonstrate value.”

Though it wasn’t published until January of 2010, we actually wrote the paper almost three years ago.  Still so much work to do.

Michael
On Twitter @PRIUM1

Texas Closed Formulary: So Far, So Good... But What About the Legacy Claims?

Warning: anecdotal evidence only contained in this post.  I’m as data-driven a professional as you’ll come across, so it pains me a bit to share a thought or two not entirely supported by a spreadsheet, but…

Many of the work comp PBM professionals I talk with on a regular basis have indicated that the new “closed formulary” rules in Texas appear to be stemming the flow of prescription narcotics to newly injured workers.  The number of pre-authorization requests being processed is less than was expected (in some cases, far less than what was expected).  Too early to draw conclusions, but leading indicators point to a potentially disappointing (though not terribly surprising) fact:  the mere adoption of the new rules appears to have altered physician prescribing habits. 

Not that the nature of industrial injuries has changed.  Not that the disposition of the individual patients is different.  Not that new medical evidence has emerged.  No, the state of Texas said, “you have to ask first” and the docs have quietly acquiesced, silently acknowledging that the care being rendered prior to the adoption of the rules was inappropriate. 

So kudos to Texas.  This is a rare example of effective formulation and implementation of public policy to begin addressing a major issue in the work comp space. 

Emphasis in that last sentence should be on the word “begin.” While the new rules appear to be having an effect on new injuries, little attention has been paid to the parts of the new rules addressing legacy claims.  Employers and carriers have to begin addressing those legacy claims no later than March of 2013 in preparation for the application of the closed formulary to those claims starting in September of 2013.  Smart payers won’t wait that long. 

The rules specifically outline a procedure that facilitates payers proactively reaching out to treating providers to discuss these legacy cases, rationalize the pharmaceutical regimen in light of evidence-based guidelines, and document the agreed-upon treatment plan to ensure no interruption of therapy in September of 2013.  Given the number of claimants in Texas currently being prescribed N drugs, I think that NOW is the time to start addressing those claims.

Look for a forthcoming white paper on this topic from my colleague and co-blogger, Mark Pew. 

- Michael
On Twitter @PRIUM1