Sky Falling? Coventry’s View on Opioids.

Their answer?  Well, maybe. 

I commend Coventry for their seemingly thorough data analysis and for their very rational advice regarding solutions: “the soundest approach seems to use common sense.”  With that, I agree wholeheartedly.  They also do a decent job of providing guidance on how certain stakeholders should deal with opioids, from leveraging evidence-based guidelines to ensuring that PBMs and nurse case managers are properly focused on the issue.

I was surprised, however, by the results of some of the analysis and by the tone struck by the authors in some areas of the report.  For instance:

The authors state that “despite media headlines, it’s important to remember that just because a pain reliever is an opioid doesn’t automatically mean its use is inappropriate.  Increasing opioid use is part of an overall increase in prescription drug utilization in society.”  All true.  But is this the tone we want to strike in our industry when it comes to dealing with the issue? The authors quickly attempt to rebalance themselves by stating, “regardless, the issues are real, and clarity is needed.”  Well, glad we’re back on the same page.     

Later, the report states, “while not conclusive, the examination of diagnoses using bill review data and claim injury information does suggest that many of the claimants receiving Schedule II opioid drugs may be suffering from injuries that warrant at least some use of [opioid pain relievers].”  Suggesting that many of these claimants need these drugs flies in the face of the evidence-based guidelines quoted elsewhere in the report and provides for an incongruent and inconsistent message.  If it’s not conclusive, why suggest it?  Candidly, I’d love to see the data.  This is not what we’re seeing when we conduct triages of our customer’s claims.  Rather, we're seeing that about 75% of the opioids being prescribed are not medically necessary according to the guidelines.     

And their “drill down” on Fentanyl suggests that a “measurable number of claimants did have cancer diagnoses; therefore, Fentanyl use was more likely to be appropriate.”  I’m filled with questions on this one.  What constitutes a “measurable number”?  And are they suggesting that Fentanyl was more likely appropriate for just that “measurable number”?  And what kind of cancer diagnoses are we talking about?  Stage IV lymphoma?  Or Stage 1 prostate cancer (with which, I bet, a “measurable number” of middle aged males with bad backs have been diagnosed)?  If you’re going to talk about Fentanyl and even passingly suggest where/when it might be appropriate in work comp, you have to come with more than “a measurable number.”  (Though I'll give them credit for highlighting the obvious question of compensability). 

Perhaps I’ve seen too much of the dark side of opioid use.  It’s what we do here, day in and day out.  I commend Coventry for taking such a data-driven approach and for trying to present a balanced picture of the issue. 

I’m simply one who believes that if we’re going to make meaningful progress towards ridding work comp of medically unnecessary prescription narcotics, all of us must choose our words very, very carefully.

Michael
On Twitter @PRIUM1

Guiding Principles for Prescription Drug Management

I’ve advised insurers, employers, and TPAs to “get to work on a market-driven solution” for prescription drug management (both in person and in this blog on numerous occasions).  While Mark and I strive to ensure Evidence Based does not become a venue through which we promote PRIUM’s services, we have learned a few things from our experiences on the thousands of claims in which PRIUM has intervened.  While our program is built around these guiding principles, Mark and I share a broader desire to move the industry in the right direction.  So whether you use us or not, these are the hallmarks of a strong prescription drug utilization management program that results in positive clinical and financial outcomes:

1)      Discussion: This should be peer-to-peer.  Perhaps having pharmacists and/or nurses engage in initial discussion works from time to time, but the most reliable, replicable and appropriate physician outreach is one conducted by a peer.  The conversation should be collegial and it should be grounded in evidence-based medicine (with specific emphasis on jurisdictionally-specific guidelines). 

2)      Enforcement: While your PBM might be taking the lead on your drug utilization management program, this won’t always be the case (and even if they do, it might not always be effective).  Integrating the results of the peer-to-peer conversation into the point of sale system is critical (blocks, exclusions, prior-auths, etc.)

3)      Oversight: This step should also be clinician-led.  We’ve found that the best approach is to employ nurses with work comp case management experience who are dedicated to doing everything possible to ensure implementation of treatment changes agreed upon in the peer-to-peer conversation.  This oversight has to be consistent, it must rely on the peer review as a roadmap, and it must be focused on facilitating the weaning and discontinuation of medically unnecessary drugs.

4)      Education: Foundational to any strong drug utilization management program is education that is focused on the prescriber, the patient, and the adjuster/claims manager.  Weaning patients off of highly addictive prescription narcotics is clinically challenging.  Preventing the patient from becoming addicted in the first place is equally challenging.  Education is the key to helping all parties understand what the process looks like and where the potential pitfalls exist.  

Each of these steps is important unto itself, but the integration and coordination amongst these guiding principles is the real secret to success.  And when these attempts at collegial interaction don’t yield results, it’s time to use “the hammer.”  While the handshake should be preferred over the hammer (which varies by jurisdiction), don’t be afraid to deploy utilization review, direction of care, court motions, IME, dispute resolution, etc. to ensure that medically unnecessary drugs disappear and don’t come back.

This is a rare instance in health care where clinical and financial incentives completely align.  Make sure you're using every tool at your disposal to get the outcomes you need (and the outcomes your claimants need). 

Michael  
On Twitter @PRIUM1

Bad outcomes, Bad consequences in Texas

On Tuesday Feb 21 I listed one of the ways for dealing with treating physicians that do not "get it" was to Pursue Legally.  Coincidentally, two days after that the Texas Medical Board announced the discipline of 58 physicians.  The most prominent was the revocation of the medical license for Rosemary Ann Stogre in Houston, who allegedly continued to prescribe controlled substances after surrendering her DEA and DPS privileges and one of her patients died as a result of misuse of prescription drugs (some of the drugs were prescribed by Dr. Stogre).  The (formerly Doctor) Stogre did not respond to the complaint, therefore the allegations are deemed true.

Overall, a large number of those were sanctioned for inappropriate prescribing behaviors or poor pain management practices:

• 2 of the 6 who voluntarily surrendered their licenses
• 17 of the 25 who had quality of care issues
• 1 of the 2 who were issued a cease and desist order from practicing medicine
• 1 of the 2 who were engaged in criminal behavior

I know all states have a process for review, but they only know of physicians who do not follow best practices and/or have poor outcomes when reported.  There must be accountability, and we all must be the sentinels.

In this together – Mark

On Twitter @PRIUM1

Moving patients from drugs to independence

Last week I visited two facilities in California that are successfully doing what we all want done – transitioning injured workers to non-narcotic methods to manage their chronic pain.  I often hear a cynicism regarding effectiveness/cost as “pain management clinics” have accumulated a bad reputation over time for high expense and high recidivism rate.   After detailed in-person discussions and evaluation of case studies, I believe these two have shown success that break the mold:

• Savvy Health Solutions: The F.I.T. Academy (Functional Intervention Training) program works outside of the medical model to restore function by treating the whole person in a fitness environment.  They challenge the physical, intellectual and motivational components of the person, with an ultimate goal of independence and personal responsibility and maximized ADL’s.  As long as the injured worker doesn’t need medical oversight during the detox process, they will work in conjunction with the treating physician and employer and claims adjuster to define the most appropriate path to the goal.  Founder Paul Wright says it takes patience (approximately 40 sessions over 4-5 months), but he showed me several pictorial examples of “before” and “after” (even meeting one of their patients) and their data that showed a 69% decrease in WC claim costs and 65% reduction in the length of open claims.
• Pacifica Pain Management Services: Dr. Gary Mills has created a comprehensive non-narcotic pain management program that lessens pain by emphasizing pain syndrome management and reducing drugs, depression and dysfunction.  In some cases an in-patient detox with full medical supervision is required, but the residential inpatient approach (with a 60% individual / 40% group model and 2:1 staff to patient ratio) allows their team of MD, PhD, PT and personal trainers to recalibrate how the patient deals with pain through a full daily schedule for 4-6 weeks.  Interestingly, they mandate a 1-year contract of continuous engagement with the treating physician and claims adjuster (and visits every 2 weeks) to be the continued conscience.  Their outcomes (69-72% stay “clean” when they fully exit the program) exceed the industry (typical goal of 50%).

While these two facilities are focused on northern California, there are others (like Solutions Recovery in Las Vegas, whom I’ve also vetted) that likewise have solid methods and positive results.  The key I have found is patience – while guidelines typically suggest 6-8 weeks / 180 hours for a FRP (functional restoration program), that likely isn’t enough time to enact lifetime changes.

When judging a pain management or functional restoration program, the first questions must be:

1. Show me examples where you’ve been successful
2. Show me your recidivism rate

Without demonstrated success of transitioning patients to a lifetime of managing their chronic pain without narcotics, you will likely be throwing your money away.

One of my projects this year is to identify centers of excellence because our corporate goal (and my personal goal) is to get patients off harmful drugs, whatever the method.  So if you have suggestions of other successful facilities I would be pleased to hear from you.

In this together – Mark

Florida Repackaged Drugs: An Illogical Amendment Arises

Thanks to Health Regulation Committee Chair Rene Garcia (R-Hialeah), things are looking a lot brighter for Automated Healthcare Solutions in Florida.  Good news for ACHS, however, is bad news for the work comp system in the state. 

According to workcompcentral today, Garcia has offered an amendment to SB 668 to remove (yes, remove) the proposed price cap on repackaged drugs and replace it with a $15 rebate to the insurer/employer on any repackaged drug priced at greater than $25. 

The folks at workcompcentral are real reporters striving for journalistic integrity, so they simply stated, as a matter of fact, that Mr. Garcia serves as vice president of community relations for Dade Medical College.  I’m not a reporter, so I’ll go ahead and point out the absolutely glaring conflict of interest that appears to exist here.  A state senator, who (when he’s not in Tallahassee) represents a school that feeds professionals into physicians’ offices, is suggesting an economically and clinically incoherent and illogical amendment to a bill that would have saved the Florida work comp system $6.2 million, but given this amendment, would now have no hope of doing so.  In fact, NCCI (correctly, we think) points out that system costs will likely rise should the bill be passed with the amendment included. 

Mr. Garcia’s response: “NCCI is assuming that the members (of the medical community) are going to defraud the system.  That is just absurd, and I take offense to that.” 

Most of these docs aren’t trying to “defraud the system,” Mr. Garcia.  Most of them are just trying to make a buck.  And given the current rules, I don’t blame them for exploiting the opportunity to make up their own NDC code, slap a 300% surcharge on a medication, and bill it to the insurer.  They’re currently allowed to do so.  This isn’t fraud.  It’s just not economically and clinically sustainable and it’s a practice that has to cease. 

Bottom-line: The fight to restore the original version of SB 668 is an important one.  The likes of Mr. Garcia cannot be allowed to carry the day. 

Michael
On Twitter @PRIUM1

To Defend or Settle

One of the interesting sessions I attended at the PARMA (Public Agency Risk Managers Association) conference in Monterey CA last week was “To Defend or to Settle, That is the Question”.  It was presented by Terry Cassidy (shareholder at the Porter Scott firm), Jack Blyskal and Doug Taylor of CSAC, excess insurance authority JPA.  While their presentation was focused primarily on Liability claims, I believe the following points are pertinent to Work Comp as well:

• Attorney fees (for both plaintiff and defense) can quickly exceed the true value of the claim
• An assessment should be performed early whether settlement (indemnity and/or medical) is the goal
• Expectations are often not set properly due to unrealistic initial demands by the plaintiff and/or the defense perspective that an early offer is a sign of weakness
• Chicken or Egg: Does defense wait for an offer that can provide enough information for rebuttal or proactively make an offer based on the merits of the case?  There was a lot of dialogue on this subject, both on the panel and from the audience, and no definitive plan as the right answer is always unique to each individual situation
• Mediation is a good option if it is a facilitated negotiation and unbiased / objective (sometimes finding one without a history of preference is difficult), but a direct route should be primary and is preferable
• Due diligence on the appropriateness of scope and duration for medical treatment allows better questions to be asked (and a stronger case to be made)

Bottom line is that open and transparent communication is important throughout the process.  I'm not an attorney, but the dialogue I observed during the session seemed to affirm these as helpful insights.  The presentation materials can be found on the PARMA website and allow you to make your own decision.

In this together – Mark

On Twitter @PRIUM1

Ohio’s Formulary Updates: Excellent Progress

I picked on Ohio’s new “lock in” program last month.  While I liked the overall concept, I was concerned that medically unnecessary drugs would still be prescribed and dispensed (albeit by a single physician and a single pharmacy).  And then I saw some of the formulary changes BWC has made (effective February 1).  Some highlights:

• Morphine sulfate will be the only sustained release opiate eligible for reimbursement as an initial sustained release opiate (i.e., don’t even try to jump right to Oxycontin or Fentanyl – BWC won’t pay for it).
• Fentanyl patches won’t be reimbursed if combined with another long acting opiate.
• Unless there is a documented treatment failure or allergy to MS CR tablets and Oxycontin tablets, Fentanyl patches will only be approved for claims when the injured worker cannot swallow or absorb oral products.

While there’s still work to be done, this is a move in the right direction to clean up Ohio’s work comp prescription drug issue.  To Stephen Buehrer (Administrator/CEO of BWC) and John Hanna (Pharmacy Director of BWC), I say well done.  To work comp professionals in other, non-monopolistic states, I say (as I’ve said before) don’t wait for your state legislature; get to work on a market-driven solution.

Michael
On Twitter @PRIUM1

Prescribing physicians who do not “get it”

As mentioned yesterday, according to CWCI’s research, 10% of the physicians in California that prescribed Schedule II drugs accounted for nearly 80% of all prescriptions in 2011.  Take that 10% and add in those that dispense from their office (where the treating physician actually has a financial interest to maintain and even grow pill counts) and physicians who are not interested in other people’s opinion.  That leaves about 65% of physicians who are willing to make changes to an inappropriate drug regimen based on Evidence Based Medicine (EBM) and a collegial dialogue with a peer (this is the rate since 2010 in which our reviewing physician can reach agreement with a treating physician on changes).

So the struggle is with the approximately 35% of treating physicians who are not interested in cooperation (whatever their motivation).  I’ve heard of a variety of strategies:

• Force thru Utilization Review: If the treating physician will not cooperate in a collegial, voluntary manner then enforce UR at the pharmacy Point-of-Sale (POS) and do not allow inappropriate drugs to be dispensed (or when third-party billed, deny payment based on UR).  This puts the treating physician and patient on notice they will need to appeal and prove why the drugs are appropriate.
• Depose the doctor: Under oath, ask the treating physician for their clinical rationale for continued use of drugs that EBM and peer review view as inappropriate.  Assuming recommendations have already been rendered utilizing EBM, science should trump “because it helps the patient” without objective proof that the patient is getting better or has truly reached Maximum Medical Improvement (MMI).
• Change the contract: The State Compensation Insurance Fund (SCIF) in 2011 modified their MPN contracts to require a physician to limit prescribing opioids for no more than 60 days.  This is very similar to Washington state requirements that require a "second opinion" on aggregate dosage exceeding 120mg MED, and the Texas Closed Formulary that requires preauthorization of an ODG "N" drug.  However it is implemented, requiring a "deep breath" before starting down the path of highly addictive drugs is common sense.
• Pursue legally: There are currently attempts underway to pursue legal and malpractice action against physicians who truly practice bad (and dangerous) medicine in California.  Interestingly, an article this morning in workcompcentral (requires subscription) documents a Chicago physician, Dr. Paul H. Volkman, who has been sentenced in Ohio to 4 life terms in prison because of the overdose deaths of four of his patients between 2003 and 2005.  A representative of the Texas Medical Association mentioned three weeks ago that "quality of care" issues should be reported to the TMA for action against the physician.  Bad outcomes should trigger bad consequences.

There are other, creative, methods being used in California (and every other jurisdiction) to address these “bad actors”.  As government leaders are prone to say in difficult circumstances, “all options are on the table”, and to me the only bad idea is the one that has been tried and failed.

In this together – Mark

On Twitter @PRIUM1

The Work Comp world according to California

I was in California last week as I am often.  After meetings in Calabasas, Burbank, San Mateo and Napa in addition to attending the PARMA (Public Agency Risk Managers Association) conference in Monterey, I found several interesting things:

• Good work with reduced resources: Cuts last year in California reduced a $25.4B state budget deficit to $9.6B with an ongoing $10B operational shortfall.  Budget cuts, now and in the future, mean less resources for all aspects of state, county and local government, including Work Comp.  The effect of resource reduction was apparent in discussions at PARMA, but it was also obvious that everyone is trying their best to be productive (and creative) with what they have.  Every single dollar counts, in expense and savings, and every decision is strategic.
• Prescription drug over-utilization dominates conversation: While Work Comp costs are complex and have many contributors, the high use of prescription drugs remains a key component.  But I also have seen this becoming less of an academic exercise (at this point, everybody acknowledges it is a problem) and more of a conscious action plan.  From requiring pre-authorization by contract … to deposition of treating physicians … to the use of a Pharmacy Benefit Network (PBN) … to physician engagement via programs like our QMI Program … status quo is no longer the standard.
• Physicians are trying: There are physicians with bad outcomes and seemingly bad intentions (in March 2011 the California Workers’ Compensation Institute (CWCI) reported that 10% of physicians that prescribe Schedule II drugs account for nearly 80% of all prescriptions).  However, the majority of physicians are trying hard to do the right thing and in some cases not fully educated on the negative long-term repercussions to these drugs.  For those that are inattentive or oblivious, an epiphany by engagement is critical.  For the “bad actors”, forcing the issue through UR is an imperative.
• There is success in removing patients from drugs: While the general assumption is that removing patients from drugs is almost an unattainable goal, there are clinics with unique approaches and solid outcomes that are having a positive impact.  I met with two such facilities and will discuss them further this week.

I look forward to diving into more detail this week.

In this together – Mark

On Twitter @PRIUM1

The Hartford: Paulson Advocates a Break Up

Remember last week when I commented on The Hartford’s earnings (which took a major blow specifically from the work comp line)?  I conjectured that poor earnings and a promise from the CEO to “evaluate the business portfolio” portended change…

I learned earlier this week that John Paulson, billionaire hedge fund manager and largest individual shareholder in The Hartford, has advocated just that.   On the February 8 investor conference call, Paulson suggested that CEO Liam McGree do “something drastic” to ensure the future success of the organization.  His view was based, at least in part, on a report from Goldman Sachs suggesting that significant shareholder value might be created by splitting the life and P&C lines into two different entities

McGee claims to have analyzed such a scenario and while he acknowledged the potential benefits, he notes that “the split would not create the kind of shareholder value that the Goldman Sachs report suggests.”  From my perspective, the challenges associated with such a split would include, but would not be limited to, the redundancy of back office administrative functions, the culture shock, and the loss of incentive for leveraging cross-sell opportunities. 

But what did the stock do in early afternoon trading on February 8^th (as news of Paulson’s view came to light)?  Up 9.3%.  Yikes.   

Most importantly, I think this is the first of many “management vs. shareholder” fights that we’ll see in the health, life, and P&C insurance business over the next 3 to 5 years.  In light of extreme uncertainty, the right strategy for maximizing shareholder value is, at best, unclear... and, at worst, unattainable.   

Michael
On Twitter @PRIUM1

Georgia Takes a Giant Step… Backwards

Georgia House Bill 971, filed on Thursday of last week, does not include the authority for the State Board of Workers’ Compensation to implement medical treatment guidelines.  Any guesses as to who opposed the inclusion of such language?  That’s right!  The physicians; specifically in this case, the Medical Association of Georgia (MAG). 

Clearly, citizens of this great state (PRIUM is located just outside of Atlanta) possess bodies that function differently or somehow respond differently to treatment of injury versus those that live in, say, California, Florida, Hawaii, Kansas, Massachusetts, Missouri, Nevada, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, Texas, Utah, Vermont, and West Virginia (all states that have, to one extent or another, adopted the Work Loss Data Institute’s Official Disability Guidelines as medical treatment guidelines, just as an example.)

The rationale of the physician community?  Georgia has fared better than some states in controlling work comp medical costs.  Congratulations.  That’s like not hiring a crossing guard at one intersection because fewer kids get hit by cars at that particular intersection than in most of the other intersections in town.  There’s still a major public health problem here – and it needs to be addressed.  Just because Georgia does a little better than its neighbors is no excuse to ignore the issue.    

Good doctors need not fear the adoption of treatment guidelines.  It’s a shame when the physician lobby goes out of its way to protect the few among them that benefit from playing the fee-for-service game by providing care that isn’t medically necessary.  

Michael

On Twitter @PRIUM1

Work Comp and Group Health: Lessons from Emory University’s Healthcare Forum

This past Friday, Emory University’s Goizueta Business School hosted its annual Healthcare Forum.  As a graduate of the MBA program there, I’m sometimes invited back to participate in a panel discussion during the event.  This year, I was on a panel entitled “Achieving Financial Objectives” and the discussion focused on the sustainability of the health care financing structure we currently have in place (guess what... it's not sustainable).  The panel was a mix of management consultants, entrepreneurs, and investment bankers – and I thought it was an informative and lively discussion. 

Two insights, in particular, have stuck with me from the discussion:

1)      I know few of us are satisfied with the current state of work comp medical management, but there are some things that our little niche does right.  When I spoke of evidence-based guidelines being presumptively correct and that this was supported, by statute, in certain jurisdictions – well, this got the attention of many of the attendees.  While evidence may be lacking in several areas of health care diagnosis and treatment, physical and occupational medicine is blessed to have ACOEM, ODG, MTUS, and other jurisdictionally-specific sets of guidelines.  We have a long way to go (see Arizona’s battle over the adoption of such guidelines), but we’re headed in the right direction. 

2)      I was surprised at the lack of clarity around the implementation of health care reform.  The investments being made by large providers (hospital systems and large physician groups) as well as the health insurance sector are being made in the context of extreme uncertainty.  I have a better appreciation for the conundrum that most payer CEOs face: hold back chips and wait for the air to clear, running the risk of being late to the game… or go “all in” now and hope it’s the right strategy.  Billions of dollars and lots of “covered lives” hang in the balance.  Tricky times, indeed.

Besides the great panel discussions, we were also treated to an overview of IBM’s Watson technology (of Jeopardy fame) and its potential application in the health care space.  Fascinating presentation.

And we also heard an update from Dr. Richard Wild, Chief Medical Officer for the Atlanta Regional Office of CMS.  He offered an overview of the CMS Value Based Purchasing initiative.  Even the hardcore conservatives in the room had to admit that the strategy appears promising (though implementation may prove increasingly difficult as the program expands).

Michael
On Twitter @PRIUM1

Generation Rx

I was at a conference in Austin last week and one of the panelists, Stuart Colburn (attorney at Downs and Stanford, P.C.), mentioned the concept of “Generation Rx”.  I have obviously heard of Gen-X and Gen-Y, but not Gen-Rx and it piqued my interest.  For those of us concerned about our country’s significant issue with prescription drug over-utilization, the term is likely self-defining.  We are raising a generation that look at prescription drugs (theirs or others) as a legitimate solution for their problems, and for those wanting to escape reality as a cheaper and more accessible alternative (or in addition) to illicit drugs and alcohol.  Some interesting tidbits:

• The “Vegas Cocktail” is a combination of Soma/Carisoprodol and Hydrocodone/Acetaminophen (Vicodin).  The “Soma Coma” is a combination of Soma and Codeine.  Both produce a euphoric effect, are addictive, and the combination can cost less than $100 per month.  The US Department of Justice has a nice overview which states 2,276,000 U.S. residents aged 12 and older used Soma non-medically at least once in their lifetime.  These combinations of drugs are in our “trigger list” for when a clinical evaluation is appropriate.
• A “Pharm Party” is where people get together and the price of admission is a bottle of prescription drugs, which are mixed in a bowl and randomly ingested by the participants.  There is some dispute how prevalent this is or even if it’s a media invention, but a 2006 Monitoring the Future study shows that prescription drug use among teenagers is second only to marijuana and is second to none among 12- and 13- year olds (think about that for a moment).  In addition, Partnership for a Drug-Free America found that 62% of teenagers say that prescription pain relievers are easy to get from their parent’s medicine cabinet.   These and other sobering statistics can be found at the Adolescent Substance Abuse Knowledge Base.
• The Ohio State University School of Pharmacy feels so strongly about the issue that they’ve consolidated resources on prescription drug abuse by Generation Rx.

This reinforces the fact that our issue in Work Comp is just a microcosm of the U.S. society in general (which is why the CDC labels it an epidemic with 14,800 overdose deaths in 2008 from prescription painkillers), and one cannot be fixed without the other.  It is also convicting that responsible adults need to better manage (i.e. protect) their legitimate uses of prescription drugs to reduce the number of new entrants to Generation Rx.

In this together – Mark

On Twitter @PRIUM1

Evidence Based Medicine Guidelines for Work Comp

The active use of Evidence Based Medicine (EBM) within Workers’ Compensation is less than a decade old.  While there have long been research and studies and scientific evidence available for when treatments should / should not be used, in my opinion there were two triggering events to bring this into the forefront:

• California SB 899 in 2004 that changed the “presumption of correctness” from the treating physician to American College of Occupational and Environmental Medicine (ACOEM) as the standard of care (and since then the custom-written MTUS guidelines were added)
• Texas HB 7 in 2005 that set the stage for establishing Official Disability Guidelines (ODG) in 2007 as the standard of care

In both cases, the statutes and subsequent rules were required because Work Comp costs were dramatically increasing each year (and driving employers away) and Payers had very little leverage in contesting the medical appropriateness of care since the treating physician’s opinion was irrefutable.  The advent of EBM and scientifically-based standards of care at least made for a level playing field and slowed the growth of Work Comp costs (although there are so many variables that continued cost escalation was inevitable).  Giving carte blanche to anyone, including physicians, without some form of reconciliation to objective best practices do not make sense.

Currently there are:

• 14 states that use ODG, ACOEM, or a combination of both (9 use ODG exclusively)
• 21 states currently have no guidelines (although 10 are considering them)
• 16 states who crafted guidelines locally (6 use excerpts from ODG while Louisiana still seems to be fighting over the Supreme Court decision on the final composition)

An interesting case study about the process of “creating” guidelines is Arizona.  Michael blogged about their approach on Feb 1, but an interesting thing happened yesterday on the way to the victory party.  HB 2365 proposed a change of “presumption in correctness” be changed to nationally recognized guidelines by 07/01/14 and if none explicitly selected then ODG or ACOEM would be the default.  There are two very good summaries of this published today, an article by Greg Jones of workcompcentral (requires a subscription) and a blogpost by David DePaolo, so I won’t go into the details here.  Suffice to say that when you have so many constituents and stakeholders who have a myriad of competing incentives (and most are not aligned with the Work Comp goal of returning a claimant to work and health ASAP), it is almost impossible to reach consensus.  In Arizona’s case, competing forces won and HB 2365 was deferred.

When special interests (with revenue at stake) and politicians (with votes at stake) allow decisions to be made about healthcare without the clinical objectivity of scientific evidence, patients lose.  And especially in the vacuum where no objective standard of care exists, all bets are off.

In this together – Mark

On Twitter @PRIUM1

Ohio’s New Rules: Clarification

Update to my post of 1/31 on Ohio’s new “lock in” program:  John Hanna, Pharmacy Director for Ohio BWC, was kind enough to reach out to me for a discussion on the new rules.  I always appreciate the opportunity to connect with leaders who are integrally involved in the formation and implementation of new statutes and rules.  John was kind enough to provide two points of clarification on my original post. 

1)      The $15 million in cost savings mentioned in my post is a result of Ohio’s new formulary rules for work comp claimants and not a result of the “lock in” program.  Further, John clarified that the new formulary rules are based on relatedness to the work comp injury (as opposed to other jurisdictions, like Texas, which have recently adopted new work comp formularies based on medical necessity).

2)      I suggested in my post that the physicians participating in the “lock in” program were “pre-qualified.”  While this is true in a strict sense, it’s important to point out that “any willing provider” in the state of Ohio may participate in the program and that BWC has not created any sort of network or panel of physicians for the “lock in” program. 

The main point of my post, though, was to point out that these new rules are, in my view, necessary, but not sufficient, to fix the issue of over-utilization of prescription narcotics in the state of Ohio.  While I appreciate Mr. Hanna’s clarifications, I stand by that view.

Michael
On Twitter @PRIUM1

The Hartford: 2011 Financial Results

I’ll leave the analysis of the full results to others, but the work comp portion of The Hartford’s 2011 financial performance caught my eye. 

Of the 61% drop in net income from ’10 to ’11, The Hartford attributed a material portion of that to reserve fund strengthening costs, including $161 million in work comp (just for the 4^th quarter).  For all other P&C lines during the same time period, The Hartford actually released reserves of $52 million.  Ouch. 

And the commentary from President and CEO Liam McGee?  “…we are evaluating our strategy and business portfolio for opportunities to deliver greater value for shareholders.” 

Once upon a time, I was a management consultant and provided strategic advisory services and financial advice to Fortune 100 companies (a couple of them direct competitors of The Hartford).  I can’t tell you what’s next, but when a CEO follows up on a strategic business unit loss of that magnitude with a comment like “we’re evaluating our strategy and business portfolio”… well, change is coming. 

Michael
On Twitter @PRIUM1

Prescription Drugs Best Practices – Federal Perspective

The Federal government has been very outspoken on clinical best practices for how to properly prescribe and manage prescription drugs for chronic pain.  For example:

• The Food and Drug Administration Amendments Act of 2007 gave FDA the authority to require a Risk Evaluation and Mitigation Strategy (REMS) from manufacturers to ensure that the benefits of a drug or biological product outweigh its risks.
• A component of REMS is the FDA’s “Blueprint for Prescribing Continuing Education Program” whose first draft was published on 10/25/11.  The intended audience is physicians who prescribe extended-release and long-acting opioids, and its content expounds upon what the FDA considers to be “best practices.”  While the FDA has not announced its timeframe for the comment period, it is obvious that the evolving REMS strategy is a priority.  As a side note, Dr. Suzanne Novak opined to workcompcentral (subscription required) on 12/15/11 that this blueprint should be provided as mandated CME courses.
• In 2011 President Obama launched a national drug control strategy that includes a specific “Epidemic: Responding to America’s Prescription Drug Abuse Crisis”  The four cornerstones are education, tracking and monitoring, proper medication disposal, and enforcement.   One key tactic is to build Prescription Drug Monitoring Program (PDMP) interoperability across state lines (for a good overview visit The Alliance of States with Prescription Monitoring Programs).
• While not new, the U.S. Department of Health and Human Services manages a National Guideline Clearinghouse that consolidates evidence-based clinical practice guidelines.

Tomorrow I will focus on specific guidelines used in Work Comp.

In this together – Mark

On Twitter @PRIUM1

Accident Fund Holdings, Inc. Launches Narcotics Program to Protect Injured Workers from Drugs Used to Manage Chronic Pain

Just a quick note to get the word out on a company doing the right thing.  Today's press release was interesting in and of itself, though I'm anxious to see the results of the study they did with Johns Hopkins on the use of opioids to manage chronic pain.  More to come on this, I'm sure...

Michael

Best Practices for Managing Chronic Pain with Prescription Drugs

This week I will be focused on best practices for managing chronic pain with prescription drugs.  There is no absence of data identifying the issue of prescription drug over-utilization, in society and in microcosm the Workers’ Compensation system.  And likewise there are many resources that document when and how prescription drugs should be used.

I do not know chronic pain.  I definitely know episodic pain: countless sprained ankles from sports, broken ankle and wrist, toe surgery.  I understand first-hand how the use of prescription drugs can calm the body (and my nerves) down so the natural healing process of the body can commence.  Whatever pain I’ve had, I know will go away after a certain point.  What I have not known, and to be honest cannot fully understand, is pain that never goes away from the time you wake up until the time you attempt to go to sleep with no end to the cycle in the foreseeable future.  But I know chronic pain is real, and that people have chronic pain, and that it must be managed by the sufferer in a way that facilitates quality of life.  I am not a doctor, but as an observer I know this to be true.

And in my role as an observer, I am certain that the following is also true from talking to people a lot smarter than me:

1. The level of chronic pain cannot be totally defined based on subjective means like what we all know as the VAS (visual analog scale) of 1-10.  While the patient’s self-reporting of pain is important, objectively identifying and dealing with the source of the pain is even more important.
2. The treatment of pain must be based on scientific evidence.  While the personal experience (education, practice) of treating physicians is certainly key, comparing that to best practices and the scientific evidence of what works (and what doesn’t) is equally important.
3. Without demonstrated functional improvement over time, the method for managing the pain is likely flawed and a reassessment is required.
4. The majority of treating physicians do the right things and their patients get better or at least can maintain a level of function.  We typically review the doctors who are over-treating or are over their head or appear focused on incentives other than the patient’s health (per the CWCI March 2011 report, the top 3% prescribers in California accounted for 54% of all Schedule II prescriptions and 62% of opioid morphine equivalents), but I know the majority are doing their best.

Tomorrow I will discuss some of the clinical sources of best practices.

In this together - Mark

On Twitter @PRIUM1

PRIUM’s View on Repackaged Drugs

I had three different conversations today, two with customers and one with a reporter, that all went relatively well… until the issue of repackaged drugs came up.  Many have pointed out the ills of this rather despicable practice.  Excess expense, perverse economic incentives, inappropriate utilization… the list goes on.

The last NCCI prescription drug update from August of 2011 included some sobering statistics:

• Physician-dispensed medications make up 28% of all prescription drug spend in work comp
• In three states (FL, CA, and GA), greater than 40% of the dollar value of work comp medications comes from a physician’s office (with MD, PA, and IL not far behind – all in the 30% range)
• Perhaps most galling, the mix of drugs is shifting.  In 2005, the most common physician-dispensed drug in Georgia was ibuprofen (avg. script = $13).  In 2009, it was meloxicam (avg. script = $199). 

One of the first steps in PRIUM’s process is a physician-led intervention that focuses on a collegial, evidence-based conversation between two peers.  How do you think that conversation goes when the prescriber is looking at a material economic loss if he complies with the guidelines-driven, evidence-based treatment plan we present? 

So what to do?  Three actions we can take:

1)      Get aggressive on these claims.  Leverage every possible statute, rule, tool, mechanism, and method at your disposal.  We brought on in-house legal counsel here at PRIUM to help us advise clients on how to fight the good fight, jurisdiction by jurisdiction.  When going to battle with a dispensing doc, you have the moral (and sometimes legal) high ground.  Use it.

2)      Join with me in following Joe Paduda’s lead; email Florida legislators in support of SB668 which eliminates the economic incentive for doctors to dispense drugs from their offices.  The link to Joe’s post with specific instructions is here.   

3)      For larger payers/employers, read the Florida bill and get active in the state legislatures where you do business.  Ridding the world of the practice itself may not be necessary – let’s just take the financial incentive away.   

I recognize that when we squeeze the balloon on one end (physician dispensing), we often end up simply shifting the fee-for-service engine that is our modern health care system in another direction… but this particular issue is worth the stand we all need to take.

Michael
On Twitter @PRIUM1

National Rx Abuse Summit

The inaugural National Rx Abuse Summit is being held April 10-12 in Orlando, FL.  The conference is bringing together stakeholders from business, government, and law enforcement to engage in dialog around this important issue.  To quote from the materials available online, the goal is “to foster better understanding and cooperation among all stakeholders in the prescription drug abuse arena – state and national leaders, law enforcement officials, medical professionals, community advocates, treatment experts, educators, insurance and benefits managers, private industry leaders, and others – who are finding success in battling this nationwide epidemic, and how that cooperation can lead to successful outcomes.”

While work comp isn’t the focus of the conference, I’m certain many from the industry will attend.  Mark Walls has promoted the conference on the LinkedIn Work Comp Analysis group. 

From my interactions with the organizers, it’s clear they’re being very careful about participation on the part of pharmaceutical companies.  In order to make progress on this issue, the moral high ground is critical – I was happy to see the stringent guidelines associated with sponsorships and exhibiting.

Full disclosure – I’ll be presenting in one of the breakout sessions on the “Human Resources” track entitled “The Financial Impact to Employers.”

But don’t let that deter you.  Join us in Orlando anyway.

http://nationalrxdrugabusesummit.org/

Michael
On Twitter @PRIUM1

Arizona: The Simple Path to Controlling Narcotics in Non-Monopolistic States

Arizona House Bill 2365, currently awaiting a hearing in the Banking and Insurance Committee of the Arizona State House, would establish the American College of Occupational and Environmental Medicine Treatment Guidelines (ACOEM, for short) as presumptively correct on issues concerning the extent and scope of medical treatment.  The bill also allows for other evidence-based guidelines to be used if a particular procedure or therapy isn’t covered in ACOEM. 

In several recent posts on new prescription drug rules in monopolistic states like Washington and Ohio, I made mention that payors in other states need to get to work on a market-driven solution.  I’d like to clarify what such a solution might look like.  Arizona presents a potentially solid test case. 

There is a difference between simply recognizing treatment guidelines (like ACOEM, MTUS, or ODG) and establishing those guidelines as presumptively correct via statute.  Arizona is (potentially) following the lead of other states like Texas and California in making it clear to the medical community that the burden of proof for the necessity of treatment that is inconsistent with the guidelines rests with the claimant and his physician.  This is a simple, but powerful approach to appropriately controlling the utilization of health care services, including medications.  When evidence-based medicine prevails, both the payor and the claimant win. 

Additionally, this approach allows for market-based mechanisms like utilization review agents, independent medical examiners, pharmacy benefit managers, case managers, and others to take credible, evidence-based, statutorily supported positions on specific treatments for individual claims.  Ultimately, this gives the payers the medical-legal high ground on treatment and payment disputes and, when used properly, prevents egregious, out of control drug regimens.  

AZ House Bill 2365 is a smart first step to eliminating the inappropriate use of prescription narcotics in the Arizona work comp system.  Other states that have not already done so would be wise to follow suit. 

Michael
On Twitter @PRIUM1