A new ruling from Texas adds to the list of states that have found payers liable for a range of opioid-related side effects ranging from addiction to death. In this particular case, the payer was found liable for death benefits in light of the injured worker's death caused by hydrocodone overdose. This adds to recent rulings in several other jurisdictions (e.g., Pennsylvania, Texas, North Carolina - these are the ones I've seen, I believe there are others) in which payers have found themselves on the hook for death benefits due to drug overdose.
Prediction: This is just the beginning. Why? Because we know too much. And our unwillingness (or inability), as an industry, to apply what we know is going to cause a lot of financial pain over the next several years.
We really do know too much. We have sound, evidence-based clinical guidelines. We have peer reviewed studies (many of which are incorporated into the guidelines) that suggest the limited benefits (and significant harm) that results from chronic opioid therapy. We have thought leaders, in both the clinical and business realms, offering a constant drumbeat of warnings that solutions are needed. We have industry conferences devoted entirely to this issue. We have a growing body of regulatory mechanisms intended to help control opioid misuse (e.g., Texas closed formulary rules, new Tennessee UR rules, Washington's guidelines, etc.) We have public health agencies, including the CDC, calling the issue of prescription drug abuse an "epidemic" and a "public health crisis".
I hear various excuses for why payer organizations aren't attacking the problem with greater force. "Look," they say, "this is really complicated... these people are addicted". Or "we don't have sufficient clinical resources"... or "we're pretty sure plaintiff's counsel is going to come at us pretty hard"... or "we're working on it"... or "our PBM has a handle on it".
Enough. There's going to be noise. Deal with it. We're on the right side of this fight. By taking aggressive action, we have the opportunity to improve overall patient health while simultaneously saving money. This is exactly what our health care system needs.
Let's get to work.
Michael
On Twitter @PRIUM1
Friday, May 25, 2012
Thursday, May 24, 2012
Health Wonk Review
Health Wonk Review is up. Thanks to Jaan Sidorov at Disease Management Care Blog for hosting.
Enjoy!
http://diseasemanagementcareblog.blogspot.com/2012/05/health-wonk-review-come-back-well-leave.html
On Twitter @PRIUM1
On Twitter @PRIUM1
Wednesday, May 23, 2012
Attitude Matters: A Case Study
A couple of weeks ago, Bob Wilson at WorkersCompensation.com wrote a piece called "Breaking the Cylce of Entitlement." Apparently, Bob caught a lot of flack from injured workers. Bob claims they missed his point (and I agree). He wrote a second piece in an attempt to clarify.
Last week, I highlighted a study from German researchers suggesting that exercise could be a key to managing chronic pain without the need for prescription opioids. I got feedback on that post similar to what Bob received on his original article. Apparently, the phrase "Grab Your Running Shoes" offended people who don't feel they have the ability to do so.
Two days ago, Bob posted this video. After watching it, I realized we could have skipped all of the articles, the back and forth, the arguing, etc. and just asked people to watch this.
Attitude matters. Don't ever let anyone tell you how the rest of your life is going to play out. Even if you've been injured. Even if you're in pain. Even if your own doctors are telling you it's not going to get better.
Michael
On Twitter @PRIUM1
Last week, I highlighted a study from German researchers suggesting that exercise could be a key to managing chronic pain without the need for prescription opioids. I got feedback on that post similar to what Bob received on his original article. Apparently, the phrase "Grab Your Running Shoes" offended people who don't feel they have the ability to do so.
Two days ago, Bob posted this video. After watching it, I realized we could have skipped all of the articles, the back and forth, the arguing, etc. and just asked people to watch this.
Attitude matters. Don't ever let anyone tell you how the rest of your life is going to play out. Even if you've been injured. Even if you're in pain. Even if your own doctors are telling you it's not going to get better.
Michael
On Twitter @PRIUM1
Monday, May 21, 2012
Age and Opioid Misuse: Probably Not What You Think
Ameritox announced last week the release of a peer-reviewed poster at the annual meeting of the American Pain Society that draws some surprising conclusions about age and opioid misuse. Turns out being older doesn't necessarily make you more responsible.
The study is based on over 700,000 urine drug monitoring samples from chronic pain patients over the age of 50. Notable results:
7.6% had an illicit drug detected (e.g., marijuana, cocaine metabolite, heroin metabolite or PCP)
28.1% had a non-prescribed drug detected (e.g., opiates, benzodiazepines, barbiturates, etc.)
31.8% did not have a prescribed drug detected (e.g., a prescribed pain medication)
45.9% of samples had no abnormality found.
Wow. 54% of the samples had some inconsistency detected.
I've learned from past experience (and from conversations with Dr. Leider, Chief Medical Officer for Ameritox) that one cannot jump to conclusions based on UDM testing alone. Grandpa isn't necessarily selling his Oxycontin just because it didn't show up in his drug screen.
But this study does suggest that equal vigilance is required by the medical community (physicians, payors, caregivers, etc.) in monitoring opioid use among older patients as with younger patients. It would be entirely inappropriate for a physician to forego regular, random drug screening for a chronic pain patient on opioid therapy just because the patient appears old enough to have grandkids.
It's also important to note that even a perfectly implemented drug monitoring program can't fix these issues by itself. A strong UDM program should prompt conversations between prescribers and patients to ensure that the right therapy is being delivered safely and effectively to accomplish the established treatment goals. If nefarious behavior is uncovered, providers need to act judiciously to ensure the patient has an opportunity to get help if needed.
Michael
On Twitter @PRIUM1
The study is based on over 700,000 urine drug monitoring samples from chronic pain patients over the age of 50. Notable results:
Wow. 54% of the samples had some inconsistency detected.
I've learned from past experience (and from conversations with Dr. Leider, Chief Medical Officer for Ameritox) that one cannot jump to conclusions based on UDM testing alone. Grandpa isn't necessarily selling his Oxycontin just because it didn't show up in his drug screen.
But this study does suggest that equal vigilance is required by the medical community (physicians, payors, caregivers, etc.) in monitoring opioid use among older patients as with younger patients. It would be entirely inappropriate for a physician to forego regular, random drug screening for a chronic pain patient on opioid therapy just because the patient appears old enough to have grandkids.
It's also important to note that even a perfectly implemented drug monitoring program can't fix these issues by itself. A strong UDM program should prompt conversations between prescribers and patients to ensure that the right therapy is being delivered safely and effectively to accomplish the established treatment goals. If nefarious behavior is uncovered, providers need to act judiciously to ensure the patient has an opportunity to get help if needed.
Michael
On Twitter @PRIUM1
Friday, May 18, 2012
Pain Management Without Drugs: Grab Your Running Shoes
Interesting study in the journal Pain (here's an article that provides a brief overview).
The basic premise is that while most of us have similar pain thresholds, athletes (specifically, endurance athletes) have developed superior coping mechanisms that help them deal with chronic pain, even while they're at rest. One potential conclusion is that exercise may be a key to dealing with chronic pain, both psychologically and physically. This study caught my eye for both professional and personal reasons - I've been a long distance runner and, more recently, an amateur triathlete (heavy emphasis on "amateur") for many years and I've always felt that the psychological and physical rigor that comes with endurance athletics created benefit outside of the exercise itself.
The study is actually a meta-analysis of 15 studies and was conducted by German researchers at the University of Heidelberg. The authors note: "Athletes are frequently exposed to unpleasant sensory experiences during their daily physical efforts, and high physical and psychological resistances must be overcome during competitions or very exhausting activities. However, athletes are forced to develop efficient pain-coping skills because of their systematic exposure to brief periods of intense pain."
I'll add that there's a side benefit to introducing exercise as a key component of dealing with chronic pain - it may help stem the rise of obesity as one of the most common comorbid conditions related to industrial injury. I'd also hypothesize that it would help with depression as well.
Fewer pills... more exercise... the world would be a better place (and medical care wouldn't be nearly as expensive).
Michael
On Twitter @PRIUM1
The basic premise is that while most of us have similar pain thresholds, athletes (specifically, endurance athletes) have developed superior coping mechanisms that help them deal with chronic pain, even while they're at rest. One potential conclusion is that exercise may be a key to dealing with chronic pain, both psychologically and physically. This study caught my eye for both professional and personal reasons - I've been a long distance runner and, more recently, an amateur triathlete (heavy emphasis on "amateur") for many years and I've always felt that the psychological and physical rigor that comes with endurance athletics created benefit outside of the exercise itself.
The study is actually a meta-analysis of 15 studies and was conducted by German researchers at the University of Heidelberg. The authors note: "Athletes are frequently exposed to unpleasant sensory experiences during their daily physical efforts, and high physical and psychological resistances must be overcome during competitions or very exhausting activities. However, athletes are forced to develop efficient pain-coping skills because of their systematic exposure to brief periods of intense pain."
I'll add that there's a side benefit to introducing exercise as a key component of dealing with chronic pain - it may help stem the rise of obesity as one of the most common comorbid conditions related to industrial injury. I'd also hypothesize that it would help with depression as well.
Fewer pills... more exercise... the world would be a better place (and medical care wouldn't be nearly as expensive).
Michael
On Twitter @PRIUM1
Thursday, May 17, 2012
Connecticut Opioid Protocols: Great Step, Now Let Us Talk to the Docs
The State of Connecticut's Workers' Compensation Commission (WCC) released revised protocols for opioid prescribing. Like several other states, CT goes out of its way to emphasize that "the protocols are not meant to be absolute; there must be room for medical judgment." Granted.
I was pleased to read, though, that the WCC has placed a 90 mg morphine equivalent dosage (MED) per day as the threshold above which opioid treatment should not rise unless there is "measured improvement in function, pain, or work capacity" (which we almost never see - once you get in the 100 mg MED range, we consistently see evidence in medical records of declining function). Most of the literature suggests 120 mg MED as an appropriate threshold, so the more aggressive approach in CT is enlightened.
I also thought it was interesting that the WCC encourages treating physicians to contact the insurer if treatment beyond the protocol is needed. I'm left wondering how nice it would be if the reverse was possible - if the insurer could easily and reliably engage the treating physician to discuss the care of the patient.
In CT, communication between payor and the attending physician where such communication would involve unilateral disclosure or discussion of material information is not allowed.
Payors, however, may request the physician to complete the "Employee Medical & Work Status Form" form or provide progress notes. Copies of this communication, as well as any responses from the physician, must be provided to the injured worker or his/her representative (Payor and Medical Provider Guidelines to Improve the Coordination of Medical Services, 2010).
But there is no allowance for the insurer to launch a call to the treating physician and say, "Hey Dr. Smith... can we chat about why Joe has been on OxyContin for three years? The evidence suggests that might not be good for him. Are there mitigating circumstances? Do you need help with weaning? How can we be of assistance?" In CT, that call can't happen. And that's a shame.
Workers compensation attorneys in Connecticut agree that these guidelines are strictly followed and that there is no ex parte communication with treating physicians. The only time that ex parte communication is permitted is when the claimant has approved a Nurse Case Manager. In that case the NCM may discuss treatment and medical data with the treating physician. But how many plaintiff's attorneys are going to say to their clients, "Yeah, sure, let's get an NCM involved"? Not many.
These WCC rules make it nearly impossible for insurers to collegially engage treating physicians in CT to discuss how best to rationalize pharmacological treatment. CT is one of the few states where this is the case.
Michael
On Twitter @PRIUM1
I was pleased to read, though, that the WCC has placed a 90 mg morphine equivalent dosage (MED) per day as the threshold above which opioid treatment should not rise unless there is "measured improvement in function, pain, or work capacity" (which we almost never see - once you get in the 100 mg MED range, we consistently see evidence in medical records of declining function). Most of the literature suggests 120 mg MED as an appropriate threshold, so the more aggressive approach in CT is enlightened.
I also thought it was interesting that the WCC encourages treating physicians to contact the insurer if treatment beyond the protocol is needed. I'm left wondering how nice it would be if the reverse was possible - if the insurer could easily and reliably engage the treating physician to discuss the care of the patient.
In CT, communication between payor and the attending physician where such communication would involve unilateral disclosure or discussion of material information is not allowed.
Payors, however, may request the physician to complete the "Employee Medical & Work Status Form" form or provide progress notes. Copies of this communication, as well as any responses from the physician, must be provided to the injured worker or his/her representative (Payor and Medical Provider Guidelines to Improve the Coordination of Medical Services, 2010).
But there is no allowance for the insurer to launch a call to the treating physician and say, "Hey Dr. Smith... can we chat about why Joe has been on OxyContin for three years? The evidence suggests that might not be good for him. Are there mitigating circumstances? Do you need help with weaning? How can we be of assistance?" In CT, that call can't happen. And that's a shame.
Workers compensation attorneys in Connecticut agree that these guidelines are strictly followed and that there is no ex parte communication with treating physicians. The only time that ex parte communication is permitted is when the claimant has approved a Nurse Case Manager. In that case the NCM may discuss treatment and medical data with the treating physician. But how many plaintiff's attorneys are going to say to their clients, "Yeah, sure, let's get an NCM involved"? Not many.
These WCC rules make it nearly impossible for insurers to collegially engage treating physicians in CT to discuss how best to rationalize pharmacological treatment. CT is one of the few states where this is the case.
Michael
On Twitter @PRIUM1
Wednesday, May 16, 2012
A Tale of Two Claim Types: Healthcare Solutions Drug Trends Report
The first thing you notice about the 2012 Workers' Compensation Drug Trends Report from Healthcare Solutions is that the authors have decided to tell two different stories with the data - one focused on "developing claims" (0-3 years from date of injury) and another focused on "mature claims" (3+ years from the date of injury).
Kudos to Jim Andrews and his team for giving us some insight into what all of us intuitively suspected as we examined other drug trend reports: that the behavior of claims changes markedly over time... and that looking at all claims together in one big lump wasn't allowing us to glean intelligent conclusions.
If I had one request, though, it would be to create an even more granular look at the data. The report notes that "significant increases in both the number of prescriptions and the prices of prescriptions occur in the first three years of a claim. The most significant increase occurs between the first and second service year when a 65% increase in the number of prescriptions and a 76% increase in the average price per prescriptions is observed." Instead of grouping these claims into the "developing" category, I think it would be fascinating to pull the data set into a sub-set of first year, second year, and third year claims to see how drug mix, drug class, and spend change even within that time period. But then the report would run 100 pages instead of 25...
The most interesting story that I see in the data is around the long term impact of opioid use. Among developing claims, opioids are used by 65.7% of injured workers while other drug classes are relatively uncommon in this stage of the claim life cycle (anticonvulsants are used by 9.9% of injured workers, antidepressants by 4.8%, and ulcer drugs by 2.4%).
And what happens as claims age into the "mature" category? Opioids are used by 71.2% of these injured workers. But more importantly, we begin to see the complexities of long term use of analgesics. The side effects are clear: depression (antidepressant use goes up almost 5X to 23.5% of injured workers), neuropathic - or idiopathic - pain (anticonvulsant usages goes up almost 3X to 28.2%), and GI issues (usage of ulcer drugs goes up more than 5X to 12.4% of injured workers).
Coincidence? No.
A direct consequence of the original work injury? Probably not.
Additional costs being driven by underlying overutilization of narcotics? Most likely.
Michael
On Twitter @PRIUM1
Kudos to Jim Andrews and his team for giving us some insight into what all of us intuitively suspected as we examined other drug trend reports: that the behavior of claims changes markedly over time... and that looking at all claims together in one big lump wasn't allowing us to glean intelligent conclusions.
If I had one request, though, it would be to create an even more granular look at the data. The report notes that "significant increases in both the number of prescriptions and the prices of prescriptions occur in the first three years of a claim. The most significant increase occurs between the first and second service year when a 65% increase in the number of prescriptions and a 76% increase in the average price per prescriptions is observed." Instead of grouping these claims into the "developing" category, I think it would be fascinating to pull the data set into a sub-set of first year, second year, and third year claims to see how drug mix, drug class, and spend change even within that time period. But then the report would run 100 pages instead of 25...
The most interesting story that I see in the data is around the long term impact of opioid use. Among developing claims, opioids are used by 65.7% of injured workers while other drug classes are relatively uncommon in this stage of the claim life cycle (anticonvulsants are used by 9.9% of injured workers, antidepressants by 4.8%, and ulcer drugs by 2.4%).
And what happens as claims age into the "mature" category? Opioids are used by 71.2% of these injured workers. But more importantly, we begin to see the complexities of long term use of analgesics. The side effects are clear: depression (antidepressant use goes up almost 5X to 23.5% of injured workers), neuropathic - or idiopathic - pain (anticonvulsant usages goes up almost 3X to 28.2%), and GI issues (usage of ulcer drugs goes up more than 5X to 12.4% of injured workers).
Coincidence? No.
A direct consequence of the original work injury? Probably not.
Additional costs being driven by underlying overutilization of narcotics? Most likely.
Michael
On Twitter @PRIUM1
Tuesday, May 15, 2012
Pop Quiz in the WSJ: Get Rid of Painkillers
This morning's Wall Street Journal had an interesting article in the Personal Journal section called "The Medicine Cabinet Quiz." (Yes... I am one of the last few that actually gets a paper delivered in my driveway each morning). One of the questions, in particular, caught my attention:
Q: For a sore back or sprained ankle, which options make sense?
A) Heat
B) Ice
C) Heat rub
D) Prescription painkiller
The answer was obvious to most of us: A, B, and C (conspicuous in its absence was choice D). The article explains: "While many people don't finish prescriptions for Percocet, Vicodin, or generic equivalents prescribed after surgery or dental work, it is a bad idea to take them for something else. Leftover painkillers are an invitation for abuse - by yourself, by your children, or by nosy visitors. Studies show that 68% of prescription drug abusers obtain them from home or from friends."
If you've got leftover pills sitting around, get rid of them. Today.
Michael
On Twitter @PRIUM1
Q: For a sore back or sprained ankle, which options make sense?
A) Heat
B) Ice
C) Heat rub
D) Prescription painkiller
The answer was obvious to most of us: A, B, and C (conspicuous in its absence was choice D). The article explains: "While many people don't finish prescriptions for Percocet, Vicodin, or generic equivalents prescribed after surgery or dental work, it is a bad idea to take them for something else. Leftover painkillers are an invitation for abuse - by yourself, by your children, or by nosy visitors. Studies show that 68% of prescription drug abusers obtain them from home or from friends."
If you've got leftover pills sitting around, get rid of them. Today.
Michael
On Twitter @PRIUM1
Monday, May 14, 2012
American Pain Foundation Shuts Down
The American Pain Foundation announced last Tuesday evening that it would "cease to exist, effective immediately." That should make all of us fighting prescription drug abuse "very happy, effective immediately."
The organization had received a letter from the Senate Finance Committee notifying it of an investigation launched by the committee to uncover the details of relationships amongst pharmaceutical manufacturers, physicians, and "patient advocacy" organizations like the American Pain Foundation. This comes on the heels of a great piece by ProPublica in December that found the group had received 90% of its funding in 2010 from the pharma and medical device indisturies.
Turns out, this made it hard for APF to find anyone to give them money.
On its web site, the group states the following: "As you unfortunately know, the need for public outcry around the needs of Americans struggling with pain conditions is greater today than ever before in light of the multi-front assault occurring daily on our right to dignified care. Misguided state and federal policies are impeding access to appropriate and reasonable medical care for people struggling with pain, and deterring even the most compassionate medical providers from treating anyone with pain conditions."
You see? This is why the dissolution of the organization is a good thing. While the rest of us are fighting to ensure the appropriate use of prescription medications, this group was complaining about "misguided state and federal policies." While we acknowledged that new statutes and rules should (and many do) create carve-outs for those with cancer diagnoses and instead focused our efforts on limiting the use of powerful narcotics for non-malignant musculoskeletal pain, the APF told anecdotal stories about patients not able to access needed drugs.
An early victory for Senators Grassley and Baucus. Unintended, perhaps... but a victory nonetheless.
Michael
On Twitter @PRIUM1
The organization had received a letter from the Senate Finance Committee notifying it of an investigation launched by the committee to uncover the details of relationships amongst pharmaceutical manufacturers, physicians, and "patient advocacy" organizations like the American Pain Foundation. This comes on the heels of a great piece by ProPublica in December that found the group had received 90% of its funding in 2010 from the pharma and medical device indisturies.
Turns out, this made it hard for APF to find anyone to give them money.
On its web site, the group states the following: "As you unfortunately know, the need for public outcry around the needs of Americans struggling with pain conditions is greater today than ever before in light of the multi-front assault occurring daily on our right to dignified care. Misguided state and federal policies are impeding access to appropriate and reasonable medical care for people struggling with pain, and deterring even the most compassionate medical providers from treating anyone with pain conditions."
You see? This is why the dissolution of the organization is a good thing. While the rest of us are fighting to ensure the appropriate use of prescription medications, this group was complaining about "misguided state and federal policies." While we acknowledged that new statutes and rules should (and many do) create carve-outs for those with cancer diagnoses and instead focused our efforts on limiting the use of powerful narcotics for non-malignant musculoskeletal pain, the APF told anecdotal stories about patients not able to access needed drugs.
An early victory for Senators Grassley and Baucus. Unintended, perhaps... but a victory nonetheless.
Michael
On Twitter @PRIUM1
Quick Hits from Evidence Based: NCCI, CA, and IL
NCCI released research data on comorbidities in work comp:
- Claims that involve comorbid conditions are TWICE as expensive as claims that do not.
- 81% of claims that involved treatment for obesity involved lost time, 19% were medical only.
- For all claims, it's the exact OPPOSITE: 81% are medical only, 19% involve lost time.
Wow.
A California bill passed out of committee last week that will award attorney's fees in successful challenges to utilization review decisions. A consultant to the Appropriations Committee said the bill would have minimal impact because "somewhere between 6% and 20% of all utilization review requests result in denial and of those, only a portion will be challenged."
Yeah... until attorney's fees are awarded for successful challenges. In light of systemic change, historical data has little bearing on future system behavior.
Illinois state lawmakers will vote soon on privatizing management of state workers' comp claims. Organized labor is pushing back, but this is a logical step given the absolute and unmitigated disaster the state auditor found. I wonder if there are other state funds as screwed up as Illinois?
On Twitter @PRIUM1
- Claims that involve comorbid conditions are TWICE as expensive as claims that do not.
- 81% of claims that involved treatment for obesity involved lost time, 19% were medical only.
- For all claims, it's the exact OPPOSITE: 81% are medical only, 19% involve lost time.
Wow.
A California bill passed out of committee last week that will award attorney's fees in successful challenges to utilization review decisions. A consultant to the Appropriations Committee said the bill would have minimal impact because "somewhere between 6% and 20% of all utilization review requests result in denial and of those, only a portion will be challenged."
Yeah... until attorney's fees are awarded for successful challenges. In light of systemic change, historical data has little bearing on future system behavior.
Illinois state lawmakers will vote soon on privatizing management of state workers' comp claims. Organized labor is pushing back, but this is a logical step given the absolute and unmitigated disaster the state auditor found. I wonder if there are other state funds as screwed up as Illinois?
On Twitter @PRIUM1
Thursday, May 10, 2012
New Health Wonk Review
New Health Wonk Review is up... with Evidence Based making another appearance!
http://insureblog.blogspot.com/2012/05/health-wonk-review-spring-hath-sprung.html
Michael
On Twitter @PRIUM1
http://insureblog.blogspot.com/2012/05/health-wonk-review-spring-hath-sprung.html
Michael
On Twitter @PRIUM1
Something Rotten in the State of Opioid Prescribing
There's something rotten in the state of opioid prescribing...
The New York Times reported yesterday that the Senate Finance Committee has launched an investigation into the financial ties amongst pharmaceutical manufacturers of analgesics, pain "experts," advocacy groups, and organizations that set guidelines for the use of these drugs.
Tired of partisan politics in Washington? The letter that went out announcing the investigation was signed by Max Baucus (D-Montana) and Charles Grassley (R-Iowa). This is a bi-partisan slam dunk. While I don't have any direct evidence of malfeasance, I'm not the least bit surprised that the committee has chosen this as an area of focus.
As a quick aside, the Times article quotes Dr. Andrew Kolodny, a psychiatrist in New York. I mention this for two reasons: 1) I've met Dr. Kolodny and think highly not only of his stance on these issues, but also of the way he communicates his perspective; 2) He leads the Physicians for Responsible Opioid Prescribing, the web site of which is an outstanding resource to get educated on the topic of opioid over-utilization. We use the videos here at PRIUM for training and we recommend the site as a resource to our insurance and employer clients looking for free, web-based education tools. Excellent stuff.
Back to the investigation...
I recently had occasion to discuss the issue of opioid over-utilization with leaders from a couple of these companies. I brought up the topic of evidence-based medicine and clinical guidelines. I further explained the growing role of these tools in work comp. I was surprised by two things:
1) The concept seemed completely new to them; 2) the looks on their faces were priceless: it was as if I had committed some unforgivable offense. Monitor, influence, or perhaps even CHANGE a physician's prescribing habits based on peer-reviewed medical evidence? Who would do such a thing?
This is an industry that needs to be investigated. I'm encouraged the Senate is taking action. This is a public health crisis and it demands this level of scrutiny.
If nothing else, we're all going to get a really good peek at how this industry really operates.
Michael
On Twitter @PRIUM1
The New York Times reported yesterday that the Senate Finance Committee has launched an investigation into the financial ties amongst pharmaceutical manufacturers of analgesics, pain "experts," advocacy groups, and organizations that set guidelines for the use of these drugs.
Tired of partisan politics in Washington? The letter that went out announcing the investigation was signed by Max Baucus (D-Montana) and Charles Grassley (R-Iowa). This is a bi-partisan slam dunk. While I don't have any direct evidence of malfeasance, I'm not the least bit surprised that the committee has chosen this as an area of focus.
As a quick aside, the Times article quotes Dr. Andrew Kolodny, a psychiatrist in New York. I mention this for two reasons: 1) I've met Dr. Kolodny and think highly not only of his stance on these issues, but also of the way he communicates his perspective; 2) He leads the Physicians for Responsible Opioid Prescribing, the web site of which is an outstanding resource to get educated on the topic of opioid over-utilization. We use the videos here at PRIUM for training and we recommend the site as a resource to our insurance and employer clients looking for free, web-based education tools. Excellent stuff.
Back to the investigation...
I recently had occasion to discuss the issue of opioid over-utilization with leaders from a couple of these companies. I brought up the topic of evidence-based medicine and clinical guidelines. I further explained the growing role of these tools in work comp. I was surprised by two things:
1) The concept seemed completely new to them; 2) the looks on their faces were priceless: it was as if I had committed some unforgivable offense. Monitor, influence, or perhaps even CHANGE a physician's prescribing habits based on peer-reviewed medical evidence? Who would do such a thing?
This is an industry that needs to be investigated. I'm encouraged the Senate is taking action. This is a public health crisis and it demands this level of scrutiny.
If nothing else, we're all going to get a really good peek at how this industry really operates.
Michael
On Twitter @PRIUM1
Wednesday, May 9, 2012
Obesity Outlook for 2030: Not Good News
The American Journal of Preventive Medicine published a study this week that appears to offer a glimmer of hope for the health care industry: the data (collected from 1990 through 2008) suggests that the prevalence of obesity might be leveling off. In other words, the linear regression models typically used to forecast obesity rates (and the related costs), may not be accurate. Rather, non-linear forecasting techniques now suggest the obesity rate in 2030 may be around 42% (vs. the 51% that the linear model indicates).
Good news, right?
Not really. While the growth of obesity may be moderating, the rise in prevalence is still incredible. The study shows a 33% increase in obesity between now and 2030 and a 130% increase in severe obesity over the same time frame.
The headline grabbing number many of us have seen from this study is the $549.5 billion in potential cost savings. This number assumes that the 2010 obesity rate remains constant through 2030. Nice mathematical exercise... but completely useless in reality.
Digging more deeply into the statistics (and looking for a silver lining), there is some more practical and encouraging data... A 1 percentage point decrease from the prevalence rate suggested by the model would yield 2.6 million fewer obese adults in 2020 and 2.9 million fewer in 2030. This would lead to a reduction in obesity-related medical costs of $4 billion in 2020, $4.7 billion in 2030, and a cumulative total of $84.9 billion over the next 20 years. That strikes me as achievable.
What does all of this mean?
The obesity issue in work comp is only going to get worse - it's simply a matter of how bad it gets and how quickly it gets there. Bold prediction: we're going to see some new and aggressive case law over the next decade that is going to give employers more latitude to protect themselves against obesity-related medical costs, even in the face of a legitimate industrial injury. Don't hold your breath, but I can't see the medical benefit component of work comp being sustainable without such systemic protection.
Michael
On Twitter @PRIUM1
Good news, right?
Not really. While the growth of obesity may be moderating, the rise in prevalence is still incredible. The study shows a 33% increase in obesity between now and 2030 and a 130% increase in severe obesity over the same time frame.
The headline grabbing number many of us have seen from this study is the $549.5 billion in potential cost savings. This number assumes that the 2010 obesity rate remains constant through 2030. Nice mathematical exercise... but completely useless in reality.
Digging more deeply into the statistics (and looking for a silver lining), there is some more practical and encouraging data... A 1 percentage point decrease from the prevalence rate suggested by the model would yield 2.6 million fewer obese adults in 2020 and 2.9 million fewer in 2030. This would lead to a reduction in obesity-related medical costs of $4 billion in 2020, $4.7 billion in 2030, and a cumulative total of $84.9 billion over the next 20 years. That strikes me as achievable.
What does all of this mean?
The obesity issue in work comp is only going to get worse - it's simply a matter of how bad it gets and how quickly it gets there. Bold prediction: we're going to see some new and aggressive case law over the next decade that is going to give employers more latitude to protect themselves against obesity-related medical costs, even in the face of a legitimate industrial injury. Don't hold your breath, but I can't see the medical benefit component of work comp being sustainable without such systemic protection.
Michael
On Twitter @PRIUM1
Tuesday, May 8, 2012
Texas: The Clock is Ticking on Legacy Claims
Back in January, my colleague Mark Pew penned a white paper entitled "Legacy Clean Up, Texas Style." The paper encouraged stake holders in the Texas work comp system to get started on the process of addressing legacy claims in relation to the new closed formulary rules, despite a timeline in the new rules that doesn't require action until early 2013: "Given the potentially extreme physical and psychological addiction associated with these drugs, it is time to get started towards those deadlines. This should make 2012 the 'Year of Legacy Claim Cleanup' in Texas."
Yesterday, the Insurance Council of Texas (ICT) published a bulletin emphasizing the need for the work comp insurance community to get moving on this issue. The bulletin reminded stakeholders that "the DWC has urged all involved parties to begin the legacy claims transition process 'much sooner' than the rule's mandated timelines to avoid last minute complications, and to foster timely, manageable prescribing of drugs suitable to each injured employee." Further, the ICT states that "the DWC is concerned that there are insurance carriers and physicians who may wait until the 'eleventh hour' to begin the transition of legacy claims to the Closed Formulary. The DWC believes that the delay in transitioning the legacy claims could result in interruption of the delivery of medically appropriate and necessary pharmaceutical benefits."
This is a diplomatic way of saying, "September 2, 2013 [the day after the closed formulary rules go into effect for all legacy claims] is going to a very complicated day for all of us if we don't get our act together NOW!"
This is serious, folks. Texas isn't messing around here. Come September of 2013, if a drug isn't documented as medically necessary, it isn't going to be dispensed (at least, not without a medical interlocutory order).
If only there were a clear way to deal with these claims...
Good news: DWC actually thought of that! The rules provide for a mechanism for insurance carriers to engage directly with treating physicians to determine (and clearly document prior to September 1, 2013) the applicability of the closed formulary to each individual legacy claim. This is a big task and for some carriers/employers, this is going to be a huge project. So get to work!
And if you're struggling with the issue, let us know. PRIUM has developed a continuing education module on the topic and we'd be happy to share with anyone that needs help.
Michael
On Twitter @PRIUM1
Yesterday, the Insurance Council of Texas (ICT) published a bulletin emphasizing the need for the work comp insurance community to get moving on this issue. The bulletin reminded stakeholders that "the DWC has urged all involved parties to begin the legacy claims transition process 'much sooner' than the rule's mandated timelines to avoid last minute complications, and to foster timely, manageable prescribing of drugs suitable to each injured employee." Further, the ICT states that "the DWC is concerned that there are insurance carriers and physicians who may wait until the 'eleventh hour' to begin the transition of legacy claims to the Closed Formulary. The DWC believes that the delay in transitioning the legacy claims could result in interruption of the delivery of medically appropriate and necessary pharmaceutical benefits."
This is a diplomatic way of saying, "September 2, 2013 [the day after the closed formulary rules go into effect for all legacy claims] is going to a very complicated day for all of us if we don't get our act together NOW!"
This is serious, folks. Texas isn't messing around here. Come September of 2013, if a drug isn't documented as medically necessary, it isn't going to be dispensed (at least, not without a medical interlocutory order).
If only there were a clear way to deal with these claims...
Good news: DWC actually thought of that! The rules provide for a mechanism for insurance carriers to engage directly with treating physicians to determine (and clearly document prior to September 1, 2013) the applicability of the closed formulary to each individual legacy claim. This is a big task and for some carriers/employers, this is going to be a huge project. So get to work!
And if you're struggling with the issue, let us know. PRIUM has developed a continuing education module on the topic and we'd be happy to share with anyone that needs help.
Michael
On Twitter @PRIUM1
Friday, May 4, 2012
Tennessee Steps Up: UR and Narcotics Contracts
The Tennessee General Assembly passed a bill late Tuesday that will apply the utilization review process to any schedule II, III, or IV drug prescribed for more than 90 days. Further, the bill creates stiff penalties for patients that violate narcotics contracts with treating providers.
Let's look at some of the specifics. I find the following to be particularly encouraging:
1) Employers can leverage UR for drugs - excellent step. Here at PRIUM, we still believe the best path to fixing a lot of these claims is through collegial, voluntary peer-to-peer engagement... but if that doesn't work, having UR as a statutorily recognized option is very beneficial.
2) Interestingly, if a doctor refuses to prescribe a certain drug, the claimant can (on no more than one occasion) trigger the UR process on his own behalf to essentially secure a third party's view of the appropriateness of the medication therapy. I wonder how often this will be used...
3) If an injured employee violates the narcotics contract more than once (I guess everyone deserves a mulligan), the patient's "right to pain management through prescription [drugs]... shall be terminated." Tough, but appropriate.
A few concerns:
1) The UR option appears to be off the table if there is "an initial evaluation of an injured or disabled employee by a physician specializing in pain management." I see the fingerprints of the Tennessee Medical Association here. In our experience, exempting pain management specialists from oversight rests on a set of flawed and dangerous assumptions.
2) The bill doesn't require a narcotics contract. The employee "may" sign a formal written agreement. If the employee does sign such an agreement and then violates it (more than once), the penalties are clear. But the employee doesn't have to sign one... I would have liked to have seen the word "shall" here instead of "may," but these things are a negotiation and you get what you can get.
I saw an earlier draft of the bill that did say "shall" and applied the same penalties described earlier for violators to those that refused to sign a contract. That would have been interesting. That earlier version also included mandated urinary drug monitoring... that also disappeared from the final version.
Those minor concerns notwithstanding, this is an example of appropriate legislative response to a major public health issue. One particularly good sign - Rocky McElhaney from the TN Association for Justice (representing trial lawyers) said that his organization had little choice but to accept the bill. "With the governor being a Republican and Republican majorities in the House and Senate, we don't have a lot of say in legislation these days," he said.
Sad, but true, fact: When the trial lawyers don't like it, it's usually a good sign that the legislation has a chance of making a difference.
Michael
On Twitter @PRIUM1
Let's look at some of the specifics. I find the following to be particularly encouraging:
1) Employers can leverage UR for drugs - excellent step. Here at PRIUM, we still believe the best path to fixing a lot of these claims is through collegial, voluntary peer-to-peer engagement... but if that doesn't work, having UR as a statutorily recognized option is very beneficial.
2) Interestingly, if a doctor refuses to prescribe a certain drug, the claimant can (on no more than one occasion) trigger the UR process on his own behalf to essentially secure a third party's view of the appropriateness of the medication therapy. I wonder how often this will be used...
3) If an injured employee violates the narcotics contract more than once (I guess everyone deserves a mulligan), the patient's "right to pain management through prescription [drugs]... shall be terminated." Tough, but appropriate.
A few concerns:
1) The UR option appears to be off the table if there is "an initial evaluation of an injured or disabled employee by a physician specializing in pain management." I see the fingerprints of the Tennessee Medical Association here. In our experience, exempting pain management specialists from oversight rests on a set of flawed and dangerous assumptions.
2) The bill doesn't require a narcotics contract. The employee "may" sign a formal written agreement. If the employee does sign such an agreement and then violates it (more than once), the penalties are clear. But the employee doesn't have to sign one... I would have liked to have seen the word "shall" here instead of "may," but these things are a negotiation and you get what you can get.
I saw an earlier draft of the bill that did say "shall" and applied the same penalties described earlier for violators to those that refused to sign a contract. That would have been interesting. That earlier version also included mandated urinary drug monitoring... that also disappeared from the final version.
Those minor concerns notwithstanding, this is an example of appropriate legislative response to a major public health issue. One particularly good sign - Rocky McElhaney from the TN Association for Justice (representing trial lawyers) said that his organization had little choice but to accept the bill. "With the governor being a Republican and Republican majorities in the House and Senate, we don't have a lot of say in legislation these days," he said.
Sad, but true, fact: When the trial lawyers don't like it, it's usually a good sign that the legislation has a chance of making a difference.
Michael
On Twitter @PRIUM1
Wednesday, May 2, 2012
Neonatal Abstinence Syndrome: Now I'm Really Mad
Now I'm really mad.
For the last several years here at PRIUM, we've been working on the issue of prescription drug over-utilization. We've confronted the issues of tolerance, dependence, and addiction and worked hard to develop solutions to help providers, patients, and payers stem the tide of opioid abuse. We're passionate about what we do and we're known to get more than a little upset about the medical, societal, and economic impact of this seemingly intransigent issue.
But our righteous indignation has reached new heights today as we've reviewed the new study from the Journal of the American Medical Association (JAMA) regarding neonatal abstinence syndrome (NAS). According to JAMA, NAS is a "drug withdrawal syndrome in newborns following birth... characterized by a wide array of symptoms including increased irritability, hypertonia, tremors, feeding intolerance, emesis, watery stools, seizures, and respiratory distress."
The statistics are sobering. The study found that 16.2% of pregnant teens engage in some form of illicit drug use (7.4% among pregnant women aged 18 to 25). The symptoms described above occur in about 60% to 80% of newborns exposed to opiates in utero. Even worse, perhaps, than the incidence rates is the growth of the problem. The study is longitudinal in nature and tracked the incidence of NAS from 2000, 2003, 2006, and 2009. In 2000, antepartum maternal opiate use occurred in 1.19 births per 1,000. In 2009, that grew to 5.63 births per 1,000. That's a 373% increase in less than a decade.
Most of our cases come from work comp and I'm quite certain we don't see a lot of pregnant mothers in our flow of cases. I'm equally certain that OB/GYN docs aren't regularly prescribing opiates to expectant mothers. The issue highlighted by JAMA is more an issue of illicit/illegal drug use.
But it speaks to the larger epidemic (and I don't use that word lightly - the CDC calls prescription drug misuse/abuse an epidemic). I have no data to support this, but some portion of the drugs consumed by pregnant mothers are likely prescribed "legally," but eventually diverted. These drugs are causing harm well beyond the direct costs associated with long term opioid use. Perhaps if you suspect abuse/misuse/diversion on a particular claim, you might think about where those drugs might ultimately be consumed.
So add another cost to the epidemic of opioid abuse. Perhaps the saddest cost yet.
Michael
On Twitter @PRIUM1
For the last several years here at PRIUM, we've been working on the issue of prescription drug over-utilization. We've confronted the issues of tolerance, dependence, and addiction and worked hard to develop solutions to help providers, patients, and payers stem the tide of opioid abuse. We're passionate about what we do and we're known to get more than a little upset about the medical, societal, and economic impact of this seemingly intransigent issue.
But our righteous indignation has reached new heights today as we've reviewed the new study from the Journal of the American Medical Association (JAMA) regarding neonatal abstinence syndrome (NAS). According to JAMA, NAS is a "drug withdrawal syndrome in newborns following birth... characterized by a wide array of symptoms including increased irritability, hypertonia, tremors, feeding intolerance, emesis, watery stools, seizures, and respiratory distress."
The statistics are sobering. The study found that 16.2% of pregnant teens engage in some form of illicit drug use (7.4% among pregnant women aged 18 to 25). The symptoms described above occur in about 60% to 80% of newborns exposed to opiates in utero. Even worse, perhaps, than the incidence rates is the growth of the problem. The study is longitudinal in nature and tracked the incidence of NAS from 2000, 2003, 2006, and 2009. In 2000, antepartum maternal opiate use occurred in 1.19 births per 1,000. In 2009, that grew to 5.63 births per 1,000. That's a 373% increase in less than a decade.
Most of our cases come from work comp and I'm quite certain we don't see a lot of pregnant mothers in our flow of cases. I'm equally certain that OB/GYN docs aren't regularly prescribing opiates to expectant mothers. The issue highlighted by JAMA is more an issue of illicit/illegal drug use.
But it speaks to the larger epidemic (and I don't use that word lightly - the CDC calls prescription drug misuse/abuse an epidemic). I have no data to support this, but some portion of the drugs consumed by pregnant mothers are likely prescribed "legally," but eventually diverted. These drugs are causing harm well beyond the direct costs associated with long term opioid use. Perhaps if you suspect abuse/misuse/diversion on a particular claim, you might think about where those drugs might ultimately be consumed.
So add another cost to the epidemic of opioid abuse. Perhaps the saddest cost yet.
Michael
On Twitter @PRIUM1
Tuesday, May 1, 2012
60 Minutes: The Science of Addiction
60 Minutes did an excellent piece on Dr. Nora Volkow and her work on the science of addiction entitled "Hooked: Why bad habits are hard to break." I was on Twitter Sunday evening pumping out my favorite quotes from the piece (@PRIUM1 if you're interested in my 140 character musings), but here's a quick recap of the highlights:
Dr. Volkow pointed out that there were 210 million prescriptions written for opioids last year. Morley Safer added that this was enough to medicate every adult in the US around the clock for a month.
This led Dr. Volkow to comment, "Being honest, I think that many physicians have not been properly trained on how to prescribe opiate medications. Either we're a nation in severe pain or we're overprescribing."
She's being diplomatic, of course. We're overprescribing.
The piece is more than just a recap of the statistics we all know, however. Dr. Volkow's work is helping us understand the brain chemistry behind addiction and why "just saying no" is an unrealistic option. She explores the role of dopamine in not only creating addiction, but fueling it. If you've ever wondered exactly how tolerance to opioids develops (i.e., why your claimants require ever higher dosage levels to achieve the same pain relief), she's developing the biological answer to that question.
And in a weird twist to the story for you Russian history buffs, Dr. Volkow happens to be the great grand daugher of Leon Trotsky, the great political rival of Joseph Stalin who was assassinated on Stalin's orders while living in exile. Obviously, this has little to do with her work, but 60 Minutes couldn't resist...
Michael
On Twitter @PRIUM1
Dr. Volkow pointed out that there were 210 million prescriptions written for opioids last year. Morley Safer added that this was enough to medicate every adult in the US around the clock for a month.
This led Dr. Volkow to comment, "Being honest, I think that many physicians have not been properly trained on how to prescribe opiate medications. Either we're a nation in severe pain or we're overprescribing."
She's being diplomatic, of course. We're overprescribing.
The piece is more than just a recap of the statistics we all know, however. Dr. Volkow's work is helping us understand the brain chemistry behind addiction and why "just saying no" is an unrealistic option. She explores the role of dopamine in not only creating addiction, but fueling it. If you've ever wondered exactly how tolerance to opioids develops (i.e., why your claimants require ever higher dosage levels to achieve the same pain relief), she's developing the biological answer to that question.
And in a weird twist to the story for you Russian history buffs, Dr. Volkow happens to be the great grand daugher of Leon Trotsky, the great political rival of Joseph Stalin who was assassinated on Stalin's orders while living in exile. Obviously, this has little to do with her work, but 60 Minutes couldn't resist...
Michael
On Twitter @PRIUM1
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