Pain and Patient Satisfaction Surveys

Consumerism is all around us, particularly at this time of year.  The last decade has introduced a new level of consumerism in health care in various forms: high deductible plans that encourage choice of lower price providers, public and private agencies publishing hospital safety and efficacy data, and of course, the concept of patient satisfaction and its accompanying surveys, consequences, and controversies. 

I used to be a hospital strategy consultant and I've seen hospital leaders grapple with the concept of patient satisfaction.  On the one hand, there appears to be a correlation between patient satisfaction and overall health outcomes for an institution.  On the other hand, an individual patient's definition of "satisfaction" can be shockingly misaligned with the appropriate care pathway. 

Perhaps no better example of this can be found than in the area of chronic pain treatment.  The patient wants the pain to go away.  The doctor (unfortunately and all too often) wants the patient to go away.  The harsh reality of treating chronic pain: once all the surgeries and procedures have been tried, there isn't much money to be made in maintenance care.  (The exception, of course, is the physician who dispenses drugs from his office, creating one of healthcare's most obvious, most egregious, and most perverse incentives).

The best way to deal with this set of circumstances and keep the patient "satisfied" is to write another set of prescriptions.  Better yet, just call it into the pharmacy and have the patient go pick it up. 

I was encouraged to see Dr. Zachary Meisel and Dr. Jeanmarie Perrone take a stand on this topic in a piece that wrote for Time magazine:

"Medical guidelines already state that doctors shouldn’t be choosing opioids for most patients with chronic pain. But we doctors also need to start scaling back on prescribing opioids for acute pain, since some acute pain turns into chronic pain. Everyone with new pain should be started on a high dose of ibuprofen (like Motrin or Advil) or acetaminophen (like Tylenol). These medications have been proved to work as well as the opioids even for conditions like gall-stone attacks. For some patients, we can add a prescription for a limited number of opioid pills to be filled only if absolutely necessary. With that small prescription should come a big warning. Something like: 'These drugs are highly addictive, even in short-term use. These drugs have been associated with death, even in therapeutic dosing. These drugs, when accidentally ingested by children, are fatal.' As doctors, we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain. It may take an extra few minutes, but it will save lives."

Agreed.

Michael
On Twitter @PRIUM1

Pennsylvania Supreme Court Saves Patient's Life

The Pennsylvania Supreme Court saved a patient's life last week.  Interestingly, the court accomplished this great feat by doing nothing. 

Linda Turner was injured on the job in December of 1987.  She underwent two surgical procedures and was diagnosed, over a number of years, with arachnoiditis, failed spinal fusion surgery, small fiber neuropathy, chronic pain syndrome, discitis, osteomyelitis, spinal stenosis, and mood disorder.  Her treatment, in May of 2009, consisted of Fentanyl 125 mcg patch every three days and Fetanyl 600 mcg lozenge four times a day for breakthrough pain.  I'll save you the math... that's about 400 mg morphine equivalents per day. 

Her employer conducted utilization review on the treatment and the lozenges were found to be unnecessary and unreasonable care.  This finding was not based on assessment of functionality or objective clinical evidence of sources of pain (as is often the case), but rather on the addictive nature of the medication, it's FDA approved indications (palliative care for late stage cancer patients), and the risk to the patient.  A Workers' Compensation Judge (WCJ) denied Turner's petition for review of the UR decision. 

The Workers' Compensation Appeals Board then reversed the WCJ, finding that the employer did not satisfy its burden of proving the Fentanyl lozenges were not reasonable and necessary. 

On appeal, the Commonwealth Court of Pennsylvania reversed the Board and reinstated the WCJ's denial of petition for review of the original UR decision. 

Last week, the Pennsylvania Supreme Court declined to hear Turner's appeal, thus giving credibility to the UR process, leverage for employers in Pennsylvania to avoid payment for unnecessary and unreasonable care, and saving Linda Turner's life (despite the fact the she probably doesn't realize it now).

The section of the Commonwealth Court's opinion I found most illuminating was on page 10:  "Further, in determining the reasonableness and necessity of a prescribed medication, it is entirely appropriate for a UR reviewer to consider the risk to the patient.  In other words, a UR reviewer may consider whether it is reasonable and necessary for a provider to expose a patient to the level of risk presented by a medication." 

Funny... all of us are in the "risk management" business.  Yet we often overlook the risks inherent in the treatment of these injured workers.  I hope more states take the view that PA has taken - risk to life and limb of the patient, even at the hands of a qualified physician, needs to be weighed when assessing the reasonableness of care. 

Michael
On Twitter @PRIUM1

Opioids for Chronic Pain: Modern-Day Bloodletting

I came across an amazing piece today written by Malcolm Butler, MD, Medical Director at Columbia Valley Community Health Services in Washington State.  This should be required reading for all of us doing battle in the trenches of the opioid epidemic. 

A link to the full piece is here.  In summary, Dr. Butler confronted the central challenge of his clinic by taking proactive steps to eliminate medically inappropriate opioid prescriptions from his practice.  He sums up the results of the initiative as follows:

"Here is what we have learned:

1. After 15 years of trying to follow published standards of high quality pain management,
   1. There is NO evidence that opioids improve outcomes in chronic pain.
   2. There is good evidence that opioids impair social function, contribute to behavioral comorbidities, and decrease function.
   3. Opioids are excellent for acute pain but are just the wrong tool for chronic pain.
   4. It makes about as much sense to treat chronic pain with alcohol as with opioids. Both will help pain in the short run. Both will cause new and more difficult challenges in the long run.
2. By asking every patient about pain at every visit, we had “medicalized” pain.
   1. Pain is a normal component of everyday life – it is not an anomaly requiring treatment.
   2. Pain is a protective reflex. It galvanizes us to improve and change. Removing it does the opposite, allowing us to become victims and to stagnate.
3. As we have weaned our patients down on their opioids – nothing has changed. The patients who were working while taking 400mg a day are still working when taking 100mg a day. Those who were lying on the couch while taking 400mg a day are still lying on the couch while taking 100mg a day.
   1. There appears to be a dose above which more opioids don’t improve function in chronic pain – and it must be pretty low, as we still haven’t found it.
   2. As we have decreased the volumes of opioids we prescribe, bad behavior of all types has decreased within the clinic. Whereas the OOC used to review 6 cases per month, we now review 2 cases every 3 months.
4. Chronic pain is a mélange of nociceptive pain, emotional pain, boredom, and anhedonia – all of which feel better on opioids, and all but one of which are made worse by chronic opioids.
1. Acute pain is almost entirely nociceptive pain, and is well managed with opioids.
2. Chronic pain is amplified and prolonged by the use of opioids."

This is what it takes.  Courage, transparency, honesty... and the ability to say NO.

Michael
On Twitter @PRIUM1



Tennessee Follow Up: Fumble Recovered

I was able to speak with someone at TDOL regarding my post this week on SB 3315.  While TDOL acknowledges that the interpretation of the statute as I outlined was at one time accurate, the current TDOL interpretation is now much more in line with the legislative intent of the bill. 

Any Schedule II, III, or IV drug prescribed for pain management for more than 90 days will be subject to utilization review. 

Several pieces of good news here:

1)  TDOL is listening.  I was very pleased with the transparent and candid nature of my discussion with my contact there.  TDOL is really trying to get this right and wants to be a resource not just to injured workers, but to employers and carriers doing business in Tennessee. 

2) The state has, in fact, created a statutory framework for addressing opioid dependence.  That doesn't mean this is simple (a single adverse UR determination for someone on oxycodone for the past five years doesn't fix the issue), but it does mean progress is possible if employers and carriers are prepared to offer a clinically responsible path to weaning these medications. 

3) My contact at TDOL has no direct knowledge of any impending rule-making process; doesn't mean there won't be one at some point, but for now we all need to operate on the basis of the language in SB 3315.  So let's get to work.

One note: despite this strengthened UR statute in TN, I'm still a believer in UR as a "Plan B".  Plan A ought to be a voluntary, collegial, evidence-based engagement with the treating physician to explore alternative treatment.  The time frames and technicalities of UR should only be deployed when attempts at real clinical engagement have failed. 

And for those that have heard rumors (or had specific experience) with regard to adverse UR determinations being overturned by TDOL, my understanding is that this has been driven largely by the date range issue (the 90-day clock starting ticking on July 1 even if the patient had been on opioids for years previous to July 1).  Some payors apparently jumped in too early. 

Progress in Tennessee. 

Michael
On Twitter @PRIUM1

Death Benefits: More (Disturbing) Case Law

This morning's workcompcentral brings news of a Washington state decision that, in short, upheld surviving spousal benefits in light of an accidental death caused by a combination of six different medications and alcohol.  I'm not an attorney and won't dive into specifics (the article is here, the court decision here, and the dissent is here), but I was struck by two overarching facts:

First, this is just the beginning.  The work comp industry is going to see more and more accidental overdose deaths and courts are more likely than not to award death benefits as a result.  This is going to be expensive and has already caused some insurers and excess carriers to exit the work comp market.  Aggressively intervening in chronic pain cases with complex drug regimens is imperative or your claims organization is going to face liabilities not contemplated when the policy was underwritten. 

Second, note that the original 2004 claim for back injury was, in fact, closed.  And at the time the claim was closed in March 2005 (with no award for permanent partial disability), the injured worker was only taking ibuprofen.  Two years later, at 37 years old, the injured worker's wife found him dead.  Cause of death was determined to be accidental; the injured worker's blood alcohol level was actually lower than the state-presumed intoxication level, but traces of oxycodone, citalopram, desmethylcitalopram, alprazolam, Nortryptyline, amitriptyline, carbamazepine, Promethazine, and acetometophen were found in his system.  Quite a cocktail. 

The court determined that the causal link between the original injury and the accidental overdose had not been broken - not by the claim's closure, not by the time elapsed, not by the alcohol use, not by the mix of drugs consumed.  One could rationally argue, as the dissent in this case does, that the causal chain was, in fact, broken.

I happen to agree with the dissent.  But you know what?  Doesn't matter. 
Get ready to start paying more benefits related to accidental overdoses, perhaps even on claims you think are closed and never to be heard from again.

Michael
On Twitter @PRIUM1

Tennessee and Opioids: Fumble at the Goal Line

(An update to this post is available here).

I was as excited as anyone this past summer when Tennessee’s legislature passed Senate Bill 3315.  SB 3315 amends the definition of Utilization Review to explicitly include Schedule II, III, and IV drugs being used for pain management.  Specifically, the bill states “it is the intent of the general assembly to ensure the availability of quality medical care services for injured and disabled employees and to manage medical costs in workers’ compensation matters by eradicating prescription drug abuse through the employment of the system established by subsection (a) to review any health care provider prescribing one (1) or more Schedule II, III, or IV controlled substances for pain management to an injured or disabled employee for a period of time exceeding ninety (90) days from the initial prescription of such controlled substances.”  Pretty clear legislative intent. 

Elsewhere in TN regs (specifically Chapter 0800-02-06.05 of the General Rules of the Workers’ Compensation Program), the circumstances under which mandatory UR can be invoked are clearly outlined: “The parties are required to participate in utilization review under this Chapter whenever a dispute arises as to the medical necessity of a recommended treatment.”

So, this should be simple.  Any opioid prescribed for pain management for more than 90 days should be subject to utilization review, allowing for a 3^rd party assessment of medical necessity and offering the payor community a statutorily recognized path to rein in opioid abuse.  Great news. 

If only that were the interpretation being offered by the Tennessee Department of Labor (TDOL)…   We’re hearing from several of our TN customers that SB 3315 is being misinterpreted by TDOL. 

There are several other components of SB 3315 among which is a section that states “If a treating physician determines that pain is persisting for an injured or disabled employee beyond an expected period for healing, the treating physician may either prescribe, if the physician is a qualified physician as defined… or refer, such injured or disabled employee for pain management encompassing pharmacological, non-pharmacological and other approaches to manage chronic pain.” 

Apparently, TDOL is unwilling to consider an otherwise valid UR determination unless:

1)      The treating physician has first documented that the pain has persisted “beyond an expected period for healing”; and

2)      The referral to a “qualified physician” has occurred and that physician has reached the same conclusion (that the pain has persisted “beyond an expected period for healing”); and

3)      An additional 90 days have elapsed.

I see several issues.

First, I’ve read SB 3315 over and over… and I have no idea how TDOL could stitch together these requirements, particularly based on the clearly stated legislative intent.

Second, the path outlined here relies entirely on a treating physician, who in many cases caused or at least contributed to the opioid dependence, to suddenly concede that his treatment might not be working after all… despite the increasing dosage of opioids and the addition of half a dozen companion drugs over the last 5 years.  Never.  Going.  To.  Happen.

Third, there are no statutorily recognized treatment guidelines in TN.  How is the “expected period of healing” to be determined by the physician?  On what should that determination be based? 

Fourth, this process has no chance of achieving the stated goal of SB 3315: to manage costs by eradicating (the bill actually uses the word “eradicate”!) prescription drug abuse.

SB 3315 had a chance of making a real impact.  Given the misinterpretation of the bill by TDOL, I fear Tennessee is coughing up the ball right at the goal line. 

If TDOL doesn’t straighten this out, we’ll be left with a court battle as TN payors fight for a proper regulatory interpretation of the legislative intent of SB 3315.  I hope it doesn’t come to that, but if it does, the real loser will be patients who continue to grow ever more dependent on opioid medications that have no hope of alleviating their chronic pain over the long term. 
On Twitter @PRIUM1

NWCDC: PRIUM Events

PRIUM has several events planned this week and wanted to let you know where to find us!

First and foremost, we're at booth 117.  Come by and see us. 

Second, we're sponsoring the Wednesday afternoon cocktail reception in the exhibit hall along with our friends at Health Care Solutions.  Grab a drink, a PRIUM koozie, and enjoy the networking opportunity in the exhibit hall before running out to the ten events you have to attend that night!

Third, PRIUM is excited to be participating in this year's "Opioid Solutions" track.  Mark Pew, PRIUM's SVP, is presenting on two panels this week:

On Thursday morning, Mark is co-presenting with Jim Andrews from Health Care Solutions.  You can catch their session, "Claim Cleanup: Review of Texas' Closed Formulary and National Implications" in LVCC N252 at 8:45 am Thursday.

On Friday morning, Mark is co-presenting with Jeff White and Paul Kauffman from Accident Fund.  Their presentation, "The Insurer's View: Developing a Narcotics Management Program" is at 9:00 am in LVCC N252. 

Busy week ahead.  Travel safely and enjoy the conference.

Michael
On Twitter @PRIUM1

Texas Closed Formulary: Still an Education Gap

The Texas Department of Workers' Compensation is hearing about some troubling, albeit isolated, incidents of adjusters denying medication therapy for legacy claims (i.e., claims with dates of injury prior to 9/1/11).  These claims are still subject to the "open formulary" - and even when the "closed formulary" kicks in on 9/1/13, these medications still must run through the established preauthorization process (unless, alternatively, the applicability of the closed formulary has been documented between the carrier/employer and the prescriber prior to 9/1/13). 

We spend a lot of time here at PRIUM thinking about, traveling to, and conducting business in Texas.  I am still uncomfortably surprised at how little is understood about the new closed formulary rules.  Granted, carriers, employers, and providers routinely express that they've heard about the rules and loosely understand them... but too often, they go on to completely and totally misinterpret the timeline, process, and rules associated with the closed formulary. 

I try very hard to ensure this blog isn't used as a direct marketing tool and I'm not going to start now. 
Whether you use PRIUM as your preferred URA or not, give us a call.  We'll deliver our certified continuing education unit to you, your team, your office, your company, etc. and we won't try to sell you anything (unless, of course, you ask).  We've worked hard to develop a deep understanding of the necessary approach to addressing the legacy claims and we're happy to help in any way we can - even if it's a simple webinar to walk through the rules and the associated process steps. 

If you don't take appropriate action now, legacy claim management is going to get tough come next September.  Let us know if we can help.

Michael
On Twitter @PRIUM1