Thursday, March 29, 2012

TX DWC: A Missed Opportunity

Readers of this blog know that, in general, I'm a fan of the way Texas has begun to attack the issue of over-utilization of prescription narcotics.  In the past, I've written that the (relatively) new Texas Closed Formulary Rules represent "a rare example of effective formulation and implementation of public policy to begin addressing a major issue in the work comp space." 

But alas, Texas has missed a major opportunity to signal to the physician community that it's serious about fixing the opioid issue.  DWC has rejected the idea of including opioid prescriptions as part of the 2013 report card for physicians who treat injured workers in Texas.  It's not entirely clear why this is.  The measure had the support of the Insurance Council of Texas (which would be expected) but also had the support of the Texas Medical Association.  Insurers and doctors were both supportive, so it surpasses understanding why the DWC wouldn't take the logical step of measuring opioid prescriptions.

So what does the DWC measure on the "report card"?  Three metrics:
1) Timely filing and completeness of the return to work form (DWC-073)
2) Timely filing of the medical evaluation form (DWC-069)
3) Use of MRI in low-back injury cases

If my kids' report cards looked like this, I would likely only be able to tell that they made it to class on time and, perhaps, used a protractor correctly in geometry.  That's it.  Timeliness and the use of a single modality for a single diagnosis.  This offers very little insight into the quality of the actual care being rendered.

Until we start getting serious about measuring the quality of care being delivered in work comp, you can expect medical costs to continue the upward climb toward absurdity. 

On Twitter @PRIUM1

Tuesday, March 27, 2012

Getting MSAs Right: Rationalization Before Settlement

I'm headed to the NAMSAP conference this evening (National Association of Medicare Set-Aside Professionals), so I've been thinking about and talking about the MSA process with our customers quite a bit over the last few weeks.  I'm not an expert in the field, but I have made a few observations that I hope are helpful.  (Note: The Medicare Secondary Payer rules are mind boggling.  I have a great deal of respect for those that deal with this process day in and day out.) 

First, the MSA process is largely percieved as arbitrary (at best) and capricious (at worst).  I know there are professionals that have a better read on CMS and can offer insight and manage expectations appropriately, but among the claims professionals I've been talking with, I hear frustration, disappointment, and genuine surprise regarding the CMS response to MSA submissions. 

Second, as inefficient as the process is perceived to be, there are some clear areas of concern that are both apparent and potentially controllable by both the carrier and the injured worker.  One of those areas happens to be the money spent on drugs.

I've heard countless stories of MSA calculations resulting in potential settlement amounts in the hundreds of thousands or millions of dollars, driven in large part by the medication regimen.  A few thousand dollars a month worth of drugs... and a rated life expectancy of 20+ years... the numbers get big pretty quickly. 

A few quick tips.  These would fall under the category of "MSAs for Dummies," because I personally know a few people that could teach a semester-long class on this topic.  But here are a few easy concepts for those new to MSAs or struggling with a particular case at the moment:

1) Don't settle a case until the MSA is approved by CMS.  Some of you might bristle at this (who would do such a thing?)  I've worked with payers on several cases recently where CMS came back with a revised MSA that was significantly higher than the settlement amount.  This creates a multitude of issues, not the least of which will be a demand from plaintiff's counsel for the difference.

2) If you suspect the drugs are going to result in a large MSA calculation, don't conduct the calculation until you're certain the drugs are medically necessary and related to the work injury.  If you suspect the drugs don't meet that criteria, clearly establish that fact before moving forward with the MSA.  This isn't easy.  In fact, it can take anywhere from 3 months to a year to do this right.  For those that need additional guidance in this area, let me know. 

3) If you've already had an MSA drafted and it's clear that due to the number, settlement isn't probable... see #2 above.

Rationalizing treatment before fully engaging in the MSA process is a great way to increase the probability of successful settlement for cases with high dollar drug spend. 

On Twitter @PRIUM1

Monday, March 26, 2012

All Eyes (and Ears) on SCOTUS

My kids are excited about spring break.  I'm even more excited than they are... but for an entirely different reason.  Today is the first of three days of oral arguments in front of the Supreme Court regarding the Affordable Care Act.  The High Court hasn't devoted this much time (approximately 18 hours of oral argument) to a single case in 40 years.  The court room only has seats for 60 members of the general public (the rest are held for media, I suppose) and the line began to form on Friday afternoon for this morning's session.    

The Court will actually consider four distinct issues over the next three days all related to the health care law.  Today's argument focuses on a rather arcane, but quite critical, argument that the court doesn't even have the right to hear the remaining three issues at this point.  The 1867 Anti-Injunction Act stipulates that a tax must be paid before its constitutionality can be contested.  The individual mandate doesn't kick in until 2014 and the penalty for not having insurance (the "tax" being contested) isn't assessed until 2015.  The government will argue that because the tax has yet to be paid, the rest of the case has no standing.  Here's the reality, though: for the Court, this is a once-in-a-generation sort of case and this kind of technicality isn't going to get in the way of the justices casting opinions on the broader law.

Tuesday and Wednesday will bring the meat of the arguments, mostly revolving around the expansion of the Medicaid program and the individual mandate. 

And for those as fascinated as I am comes this interesting twist: the Court will post the audio of the oral arguments each day this week by 4:00 pm.  The Court has posted the audio of oral arguments online for some time, but typically a week or so after the case is heard.  Not since Bush vs. Gore in 2000 has the Court posted the audio on the same day as the arguments.  You can find the audio here:

These next three days, and the decision(s) that follow, will impact how we access, pay for, and receive health care services for at least a generation.  The ripple effects cannot be overstated.  The Supreme Court is going to decide how a $3 trillion industry should fundamentally operate.  If you're in health care, this is the most important moment since LBJ signed Medicare into being in July of 1965.

On Twitter @PRIUM1

Friday, March 23, 2012

Arizona is making progress

I was in Phoenix yesterday presenting our Continuing Education program “Best Practices in Opioid Management” to a large Payer and received some feedback I was not expecting.

If you read this blog regularly, you know that Michael and I are both big believers in Evidence Based Medicine (EBM).  Using the patient’s subjective perception of pain and a physician’s personal clinical expertise and experience as the sole determinant of ongoing treatment plans is one of the reasons the U.S. has what the CDC calls an “epidemic” of prescription drug over-utilization.  In my opinion, and that of others much smarter than me, this should be augmented regularly with the science of EBM as a baseline standard of care and reference point for how to manage pain.  While I do not have any specific rooting interest on the tool, I do believe strongly it is more effective to use EBM than consensus-based guidelines (i.e. Colorado, New York) as those potentially allow for lobbyists (clinical and business) to flip the science to fit their purposes.  But I digress …

When I began talking about the concepts and application of EBM, one of the attendees said that Arizona had just passed a bill regarding EBM but wasn’t sure of the details.  And according to workcompcentral this morning, there was indeed an omnibus bill signed by Governor Brewer to allow electronic payment of Work Comp benefits, but nothing that I could find about EBM.  Michael and I have been following the subject of EBM in Arizona for awhile (see his post on February 1 on House Bill 2365).  But it prompted more digging and I found there is being progress made on prescription drug management:
  • House Bill 2365, “Workers’ compensation; evidence based treatment”: No progress listed since February 6, but it does select ACOEM as “presumptively correct on the issue of extent and scope of medical treatment.”  You can see the full bill here.
  • House Bill 2155, “Controlled substances, workers’ compensation”:  This was passed by the House on February 7, and yesterday was passed by the Senate with amendments and referred back to the House.  You can see the full bill here.  There are two primary major initiatives in this legislation:
    1. Section 23-1026: If the employee refuses to submit to a periodic medical examination then the right to compensation can be suspended until that examination occurs, and if the result of the examination shows the employee persists in unsanitary or injurious practices or refuses to submit to reasonable medical/surgical treatment to promote their recovery then compensation can be reduced or suspended.
    2. Section 23-1062.02: A treating physician, upon written request by an “interested party”, shall include justification for use of the controlled substance and a treatment plan that includes a description of measures to monitor and prevent the development of abuse, addiction or diversion by the employee.  The physician shall include in their reports the off-label use of a narcotic or Schedule II substance, the use of a narcotic exceeding 120mg MED per day and the prescription of long-acting opioid.  If the physician does not comply, the “interested party” is not responsible for payment of the physician’s services and the employer or carrier or commission may request a change of physician.
This is all very good news, but it hasn’t reached the Governor’s desk yet.  It seems as though the battle of consensus-based vs. evidence-based has been won (which is the right decision), and HB 2155 is forcing (with the use of “shall”) the treating physicians to comply with best practices.  The attendees in Phoenix were frustrated with the number of claimants on obviously inappropriate drug regimens without much course of action.  My speculation is that the Arizona legislature has decided to set the rules of engagement in place first with HB 2155 as that seems to be on the fast-track, then follow-up with the establishment of the standard of care with HB 2365.

If you’re interested in making a change for the betterment of patient health and safety in Arizona, let’s hope these bills pass and soon.

In this together – Mark

On Twitter @PRIUM1

Thursday, March 22, 2012

Lack of Predictability: Yet Another Challenge in Chronic Opioid Therapy

Consider three workers.  I'll call them John, Joe, and Jim.  All three are 42 year old males.  All work for the same company and in the same function/position.  All suffer from work-related low back pain derived from the same mechanism of injury.  All three have failed initial conservative therapy and have had back surgery... with mixed results at best.  The physicians for all three have tried prescribing NSAIDs, but with little impact. 

For all three, a trial of a low-dose opioid is initiated.  From this point, John, Joe, and Jim head down very different paths.

John experiences pain relief, increase in function, does not up-titrate, and returns to work fairly quickly.  The opioid is used "as needed" for flare up pain in the short-term, but as John leverages his increase in functionality to engage in light/moderate exercise, his back gets stronger and he no longer needs any pharmacological therapy. 

Joe experiences pain relief, but instead of increase in functionality, he experiences opioid tolerance and his physician escalates his dosage.  Eventually, the doctor switchtes Joe to Oxycontin.  He develops dependence on the drug.  He fails to return to work.  The dosage of the Oxycontin goes from 20 mg... to 40 mg... to 80 mg.  Eventually, Joe is referred to a functional restoration program with a focus on addiction/rehab.  But Joe is motivated to change his life.  He knows the drugs don't work for him and cause him more harm than good.  He is highly engaged in his treatment and eventually gets back to work.

Jim, like Joe, ends up going down the path of tolerance, dependence, and addiction.  But Jim lacks the motivation that Joe had to change his life and get rid of the drugs.  In fact, Jim wants more drugs, not less.  He needs drugs to treat all of the side effects of the opiods (sexual dysfunction, constipation, depression, etc.)  And he's not interested in working.  He was hurt on the job and his view of the world is that he's entitled to every penny the employer pays, either directly to him or on his behalf for his medical treatment.  He has an attorney and he's going to fight tooth and nail to maximize his settlement such that he never needs to work again. 

Here's the problem: At the date of injury, it's really hard to distinguish John from Joe from Jim.

I've heard lots of talk of genetic testing that might help predict likelihood of addiction.  The path to actually applying that science is so fraught with complication and complexity, it's difficult to even wrap my head around it.

There is one area, though, where we can put some focus that will yield results: Understand the psycho-social disposition of the injured worker early and assess the likelihood of addiction in this context.  Stop being afraid of psych evals because you're nervous that will open up the claim for additional compensable issues. 

When it comes to work comp and opioids, those that avoid dealing with the psycho-social elements of the patient's care do so at their peril. 

On Twitter @PRIUM1

Tuesday, March 20, 2012

To Opt In or Out: Follow Up

Building on Mark's post yesterday...
Discussions are under way to expand the pool of businesses that would qualify for the new Oklahoma opt out program.  Details are on workcompcentral here.

On Twitter @PRIUM1

Monday, March 19, 2012

To Opt In or Out, that is the Question

As you may know, Texas is the only state that allows employers to not subscribe to the Workers’ Compensation system, which means they have chosen to not participate in Work Comp and therefore the rules/statutes managed by the DWC do not apply.  They, instead, create their own rules to best manage benefits and workplace injury prevention.  This is not the same as a self-insured employer who continues to participate in Work Comp and thereby follow the system’s rules.  Texas Association of Responsible Non-Subscribers outline the background of this option and what they consider to be best practices.  According to TXANS, some of the reasons for choosing non-subscription are cost reduction, reinvesting cost savings, improved healthcare, flexibility, improved safety and care, survival, jobs and economy, better relations and higher productivity.  They estimate 114,000 employers operate as non-subscribers.

According to a 03/15/12 workcompcentral article, Oklahoma is working towards becoming the second state to provide an avenue for opting out of the Work Comp system.  Senate Bill 1378 and House Bill 2155 have both passed and now are in the process of reconciliation to a revised bill that will be submitted to each house for a final vote (so the actual rules are still in-flux).

There are some differences between Oklahoma and Texas, according to the article.  Oklahoma will require the benefit plan to be regulated by the Federal government under ERISA to provide medical and indemnity benefits to injured workers, have at least 50 workers, and Work Comp experience factor criteria.

One downside to opting out in both states is liability – the Work Comp system limits liability and typically excludes negligence claims, whereas non-subscribers do not have that protection (but can use insurance).  Another downside is the lack of a refined dispute resolution process.  And an apparent fear in Oklahoma is that large employers will leave the Work Comp system and reduce the influence and desire to enact needed reforms in the Work Comp system.

So, which is the right approach?  The list of pros and cons is long, and this may not be a decision of black and white but shades of gray.  Obviously every employer in Texas has made a choice.  A very good point/counter-point was published by Steve Nichols of the Insurance Council of Texas and proponents of both sides offered strong arguments.  The article quotes a 2006 non-subscription survey conducted by the TDI Work Comp Research and Analysis Group that found 37% of employers were non-subscribers and 23% of all employees had opt-out employers.  An undated but assumed updated TDI survey shows that has increased to 44% of employers but decreased to 20% of employees.

If you have made the decision between Opt In and Opt Out, I would appreciate your input on how you made that decision.

So, is this approach right for other states?  There do not appear to be any states other than Oklahoma moving in this direction, but theirs is a strong and dedicated focus on making it happen.  If it passes, we will likely find out soon.

In this together – Mark

On Twitter @PRIUM1

Friday, March 16, 2012

Let's Talk: A More Enlightened Approach to Utilization Review

PRIUM's General Counsel fielded an irate call this week from a plaintiff's attorney in California. The attorney was upset that we had attempted to have a PRIUM physician discuss the care of his client with the client's treating physician. "There's a UR process, you know," he said.

Right. Utilization Review. That potentially contentious and often antagonistic process by which non-certifications are issued... and then, for complex treatment like chronic opioid therapy, often ignored by adjusters either too busy or too frightened to put their proverbial foot down. The UR process has it's place, but we can do better.

Once it was explained to this attorney that PRIUM (more accurately, our customer, a CA-based TPA) was actually trying to avoid engaging the UR process and was instead attempting to engage the treating physician in a collegial conversation about current treatment, expectations going forward, MTUS guidelines, and his overall goals for the patient... well, he thought that actually sounded like a good idea. When it was further explained that when the drug regimen of his client was rationalized, settlement might be a real possibility, he got even more excited. The employer had zero interest in settlement involving hundreds of thousands in drug spend, but given some time, some engagement with the treater, and some cooperation on weaning and discontinuing medically unnecessary drugs, settlement might be possible.

PRIUM doesn't hesitate to engage the UR process in cases where doctors are unwillingly to talk with us or to respond to evidence-based medicine. And we're really quite good at it. But that is not our first line intervention strategy.

Before you rush into UR, stop and think about the potential value of "let's talk..."

On Twitter @PRIUM1

Thursday, March 15, 2012

New York Treatment Guidelines: Return Requires Investment

A report from the New York Workers' Compensation Alliance indicates that the application of medical treatment guidelines in the state has created an additional $60 million in costs for the workers' compensation system.  Let's place aside the fact that the source may be biased (the alliance "is a coalition of injured workers and other stakeholders committed to protecting the rights of injured workers") and assume the $60 million is a directionally correct number.

The report points out that the cost increase is due, in large part, to the application of the guidelines retrospectively.  As such, the Alliance argues, the state is now denying care it previously authorized and this is illogical and unfair.  I suppose it's somehow logical and fair to subject the care of newly injured workers to evidence-based medical treatment guidelines, but not apply those same standards of care to workers injured one year ago... or ten years ago.  I would argue that's patently unfair to workers injured prior to the adoption of the guidelines.  With new evidence comes new knowledge about treatments that work... and treatments that don't.  Why wouldn't we apply the best medical evidence we have to all claims involving ongoing medical treatment?  To do otherwise would create two different standards of care in New York.  (Personally, I would have liked to have seen a phased in approach - like Texas is using for the new closed formulary rules - but New York chose not to do it that way.)

My view of the $60 million is that of an investment.  And I believe there will be return.

New York is experiencing the pain of establishing a new set of expectations for medical care delivery to work comp claimants.  This pain is political, cultural, and financial in nature.  But if the state will stick to its guns (and if the courts uphold the state's position), the return will come as providers adjust to the new treatment guidelines.  System costs will diminish as the clinical rationale necessary to secure a variance becomes clear to the provider community. 

But perhaps the greatest return will come in form of improved health and function for injured workers.  This statement will be anathema to the Work Comp Alliance.  In fact, the report states "unlike
medical treatment, which benefits the injured worker, the Medical Treatment Guidelines benefit no one in the workers’ compensation system."  This is unbelievably short-sighted and completely contrary to what we've learned about medicine over the past half century.  Not all medical treatment is good for the injured worker. 

The right care at the right time delivered to the right patient by the right provider - that's the goal of evidence-based medicine.  That should be the goal of any work comp system.  And that's the recipe for providing value in the delivery of medical care to work comp claimants. 

On Twitter @PRIUM1

Tuesday, March 13, 2012

Accountable Care Organizations and Work Comp

As we begin to see early (and encouraging) signs of success from Accountable Care Organizations (ACOs) around the country, I wonder what promise this might hold for work comp.

In Illinois, Chicago-based Advocate Health Care has teamed with Blue Cross Blue Shield of Illinois to deploy an ACO that appears to be yielding solid results. According to Kaiser Health News, the ACO has led to a 10.6% drop in inpatient admissions and a 5.4% drop in ED visits over the first 6 months of 2011. These data points exceeded the reduction in utilization across the rest of BCBS's book of business in Illinois.

Success factors? "Key to the results were the hiring of 60 'care managers,' many embedded in physician practices,  to manage high-risk cases and post-acute care. Also important are a relatively narrow provider network, anchored by Advocate’s 10 hospitals and about 4,000 physicians, and a payment system that incentivizes Advocate to contain costs but doesn’t put it at risk of catastrophic loss, said Dr. H. Scott Sarran, BCBSIL’s chief medical officer."

Case management and a tight, well-managed network... where have I heard that before?

These are the same strategies that many in work comp have tried to leverage to get a hold on utilization... but to no avail. So what's the difference?

In the ACO model, the case management is driven from the provider's perspective, not the insurer's. In the ACO model, there are real financial incentives embedded for network performance - its not simply fee for service delivered through a select group of providers. And finally, patients bear some level of financial responsibility for their utilization of resources within the ACO.

What needs to happen for us to see this model in work comp?

On Twitter @PRIUM1

Monday, March 12, 2012

Florida Employers: Fight Back on Repackaged Drugs

Now that AHCS has won the day in Florida, it's time for the state's employers to fight fire with fire. Clearly, the proposed amendments to SB 668 (offering rebates and rate roll backs) were not at all a genuine attempt at political compromise, but rather an intentional obfuscation of the process intended to stall the bill in committee. Bad outcome, but solid strategy. So what to do?

First, leverage utilization review to ensure the drugs being dispensed are, in fact, medically necessary. If not, stop paying. If they are, explore following the lead of the Miami-Dade School System (and a few other fed up employers) that may have figured out another potential solution.

According to a workcompcentral article from February 24, "Florida Statute 440.13 (12) establishes the current fee cap, but allows carriers to contract for a lower amount. The statute also allows carriers to pay contract amounts even if a provider is not a party to a contract... In October 2010, after Crist vetoed the first repackaging price cap, Miami-Dade Public Schools cited that section of the workers' compensation law and refused to pay repackaged drug prices for its 48,000 workers."

Here's how this works: An injured worker gets hurt and sees a doctor. The doctor prescribes and dispenses a drug, then makes up an NDC code, marks it up 300%, and bills the insurer. However, if a retail pharmacy, under contract with the insurer, is reasonably accessible for the injured worker, the insurer can re-price the drug to the contracted rate. I've talked to the Florida DWC about the definition of "reasonably accessible" - candidly, they're not really sure what would hold up in court.

This strategy is not without risk, but it might be worth a try for an employer tired of paying way too much and willing to put some legal dollars behind what is sure to be a well-financed fight with the likes of AHCS.

On Twitter @PRIUM1

Friday, March 9, 2012

Had enough? Report Quality of Care issues to your state Medical Association

On February 21 I talked about the concept of Prescribing physicians who do not “get it”.  I followed that up on February 27 with some specific examples in Texas where physicians are being held accountable.  Since then, there have been several other notices of similar progress on workcompcentral (all links below require subscription):
  • Florida: An article on February 28 follows the U.S. Attorney in his ongoing investigation into “Oxy Alley” of southern Florida “pill mills”.  Twenty-six defendants have been sentenced thus far, and interestingly only 13 defendants were doctors.  Two individuals, operating four “pain” clinics, distributed 20M (yes, 20,000,000) Oxycodone pills from 2008-2010 totaling $40M (yes, $40,000,000) in sales.
  • California: An article on March 2 notes that Dr. Hsiu-Tyin Tseng is being held on $3M bail by the Major Narcotics Division of Los Angeles County on three counts of second-degree murder, one felony count of prescribing drugs using fraud, and 20 felony counts of prescribing drugs without a legitimate purpose.  She had formerly agreed to pay $275K to the parents of one patient who overdosed from a combination of Xanax, Roxicodone and alcohol.  She also agreed to pay $225K to the family of another patient who died from drugs prescribed by Dr. Tseng.  She was also under federal investigation for running a “pill mill”.
  • Florida: An article today (March 9) talks about a “pill mill” being busted in Winter Haven FL where a NON-physician wrote scripts using the names of doctors who previously worked at the clinic and then hired hundreds of people to fill phony prescriptions (2,500 in total).  The vast majority of scripts were for the combination of Oxycodone (OxyContin) and Alprazolam (Xanax).
As I travel the country, our clients (carriers, TPA’s, self-insured employers, municipalities, excess carriers, captives, etc.) all are justifiably upset about what “bad” doctors do to their patients.  One, in North Carolina, made a very emphatic point that the problem IS the doctor.  While there are a variety of enablers throughout our society and our industry, I agree that primary culpability lies with the prescribing physicians (or, in some of the cases above, non-physicians).

If you pay a bill, you know the doctors who are over-prescribing because their name is listed.  If you see a trend over time, a prescribing physician on multiple claims with similar inappropriate regimens, compile the data and report them to your state’s Medical Association.  If it an issue of legality, report them to law enforcement.  I heard the Texas Medical Association specifically request Payers to notify them of “Quality of Care” issues.  The DEA and state/county/local officials need evidence to pursue investigations.

Hand wringing time is over.  We have the moral high ground and it's time to get these over-prescribers away from patients.

In this together – Mark

On Twitter @PRIUM1

Wednesday, March 7, 2012

The Middle Matters

A rceent sudty funod that it deosnt meattr waht odrer the ltteers of a wrod are in, the olny ipmoraotnt tihing is that the fsirt and lsat ltteers are in the crrocet piotison.

So from a reading comprehension standpoint, the details of what is in the middle are somewhat immaterial as our brain tends to do “word scramble” almost automatically.  However, in the rest of our lives, and certainly in Work Comp, what happens in the middle is extremely important.  Your origination point in everything you do is just that, a starting point.  Your intended destination, or in Work Comp your “outcomes”, is what you strive for.  How you get there – methods, management, motivations – determines if your defined goal is achievable.

I believe that most people (including most injured workers) that become tolerant / dependent / addicted to prescription drugs did not start with that as their goal.  Some may be predisposed to addictive behaviors because their starting point includes a history of family or personal abuse or addiction, but even they are not predestined for the end result of addiction.  It is the process in the middle, the enablers in the physician’s office and the home and the attorney’s office and the Payer’s checkbook, and an overall Work Comp system whose participants typically have financial motivators contrary to stopping treatment, that determines the destination and outcomes.  There are a lot of people in this industry that are trying to do the right thing, but on many claims we still end up far short of the intended outcome (the injured worker back to work and health ASAP).

A plan is not a plan unless it is envisioned, conscious and executed minute by minute.  So if you find yourself, personally or in your work life, just floating along the river and allowing the currents to take you where they will, your destination is undetermined and likely far different than what you had hoped for from the starting point.  Make the middle matter.

Monday, March 5, 2012

PRIUM accepts 2012 Innovation Award

If you have read this blog, you know that Michael and I don't use this platform to market for our company as we strive to focus Evidence Based on opinion and education.  However, a momentous occasion happened for us last Wednesday (Feb 29) when we accepted the 2012 Innovation Award from Business Insurance at the Waldorf-Astoria in NYC for our Qualified Medical Intervention (QMI) Program.

Here is how Business Insurance describes the award: “The Business Insurance Innovation Awards is a program intended to recognize leadership, inventiveness and ingenuity in products and services designed for professional risk managers.  This award was created in 2010.  Organizations submit their programs and products to be judged by a neutral panel of risk managers and awards are presented in conjunction with the Risk Management Summit.”

Our CEO and founder, Jim Pritchard, gave a gracious acceptance speech in the company of eight other recipients (out of 50 total applicants).  Michael was given the platform to explain our QMI Program to the 200+ risk managers in attendance.  And I witnessed the objective validation by our peers of the process we have created over the past 2+ years to successfully change patients’ lives through discontinuance of inappropriate drug regimens.

We are extremely appreciative to Business Insurance for sponsoring the awards, the panel of risk managers that evaluated the proposals, and our customers whose faith in us motivates our entire team.  Not only are we committed to further expanding the scope and success of our QMI outcomes in 2012, but to apply our innovative thinking to other issues and be in this same position again next year.

In this together – Mark
On Twitter @PRIUM1

Friday, March 2, 2012

CA: On the Compensability of Pain

David DePaolo’s post this morning on the recently released opinion by the CA 4th DCA is a critical read for anyone struggling with CA claims in which opioids are being used for somataform disorders (or physical symptoms that suggest a general medical condition but cannot be fully explained by that condition – more on this in a moment). 
I wanted to follow up on David’s question and supposition: “How many work comp cases allege fibromyalgia, or some other pain that is not reasonably explained by physical findings? I believe there is actually quite a large population of those cases in the system.”
David’s right – there are a lot.  Granted, when PRIUM looks at a case, it’s usually because there’s an issue that’s been identified (so we have a bit of selection bias), but we see some sort of unexplained pain disorder in about 30-40% of the cases in which we intervene.  The most common diagnoses we see in this area are chronic regional pain syndrome (CRPS) and fibromyalgia. 
This is a material issue in dealing with the drug regimen for these patients.  Co-morbid conditions are always a challenge, but those that are deemed psychiatric in nature are by far the most challenging.  Often, physicians are left practicing defensive medicine against a source of pain they cannot easily identify – and the most popular tool to fight this fight is a prescription narcotic (or a cocktail of narcotics and other medications).  
The CA decision could completely reset the way we think about these cases.  David’s explanation is very thorough, but in summary, the ruling states “that physical symptoms that are the product of psychological injury are not compensable if they are the product of lawful, nondiscriminatory, good faith personnel actions.”
I wonder, though, if this is opening Pandora’s box… or, contrary to mythical lure, somehow managing to put some things back in the box?  Those of us on the front lines in the fight against prescription drug over-utilization tend to view the myth from a different perspective. 
On Twitter @PRIUM1