Physician Dispensing: Even More Expensive Than You Think

Fantastic research piece on the costs of physician dispensed medications from CWCI's Alex Swedlow, Laura Gardner, and John Ireland.

The statistics are compelling on many levels. 

No, there doesn't appear to be any overall claim cost savings associated with physician dispensed medication (as those that dispense medications have claimed).  In fact, claims involving physician dispensed medications exhibit 16.9% greater medical costs and 13.2% greater indemnity costs. 

While that data is troubling, I was more truly surprised by the contrast between the pre-2007-reform and post-2007-reform data sets.  While the percentage of claims which included physician dispensed medications dropped from 28% of claims to 6% of claims, the differential in medical and indemnity spend was actually exacerbated.  The pre-reform difference in medical spend was 16.4%... the post-reform differential jumped to 37.3%.  The pre-reform difference in indemnity spend was 6.9%... the post reform differential jumped to 28.2%. 

At about the same time that Mr. Swedlow was discussing this report in Boston at the Physician Dispensing Summit, I was in South Carolina presenting to a roomful of adjusters, case managers, attorneys and doctors at the South Carolina Workers' Compensation Education Conference.  As part of my presentation, I made mention of the CWCI report and its findings.  I'll share with you exactly what I shared in Charleston:

Just because you limit the physician's ability to charge outrageous prices (which South Carolina has done) doesn't mean you have eliminated the problem.  Don't take your eye off the ball.  There may be fewer cases in the future for which physicians dispense meds, but these claims can be real cost drivers if not monitored very closely. 

Michael
On Twitter @PRIUM1

NCOIL Picks Up Where IAIABC Left Off

There's hope for state legislators looking for guidance on how best to handle the opioid crisis within the work comp system.  And the source of that hope turns about to be the legislators themselves.

According to WorkCompCentral, the National Conference of Insurance Legislators (NCOIL) will take up the issue as part of its spring meeting in DC this year.  Specifically, the group's Workers' Compensation Insurance Committee has scheduled a special session to address the issue with the aim of providing a draft set of standards which specific jurisdictions can use to guide state-level reform efforts. 

The group had expected to review the IAIABC draft legislation and regulatory framework, but given IAIABC's failure to approve those drafts, NCOIL will begin the effort anew. 

Comments from NCOIL included in the WorkCompCentral article indicate an interest in the approach Kentucky has taken.  Last year's HB 1 isn't perfect and has certainly sparked controversy, but NCOIL is headed in the right direction.  (You can read my thoughts on Kentucky's HB 1 - and some of the colorful comments I received - here and here). 

Well done, NCOIL. 

Michael
On Twitter @PRIUM1

Abject Failure at the IAIABC

Bob Wilson and Joe Paduda have both covered this topic, but because I spent a significant amount of personal time and effort on this... and because I'm incredibly upset about it... I figured I'd pile on and write about it, too.

The International Association of Industrial Accident Boards and Commissions is a non-profit trade association representing government agencies charged with administering work comp systems, primarily here in North America.  For over a year, they've been working on both model legislation and a model regulatory framework to provide guidance to states on how best to deal with the opioid crisis in work comp.  I've commented on the those guidelines extensively (first here, then here).  The models needed work, but IAIABC was moving in the right direction.  And this is the mission of the organization, right?  "To advance the efficiency and effectiveness of workers' compensation systems throughout the world..."

Now comes word that IAIABC's Executive Committee has put the models in a drawer, failing to approve the model language that had been worked on for the past year. 
(You can find a list of Executive Committee members here.  See if your state is represented!)

The IAIABC told Mr. Paduda that the "models would be overreaching on the part of IAIABC... We believed the consequences of advancing this prescriptive approach could potentially harm jurisdictions more than help." 

That is absolute nonsense and an abject failure on the part of this organization. 

I cannot understand how "model" legislation would in any way harm a jurisdiction.  Can the elected leaders in any one of our great states not resist the vast power and influence of the IAIABC?  Is there no way that a suggested regulatory framework could be changed to the suit the needs of a specific jurisdiction?  Does the IAIABC hold such incredible sway over state legislatures throughout the land that the mere mention of controlling opioid abuse through model laws would cause political, cultural, and clinical mayhem? 

The IAIABC thinks too highly of itself.  They had an opportunity to take the high road on this incredibly important issue and show their membership that it takes courage, fortitude, and intelligence to deal with this issue.  Instead, they punted.

On the IAIABC web site, there is a list of Current Issues.  There are only four items on that list.  "Opioid Abuse in Workers' Compensation" is one of them.

They should remove that immediately.

Michael
On Twitter @PRIUM1

Big Pharma and Big Influence: Get the Reps Out of Med Schools

Two recently published studies suggest that big pharma's influence is real and that it starts very early in a doctor's career.  Medical schools have long been fertile ground for drug companies and their representatives to establish cozy relationships with doctors in hopes of influencing future prescribing habits.  Turns out, the tactic works.  More on that in a moment.   

In the interest of full disclosure, I began my career out of college working at a reputable management consulting firm.  The biggest client was a drug company and my first project was launching a new cardiovascular drug in the US market.  Medical schools were target rich environments - lots of young, relatively poor, impressionable future doctors all in one place.  Show up with some pizza and you had influence.  Host a nice dinner, be a consistent presence on campus, and perhaps even provide some gifts, then you had friends... and potential future prescribers.  This was a sales tactic I once advocated.  It works.   

American Medical News provides a nice overview of both pieces of research.  I'll highlight the results of the first study, published last month in a British medical journal, which showed a stark contrast between a group of 2,500 medical school graduates from 14 schools that had put pharmaceutical company gift bans in place starting in 2004 vs. a matching set of doctors from different schools that lacked such a ban.  The study looks at the prescribing habits of the two groups with respect to three separate drugs.  For one drug (an antidepressant from Pfizer), the statistical difference between the two groups was insignificant.  But for the other two drugs (an ADHD drug from Shire called Vyvanse and an antipsycotic drug from Janssen called Invega) the results were staggering: the med school graduates from the 14 school test group were 56% and 75% less likely to prescribe those two drugs, respectively. 

Percentage of medical schools with gift bans (from the American Medical Student Association):
2008: 13%
2009: 29%
2010: 43%
2011-12: 53%

We know the influence of big pharma has played a significant role in the over-utilization of prescription opioids in work comp and beyond.  Though it'll take the better part of two decades (and we certainly can't wait that long), I nonetheless find it comforting to know that the next generation of doctors may start out with a cleaner slate than their predecessors. 

Michael

(Thanks to Jeff Woldanski at Allsup for the link to the article.) 

On Twitter @PRIUM1

Let's Make a Deal: Pain Management in the Age of Opioids

From time to time, I read letters written by treating physicians to PRIUM reviewing physicians.  These letters represent a great deal of what is wrong with pain management today.  While not emblematic at all of the best practitioners out there, these letters nonetheless reflect the thinking of too many physicians treating chronic pain patients. 

These prescribers try to strike deals.  Some offer to wean the opioids in exchange for pre-authorization of injections or other procedures.  A recent letter suggested that, if we were so concerned about the opioids, the doctor would be happy to wean them... if he could make a little money in the process doing some procedures. 

Some suggest they're doing the payer a favor already.  Methadone is a lot cheaper than Oxycontin, right?  So we should all just be grateful that the 800 mg MED is coming from a cheap source and not an expensive name brand drug.  As if incredibly dangerous drug regimens are somehow made more appropriate because the monthly cost is lower than it might be. 

Some note the nobility of our efforts, but label them as futile from the start.  They suggest outright disbelief that a particular injured worker will ever be able to reduce intake of opioids, however medically unnecessary the drugs may be.  The doctor is happy to refer them to a comprehensive pain management program... and they'll be equally happy to begin prescribing opioids again when the program fails.  The prevailing attitude: these patients can't live without these drugs, so let's just prescribe away the pain. 

Here's the thing, payers: You're financing all of this.  Make no mistake: If you stop paying for it, there will be noise. Nasty phone calls, unsettling letters, complaints left and right. But there are ways to cease payment without creating emergent clinical events for the injured worker. There's a right way to do this. And while I wish there was a simple solution to this very complicated problem, there's not. The solution is sophisticated, multi-faceted, and requires clinical, medical/legal, and jurisdictional expertise. There are no cookie cutters here... just a lot of claims and a lot of hard work to do.     

Ask yourself this question: When will the real liability of continued payment for a dangerous drug regimen outweigh the perceived liability of NOT paying for it?

No more deals.  Let's get to work. 

Michael
On Twitter @PRIUM1

Toilet Paper, Plumbers, and the Death Penalty: Hyperbole Not Helping

California’s SB 863 created a new process for dispute resolution in connection with the utilization review (UR) process.  After the standard UR process has run its course and an adverse determination has been rendered, an injured worker can request an Independent Medical Review (IMR).  The IMR is a mechanism to remove disputes over medical necessity from judges and put them in the hands of doctors.  Not a bad idea. 

The vendor for IMR services is Maximus Federal Services.  As reported in a workcompcentral article, the company recently sent a recruitment letter to California doctors offering $150 per case for standard reviews and $200 per case for expedited reviews.  At least one doctor, a cardiologist in Southern California by the name of Paul Grodan, thinks those rates are “ridiculous.”  But not just “ridiculous”… he shared some other choice words with author Greg Jones:

Reports for which doctors were paid those rates “would be worth toilet paper.” 

“I can’t even get a plumber to my house for that.” 

And my personal favorite: “It’s tantamount to having a death penalty case and paying the death penalty lawyer $150 for the appeal.” 

Wow.

(Leaving aside for a moment that the vast majority of death row inmates don’t even have legal counsel and among those that do, most of the work is done pro bono…)

Clearly, Dr. Grodan has taken the offer as a personal affront.  But such hyperbole has no place in the discussion on how best to deal with the dispute resolution process and how to make the IMR process work.  While acknowledging that a flat-fee arrangement might work under certain conditions, Dr. Grodan predicts the imminent failure of the IMR concept as currently contemplated. 

Here’s the reality of work comp UR: it is much more process-oriented than Dr. Grodan thinks.  The typical UR case constitutes a request for a medical test, procedure, or therapy.  The request is compared to evidence-based guidelines.  There’s a match… or there’s not.  A decision is rendered.  Are there cases that end up in a gray area?  Of course.  But those cases require more professional judgment than painstaking review of thousands of pages of medical records. 

Mr. Jones should have interviewed more than one doctor.  Dr. Grodan should have chosen his words a bit more judiciously.  If we step back, consider multiple view points, and remove the hyperbole, we’re likely to find a tenable solution to this simple economic issue. 

Michael
On Twitter @PRIUM1

Let the People Decide! Prescription Drugs and the Democratic Process

From what I can gather, 43 states have some form of Prescription Drug Monitoring Program (PDMP) up and running.  An additional 6 states have authorized such a program, but the systems are not yet functional or the concept hasn't yet been adequately funded.  That leaves a single state lagging behind all the rest: Missouri. 

Last year's legislative session saw Representative Kevin Engler introduce legislation that would create a PDMP.  The bill never came to a vote in the Missouri State Senate thanks to an 8 hour filibuster from Senator Rob Schaaf, a trained physician whose concern about patient privacy over patient safety made his state a bit of a laughing stock among those serious about combating prescription drug misuse.  (See PDMPs: NY Sets the Standard, MO Lags Behind).

Senator Schaaf is back this legislative session and has a new idea for how best to reconcile the competing ideals of privacy and safety: punt.  The good Senator apparently isn't comfortable with the idea of legislative representation, so his Senate Bill 146 calls for a state-wide referendum on the issue.  If the people of the Show Me State don't want to become the nation's capital for prescription drug abuse, well that's going to be on their heads... not on Senator Schaaf's. 

The more I think about it, though, the more I'm convinced he's on to something.  Perhaps things in most states would work better if state legislators got out of the way and let the people decide how the system should work.  In reality, this is impractical given the thousands of nuances and technicalities involved.  But for fundamental issues - like ones involving trade-offs between basic, but competing ideals - turning to the people might not be a bad idea.

Let's just hope, if SB 146 passes, that the people of Missouri do the right thing.

Michael
On Twitter @PRIUM1

Another Sad Story: Prescription Therapy Gone Awry

The front page of the Sunday New York Times yesterday featured the sad story of Richard Fee, a bright, talented baseball player who, as the title of the article states, Drowned in a Stream of Prescriptions.  His particular addiction was Adderall, an amphetamine-based medication used for the treatment of ADHD, a diagnosis which was questionable at best in Richard’s case. 

The story resonated with me, though, because of its implied indictment of our collective approach to any form of care delivery that might take more than a five minute office visit or a thirty minute trip to the operating room.  In particular, I saw themes throughout the article indicative of our culture of overtreatment and overreliance on prescription medication.  We’re dealing with more than just an opioid problem.  We’re dealing with more than just a chronic pain problem.  The fundamental model of care delivery is broken.

Below, I’ve taken several quotes from the Times article and simply removed the name of the drug and the diagnoses.  Ask yourself: How many injured workers do you know that fit the descriptions below?

“Through the remainder of 2010, in appointments with Dr. Ellison that usually lasted under five minutes, Richard returned for refills… Records indicate that he received only what was consistently coded as ‘pharmacological management’ – the official term for quick appraisals of medication effects – and none of the more conventional talk-based therapy that experts generally consider an important component… of treatment.”

“His [prescriptions] were always for the fast-acting variety, rather than the extended-release formula that is less prone to abuse.”

“Virginia is one of 43 states with a formal Prescription Drug Monitoring Program… Although pharmacies are required to enter all prescriptions for controlled substances into the system, Virginia law does not require doctors to consult it.” 

“’The doctor wouldn’t give me anything that’s bad for me,’ Mr. Fee recalled his son saying… ‘I’m not buying it on the street corner.’”

“He had it in his mind that because it came from a doctor, it was OK.” 

DeAnsin Parker, a clinical neuropsychologist in New York: “Diagnoses are made just this quickly, and medication is filled just this quickly.  And the lack of therapy is really sad.  Doctors are saying, ‘Just take the meds and see if they help.’”

Richard Fee eventually took his own life, unable to deal with his addiction and its consequences. 

We must do everything we can to stop addiction before it starts, provide alternative non-pharmacological therapy wherever we can, and help safely wean those already addicted to medications that are doing more harm than good.  This won’t be easy and it won’t be cheap.  But we have to do it anyway.

Michael   
On Twitter @PRIUM1