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
Wednesday, May 2, 2012
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
Monday, April 30, 2012
Louisiana Case: Correlation and Causation
Louisiana's First Circuit Court of Appeal has offered a ruling on a work comp case that (finally) highlights an example of how an employer might effectively deal with the compensability issues that arise from chronic opioid use. The case is John Morgan vs. Barber Brothers Contracting Co., which began when Mr. Morgan suffered a legitimate, industrial-related neck injury in 1997. Cervical fusion followed... then 14 years of prescription narcotics to deal with the pain. Roberto Ceniceros offers a great overview on Business Insurance here.
Before we get into the specifics, let's discuss one of the great statistical misunderstandings of our time. We're constantly bombarded with news stories about the latest, greatest "study" that says "product x causes cancer" or "playing video games makes us smarter" or some other eye-catching claim. The first thought I have when I hear about one of these studies? Is this correlation? Or causation? Are the two activities ("eating ice cream" and "being diagnosed with cancer") simply correlated? Or does "eating ice cream" actually cause cancer? (Let's hope not). Get into the habit of asking yourself this question. The answer is often unknown, which should cause us to look at these studies with a bit more skepticism than we often do.
Back to Mr. Morgan. After 14 years of using prescription narcotics, Mr. Morgan developed sleep issues, depression, lethargy, fatigue, and sexual dysfunction. When asked to pay for sleep apnea testing and treatment for the sexual dysfunction, the employer refused.
You see, the doctor had also ordered an inpatient treatment program to wean the narcotics (enlightened!). This left a question for the employer: Was the sleep apnea and sexual dysfunction simply correlated with the opioid use? Or were these conditions actually CAUSED by the opioid use?
The answers here go to the core of the intransigent nature of the opioid over-utilization in work comp. If someone gets hurt and ends up on chronic opioid therapy, has the payer automatically accepted the need to pay for all of the other (correlated? or causal?) issues that arise from the use of these drugs over the long term?
The First Circuit in Louisiana has done a potentially great service to the world of work comp. Rather than declare the payer liable or not liable, they've essentially taken the position that the patient should go through detox first to better ascertain whether the sleep issues and sexual dysfunction are actually caused by the drugs themselves.
Brilliant. Now let's hope this catches on in other jurisdictions.
Michael
On Twitter @PRIUM1
Before we get into the specifics, let's discuss one of the great statistical misunderstandings of our time. We're constantly bombarded with news stories about the latest, greatest "study" that says "product x causes cancer" or "playing video games makes us smarter" or some other eye-catching claim. The first thought I have when I hear about one of these studies? Is this correlation? Or causation? Are the two activities ("eating ice cream" and "being diagnosed with cancer") simply correlated? Or does "eating ice cream" actually cause cancer? (Let's hope not). Get into the habit of asking yourself this question. The answer is often unknown, which should cause us to look at these studies with a bit more skepticism than we often do.
Back to Mr. Morgan. After 14 years of using prescription narcotics, Mr. Morgan developed sleep issues, depression, lethargy, fatigue, and sexual dysfunction. When asked to pay for sleep apnea testing and treatment for the sexual dysfunction, the employer refused.
You see, the doctor had also ordered an inpatient treatment program to wean the narcotics (enlightened!). This left a question for the employer: Was the sleep apnea and sexual dysfunction simply correlated with the opioid use? Or were these conditions actually CAUSED by the opioid use?
The answers here go to the core of the intransigent nature of the opioid over-utilization in work comp. If someone gets hurt and ends up on chronic opioid therapy, has the payer automatically accepted the need to pay for all of the other (correlated? or causal?) issues that arise from the use of these drugs over the long term?
The First Circuit in Louisiana has done a potentially great service to the world of work comp. Rather than declare the payer liable or not liable, they've essentially taken the position that the patient should go through detox first to better ascertain whether the sleep issues and sexual dysfunction are actually caused by the drugs themselves.
Brilliant. Now let's hope this catches on in other jurisdictions.
Michael
On Twitter @PRIUM1
Thursday, April 26, 2012
Health Wonk Review (including Evidence Based!)
A new edition of Health Wonk Review is up... and I'm pleased that Evidence Based has made its first appearance.
Thanks to Jennifer Salopek and Sarah Sonies at Wing of Zock for hosting.
Michael
On Twitter @PRIUM1
On Twitter @PRIUM1
Texas: Plan-Based Audit for Opioids
The state of Texas (Texas Department of Insurance, Division of Workers' Compensation) is currently accepting public comment on its proposed plan-based audit for pain management services in workers' compensation. Since our comments will be made public anyway, I thought I'd throw them out here on the blog:
To: Donald Patrick, M.D., J.D., Medical Advisor
Date: Thursday, April 26, 2012
As a utilization management company focused on the application of the Official Disability Guidelines to prescription drug utilization in the State of Texas, we appreciate the opportunity to provide input and suggestions on the development of the new Plan-Based Audit for health care providers prescribing opioids. We applaud the state of Texas for its efforts thus far in the area of narcotics control in workers' compensation and hope that this new Plan-Based Audit will further limit the inappropriate use of prescription narcotics.
Regarding Section III: Scope and Methodology - We understand the budgetary limitations associated with any undertaking such as this. That said, we're concerned that a focus on early prescribing of an opioid (within 10 days of the date of injury and >30 days supply) is too narrow to capture the broad nature of the problem. Often, injured workers only end up on grossly inappropriate drug regimens well after the initial injury, perhaps even years later. Dose escalations, tolerance, dependence, and addiction develop months and years down the road. While a focus on early prescribing behavior will alleviate a portion of the problem, our view is that the most intractable cases would not be identified with the criteria as currently proposed.
We suggest the Plan-Based Audit consider focusing on a measures much more likely to capture the most prevalent (and expensive) issue in the system - long term use of high dose narcotics. We suggest the following:
- Health care providers who have prescribed opioids to injured employees where the morphine equivalent dosage (MED) exceeds 120 mg per day.
Regarding Section IV: Selection Criteria - Again, we acknowledge budgetary constraints as a real issue in deploying a program such as the Plan-Based Audit. However, selecting a mere 15 physicians may not be sufficient to change or influence overall system behavior. The stated purposed of the Plan-Based Audit is to "focus attention on the issue of opioid utilization in the Texas workers' compensation system." We fear that the relatively small scope of the current proposed plan will fail to garner sufficient attention to guide future clinical decision-making.
Regarding Section V - Roles and Responsibilities - We suggest the following questions for the Medical Advisor's consideration as he develops guidance for the MQRP experts (these questions would be in addition to the already stated objecting of ensuring "that health care providers adhere to the Official Disability Guidelines and medically accepted standards of care for prescribing pain management services including opioids"):
1) Has the patient signed an opioid treatment agreement or narcotics contract?
2) Does the provider have the patient undergo regular urine drug monitoring?
3) Did the provider consult a prescription drug monitoring database prior to writing the prescription?
4) Has an opioid risk assessment been completed to evaluate likelihood of abuse issues?
5) What are the specific treatment goals for this patient in terms of functional improvement?
These questions represent several "best practices" in prescription drug utilization management and we believe these questions provide a potential road map for evaluating the treatment patterns of selected physicians.
We appreciate of the opportunity to provide input and suggestions.
Regards,
Michael Gavin
Chief Marketing Officer
PRIUM
On Twitter @PRIUM1
To: Donald Patrick, M.D., J.D., Medical Advisor
Date: Thursday, April 26, 2012
As a utilization management company focused on the application of the Official Disability Guidelines to prescription drug utilization in the State of Texas, we appreciate the opportunity to provide input and suggestions on the development of the new Plan-Based Audit for health care providers prescribing opioids. We applaud the state of Texas for its efforts thus far in the area of narcotics control in workers' compensation and hope that this new Plan-Based Audit will further limit the inappropriate use of prescription narcotics.
Regarding Section III: Scope and Methodology - We understand the budgetary limitations associated with any undertaking such as this. That said, we're concerned that a focus on early prescribing of an opioid (within 10 days of the date of injury and >30 days supply) is too narrow to capture the broad nature of the problem. Often, injured workers only end up on grossly inappropriate drug regimens well after the initial injury, perhaps even years later. Dose escalations, tolerance, dependence, and addiction develop months and years down the road. While a focus on early prescribing behavior will alleviate a portion of the problem, our view is that the most intractable cases would not be identified with the criteria as currently proposed.
We suggest the Plan-Based Audit consider focusing on a measures much more likely to capture the most prevalent (and expensive) issue in the system - long term use of high dose narcotics. We suggest the following:
- Health care providers who have prescribed opioids to injured employees where the morphine equivalent dosage (MED) exceeds 120 mg per day.
Regarding Section IV: Selection Criteria - Again, we acknowledge budgetary constraints as a real issue in deploying a program such as the Plan-Based Audit. However, selecting a mere 15 physicians may not be sufficient to change or influence overall system behavior. The stated purposed of the Plan-Based Audit is to "focus attention on the issue of opioid utilization in the Texas workers' compensation system." We fear that the relatively small scope of the current proposed plan will fail to garner sufficient attention to guide future clinical decision-making.
Regarding Section V - Roles and Responsibilities - We suggest the following questions for the Medical Advisor's consideration as he develops guidance for the MQRP experts (these questions would be in addition to the already stated objecting of ensuring "that health care providers adhere to the Official Disability Guidelines and medically accepted standards of care for prescribing pain management services including opioids"):
1) Has the patient signed an opioid treatment agreement or narcotics contract?
2) Does the provider have the patient undergo regular urine drug monitoring?
3) Did the provider consult a prescription drug monitoring database prior to writing the prescription?
4) Has an opioid risk assessment been completed to evaluate likelihood of abuse issues?
5) What are the specific treatment goals for this patient in terms of functional improvement?
These questions represent several "best practices" in prescription drug utilization management and we believe these questions provide a potential road map for evaluating the treatment patterns of selected physicians.
We appreciate of the opportunity to provide input and suggestions.
Regards,
Michael Gavin
Chief Marketing Officer
PRIUM
On Twitter @PRIUM1
Tuesday, April 24, 2012
H.R. 1063: What the Feds Can Do to Help Work Comp
I heard some discussion at RIMS around House Resolution 1063, titled "Strengthening Medicare And Repaying Taxpayers Act" (or the SMART Act, because all federal legislation must inevitably lead to a catchy acronym). The bill is suprisingly brief (13 pages), relatively straightforward, and seems to create a much more efficient approach to protecting Medicare's interests in light of work comp settlements.
Whenever I'm with a client and we're discussing prescription drug over-utilization, I typically see a lot of nodding heads and sympathetic glances. But when the issue of MSAs comes up (which, when discussing the onslaught of drugs in work comp, almost always comes up), claims executives' faces become contorted - total anguish. The process is viewed as difficult, unreliable, unpredictable, and intractable. I'm no expert on MSAs, but federal legislation to simplify the process seems to make sense (by the way, even though I'm not an expert, PRIUM has partnered with experts in the field - if you need one, let me know).
The core of the bill appears to be found in Section II: "Not later than 65 days after the date of receipt of a request under subclause I, the Secretary shall respond to such request with a statement of reiumbursement amount, which shall constitute the conditional payment subject to clause (ii) related to such settlement, judgment, award or other payment."
So... assuming the claim is on a rational, evidence-based clinical path (big assumption, I know), this bill aims to create a more predictable timeline for CMS response and could lead to greater efficiencies in closing out claims.
A link to the entire bill is here.
What says the MSA community? Helpful?
Michael
On Twitter @PRIUM1
Whenever I'm with a client and we're discussing prescription drug over-utilization, I typically see a lot of nodding heads and sympathetic glances. But when the issue of MSAs comes up (which, when discussing the onslaught of drugs in work comp, almost always comes up), claims executives' faces become contorted - total anguish. The process is viewed as difficult, unreliable, unpredictable, and intractable. I'm no expert on MSAs, but federal legislation to simplify the process seems to make sense (by the way, even though I'm not an expert, PRIUM has partnered with experts in the field - if you need one, let me know).
The core of the bill appears to be found in Section II: "Not later than 65 days after the date of receipt of a request under subclause I, the Secretary shall respond to such request with a statement of reiumbursement amount, which shall constitute the conditional payment subject to clause (ii) related to such settlement, judgment, award or other payment."
So... assuming the claim is on a rational, evidence-based clinical path (big assumption, I know), this bill aims to create a more predictable timeline for CMS response and could lead to greater efficiencies in closing out claims.
A link to the entire bill is here.
What says the MSA community? Helpful?
Michael
On Twitter @PRIUM1
Friday, April 20, 2012
Express Script's WC Drug Trend Report: Something Missing
I'm working my way through all of the drug trend reports released within the last week. I plan to provide a general overview of those within the next week or so (lots of data to sort through). I just got through the highlights from ESI, though, and found the approach interesting - and troubling.
The overview I read starts with "2011 Highlights" on page 1. And the overarching theme of the highlights is waste... $2.1 billion worth of waste in work comp. They define waste as "any additional spend on pharmacy costs that provides no incremental gain in health outcomes." Great definition.
But the report goes on to emphasize three major areas where waste occurs:
1) Utilization of high-cost brand medications when lower-cost therapeutic alternatives are available;
2) Not enough use of mail order as a mode of drug delivery (retail is more expensive);
3) Processing of prescriptions through out-of-network pharmacies and third party billers.
Those of you that know PRIUM know that I'm a bit... let's just say "focused"... but what about utilization of prescription drugs that are not medically necessary according to clinical guidelines (guidelines which, in many states, are statutorily recognized)?
Would ESI really have us believe that the way to limit inappropriate use of narcotics and other drugs can be summed up in "generics, mail order, and networks"?
Later in the report, in much smaller font, there's a section on "Narcotics Abuse and Misuse" that at least acknowledges what the CDC has called an "epidemic," but ESI offers no direct solutions. I think there's a simple reason for this: it's complicated to try to solve the problem of prescription drug abuse and misuse.
Across the thousands of reviews PRIUM has conducted over the last few years, we've found that approximately 73% of the drugs we've reviewed are not medically necessary. Granted, there's selection bias here - PRIUM is often brought it when help is clearly needed on a claim. But cut that number in half... or by two-thirds... that's still a big number.
I completely agree with ESI's definition of waste, but I think they've missed a core component of that waste. When it comes to your PBM services, don't settle for reports. Demand solutions. Demand solutions that tackle head-on the issue of medical appropriateness, abuse, and misuse.
Michael
On Twitter @PRIUM1
The overview I read starts with "2011 Highlights" on page 1. And the overarching theme of the highlights is waste... $2.1 billion worth of waste in work comp. They define waste as "any additional spend on pharmacy costs that provides no incremental gain in health outcomes." Great definition.
But the report goes on to emphasize three major areas where waste occurs:
1) Utilization of high-cost brand medications when lower-cost therapeutic alternatives are available;
2) Not enough use of mail order as a mode of drug delivery (retail is more expensive);
3) Processing of prescriptions through out-of-network pharmacies and third party billers.
Those of you that know PRIUM know that I'm a bit... let's just say "focused"... but what about utilization of prescription drugs that are not medically necessary according to clinical guidelines (guidelines which, in many states, are statutorily recognized)?
Would ESI really have us believe that the way to limit inappropriate use of narcotics and other drugs can be summed up in "generics, mail order, and networks"?
Later in the report, in much smaller font, there's a section on "Narcotics Abuse and Misuse" that at least acknowledges what the CDC has called an "epidemic," but ESI offers no direct solutions. I think there's a simple reason for this: it's complicated to try to solve the problem of prescription drug abuse and misuse.
Across the thousands of reviews PRIUM has conducted over the last few years, we've found that approximately 73% of the drugs we've reviewed are not medically necessary. Granted, there's selection bias here - PRIUM is often brought it when help is clearly needed on a claim. But cut that number in half... or by two-thirds... that's still a big number.
I completely agree with ESI's definition of waste, but I think they've missed a core component of that waste. When it comes to your PBM services, don't settle for reports. Demand solutions. Demand solutions that tackle head-on the issue of medical appropriateness, abuse, and misuse.
Michael
On Twitter @PRIUM1
Thursday, April 19, 2012
KASPER: Doctors Slowing Progress
I've been tracking the progress of HB 4 (now HB 1 in the special session) in the Kentucky state legislature for a few weeks now. The bill aims to strengthen Kentucky's ability to monitor prescription drugs and force pill mills out of business. In a state where the prescription drug abuse epidemic is particularly bad, such a measure appears to make sense and should enjoy across-the-board support.
Not so fast.
The Kentuck Medical Association has issued a "call to action" for its members to lobby for changes to the bill. They claim the bill will lead to malicious prosecution of doctors and will interfere with a doctor's ability to practice medicine in a professional manner.
So let's examine the core tenets of the bill:
- Physicians will be required to register in KASPER (only one-third of docs are registered today).
- Physicians running pain clinics would have to be on-site treating patients at least 50% of the time the clinic is open.
- Clinics will have to accept insurance vs. only cash payments.
- Physicians will be required to consult KASPER (Kentucky's PDMP - Kentucky All Schedule Prescription Electronic Reporting system) before prescribing schedule II and III drugs.
- Doctors will be restricted from dispensing more than a 48-hour supply of schedule II and II drugs.
- Move management of the database from Health and Family Services to the Attorney General's office.
- Doctors might have to pay a $50 annual fee to support the administration of the KASPER database.
I'll grant that the $50 annual fee is a bit of an annoyance and I would suggest the state legislature find a different financing mechanism. That being said, the requirement to consult the database and the restriction on physician dispensing are logical, high impact measures that will have virtually zero negative impact on the vast majority of doctors in the state of Kentucky. Some doctors are concerned about the AG's office managing the database... but if you're a good doc doing the right thing, this shouldn't be a concern (particularly because hospice and emergency care are excluded).
Governor Beshear has called a special session of the state legislature in which this bill will be addressed. The House has already passed the bill (again). Now it's up to the Senate where the bill failed during the general session mostly due to the efforts of the Kentucky Medical Association.
Other states are watching. I hope Kentucky does the right thing.
Michael
On Twitter @PRIUM1
Not so fast.
The Kentuck Medical Association has issued a "call to action" for its members to lobby for changes to the bill. They claim the bill will lead to malicious prosecution of doctors and will interfere with a doctor's ability to practice medicine in a professional manner.
So let's examine the core tenets of the bill:
- Physicians will be required to register in KASPER (only one-third of docs are registered today).
- Physicians running pain clinics would have to be on-site treating patients at least 50% of the time the clinic is open.
- Clinics will have to accept insurance vs. only cash payments.
- Physicians will be required to consult KASPER (Kentucky's PDMP - Kentucky All Schedule Prescription Electronic Reporting system) before prescribing schedule II and III drugs.
- Doctors will be restricted from dispensing more than a 48-hour supply of schedule II and II drugs.
- Move management of the database from Health and Family Services to the Attorney General's office.
- Doctors might have to pay a $50 annual fee to support the administration of the KASPER database.
I'll grant that the $50 annual fee is a bit of an annoyance and I would suggest the state legislature find a different financing mechanism. That being said, the requirement to consult the database and the restriction on physician dispensing are logical, high impact measures that will have virtually zero negative impact on the vast majority of doctors in the state of Kentucky. Some doctors are concerned about the AG's office managing the database... but if you're a good doc doing the right thing, this shouldn't be a concern (particularly because hospice and emergency care are excluded).
Governor Beshear has called a special session of the state legislature in which this bill will be addressed. The House has already passed the bill (again). Now it's up to the Senate where the bill failed during the general session mostly due to the efforts of the Kentucky Medical Association.
Other states are watching. I hope Kentucky does the right thing.
Michael
On Twitter @PRIUM1
Monday, April 16, 2012
RIMS 2012
Off to a great start here in Philadelphia. Exhibits open in an hour... and half our team is stuck in airports (with our marketing materials)... the shuttle never showed at the hotel, so I walked 8 blocks here... and our booth desperately needs a vacuum. Otherwise, we're all set!
We'll be pretty busy this week at RIMS, so posts on Evidence Based might be light. You can follow our thoughts and perspectives regarding the conference via Twitter @PRIUM1.
(Like this morning's commentary regarding the Texas DWC opioid audit: it's a start, but not enough to even make a dent.)
Michael
On Twitter @PRIUM1
We'll be pretty busy this week at RIMS, so posts on Evidence Based might be light. You can follow our thoughts and perspectives regarding the conference via Twitter @PRIUM1.
(Like this morning's commentary regarding the Texas DWC opioid audit: it's a start, but not enough to even make a dent.)
Michael
On Twitter @PRIUM1
Friday, April 13, 2012
Massachusetts: New Chronic Pain Guidelines
The new Massachusetts guidelines have been out for a while, but I finally had a chance to sit down (on an airplane, of course) and read through them in detail. A few quick comments:
Generally, I'm not a fan of state-specific sets of guidelines. While I've been accused in the past of acting as an agent of certain other sets of guidelines (no, I don't work for WLDI), I like the idea of evidence-based guidelines over consensus-based guidelines. Massachusetts chose to take Washington, Colorado, mix in a little ACOEM, and voila - new guidelines. I can understand the rationale (consensus does have a certain amount of value, albeit political value and not clinical value), but it calls into question the credibility of the guidelines from the outset. Who was on the committee? Who had influence? Who had the most lobbyists? In this case, the process appears to have been fairly inclusive, transparent, and thorough... it just creates another niche set of guidelines for all of us in work comp to have to get to know.
The section on medications in deceivingly simple. While it's roughly only a single printed page, it does contain the straightforward theme of valuing documented functional improvement above all else and does emphasize the need to incorporate the psycho-social component of care. The guidelines discuss the need to consult the Massachusetts Prescription Monitoring Program database, the need for a patient-physician agreement, and the need for ongoing drug screening. Perhaps most importantly, the guidelines strongly suggest that providers seek additional specialist-based consultation for any narcotic regimen exceeding 120 mg MED per day.
Alas, however, the guidelines in Massachusetts are only advisory in nature. They are to be considered by treating physicians, work comp judges, and utilization review agents, but none of these parties is bound by the guidelines.
A potential bright spot: Deborah Kohl, a member of the Massachusetts Academy of Trial Lawyers, commented on the new guidelines in a workcompcentral article, "On face value, I find them disturbing."
When the plaintiffs' attorneys find something disturbing, that's typically a good sign.
Michael
On Twitter @PRIUM1
Generally, I'm not a fan of state-specific sets of guidelines. While I've been accused in the past of acting as an agent of certain other sets of guidelines (no, I don't work for WLDI), I like the idea of evidence-based guidelines over consensus-based guidelines. Massachusetts chose to take Washington, Colorado, mix in a little ACOEM, and voila - new guidelines. I can understand the rationale (consensus does have a certain amount of value, albeit political value and not clinical value), but it calls into question the credibility of the guidelines from the outset. Who was on the committee? Who had influence? Who had the most lobbyists? In this case, the process appears to have been fairly inclusive, transparent, and thorough... it just creates another niche set of guidelines for all of us in work comp to have to get to know.
The section on medications in deceivingly simple. While it's roughly only a single printed page, it does contain the straightforward theme of valuing documented functional improvement above all else and does emphasize the need to incorporate the psycho-social component of care. The guidelines discuss the need to consult the Massachusetts Prescription Monitoring Program database, the need for a patient-physician agreement, and the need for ongoing drug screening. Perhaps most importantly, the guidelines strongly suggest that providers seek additional specialist-based consultation for any narcotic regimen exceeding 120 mg MED per day.
Alas, however, the guidelines in Massachusetts are only advisory in nature. They are to be considered by treating physicians, work comp judges, and utilization review agents, but none of these parties is bound by the guidelines.
A potential bright spot: Deborah Kohl, a member of the Massachusetts Academy of Trial Lawyers, commented on the new guidelines in a workcompcentral article, "On face value, I find them disturbing."
When the plaintiffs' attorneys find something disturbing, that's typically a good sign.
Michael
On Twitter @PRIUM1
Thursday, April 12, 2012
Texas: An Opportunity Revived?
In a post two weeks ago (TX: A Missed Opportunity), I wrote about what appeared to be an unfortunate decision on the part of the Division of Workers' Compensation in Texas to not include a performance-based measure for opioid prescribing on its 2013 provider report card. This morning's workcompcentral brings news that DWC Commissioner Ron Bordelon has said, "Nothing is final until I sign off on it." He is apparently willing to consider inclusion of a new measure for opioid prescribing (specifically, the level of narcotics prescribed either two months post-injury or two months post-surgery... definitely not the entire picture, but a start).
Mr. Bordelon also rightly pointed out that the new closed formulary rules are a solid sign that Texas is doing something about the opioid epidemic in work comp. Initial signs point to the potential success of the new rules. PRIUM's analysis showed a nearly two-thirds drop in prescriptions for drugs labeled "N" by the Official Disability Guidelines. PMSI just released their own analysis which appears to show about a 50% drop in "N" drug prescriptions as proportion of total prescriptions (Q4 2010 vs. Q4 2011). Interestingly, for the entire fourth quarter of 2011, PMSI saw a total of 142 prescriptions for "N" drugs, 141 of which were blocked at the point of sale. Only 1 script had a valid pre-authorization associated with it.
As he considers the opportunity, though, to include opioid prescribing behavior on the 2013 provider report card, I offer two management maxims that I personally live by:
1) You cannot manage what you do not measure.
2) Performance measured is performance improved.
I'll add my voice to the chorus of those calling for inclusion of the new measure.
Michael
On Twitter @PRIUM1
Mr. Bordelon also rightly pointed out that the new closed formulary rules are a solid sign that Texas is doing something about the opioid epidemic in work comp. Initial signs point to the potential success of the new rules. PRIUM's analysis showed a nearly two-thirds drop in prescriptions for drugs labeled "N" by the Official Disability Guidelines. PMSI just released their own analysis which appears to show about a 50% drop in "N" drug prescriptions as proportion of total prescriptions (Q4 2010 vs. Q4 2011). Interestingly, for the entire fourth quarter of 2011, PMSI saw a total of 142 prescriptions for "N" drugs, 141 of which were blocked at the point of sale. Only 1 script had a valid pre-authorization associated with it.
As he considers the opportunity, though, to include opioid prescribing behavior on the 2013 provider report card, I offer two management maxims that I personally live by:
1) You cannot manage what you do not measure.
2) Performance measured is performance improved.
I'll add my voice to the chorus of those calling for inclusion of the new measure.
Michael
On Twitter @PRIUM1
Wednesday, April 11, 2012
From the National Rx Abuse Summit
Thanks to those of you who attended the session yesterday here in Orlando. And a special thanks to those of you who noted that you read Evidence Based.
The discussion in yesterday's session (Financial Impact to Employers) had a few highlights I wanted to share.
First, I had planned to show a short video clip from Physicians for Responsible Opioid Prescribing. While the audio worked well, the video didn't. Serendipitously, though, one of the doctors featured in the video was in the room and shared his thoughts on the topic live and in-person. Many thanks to Dr. Andrew Kolodny for being willing to fill in where the A/V system fell short. Dr. Kolodny's presence was also confirmation for many of us that this conference is the right place to be for those of us dedicated to eliminating inappropriate use of prescription narcotics in work comp.
Speaking of work comp, I began my presentation yesterday by noting that PRIUM is focused in the work comp space, but that I planned to broaden the discussion to other payers and stakeholders. But as I scanned the room, I saw lots of familiar faces... and as we moved to Q&A, it was confirmed for me that the room was filled with predominantly work comp folks.
Do we in work comp "get it"? Is the problem of prescription drug abuse more prevalent in comp than in the group or government payer sectors? Or did the work comp sector just do a better job of networking and creating awareness for the event?
Genuinely interested in your thoughts...
Michael
On Twitter @PRIUM1
The discussion in yesterday's session (Financial Impact to Employers) had a few highlights I wanted to share.
First, I had planned to show a short video clip from Physicians for Responsible Opioid Prescribing. While the audio worked well, the video didn't. Serendipitously, though, one of the doctors featured in the video was in the room and shared his thoughts on the topic live and in-person. Many thanks to Dr. Andrew Kolodny for being willing to fill in where the A/V system fell short. Dr. Kolodny's presence was also confirmation for many of us that this conference is the right place to be for those of us dedicated to eliminating inappropriate use of prescription narcotics in work comp.
Speaking of work comp, I began my presentation yesterday by noting that PRIUM is focused in the work comp space, but that I planned to broaden the discussion to other payers and stakeholders. But as I scanned the room, I saw lots of familiar faces... and as we moved to Q&A, it was confirmed for me that the room was filled with predominantly work comp folks.
Do we in work comp "get it"? Is the problem of prescription drug abuse more prevalent in comp than in the group or government payer sectors? Or did the work comp sector just do a better job of networking and creating awareness for the event?
Genuinely interested in your thoughts...
Michael
On Twitter @PRIUM1
Monday, April 9, 2012
Choosing Wisely: Evidence-Based Medicine Comes to the Masses
Last week, nine medical specialty societies (in concert with the ABIM Foundation) announced lists of tests and procedures that are frequently used, but show little clinical evidence of effectiveness. Interestingly, each of the "lists" is titled: Five Things Physicians and Patients Should Question.
That's physicians... and PATIENTS. I congratulate the Choosing Wisely initiative for involving the patient in the care decision, empowering the patient to participate in the decison-making process, and expecting that the patient can bear this responsibility.
My personal favorite comes from the American College of Physicians:
Don’t obtain imaging studies in patients with non-specific low back pain. In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., non-specific low back pain), imaging with plain radiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI) does not improve patient outcomes.
And similarly from the American Academy of Family Physicians:
Don’t do imaging for low back pain within the first six weeks, unless red flags are present. Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.
The lists from all nine groups can be found here.
This is excellent work in that it is:
1) Data-driven
2) Consenus-backed
3) Patient-focused
For your reference, the nine participating groups were:
American Academy of Allergy, Asthma & Immunology
American Academy of Family Physicians
American College of Cardiology
American College of Physicians
American College of Radiology
American Gastroenterological Association
American Society of Clinical Oncology
American Society of Nephrology
American Society of Nuclear Cardiology
Now if we could only get the American Academy of Pain Management to participate...
Michael
On Twitter @PRIUM1
That's physicians... and PATIENTS. I congratulate the Choosing Wisely initiative for involving the patient in the care decision, empowering the patient to participate in the decison-making process, and expecting that the patient can bear this responsibility.
Don’t obtain imaging studies in patients with non-specific low back pain. In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., non-specific low back pain), imaging with plain radiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI) does not improve patient outcomes.
And similarly from the American Academy of Family Physicians:
The lists from all nine groups can be found here.
This is excellent work in that it is:
1) Data-driven
2) Consenus-backed
3) Patient-focused
For your reference, the nine participating groups were:
American Academy of Allergy, Asthma & Immunology
American Academy of Family Physicians
American College of Cardiology
American College of Physicians
American College of Radiology
American Gastroenterological Association
American Society of Clinical Oncology
American Society of Nephrology
American Society of Nuclear Cardiology
Now if we could only get the American Academy of Pain Management to participate...
Michael
On Twitter @PRIUM1
Thursday, April 5, 2012
The full cost of opioid over-utilization
Joe Paduda's blog today, "Is your hair on fire yet?", puts forth an excellent explanation as to the total cost of opioid over-utilization. Beyond the costs to patients' health and payers' claims, a possible hidden cost to some payers is the lost time due to patients not being able to return to work, or not allowed back to work because of liability related to their ongoing drug use. While that might seem to be obvious, in my discussions in the marketplace I completely concur with Joe that it is in large part not actively being addressed.
At this juncture, there is no lack of exposure to the problem (at this rate I'm anticipating a new 24/7 cable channel to deal exclusively with the U.S. prescription drug abuse issue). And if you have read this blog, you know how passionate both Michael and I are on this subject.
So to Joe on behalf of Michael, myself and the PRIUM team, all I can say is ... Amen!
In this together – Mark
On Twitter @PRIUM1
At this juncture, there is no lack of exposure to the problem (at this rate I'm anticipating a new 24/7 cable channel to deal exclusively with the U.S. prescription drug abuse issue). And if you have read this blog, you know how passionate both Michael and I are on this subject.
So to Joe on behalf of Michael, myself and the PRIUM team, all I can say is ... Amen!
In this together – Mark
On Twitter @PRIUM1
Wednesday, April 4, 2012
Two steps forward, one standing still
My morning had a good start with my daily read of workcompcentral for activity on April 3:
In this together – Mark
On Twitter @PRIUM1
- Arizona Guidelines: The Senate passed an omnibus bill (HB 2368) that “requires the Industrial Commission (ICA) to develop and implement a process for the use of evidence based medical treatment guidelines, where appropriate, to treat injured workers no later than December 31, 2014.” The ICA is to provide status updates each December 31 (starting in 2012), and if consensus cannot be reached by 2014 then at least a timetable will be established. The floor amendment does not mandate what guidelines to create/select, or the criteria for selection, but at least sets the process into motion. Obviously this isn’t law yet but this legislative consensus is a very good sign that a standard of care beyond the treating physician’s personal opinion is coming. Feel free to go back in time and read my March 23 blog about Arizona.
- Oklahoma Opt-Out: The compromise process in the legislature appears to be working as the Oklahoma Senate Judiciary Committee approved that employers with as few as one employee could choose to opt-out of the Work Comp system. The original bill required fifty employees, which became a sticking point as the perception of bias towards larger employers. Their substitute plan to offer medical and indemnity benefits would still be subject to Employee Retirement Income Security Act (ERISA) regulated by the federal government. Not surprisingly, business and employer groups support this new option while insurers and insurance organizations oppose (they obviously have some skin in the game). Several obstacles remain to this becoming law, including approval by the full Senate and then the House, but it certainly appears as though this is now much closer to happening. Feel free to go back in time and read my March 19 blog about this opt-out provision.
- Mississippi Reform: Unfortunately, the good news stops here. Mississippi appears to be at a standstill in regards to SB 2576 and HB 555 that would shift presumption in favor of employers in many cases, increase benefits for death and disfigurement, limit claimant’s attorneys’ fees, and allow employers to require drug tests of workers suspected of alcohol and drug contribution to work-related accidents. As we all know, the “sausage making” process of legislating can be messy at times, and it is difficult to understand everything that happens outside of the spotlight and behind closed doors (“Gary Chism, R-Columbus, said that members were lobbied intensely over the weekend to pull back the measure”). Obviously, there is more than meets the eye here as Mississippi tries to join the majority of states that at least give balance to the process of assessing medical appropriateness, but hopefully change will eventually come.
In this together – Mark
On Twitter @PRIUM1
Tuesday, April 3, 2012
Y doesn’t necessarily mean Yes
As readers of this blog know, I am keenly interested in the Texas Closed Formulary (TCF) and the effect those rules have on treatment and prescription behavior. My January 2012 whitepaper documented a more than 50% reduction in the use of “N” drugs (as classified by ODG’s Work Comp Drug Formulary) for claims requiring preauthorization on dates of injury on or after 9/1/11. Other sources subsequently documented similar or even greater reduction in the use of “N” drugs for new injuries.
Since February I have been seeking input as to what is happening with that 50% not using “N” drugs. There is no consensus but many theories, including:
The ODG drug formulary applied a Status of “N” if the drug is not recommended as first-line treatment and preauthorization is recommended to assess their appropriateness and necessity. A drug with a status of “Y” is a preferred drug for first-line therapy.
For example, all benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam, temazepam, etc.) have an “N” status. All non-prescription analgesics (acetaminophen, ibuprofen, naproxen) have a “Y” status. For oxycodone opioids, OxyIR is a “Y” while Oxecta (recommended for patients with risk of abuse but not as first-line therapy for other patients) and OxyContin (second-line therapy due to issues of abuse and Black Box FDA warnings) are “N”. But just because OxyIR is “Y” doesn’t mean it is medically appropriate as it still needs to meet the criteria of opioid treatment (conservative therapies and less potent analgesics were unsuccessful in controlling pain, risk management pre-screening has been completed for opioid use, etc.).
Other opioids that are “Y” include Suboxone (Buprenorphine), Codeine, Duragesic (Fentanyl) patches, Vicodin and Lortab (Hydrocodone/APAP), Dilaudid (Hydromorphone), Levo-Dromoran (Levorphanol), Morphine, Embeda (Morphine ER), Percocet (Oxycodone/APAP), Ultram (Tramadol), Ultracet (Tramadol/APAP). If you have been involved in Work Comp, you probably recognize many of these drugs, and probably question their use in cases. And that is my point. Just because the drug is a “Y” in ODG, or not included in ODG’s formulary (i.e. non-FDA approved), does not mean they are automatically medically appropriate.
In this together – Mark
On Twitter @PRIUM1
Since February I have been seeking input as to what is happening with that 50% not using “N” drugs. There is no consensus but many theories, including:
- Switching to more conservative therapy
- Switching to “Y” drugs
- Switching to interventional methods like injections or nerve blocks
- Cost shifting to the injured worker’s group health policy or Medicare/Medicaid
- Injured worker paying for the drugs themselves
- It was a statistical anomaly that will even out over time
The ODG drug formulary applied a Status of “N” if the drug is not recommended as first-line treatment and preauthorization is recommended to assess their appropriateness and necessity. A drug with a status of “Y” is a preferred drug for first-line therapy.
For example, all benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam, temazepam, etc.) have an “N” status. All non-prescription analgesics (acetaminophen, ibuprofen, naproxen) have a “Y” status. For oxycodone opioids, OxyIR is a “Y” while Oxecta (recommended for patients with risk of abuse but not as first-line therapy for other patients) and OxyContin (second-line therapy due to issues of abuse and Black Box FDA warnings) are “N”. But just because OxyIR is “Y” doesn’t mean it is medically appropriate as it still needs to meet the criteria of opioid treatment (conservative therapies and less potent analgesics were unsuccessful in controlling pain, risk management pre-screening has been completed for opioid use, etc.).
Other opioids that are “Y” include Suboxone (Buprenorphine), Codeine, Duragesic (Fentanyl) patches, Vicodin and Lortab (Hydrocodone/APAP), Dilaudid (Hydromorphone), Levo-Dromoran (Levorphanol), Morphine, Embeda (Morphine ER), Percocet (Oxycodone/APAP), Ultram (Tramadol), Ultracet (Tramadol/APAP). If you have been involved in Work Comp, you probably recognize many of these drugs, and probably question their use in cases. And that is my point. Just because the drug is a “Y” in ODG, or not included in ODG’s formulary (i.e. non-FDA approved), does not mean they are automatically medically appropriate.
In this together – Mark
On Twitter @PRIUM1
Monday, April 2, 2012
Opioids Just the Start: The True Complexity of Drug Regimens
With our industry's intense focus on chronic opioid therapy, I thought it would be enlightening to point out that the opioid itself is generally the most expensive and prominent drug in the regimen, but typically leads to the use of a host of other medications, often used to treat the side effects of the opioid therapy.
Does this picture look familiar?
I'm consistently shocked at the content of the medical records we review here at PRIUM. Often (though I acknowledge, not always), each of these conditions is treated as if it arose independent of the opioid therapy itself. The treating physician documents the lack of good sleep hygiene, the muscle spasms, the depression, the weight gain, the sexual dysfunction, the constipation... all as if they arose as separate and distinct diagnoses.
Does this picture look familiar?
I'm consistently shocked at the content of the medical records we review here at PRIUM. Often (though I acknowledge, not always), each of these conditions is treated as if it arose independent of the opioid therapy itself. The treating physician documents the lack of good sleep hygiene, the muscle spasms, the depression, the weight gain, the sexual dysfunction, the constipation... all as if they arose as separate and distinct diagnoses.
The reality is that the physician is likely aware of the connection between the chronic opioid therapy and its side-effects, but I suspect documenting such is tricky. To do so explicitly would lead to the logical conclusion that the opioid "trial" has failed and the drug(s) clearly need to be weaned and/or discontinued. But this isn't what the patient wants - the patient wants his drugs. He's in pain and that pain needs to be treated, even if that means the patient's medicine cabinet looks like a veritable retail pharmacy operation.
Welcome to the reality of 21st century medicine: patient-directed care and a plethora of pills.
All the more reason to STOP opioid therapy if it does not lead to clearly documented functional improvement. There is no other valid clinical test. If you're seeing opioid therapy on a claim without documented functional improvement, you're going to be paying for a lot of different drugs down the line (if you're not already doing so).
Michael
On Twitter @PRIUM1
On Twitter @PRIUM1
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.
Michael
On Twitter @PRIUM1
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.
Michael
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.
Michael
On Twitter @PRIUM1
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.
Michael
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:
http://www.supremecourt.gov/oral_arguments/argument_audio.aspx
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.
Michael
On Twitter @PRIUM1
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:
http://www.supremecourt.gov/oral_arguments/argument_audio.aspx
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.
Michael
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:
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
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:
- 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.
- 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.
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.
Michael
On Twitter @PRIUM1
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.
Michael
On Twitter @PRIUM1
Tuesday, March 20, 2012
To Opt In or Out: Follow Up
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
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..."
Michael
On Twitter @PRIUM1
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..."
Michael
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.
Michael
On Twitter @PRIUM1
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.
Michael
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?
Michael
On Twitter @PRIUM1
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?
Michael
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.
Michael
On Twitter @PRIUM1
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.
Michael
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):
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
- 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).
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
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.
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