Bob Wilson and Joe Paduda have both covered this topic, but because I spent a significant amount of personal time and effort on this... and because I'm incredibly upset about it... I figured I'd pile on and write about it, too.
The International Association of Industrial Accident Boards and Commissions is a non-profit trade association representing government agencies charged with administering work comp systems, primarily here in North America. For over a year, they've been working on both model legislation and a model regulatory framework to provide guidance to states on how best to deal with the opioid crisis in work comp. I've commented on the those guidelines extensively (first here, then here). The models needed work, but IAIABC was moving in the right direction. And this is the mission of the organization, right? "To advance the efficiency and effectiveness of workers' compensation systems throughout the world..."
Now comes word that IAIABC's Executive Committee has put the models in a drawer, failing to approve the model language that had been worked on for the past year.
(You can find a list of Executive Committee members here. See if your state is represented!)
The IAIABC told Mr. Paduda that the "models would be overreaching on the part of IAIABC... We believed the consequences of advancing this prescriptive approach could potentially harm jurisdictions more than help."
That is absolute nonsense and an abject failure on the part of this organization.
I cannot understand how "model" legislation would in any way harm a jurisdiction. Can the elected leaders in any one of our great states not resist the vast power and influence of the IAIABC? Is there no way that a suggested regulatory framework could be changed to the suit the needs of a specific jurisdiction? Does the IAIABC hold such incredible sway over state legislatures throughout the land that the mere mention of controlling opioid abuse through model laws would cause political, cultural, and clinical mayhem?
The IAIABC thinks too highly of itself. They had an opportunity to take the high road on this incredibly important issue and show their membership that it takes courage, fortitude, and intelligence to deal with this issue. Instead, they punted.
On the IAIABC web site, there is a list of Current Issues. There are only four items on that list. "Opioid Abuse in Workers' Compensation" is one of them.
They should remove that immediately.
Michael
On Twitter @PRIUM1
Wednesday, February 20, 2013
Tuesday, February 19, 2013
Big Pharma and Big Influence: Get the Reps Out of Med Schools
Two recently published studies suggest that big pharma's influence is real and that it starts very early in a doctor's career. Medical schools have long been fertile ground for drug companies and their representatives to establish cozy relationships with doctors in hopes of influencing future prescribing habits. Turns out, the tactic works. More on that in a moment.
In the interest of full disclosure, I began my career out of college working at a reputable management consulting firm. The biggest client was a drug company and my first project was launching a new cardiovascular drug in the US market. Medical schools were target rich environments - lots of young, relatively poor, impressionable future doctors all in one place. Show up with some pizza and you had influence. Host a nice dinner, be a consistent presence on campus, and perhaps even provide some gifts, then you had friends... and potential future prescribers. This was a sales tactic I once advocated. It works.
American Medical News provides a nice overview of both pieces of research. I'll highlight the results of the first study, published last month in a British medical journal, which showed a stark contrast between a group of 2,500 medical school graduates from 14 schools that had put pharmaceutical company gift bans in place starting in 2004 vs. a matching set of doctors from different schools that lacked such a ban. The study looks at the prescribing habits of the two groups with respect to three separate drugs. For one drug (an antidepressant from Pfizer), the statistical difference between the two groups was insignificant. But for the other two drugs (an ADHD drug from Shire called Vyvanse and an antipsycotic drug from Janssen called Invega) the results were staggering: the med school graduates from the 14 school test group were 56% and 75% less likely to prescribe those two drugs, respectively.
Percentage of medical schools with gift bans (from the American Medical Student Association):
2008: 13%
2009: 29%
2010: 43%
2011-12: 53%
We know the influence of big pharma has played a significant role in the over-utilization of prescription opioids in work comp and beyond. Though it'll take the better part of two decades (and we certainly can't wait that long), I nonetheless find it comforting to know that the next generation of doctors may start out with a cleaner slate than their predecessors.
Michael
(Thanks to Jeff Woldanski at Allsup for the link to the article.)
On Twitter @PRIUM1
In the interest of full disclosure, I began my career out of college working at a reputable management consulting firm. The biggest client was a drug company and my first project was launching a new cardiovascular drug in the US market. Medical schools were target rich environments - lots of young, relatively poor, impressionable future doctors all in one place. Show up with some pizza and you had influence. Host a nice dinner, be a consistent presence on campus, and perhaps even provide some gifts, then you had friends... and potential future prescribers. This was a sales tactic I once advocated. It works.
American Medical News provides a nice overview of both pieces of research. I'll highlight the results of the first study, published last month in a British medical journal, which showed a stark contrast between a group of 2,500 medical school graduates from 14 schools that had put pharmaceutical company gift bans in place starting in 2004 vs. a matching set of doctors from different schools that lacked such a ban. The study looks at the prescribing habits of the two groups with respect to three separate drugs. For one drug (an antidepressant from Pfizer), the statistical difference between the two groups was insignificant. But for the other two drugs (an ADHD drug from Shire called Vyvanse and an antipsycotic drug from Janssen called Invega) the results were staggering: the med school graduates from the 14 school test group were 56% and 75% less likely to prescribe those two drugs, respectively.
Percentage of medical schools with gift bans (from the American Medical Student Association):
2008: 13%
2009: 29%
2010: 43%
2011-12: 53%
We know the influence of big pharma has played a significant role in the over-utilization of prescription opioids in work comp and beyond. Though it'll take the better part of two decades (and we certainly can't wait that long), I nonetheless find it comforting to know that the next generation of doctors may start out with a cleaner slate than their predecessors.
Michael
(Thanks to Jeff Woldanski at Allsup for the link to the article.)
On Twitter @PRIUM1
Monday, February 18, 2013
Let's Make a Deal: Pain Management in the Age of Opioids
From time to time, I read letters written by treating physicians to PRIUM reviewing physicians. These letters represent a great deal of what is wrong with pain management today. While not emblematic at all of the best practitioners out there, these letters nonetheless reflect the thinking of too many physicians treating chronic pain patients.
These prescribers try to strike deals. Some offer to wean the opioids in exchange for pre-authorization of injections or other procedures. A recent letter suggested that, if we were so concerned about the opioids, the doctor would be happy to wean them... if he could make a little money in the process doing some procedures.
Some suggest they're doing the payer a favor already. Methadone is a lot cheaper than Oxycontin, right? So we should all just be grateful that the 800 mg MED is coming from a cheap source and not an expensive name brand drug. As if incredibly dangerous drug regimens are somehow made more appropriate because the monthly cost is lower than it might be.
Some note the nobility of our efforts, but label them as futile from the start. They suggest outright disbelief that a particular injured worker will ever be able to reduce intake of opioids, however medically unnecessary the drugs may be. The doctor is happy to refer them to a comprehensive pain management program... and they'll be equally happy to begin prescribing opioids again when the program fails. The prevailing attitude: these patients can't live without these drugs, so let's just prescribe away the pain.
Here's the thing, payers: You're financing all of this. Make no mistake: If you stop paying for it, there will be noise. Nasty phone calls, unsettling letters, complaints left and right. But there are ways to cease payment without creating emergent clinical events for the injured worker. There's a right way to do this. And while I wish there was a simple solution to this very complicated problem, there's not. The solution is sophisticated, multi-faceted, and requires clinical, medical/legal, and jurisdictional expertise. There are no cookie cutters here... just a lot of claims and a lot of hard work to do.
Ask yourself this question: When will the real liability of continued payment for a dangerous drug regimen outweigh the perceived liability of NOT paying for it?
No more deals. Let's get to work.
Michael
On Twitter @PRIUM1
These prescribers try to strike deals. Some offer to wean the opioids in exchange for pre-authorization of injections or other procedures. A recent letter suggested that, if we were so concerned about the opioids, the doctor would be happy to wean them... if he could make a little money in the process doing some procedures.
Some suggest they're doing the payer a favor already. Methadone is a lot cheaper than Oxycontin, right? So we should all just be grateful that the 800 mg MED is coming from a cheap source and not an expensive name brand drug. As if incredibly dangerous drug regimens are somehow made more appropriate because the monthly cost is lower than it might be.
Some note the nobility of our efforts, but label them as futile from the start. They suggest outright disbelief that a particular injured worker will ever be able to reduce intake of opioids, however medically unnecessary the drugs may be. The doctor is happy to refer them to a comprehensive pain management program... and they'll be equally happy to begin prescribing opioids again when the program fails. The prevailing attitude: these patients can't live without these drugs, so let's just prescribe away the pain.
Here's the thing, payers: You're financing all of this. Make no mistake: If you stop paying for it, there will be noise. Nasty phone calls, unsettling letters, complaints left and right. But there are ways to cease payment without creating emergent clinical events for the injured worker. There's a right way to do this. And while I wish there was a simple solution to this very complicated problem, there's not. The solution is sophisticated, multi-faceted, and requires clinical, medical/legal, and jurisdictional expertise. There are no cookie cutters here... just a lot of claims and a lot of hard work to do.
Ask yourself this question: When will the real liability of continued payment for a dangerous drug regimen outweigh the perceived liability of NOT paying for it?
No more deals. Let's get to work.
Michael
On Twitter @PRIUM1
Thursday, February 7, 2013
Toilet Paper, Plumbers, and the Death Penalty: Hyperbole Not Helping
California’s SB 863 created a new process for dispute
resolution in connection with the utilization review (UR) process. After the standard UR process has run its
course and an adverse determination has been rendered, an injured worker can
request an Independent Medical Review (IMR).
The IMR is a mechanism to remove disputes over medical necessity from
judges and put them in the hands of doctors.
Not a bad idea.
The vendor for IMR services is Maximus Federal
Services. As reported in a
workcompcentral article, the company recently sent a recruitment letter to
California doctors offering $150 per case for standard reviews and $200 per
case for expedited reviews. At least one
doctor, a cardiologist in Southern California by the name of Paul Grodan,
thinks those rates are “ridiculous.” But
not just “ridiculous”… he shared some other choice words with author Greg
Jones:
Reports for which doctors
were paid those rates “would be worth toilet paper.”
“I can’t even get a
plumber to my house for that.”
And my personal
favorite: “It’s tantamount to having a death penalty case and paying the death
penalty lawyer $150 for the appeal.”
Wow.
(Leaving aside for a moment that the vast majority of death
row inmates don’t even have legal counsel and among those that do, most of the
work is done pro bono…)
Clearly, Dr. Grodan has taken the offer as a personal
affront. But such hyperbole has no place
in the discussion on how best to deal with the dispute resolution process and
how to make the IMR process work. While
acknowledging that a flat-fee arrangement might work under certain conditions,
Dr. Grodan predicts the imminent failure of the IMR concept as currently contemplated.
Here’s the reality of work comp UR: it is much more process-oriented than Dr. Grodan thinks. The typical UR case constitutes a request for
a medical test, procedure, or therapy.
The request is compared to evidence-based guidelines. There’s a match… or there’s not. A decision is rendered. Are there cases that end up in a gray
area? Of course. But those cases require more professional
judgment than painstaking review of thousands of pages of medical records.
Mr. Jones should have interviewed more than one doctor. Dr. Grodan should have chosen his words a bit
more judiciously. If we step back,
consider multiple view points, and remove the hyperbole, we’re likely to find a
tenable solution to this simple economic issue.
Tuesday, February 5, 2013
Let the People Decide! Prescription Drugs and the Democratic Process
From what I can gather, 43 states have some form of Prescription Drug Monitoring Program (PDMP) up and running. An additional 6 states have authorized such a program, but the systems are not yet functional or the concept hasn't yet been adequately funded. That leaves a single state lagging behind all the rest: Missouri.
Last year's legislative session saw Representative Kevin Engler introduce legislation that would create a PDMP. The bill never came to a vote in the Missouri State Senate thanks to an 8 hour filibuster from Senator Rob Schaaf, a trained physician whose concern about patient privacy over patient safety made his state a bit of a laughing stock among those serious about combating prescription drug misuse. (See PDMPs: NY Sets the Standard, MO Lags Behind).
Senator Schaaf is back this legislative session and has a new idea for how best to reconcile the competing ideals of privacy and safety: punt. The good Senator apparently isn't comfortable with the idea of legislative representation, so his Senate Bill 146 calls for a state-wide referendum on the issue. If the people of the Show Me State don't want to become the nation's capital for prescription drug abuse, well that's going to be on their heads... not on Senator Schaaf's.
The more I think about it, though, the more I'm convinced he's on to something. Perhaps things in most states would work better if state legislators got out of the way and let the people decide how the system should work. In reality, this is impractical given the thousands of nuances and technicalities involved. But for fundamental issues - like ones involving trade-offs between basic, but competing ideals - turning to the people might not be a bad idea.
Let's just hope, if SB 146 passes, that the people of Missouri do the right thing.
Michael
On Twitter @PRIUM1
Last year's legislative session saw Representative Kevin Engler introduce legislation that would create a PDMP. The bill never came to a vote in the Missouri State Senate thanks to an 8 hour filibuster from Senator Rob Schaaf, a trained physician whose concern about patient privacy over patient safety made his state a bit of a laughing stock among those serious about combating prescription drug misuse. (See PDMPs: NY Sets the Standard, MO Lags Behind).
Senator Schaaf is back this legislative session and has a new idea for how best to reconcile the competing ideals of privacy and safety: punt. The good Senator apparently isn't comfortable with the idea of legislative representation, so his Senate Bill 146 calls for a state-wide referendum on the issue. If the people of the Show Me State don't want to become the nation's capital for prescription drug abuse, well that's going to be on their heads... not on Senator Schaaf's.
The more I think about it, though, the more I'm convinced he's on to something. Perhaps things in most states would work better if state legislators got out of the way and let the people decide how the system should work. In reality, this is impractical given the thousands of nuances and technicalities involved. But for fundamental issues - like ones involving trade-offs between basic, but competing ideals - turning to the people might not be a bad idea.
Let's just hope, if SB 146 passes, that the people of Missouri do the right thing.
Michael
On Twitter @PRIUM1
Monday, February 4, 2013
Another Sad Story: Prescription Therapy Gone Awry
The front page of the Sunday New York Times yesterday featured
the sad story of Richard Fee, a bright, talented baseball player who, as the
title of the article states, Drowned in a Stream of Prescriptions. His particular addiction was Adderall, an
amphetamine-based medication used for the treatment of ADHD, a diagnosis which
was questionable at best in Richard’s case.
The story resonated with me, though, because of its implied indictment
of our collective approach to any form of care delivery that might take more
than a five minute office visit or a thirty minute trip to the operating room. In particular, I saw themes throughout the
article indicative of our culture of overtreatment and overreliance on
prescription medication. We’re dealing
with more than just an opioid problem.
We’re dealing with more than just a chronic pain problem. The fundamental model of care delivery is broken.
Below, I’ve taken several quotes from the Times article and simply removed the name of the drug and the diagnoses. Ask
yourself: How many injured workers do you know that fit the descriptions below?
“Through the remainder of 2010, in appointments with Dr.
Ellison that usually lasted under five minutes, Richard returned for refills… Records indicate that he received only what
was consistently coded as ‘pharmacological management’ – the official term for
quick appraisals of medication effects – and none of the more conventional
talk-based therapy that experts generally consider an important component… of
treatment.”
“His [prescriptions] were always for the fast-acting
variety, rather than the extended-release formula that is less prone to abuse.”
“Virginia is one of 43 states with a formal Prescription
Drug Monitoring Program… Although pharmacies are required to enter all
prescriptions for controlled substances into the system, Virginia law does not require doctors to consult it.”
“’The doctor wouldn’t
give me anything that’s bad for me,’ Mr. Fee recalled his son saying… ‘I’m
not buying it on the street corner.’”
“He had it in his mind that because it came from a doctor, it was OK.”
DeAnsin Parker, a clinical neuropsychologist in New York: “Diagnoses
are made just this quickly, and medication is filled just this quickly. And the lack of therapy is really sad. Doctors
are saying, ‘Just take the meds and see if they help.’”
Richard Fee eventually took his own life, unable to deal
with his addiction and its consequences.
We must do everything we can to stop addiction before it
starts, provide alternative non-pharmacological therapy wherever we can, and
help safely wean those already addicted to medications that are doing more harm
than good. This won’t be easy and it won’t
be cheap. But we have to do it anyway.
Thursday, January 31, 2013
Borders and Biology: Should a Physician's Licensure Matter?
Can someone explain to me how the physiology of a human being that lives in one state can differ so dramatically from human beings in other states? As some physicians and state regulators would have us believe, a doctor lacking licensure in a given state simply cannot understand the unique circumstances faced by patients in that state. Biology, it seems, recognizes state borders.
Take, for instance, the treating physician that recently refused to make any changes in her patient's drug regimen (which included the usual suspects - an opioid, a muscle relaxant, a sleep aid, etc... all for a twisted knee from 15 years ago). Her reasoning for not making changes? Despite the evidence presented and the collegial nature of the conversation, she stated that she was offended that the PRIUM reviewer wasn't licensed to practice medicine in her state. Our apologies, doctor. By all means, carry on with your medically unnecessary treatment.
Take the state of Illinois, where the Department of Insurance can't get out of its own way regarding some rather simple principles of utilization review. A bulletin from December appears to indicate UR physicians must be located within the state of Illinois... an unofficial response to inquiry indicates this doesn't apply to work comp... a follow up bulletin this month indicates that UR activities can't be "offshored", but doesn't provide any guidance as to the definition of offshoring, what constitutes UR activities, or whether it applies to work comp. Glad we cleared that up.
In a workcompcentral article on this topic, I noted the risk inherent in requiring UR doctors to be licensed and domiciled within the state from which the request was generated. Doctors in the same geographic area are much more likely to have trained together and may even be tied to one another's referral patterns. UR loses its independence and objectivity when conflicts of interest arise between reviewing and treating physicians that may have personal relationships or economic ties to one another.
But that's a more nuanced argument than is necessary here. The simple reality is that state licensure is a red herring - an excuse used by treating physicians when they're called out (however collegially) by a peer regarding medically unnecessary, and in some cases dangerous, treatment.
I'm tired of it. State legislators and regulators need to recognize that the injured workers in any given state will be better served by the input and oversight of the very best doctors... even if those doctors aren't the worker's treating physician... and even if they're not licensed in that state.
Michael
On Twitter @PRIUM1
Take, for instance, the treating physician that recently refused to make any changes in her patient's drug regimen (which included the usual suspects - an opioid, a muscle relaxant, a sleep aid, etc... all for a twisted knee from 15 years ago). Her reasoning for not making changes? Despite the evidence presented and the collegial nature of the conversation, she stated that she was offended that the PRIUM reviewer wasn't licensed to practice medicine in her state. Our apologies, doctor. By all means, carry on with your medically unnecessary treatment.
Take the state of Illinois, where the Department of Insurance can't get out of its own way regarding some rather simple principles of utilization review. A bulletin from December appears to indicate UR physicians must be located within the state of Illinois... an unofficial response to inquiry indicates this doesn't apply to work comp... a follow up bulletin this month indicates that UR activities can't be "offshored", but doesn't provide any guidance as to the definition of offshoring, what constitutes UR activities, or whether it applies to work comp. Glad we cleared that up.
In a workcompcentral article on this topic, I noted the risk inherent in requiring UR doctors to be licensed and domiciled within the state from which the request was generated. Doctors in the same geographic area are much more likely to have trained together and may even be tied to one another's referral patterns. UR loses its independence and objectivity when conflicts of interest arise between reviewing and treating physicians that may have personal relationships or economic ties to one another.
But that's a more nuanced argument than is necessary here. The simple reality is that state licensure is a red herring - an excuse used by treating physicians when they're called out (however collegially) by a peer regarding medically unnecessary, and in some cases dangerous, treatment.
I'm tired of it. State legislators and regulators need to recognize that the injured workers in any given state will be better served by the input and oversight of the very best doctors... even if those doctors aren't the worker's treating physician... and even if they're not licensed in that state.
Michael
On Twitter @PRIUM1
Tuesday, January 29, 2013
Comprehensive View of the Opioid Epidemic
I ran across two great pieces of writing today, one a journal article and the other an opinion piece. Both highlight how we got here and how hard it's going to be to dig out. Not exactly encouraging, but as I've said before... anyone that tells you they've solve the opioid epidemic in our society should be looked upon with great skepticism. This is hard.
The journal article comes from the Pain Physician Journal and is titled Opioid Epidemic in the United States. While there are no work comp specific statistics to be found, the paper is the most comprehensive overview of the opioid epidemic that I've read. Essentially, it's a meta analysis of other studies done over the last several years. I was left with a better appreciation of the breadth and depth of the problem at hand.
The second piece, published this past week by Dr. Jen Gunter entitled The FDA's New Restrictions on Hydrocodone are Unlikely to Solve Any Problem, is a very honest and candid assessment of the obstacles we face as a health care system and as a society in stemming the tide of opioid abuse. She points out the clinical, social, and financial drivers of the problem. While the financial drivers are different in work comp, the clinical and social factors are the same. Doctors are not sufficiently assessing depression, anxiety and other co-morbid conditions prior to the very first script. Clinicians are not adequately exploring conservative therapies before turning to pharmacological solutions. We know the story.
The hardest part to read was her conclusion:
"Requiring a new written prescription for hydrocodone every 30 days probably won’t change too much. Some doctors, to avoid the hassle, might refer a little sooner to pain programs (which will be good, if such a program is available) or to a surgeon (in general less good for chronic pain, but always available). Some doctors may refuse to start opioids (good for some patients and bad for others), but many doctors will probably just leave written prescriptions with their receptionists for their patients to pick up. In summary, the American problem with opioids and chronic pain will remain unchanged."
I hope she's not right, though I fear she might be. We need more than simple restrictions on hydrocodone scripts to get this public health issue under control.
Michael
On Twitter @PRIUM1
The journal article comes from the Pain Physician Journal and is titled Opioid Epidemic in the United States. While there are no work comp specific statistics to be found, the paper is the most comprehensive overview of the opioid epidemic that I've read. Essentially, it's a meta analysis of other studies done over the last several years. I was left with a better appreciation of the breadth and depth of the problem at hand.
The second piece, published this past week by Dr. Jen Gunter entitled The FDA's New Restrictions on Hydrocodone are Unlikely to Solve Any Problem, is a very honest and candid assessment of the obstacles we face as a health care system and as a society in stemming the tide of opioid abuse. She points out the clinical, social, and financial drivers of the problem. While the financial drivers are different in work comp, the clinical and social factors are the same. Doctors are not sufficiently assessing depression, anxiety and other co-morbid conditions prior to the very first script. Clinicians are not adequately exploring conservative therapies before turning to pharmacological solutions. We know the story.
The hardest part to read was her conclusion:
"Requiring a new written prescription for hydrocodone every 30 days probably won’t change too much. Some doctors, to avoid the hassle, might refer a little sooner to pain programs (which will be good, if such a program is available) or to a surgeon (in general less good for chronic pain, but always available). Some doctors may refuse to start opioids (good for some patients and bad for others), but many doctors will probably just leave written prescriptions with their receptionists for their patients to pick up. In summary, the American problem with opioids and chronic pain will remain unchanged."
I hope she's not right, though I fear she might be. We need more than simple restrictions on hydrocodone scripts to get this public health issue under control.
Michael
On Twitter @PRIUM1
Thursday, January 17, 2013
New Opioid Guidelines: Well Done Washington
Washington State's Department of Labor & Industries (L&I) has issued new, and quite comprehensive, guidelines for prescribing opioids to treat injured workers. Yes, Washington is a monopolistic state. Yes, I've been critical in the past of certain L&I measures that gained widespread praise, but fell short when one looked closely at the details. But the new guidelines represent a bold, clinically-focused, evidence-based, administratively-tight step that will lead to material changes in opioid use for the state. The document is dense and covers a lot of ground: the prevalence of opioid use, the impact of the drugs - both clinically and socially, the appropriate uses of the drugs by stage of injury, and best practices regarding discontinuation. Not enough room here to cover everything, but here are a few highlights:
Let's start with my favorite sentence in the entire 20 page document: "If opioids are to be prescribed beyond 12 weeks post-injury or post-surgery, the provider must have received prior authorization from the department." (By the way, the bold font for "must" is not my doing... L&I wrote it that way). Further, in order to receive such prior authorization, several important conditions must be documented, including:
- Clinically meaningful improvement in function (greater than or equal to 30%) has been established with opioid use in the acute or subacute phase.
- Failure of trials of reasonable alternatives to opioids.
- Signed treatment agreement (pain contract).
- A time limited treatment plan, addressing whether chronic opioid therapy is likely to improve the worker's vocational recovery.
- Consultation with a pain management specialist if the worker's dose is above 120 mg per day MED.
Good stuff. If every state, every carrier, every employer enforced (or, perhaps were allowed to enforce) such guidelines, we could eliminate a significant portion of the opioid problem in comp.
One concern (and I'd be happy to get some input here, particularly from Washington readers): Is L&I prepared for the administrative burden of the prior authorization process they've created here? While taking a slightly different form, Texas has effectively created a similar requirement (through its closed formularly rules). We've performed sufficient analysis and looked at enough cases in Texas to know that enforcing a pre-auth requirement takes a lot of resources, a lot of planning, and (optimally) a remediation period to address chronic opioid therapy on legacy claims. Washington appears to plan to "flip a switch" on July 1, 2013. I hope they're ready.
Michael
On Twitter @PRIUM1
Let's start with my favorite sentence in the entire 20 page document: "If opioids are to be prescribed beyond 12 weeks post-injury or post-surgery, the provider must have received prior authorization from the department." (By the way, the bold font for "must" is not my doing... L&I wrote it that way). Further, in order to receive such prior authorization, several important conditions must be documented, including:
- Clinically meaningful improvement in function (greater than or equal to 30%) has been established with opioid use in the acute or subacute phase.
- Failure of trials of reasonable alternatives to opioids.
- Signed treatment agreement (pain contract).
- A time limited treatment plan, addressing whether chronic opioid therapy is likely to improve the worker's vocational recovery.
- Consultation with a pain management specialist if the worker's dose is above 120 mg per day MED.
Good stuff. If every state, every carrier, every employer enforced (or, perhaps were allowed to enforce) such guidelines, we could eliminate a significant portion of the opioid problem in comp.
One concern (and I'd be happy to get some input here, particularly from Washington readers): Is L&I prepared for the administrative burden of the prior authorization process they've created here? While taking a slightly different form, Texas has effectively created a similar requirement (through its closed formularly rules). We've performed sufficient analysis and looked at enough cases in Texas to know that enforcing a pre-auth requirement takes a lot of resources, a lot of planning, and (optimally) a remediation period to address chronic opioid therapy on legacy claims. Washington appears to plan to "flip a switch" on July 1, 2013. I hope they're ready.
Michael
On Twitter @PRIUM1
Monday, January 14, 2013
Payer Access to Prescription Drug Information
CWCI has published a research piece suggesting that 3rd party payer access to the CURES database (Controlled Substance Utilization Review and Evaluation System) - California's Prescription Drug Monitoring program - could create material cost savings for the California work comp system.
California is on the verge of pulling the plug on CURES. Despite significant evidence from across the nation that Prescription Drug Monitoring Programs (PDMPs) are critical to fighting the inappropriate utilization of opioids, California has yet to commit to the $3.7 million in annual funding necessary to keep the system online. If funding doesn't materialize before this summer, the database will go offline in July.
So why should a state with a massive budget deficit throw $3.7 million at a database? Perhaps because it would save 15X that number if the database was accessible and usable by 3rd party payers. The analysis from CWCI is characterized as conservative, but still suggests potential savings (ranging from 3% to 7%, depending on the complexity of the claim) of nearly $60 million simply through the elimination of fraud and abuse by 3rd party payers having access to critical data not currently available to them.
Before the chorus of "privacy concerns" erupts, keep in mind that CWCI is merely suggesting that payers be granted access to data regarding services and therapies for which they are most likely already paying. The aggregation of the data by prescriber and by pharmacy offers insight into inappropriate and/or unsafe activities such doctor shopping, pharmacy shopping, drug-drug interactions, etc. and can serve as a powerful tool that an individual payer can use to help manage care more effectively.
Pain management guidelines don't appear to be working (that's a post for another time) and the study found that 41% of work comp claims end up with at least one opioid script, with >20% of injured workers receiving at least 7 opioid scripts over a 24 month period.
That's a lot of drugs. And a $3.7 million database with a potential for a $60 million return sounds like a good investment to me.
Michael
On Twitter @PRIUM1
California is on the verge of pulling the plug on CURES. Despite significant evidence from across the nation that Prescription Drug Monitoring Programs (PDMPs) are critical to fighting the inappropriate utilization of opioids, California has yet to commit to the $3.7 million in annual funding necessary to keep the system online. If funding doesn't materialize before this summer, the database will go offline in July.
So why should a state with a massive budget deficit throw $3.7 million at a database? Perhaps because it would save 15X that number if the database was accessible and usable by 3rd party payers. The analysis from CWCI is characterized as conservative, but still suggests potential savings (ranging from 3% to 7%, depending on the complexity of the claim) of nearly $60 million simply through the elimination of fraud and abuse by 3rd party payers having access to critical data not currently available to them.
Before the chorus of "privacy concerns" erupts, keep in mind that CWCI is merely suggesting that payers be granted access to data regarding services and therapies for which they are most likely already paying. The aggregation of the data by prescriber and by pharmacy offers insight into inappropriate and/or unsafe activities such doctor shopping, pharmacy shopping, drug-drug interactions, etc. and can serve as a powerful tool that an individual payer can use to help manage care more effectively.
Pain management guidelines don't appear to be working (that's a post for another time) and the study found that 41% of work comp claims end up with at least one opioid script, with >20% of injured workers receiving at least 7 opioid scripts over a 24 month period.
That's a lot of drugs. And a $3.7 million database with a potential for a $60 million return sounds like a good investment to me.
Michael
On Twitter @PRIUM1
Tuesday, January 8, 2013
Generic Opana: An Unwelcome Addition
Good news for investors of Impax Labs (NASDAQ: IPXL) turns out to be bad news for lots of other people, including injured workers and their families.
After a well publicized settlement back in 2010 with Endo, makers of the brand name version of Opana ER, Impax has begun shipping generic oxymorphone hydrochloride extended release tablets as of January 4, 2013.
Upside: As we all know, generics are cheaper.
Downsides:
1) The new formulation is not tamper-resistant. This actually creates two potential consequences: a) physicians who are aware of the fact that the new generic is non-tamper resistant may be less likely to prescribe it, therefore dampening the typical post-patent-expiration price drop of the drug; b) physicians who are not aware of the non-tamper resistant formulation - or choose to ignore its significance - will write scripts for the new generic, thus introducing a more dangerous and abuse-prone drug into the injured worker's treatment plan (and into the injured worker's home, I might add, where others may abuse or divert the drug).
2) The post-patent-expiration price drop can be a deceiving phenomenon for a work comp claim. Yes, the drug spend may go down. But is the patient improving? Does the introduction of the cheap generic opioid increase or decrease the likelihood of a positive clinical outcome? What additional medical expenses will result from the introduction of the generic opioid (side effects, exacerbation of co-morbid conditions, risk of dependence/addiction, etc)?
Cheap generics can be just as dangerous as expensive brands - don't take your eye off the ball.
Michael
On Twitter @PRIUM1
After a well publicized settlement back in 2010 with Endo, makers of the brand name version of Opana ER, Impax has begun shipping generic oxymorphone hydrochloride extended release tablets as of January 4, 2013.
Upside: As we all know, generics are cheaper.
Downsides:
1) The new formulation is not tamper-resistant. This actually creates two potential consequences: a) physicians who are aware of the fact that the new generic is non-tamper resistant may be less likely to prescribe it, therefore dampening the typical post-patent-expiration price drop of the drug; b) physicians who are not aware of the non-tamper resistant formulation - or choose to ignore its significance - will write scripts for the new generic, thus introducing a more dangerous and abuse-prone drug into the injured worker's treatment plan (and into the injured worker's home, I might add, where others may abuse or divert the drug).
2) The post-patent-expiration price drop can be a deceiving phenomenon for a work comp claim. Yes, the drug spend may go down. But is the patient improving? Does the introduction of the cheap generic opioid increase or decrease the likelihood of a positive clinical outcome? What additional medical expenses will result from the introduction of the generic opioid (side effects, exacerbation of co-morbid conditions, risk of dependence/addiction, etc)?
Cheap generics can be just as dangerous as expensive brands - don't take your eye off the ball.
Michael
On Twitter @PRIUM1
Monday, January 7, 2013
Be Not Afraid of CBT
Cognitive Behavioral Therapy (CBT) is a psychotherapeutic approach based on the premise that our thoughts are the primary cause of our behaviors and feelings (vs. events, situtations, environments, other people, etc.) CBT can help address a range of issues including how we recognize and react to pain. We're seeing an increasing emphasis on CBT from our reviewing physicians as an alternative treatment pathway for chronic pain patients that are inappropriately utilizing prescription drugs.
First, a few disclaimers. I'm not a CBT expert. I've never personally experienced it nor do I know anyone who has. And while we've seen plenty of recommendations as of late for CBT, I'm not prepared to declare it a panacea for chronic pain or opioid dependence. In fact, I'm not sure there is a panacea (and you should look upon anyone that claims to have discovered such a thing with great skepticism).
That said, for those of us who have realized that long term chronic pain and opioid dependence are much more closely associated with psycho-social issues than with biological issues, CBT offers a potential alternative worthy of exploration. CBT is goal-oriented, self-driven, and focused on correcting fundamental errors in thinking patterns (patterns like victimization, over-generalization, catastrophizing, focusing on the negative, etc... ever observed any of these in your legacy claim population?) Several of PRIUM's physician reviewers feel strongly that CBT offers a compelling opportunity to change the course of a currently intractable claim.
Plus, CBT generally runs anywhere from 6-12 sessions at a cost that ranges from $100-150/hour. In some cases, the total investment in CBT might be less than you're spending on drugs in a single month.
There are three significant barriers to CBT acceptance that we've observed:
1) Ignorance: the claims handler doesn't know what it is and would rather not find out... the path of least resistance appears to be continuation of (and payment for) ineffective pharmacotherapy. This is the minority of cases we see, but still bears mentioning. And if this is true in your claims organization, let us know. We can set up an educational session to bring you up to speed (no marketing, we promise).
2) Fear of adding "psych" to the list of compensable diagnoses: Relax. While CBT is a psychotherapeutic treatment, it is not equivalent to traditional psychotherapy and will not result in additional diagnoses. CBT is a treatment tool, not a diagnostic tool.
3) Lack of managed care coordination: Not only do PRIUM's reviewers recommend CBT, but we often find it's one of the few alternatives the treating physician will consider other than the drugs. We all get excited because the CBT referral at least offers a new path, new potential to get the patient back on track... and then it gets denied through utilization review and the adjuster either isn't authorized to override the denial or doesn't bother to do so. This is a classic example in work comp of snatching defeat from the jaws of potential victory.
To sum up: I can't offer PRIUM's highest recommendation on CBT. We have lots of potential candidates and several engaged CBT providers and we're watching cases closely and compiling data where we can. For now, I can tell you that CBT is relatively inexpensive, low risk treatment modality that's worth a shot for those patients dealing with the typical psycho-social issues that drive the costs and complexity of chronic pain claims.
Michael
On Twitter @PRIUM1
First, a few disclaimers. I'm not a CBT expert. I've never personally experienced it nor do I know anyone who has. And while we've seen plenty of recommendations as of late for CBT, I'm not prepared to declare it a panacea for chronic pain or opioid dependence. In fact, I'm not sure there is a panacea (and you should look upon anyone that claims to have discovered such a thing with great skepticism).
That said, for those of us who have realized that long term chronic pain and opioid dependence are much more closely associated with psycho-social issues than with biological issues, CBT offers a potential alternative worthy of exploration. CBT is goal-oriented, self-driven, and focused on correcting fundamental errors in thinking patterns (patterns like victimization, over-generalization, catastrophizing, focusing on the negative, etc... ever observed any of these in your legacy claim population?) Several of PRIUM's physician reviewers feel strongly that CBT offers a compelling opportunity to change the course of a currently intractable claim.
Plus, CBT generally runs anywhere from 6-12 sessions at a cost that ranges from $100-150/hour. In some cases, the total investment in CBT might be less than you're spending on drugs in a single month.
There are three significant barriers to CBT acceptance that we've observed:
1) Ignorance: the claims handler doesn't know what it is and would rather not find out... the path of least resistance appears to be continuation of (and payment for) ineffective pharmacotherapy. This is the minority of cases we see, but still bears mentioning. And if this is true in your claims organization, let us know. We can set up an educational session to bring you up to speed (no marketing, we promise).
2) Fear of adding "psych" to the list of compensable diagnoses: Relax. While CBT is a psychotherapeutic treatment, it is not equivalent to traditional psychotherapy and will not result in additional diagnoses. CBT is a treatment tool, not a diagnostic tool.
3) Lack of managed care coordination: Not only do PRIUM's reviewers recommend CBT, but we often find it's one of the few alternatives the treating physician will consider other than the drugs. We all get excited because the CBT referral at least offers a new path, new potential to get the patient back on track... and then it gets denied through utilization review and the adjuster either isn't authorized to override the denial or doesn't bother to do so. This is a classic example in work comp of snatching defeat from the jaws of potential victory.
To sum up: I can't offer PRIUM's highest recommendation on CBT. We have lots of potential candidates and several engaged CBT providers and we're watching cases closely and compiling data where we can. For now, I can tell you that CBT is relatively inexpensive, low risk treatment modality that's worth a shot for those patients dealing with the typical psycho-social issues that drive the costs and complexity of chronic pain claims.
Michael
On Twitter @PRIUM1
Monday, December 17, 2012
Florida Medical Association: Predictable, but Still Disappointing
The Florida Medical Association (FMA) has decided, according to Florida State Senator Alan Hays, to oppose forthcoming legislation intended to remove the economic incentive for physicians to dispense medication. The language of the bill is likely to mirror the language found in SB 668 from this past year's legislative session.
The bill will not, in fact, restrict the rights of physicians to dispense medications but rather will focus on eliminating egregious billing practices by forcing physicians to essentially mirror the state fee schedule when they do choose to dispense medications to patients. Given that we've seen virtually no evidence that such restrictions have resulted in either access or compliance issues for patients, this seems like something that should enjoy broad support.
While the FMA has refused public comment, Senator Hays indicated that FMA's opposition is based on the organization receiving "a significant number of emails objecting to the bill and saying it would diminish doctors' ability to dispense drugs."
Maybe the FMA should read SB 668. Or wait until Senator Hays submits his bill for the forthcoming legislative session. And then maybe the FMA could help facilitate progress by educating its membership on the language of the legislation and helping doctors to understand that, by exploiting loopholes and artificially inflating drug prices, they are not doing themselves any favors. Perhaps FMA could act strategically by helping doctors understand that the short-term economic windfall they are experiencing may not be in the best interests of the patient.
On the other hand, the FMA could stake out premature and thoughtless positions driven by what I hope is an uninformed minority of its membership.
Senator Hays thinks he has the votes either way, so let's do what we can to help him.
Michael
On Twitter @PRIUM1
The bill will not, in fact, restrict the rights of physicians to dispense medications but rather will focus on eliminating egregious billing practices by forcing physicians to essentially mirror the state fee schedule when they do choose to dispense medications to patients. Given that we've seen virtually no evidence that such restrictions have resulted in either access or compliance issues for patients, this seems like something that should enjoy broad support.
While the FMA has refused public comment, Senator Hays indicated that FMA's opposition is based on the organization receiving "a significant number of emails objecting to the bill and saying it would diminish doctors' ability to dispense drugs."
Maybe the FMA should read SB 668. Or wait until Senator Hays submits his bill for the forthcoming legislative session. And then maybe the FMA could help facilitate progress by educating its membership on the language of the legislation and helping doctors to understand that, by exploiting loopholes and artificially inflating drug prices, they are not doing themselves any favors. Perhaps FMA could act strategically by helping doctors understand that the short-term economic windfall they are experiencing may not be in the best interests of the patient.
On the other hand, the FMA could stake out premature and thoughtless positions driven by what I hope is an uninformed minority of its membership.
Senator Hays thinks he has the votes either way, so let's do what we can to help him.
Michael
On Twitter @PRIUM1
Thursday, December 13, 2012
Opioids and Cancer: Adding Risks to the List
As if we needed additional reasons to help injured workers avoid the detrimental effects of long term opioid use... we can now add cancer to the list.
A study published in the journal Anesthesiology and led by University of Chicago researcher Patrick Singleton has shown that opioids can enhance the malignant tendencies of cancer cells. The study suggests that the same mu receptor cells that enable the powerful pain relieving effects of opioids are also present in cancer cells and, when opioids are present, can influence the progression and spread of cancer.
Interestingly, this is good news in the oncology community. The article states: "In a series of labortaory studies, Drs. Singleton and Moss found that drugs which blocked the mu opioid receptors reduced cancer growth in animals and helped prevent further invasion and spread of cancer cells. Further, tumors did not grow in mice that lacked the mu opioid receptor."
Of course, I can't help but think about the inverse. How many injured workers might (emphasis on might) experience more rapid cancer growth due to the abundance of opioids being taken?
Granted, the studies thus far are all bench science - no human trials have been conducted. But the body of evidence continues to grow regarding the dangers inherent in long term opioid use.
Michael
On Twitter @PRIUM1
A study published in the journal Anesthesiology and led by University of Chicago researcher Patrick Singleton has shown that opioids can enhance the malignant tendencies of cancer cells. The study suggests that the same mu receptor cells that enable the powerful pain relieving effects of opioids are also present in cancer cells and, when opioids are present, can influence the progression and spread of cancer.
Interestingly, this is good news in the oncology community. The article states: "In a series of labortaory studies, Drs. Singleton and Moss found that drugs which blocked the mu opioid receptors reduced cancer growth in animals and helped prevent further invasion and spread of cancer cells. Further, tumors did not grow in mice that lacked the mu opioid receptor."
Of course, I can't help but think about the inverse. How many injured workers might (emphasis on might) experience more rapid cancer growth due to the abundance of opioids being taken?
Granted, the studies thus far are all bench science - no human trials have been conducted. But the body of evidence continues to grow regarding the dangers inherent in long term opioid use.
Michael
On Twitter @PRIUM1
Tuesday, December 4, 2012
Managing the Managers Who Manage Managed Care
That's not a typo. That's the challenge of contemporary workers' compensation claims management. Part of the cynicism and frustration in workers' comp today is driven by the backward incentives and cumbersome statutory constraints of the system. But another important driver of frustration is the rather complicated managed care infrastructure we've created for ourselves (albeit unintentionally). As an artifact of the regulatory process in most states, work comp is now rife with the time lines and technicalities of MPNs, UR, BR, PPOs, IMEs, WCJs, ALJs, ADLs, AOE/COE, DOIs, MMIs, and lots of other acronyms that make injured workers and payers alike crazy.
Commercial and government health plans grapple with some of these constraints, but work comp is a universe all its own when it comes to navigating a claim from start to finish (if, in fact, getting to a proverbial "finish line" is possible). Others far more experienced than I could probably walk through the detailed history of the development of all of this, but I've simplified it (mostly so I can understand it) to the following: The grand bargain of work comp (a.k.a. the exclusive remedy) is not static. In fact, it is dynamic and its evolution is marked by legislative and regulatory measures designed to rebalance the bargain when economic realities demand it.
When a state engages in "work comp reform", what that state is essentially doing is "rebalancing the bargain" because the economics of the current system are, in some material way, out of whack. This is incredibly difficult to do given the micro and macro economic forces at work both within and outside of the work comp system and the special interests that attempt to influence the outcome of the effort. Sometimes, the bargain tips too far toward the payer/employer... sometimes it tips too far toward the injured worker.
Regardless of which direction the scale tips, there is no panacea for claims management. On the other hand, the level of cynicism in work comp is creating blind spots in the claims management process that lead to missed opportunities for positive outcomes. I find too many assumptions about bad doctors, unmotivated claimants, greedy lawyers, and ineffectual judicial processes. All of these exist, no doubt. But opportunities for progress are missed when we assume that engagement and discussion won't move the needle.
Let's engage the participants in the system not in new ways, but rather the old fashioned way. Let's take the processes, time lines, and technicalities of managed care and call those "Plan B" (they have a place and we need to use those tools when necessary). And let's develop a "Plan A" that's focused on simply communicating with each other about the best path forward to achieve the clinical and financial outcomes we all want.
We've forgotten how to talk with each other.
Michael
On Twitter @PRIUM1
Commercial and government health plans grapple with some of these constraints, but work comp is a universe all its own when it comes to navigating a claim from start to finish (if, in fact, getting to a proverbial "finish line" is possible). Others far more experienced than I could probably walk through the detailed history of the development of all of this, but I've simplified it (mostly so I can understand it) to the following: The grand bargain of work comp (a.k.a. the exclusive remedy) is not static. In fact, it is dynamic and its evolution is marked by legislative and regulatory measures designed to rebalance the bargain when economic realities demand it.
When a state engages in "work comp reform", what that state is essentially doing is "rebalancing the bargain" because the economics of the current system are, in some material way, out of whack. This is incredibly difficult to do given the micro and macro economic forces at work both within and outside of the work comp system and the special interests that attempt to influence the outcome of the effort. Sometimes, the bargain tips too far toward the payer/employer... sometimes it tips too far toward the injured worker.
Regardless of which direction the scale tips, there is no panacea for claims management. On the other hand, the level of cynicism in work comp is creating blind spots in the claims management process that lead to missed opportunities for positive outcomes. I find too many assumptions about bad doctors, unmotivated claimants, greedy lawyers, and ineffectual judicial processes. All of these exist, no doubt. But opportunities for progress are missed when we assume that engagement and discussion won't move the needle.
Let's engage the participants in the system not in new ways, but rather the old fashioned way. Let's take the processes, time lines, and technicalities of managed care and call those "Plan B" (they have a place and we need to use those tools when necessary). And let's develop a "Plan A" that's focused on simply communicating with each other about the best path forward to achieve the clinical and financial outcomes we all want.
We've forgotten how to talk with each other.
Michael
On Twitter @PRIUM1
Wednesday, November 28, 2012
Pain and Patient Satisfaction Surveys
Consumerism is all around us, particularly at this time of year. The last decade has introduced a new level of consumerism in health care in various forms: high deductible plans that encourage choice of lower price providers, public and private agencies publishing hospital safety and efficacy data, and of course, the concept of patient satisfaction and its accompanying surveys, consequences, and controversies.
I used to be a hospital strategy consultant and I've seen hospital leaders grapple with the concept of patient satisfaction. On the one hand, there appears to be a correlation between patient satisfaction and overall health outcomes for an institution. On the other hand, an individual patient's definition of "satisfaction" can be shockingly misaligned with the appropriate care pathway.
Perhaps no better example of this can be found than in the area of chronic pain treatment. The patient wants the pain to go away. The doctor (unfortunately and all too often) wants the patient to go away. The harsh reality of treating chronic pain: once all the surgeries and procedures have been tried, there isn't much money to be made in maintenance care. (The exception, of course, is the physician who dispenses drugs from his office, creating one of healthcare's most obvious, most egregious, and most perverse incentives).
The best way to deal with this set of circumstances and keep the patient "satisfied" is to write another set of prescriptions. Better yet, just call it into the pharmacy and have the patient go pick it up.
I was encouraged to see Dr. Zachary Meisel and Dr. Jeanmarie Perrone take a stand on this topic in a piece that wrote for Time magazine:
"Medical guidelines already state that doctors shouldn’t be choosing opioids for most patients with chronic pain. But we doctors also need to start scaling back on prescribing opioids for acute pain, since some acute pain turns into chronic pain. Everyone with new pain should be started on a high dose of ibuprofen (like Motrin or Advil) or acetaminophen (like Tylenol). These medications have been proved to work as well as the opioids even for conditions like gall-stone attacks. For some patients, we can add a prescription for a limited number of opioid pills to be filled only if absolutely necessary. With that small prescription should come a big warning. Something like: 'These drugs are highly addictive, even in short-term use. These drugs have been associated with death, even in therapeutic dosing. These drugs, when accidentally ingested by children, are fatal.' As doctors, we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain. It may take an extra few minutes, but it will save lives."
Agreed.
Michael
On Twitter @PRIUM1
I used to be a hospital strategy consultant and I've seen hospital leaders grapple with the concept of patient satisfaction. On the one hand, there appears to be a correlation between patient satisfaction and overall health outcomes for an institution. On the other hand, an individual patient's definition of "satisfaction" can be shockingly misaligned with the appropriate care pathway.
Perhaps no better example of this can be found than in the area of chronic pain treatment. The patient wants the pain to go away. The doctor (unfortunately and all too often) wants the patient to go away. The harsh reality of treating chronic pain: once all the surgeries and procedures have been tried, there isn't much money to be made in maintenance care. (The exception, of course, is the physician who dispenses drugs from his office, creating one of healthcare's most obvious, most egregious, and most perverse incentives).
The best way to deal with this set of circumstances and keep the patient "satisfied" is to write another set of prescriptions. Better yet, just call it into the pharmacy and have the patient go pick it up.
I was encouraged to see Dr. Zachary Meisel and Dr. Jeanmarie Perrone take a stand on this topic in a piece that wrote for Time magazine:
"Medical guidelines already state that doctors shouldn’t be choosing opioids for most patients with chronic pain. But we doctors also need to start scaling back on prescribing opioids for acute pain, since some acute pain turns into chronic pain. Everyone with new pain should be started on a high dose of ibuprofen (like Motrin or Advil) or acetaminophen (like Tylenol). These medications have been proved to work as well as the opioids even for conditions like gall-stone attacks. For some patients, we can add a prescription for a limited number of opioid pills to be filled only if absolutely necessary. With that small prescription should come a big warning. Something like: 'These drugs are highly addictive, even in short-term use. These drugs have been associated with death, even in therapeutic dosing. These drugs, when accidentally ingested by children, are fatal.' As doctors, we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain. It may take an extra few minutes, but it will save lives."
Agreed.
Michael
On Twitter @PRIUM1
Tuesday, November 27, 2012
Pennsylvania Supreme Court Saves Patient's Life
The Pennsylvania Supreme Court saved a patient's life last week. Interestingly, the court accomplished this great feat by doing nothing.
Linda Turner was injured on the job in December of 1987. She underwent two surgical procedures and was diagnosed, over a number of years, with arachnoiditis, failed spinal fusion surgery, small fiber neuropathy, chronic pain syndrome, discitis, osteomyelitis, spinal stenosis, and mood disorder. Her treatment, in May of 2009, consisted of Fentanyl 125 mcg patch every three days and Fetanyl 600 mcg lozenge four times a day for breakthrough pain. I'll save you the math... that's about 400 mg morphine equivalents per day.
Her employer conducted utilization review on the treatment and the lozenges were found to be unnecessary and unreasonable care. This finding was not based on assessment of functionality or objective clinical evidence of sources of pain (as is often the case), but rather on the addictive nature of the medication, it's FDA approved indications (palliative care for late stage cancer patients), and the risk to the patient. A Workers' Compensation Judge (WCJ) denied Turner's petition for review of the UR decision.
The Workers' Compensation Appeals Board then reversed the WCJ, finding that the employer did not satisfy its burden of proving the Fentanyl lozenges were not reasonable and necessary.
On appeal, the Commonwealth Court of Pennsylvania reversed the Board and reinstated the WCJ's denial of petition for review of the original UR decision.
Last week, the Pennsylvania Supreme Court declined to hear Turner's appeal, thus giving credibility to the UR process, leverage for employers in Pennsylvania to avoid payment for unnecessary and unreasonable care, and saving Linda Turner's life (despite the fact the she probably doesn't realize it now).
The section of the Commonwealth Court's opinion I found most illuminating was on page 10: "Further, in determining the reasonableness and necessity of a prescribed medication, it is entirely appropriate for a UR reviewer to consider the risk to the patient. In other words, a UR reviewer may consider whether it is reasonable and necessary for a provider to expose a patient to the level of risk presented by a medication."
Funny... all of us are in the "risk management" business. Yet we often overlook the risks inherent in the treatment of these injured workers. I hope more states take the view that PA has taken - risk to life and limb of the patient, even at the hands of a qualified physician, needs to be weighed when assessing the reasonableness of care.
Michael
On Twitter @PRIUM1
Linda Turner was injured on the job in December of 1987. She underwent two surgical procedures and was diagnosed, over a number of years, with arachnoiditis, failed spinal fusion surgery, small fiber neuropathy, chronic pain syndrome, discitis, osteomyelitis, spinal stenosis, and mood disorder. Her treatment, in May of 2009, consisted of Fentanyl 125 mcg patch every three days and Fetanyl 600 mcg lozenge four times a day for breakthrough pain. I'll save you the math... that's about 400 mg morphine equivalents per day.
Her employer conducted utilization review on the treatment and the lozenges were found to be unnecessary and unreasonable care. This finding was not based on assessment of functionality or objective clinical evidence of sources of pain (as is often the case), but rather on the addictive nature of the medication, it's FDA approved indications (palliative care for late stage cancer patients), and the risk to the patient. A Workers' Compensation Judge (WCJ) denied Turner's petition for review of the UR decision.
The Workers' Compensation Appeals Board then reversed the WCJ, finding that the employer did not satisfy its burden of proving the Fentanyl lozenges were not reasonable and necessary.
On appeal, the Commonwealth Court of Pennsylvania reversed the Board and reinstated the WCJ's denial of petition for review of the original UR decision.
Last week, the Pennsylvania Supreme Court declined to hear Turner's appeal, thus giving credibility to the UR process, leverage for employers in Pennsylvania to avoid payment for unnecessary and unreasonable care, and saving Linda Turner's life (despite the fact the she probably doesn't realize it now).
The section of the Commonwealth Court's opinion I found most illuminating was on page 10: "Further, in determining the reasonableness and necessity of a prescribed medication, it is entirely appropriate for a UR reviewer to consider the risk to the patient. In other words, a UR reviewer may consider whether it is reasonable and necessary for a provider to expose a patient to the level of risk presented by a medication."
Funny... all of us are in the "risk management" business. Yet we often overlook the risks inherent in the treatment of these injured workers. I hope more states take the view that PA has taken - risk to life and limb of the patient, even at the hands of a qualified physician, needs to be weighed when assessing the reasonableness of care.
Michael
On Twitter @PRIUM1
Monday, November 19, 2012
Opioids for Chronic Pain: Modern-Day Bloodletting
I came across an amazing piece today written by Malcolm Butler, MD, Medical Director at Columbia Valley Community Health Services in Washington State. This should be required reading for all of us doing battle in the trenches of the opioid epidemic.
A link to the full piece is here. In summary, Dr. Butler confronted the central challenge of his clinic by taking proactive steps to eliminate medically inappropriate opioid prescriptions from his practice. He sums up the results of the initiative as follows:
A link to the full piece is here. In summary, Dr. Butler confronted the central challenge of his clinic by taking proactive steps to eliminate medically inappropriate opioid prescriptions from his practice. He sums up the results of the initiative as follows:
"Here is what we have learned:
- After 15 years of trying to follow published standards of high quality pain management,
- There is NO evidence that opioids improve outcomes in chronic pain.
- There is good evidence that opioids impair social function, contribute to behavioral comorbidities, and decrease function.
- Opioids are excellent for acute pain but are just the wrong tool for chronic pain.
- It makes about as much sense to treat chronic pain with alcohol as with opioids. Both will help pain in the short run. Both will cause new and more difficult challenges in the long run.
- By asking every patient about pain at every visit, we had “medicalized” pain.
- Pain is a normal component of everyday life – it is not an anomaly requiring treatment.
- Pain is a protective reflex. It galvanizes us to improve and change. Removing it does the opposite, allowing us to become victims and to stagnate.
- As we have weaned our patients down on their opioids – nothing has changed. The patients who were working while taking 400mg a day are still working when taking 100mg a day. Those who were lying on the couch while taking 400mg a day are still lying on the couch while taking 100mg a day.
- There appears to be a dose above which more opioids don’t improve function in chronic pain – and it must be pretty low, as we still haven’t found it.
- As we have decreased the volumes of opioids we prescribe, bad behavior of all types has decreased within the clinic. Whereas the OOC used to review 6 cases per month, we now review 2 cases every 3 months.
- Chronic pain is a m̩lange of nociceptive pain, emotional pain, boredom, and anhedonia Рall of which feel better on opioids, and all but one of which are made worse by chronic opioids.
- Acute pain is almost entirely nociceptive pain, and is well managed with opioids.
- Chronic pain is amplified and prolonged by the use of opioids."
This is what it takes. Courage, transparency, honesty... and the ability to say NO.
Thursday, November 15, 2012
Tennessee Follow Up: Fumble Recovered
I was able to speak with someone at TDOL regarding my post this week on SB 3315. While TDOL acknowledges that the interpretation of the statute as I outlined was at one time accurate, the current TDOL interpretation is now much more in line with the legislative intent of the bill.
Any Schedule II, III, or IV drug prescribed for pain management for more than 90 days will be subject to utilization review.
Several pieces of good news here:
1) TDOL is listening. I was very pleased with the transparent and candid nature of my discussion with my contact there. TDOL is really trying to get this right and wants to be a resource not just to injured workers, but to employers and carriers doing business in Tennessee.
2) The state has, in fact, created a statutory framework for addressing opioid dependence. That doesn't mean this is simple (a single adverse UR determination for someone on oxycodone for the past five years doesn't fix the issue), but it does mean progress is possible if employers and carriers are prepared to offer a clinically responsible path to weaning these medications.
3) My contact at TDOL has no direct knowledge of any impending rule-making process; doesn't mean there won't be one at some point, but for now we all need to operate on the basis of the language in SB 3315. So let's get to work.
One note: despite this strengthened UR statute in TN, I'm still a believer in UR as a "Plan B". Plan A ought to be a voluntary, collegial, evidence-based engagement with the treating physician to explore alternative treatment. The time frames and technicalities of UR should only be deployed when attempts at real clinical engagement have failed.
And for those that have heard rumors (or had specific experience) with regard to adverse UR determinations being overturned by TDOL, my understanding is that this has been driven largely by the date range issue (the 90-day clock starting ticking on July 1 even if the patient had been on opioids for years previous to July 1). Some payors apparently jumped in too early.
Progress in Tennessee.
Michael
On Twitter @PRIUM1
Any Schedule II, III, or IV drug prescribed for pain management for more than 90 days will be subject to utilization review.
Several pieces of good news here:
1) TDOL is listening. I was very pleased with the transparent and candid nature of my discussion with my contact there. TDOL is really trying to get this right and wants to be a resource not just to injured workers, but to employers and carriers doing business in Tennessee.
2) The state has, in fact, created a statutory framework for addressing opioid dependence. That doesn't mean this is simple (a single adverse UR determination for someone on oxycodone for the past five years doesn't fix the issue), but it does mean progress is possible if employers and carriers are prepared to offer a clinically responsible path to weaning these medications.
3) My contact at TDOL has no direct knowledge of any impending rule-making process; doesn't mean there won't be one at some point, but for now we all need to operate on the basis of the language in SB 3315. So let's get to work.
One note: despite this strengthened UR statute in TN, I'm still a believer in UR as a "Plan B". Plan A ought to be a voluntary, collegial, evidence-based engagement with the treating physician to explore alternative treatment. The time frames and technicalities of UR should only be deployed when attempts at real clinical engagement have failed.
And for those that have heard rumors (or had specific experience) with regard to adverse UR determinations being overturned by TDOL, my understanding is that this has been driven largely by the date range issue (the 90-day clock starting ticking on July 1 even if the patient had been on opioids for years previous to July 1). Some payors apparently jumped in too early.
Progress in Tennessee.
Michael
On Twitter @PRIUM1
Death Benefits: More (Disturbing) Case Law
This morning's workcompcentral brings news of a Washington state decision that, in short, upheld surviving spousal benefits in light of an accidental death caused by a combination of six different medications and alcohol. I'm not an attorney and won't dive into specifics (the article is here, the court decision here, and the dissent is here), but I was struck by two overarching facts:
First, this is just the beginning. The work comp industry is going to see more and more accidental overdose deaths and courts are more likely than not to award death benefits as a result. This is going to be expensive and has already caused some insurers and excess carriers to exit the work comp market. Aggressively intervening in chronic pain cases with complex drug regimens is imperative or your claims organization is going to face liabilities not contemplated when the policy was underwritten.
Second, note that the original 2004 claim for back injury was, in fact, closed. And at the time the claim was closed in March 2005 (with no award for permanent partial disability), the injured worker was only taking ibuprofen. Two years later, at 37 years old, the injured worker's wife found him dead. Cause of death was determined to be accidental; the injured worker's blood alcohol level was actually lower than the state-presumed intoxication level, but traces of oxycodone, citalopram, desmethylcitalopram, alprazolam, Nortryptyline, amitriptyline, carbamazepine, Promethazine, and acetometophen were found in his system. Quite a cocktail.
The court determined that the causal link between the original injury and the accidental overdose had not been broken - not by the claim's closure, not by the time elapsed, not by the alcohol use, not by the mix of drugs consumed. One could rationally argue, as the dissent in this case does, that the causal chain was, in fact, broken.
I happen to agree with the dissent. But you know what? Doesn't matter.
Get ready to start paying more benefits related to accidental overdoses, perhaps even on claims you think are closed and never to be heard from again.
Michael
On Twitter @PRIUM1
First, this is just the beginning. The work comp industry is going to see more and more accidental overdose deaths and courts are more likely than not to award death benefits as a result. This is going to be expensive and has already caused some insurers and excess carriers to exit the work comp market. Aggressively intervening in chronic pain cases with complex drug regimens is imperative or your claims organization is going to face liabilities not contemplated when the policy was underwritten.
Second, note that the original 2004 claim for back injury was, in fact, closed. And at the time the claim was closed in March 2005 (with no award for permanent partial disability), the injured worker was only taking ibuprofen. Two years later, at 37 years old, the injured worker's wife found him dead. Cause of death was determined to be accidental; the injured worker's blood alcohol level was actually lower than the state-presumed intoxication level, but traces of oxycodone, citalopram, desmethylcitalopram, alprazolam, Nortryptyline, amitriptyline, carbamazepine, Promethazine, and acetometophen were found in his system. Quite a cocktail.
The court determined that the causal link between the original injury and the accidental overdose had not been broken - not by the claim's closure, not by the time elapsed, not by the alcohol use, not by the mix of drugs consumed. One could rationally argue, as the dissent in this case does, that the causal chain was, in fact, broken.
I happen to agree with the dissent. But you know what? Doesn't matter.
Get ready to start paying more benefits related to accidental overdoses, perhaps even on claims you think are closed and never to be heard from again.
Michael
On Twitter @PRIUM1
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