Obesity as a Disease: All About the Economics

The American Medical Association has decided to recognize obesity as a disease.  This is a mistake, but not for the reasons you might initially think.

Let’s establish the logic behind the AMA’s decision.  There is no new study, no new statistic, no new discovery that has led the AMA to this decision.  This is about money, plain and simple.  And while I don’t object to the decision on these grounds (economic incentives can be powerful tools for behavior change), I’m not convinced the AMA has thought this all the way through. 

There is increasing frustration in the physician community around the expectation of doctors to “treat” what was previously the symptom or co-morbid condition known as obesity.  The time spent counseling patients on diet, exercise, weight loss programs, and underlying behaviors impacting weight has not been adequately reimbursed by government or commercial payers.  Thus, physicians are left with the need to treat a condition without an explicit payment mechanism for such treatment.  I understand and acknowledge that this has a negative impact on physician practice economics and/or on the overall health of obese injured workers and other patients. 

But calling obesity a disease will result in a plethora of unintended consequences. 

First, we risk creating a new fee stream to doctors that may yield little progress in the fight against obesity.  Altering physician behavior through economic incentives doesn’t necessarily translate to altering patient behavior.  This decision by the AMA (and the subsequent legislation introduced in Congress to mandate Medicare coverage of obesity treatments) is emblematic of the most basic flaw in our health care system: placing the physician at the center of the system instead of the patient.  We've been on this path for several decades now and it's not working for us.  If we're going to have a discussion about economics and obesity, let's center that discussion around the patient, not the doctor.    

Second, the economic basis for this decision is deeply rooted in the fee-for-service world in which we currently live.  While I believe the death of the fee-for-service model is greatly exaggerated by some, there is an undeniable movement toward outcomes-based payment structures for providers, both hospitals and individual doctors (the rise of the Accountable Care Organization being the most notable among such structures).  I don't know how long the transition will take, but I do believe the AMA will some day regret the classification of obesity as a disease.  When the time comes that physicians are paid NOT for mere diagnosis and treatment, but rather based on the actual weight loss of obese patients, doctors will face the harsh reality that physician accountability and patient accountability are not one in the same. 

Most physicians (but not all) would rather get paid for the treatment they render or suggest.  In a fee-for-service model, obese patients aren't likely to experience issues with provider access.  But when payment streams are linked to outcomes, will that remain the case?  When a physician's paycheck is subject to whether a 300 lb. patient can drop meaningful weight, how many physicians will be willing to see that patient?  Accountable Care Organizations will develop risk-adjusted models for measuring outcomes, but these models will be inherently complicated and difficult for the average physician to grasp.  The point here: in an attempt to create access and funding for the treatment of obesity in a fee-for-service world, the AMA may have inadvertently thwarted future access and funding for obesity in an outcomes-based payment environment.

The fight against obesity should be about accountability and responsibility, but we should be focused on the accountability and responsibility of the patient, not the doctor. 

Michael
On Twitter @PRIUM1

September 16, 1877: The Ghosts of Opioid Addiction

September 16, 1877
A letter written by Tom Barlow, catcher for the Hartfords:
“It was on the 10th of August, 1874, that there was a match game of baseball in Chicago between the White Stockings of that city and the Hartfords of Hartford, now of Brooklyn. I was catcher for the Hartfords, and Fisher was pitching. He is a lightning pitcher, and very few could catch for him. On that occasion he delivered as wicked a ball as ever left his hands, and it went through my grasp like an express train, striking me with full force in the side. I fell insensible to the ground, but was quickly picked up, placed in a carriage, and driven to my hotel. The doctor who attended me gave a hypodermic injection of morphine, but I had rather died behind the bat then [sic] have had that first dose. My injury was only temporary, but from taking prescriptions of morphine during my illness, the habit grew on me, and I am now powerless in its grasp. My morphine pleasure has cost me eight dollars a day, at least.  I was once catcher for the Mutuals, also for the Atlantics, but no one would think it to look at me now.”

Sound familiar? 

Tom Barlow (who is credited, by the way, with the invention of the bunt) was hurt on the job, received care from a physician that, while well intended, resulted in dependence and addiction.  The only difference is that, in 1874, his employer didn't pick up the tab for his addiction like employers do today.

While the scope of the issue is broader and more complicated today, we would do well to keep in mind that addiction is not a new phenomenon - and that we have a responsibility to stop it before it starts or, once a patient is in its grasp, to do everything we can to treat that addiction. 

Michael
On Twitter @PRIUM1

Opioid Education Resources

[Guest post from Scott Yasko, PRIUM Account Executive]

The work comp industry is a relatively small universe and one where a lot of us are very familiar with each other. So I am sure that a lot of you who read this blog received the same email recently from Phil LeFevre of the Work Loss Data Institute. Perhaps the most notable work that this organization does is with the Official Disability Guidelines (ODG) with which we at PRIUM utilize on a daily basis.

LeFevre’s email begins with the line, “I’ll sum up the statistics on opioids in two words: Ruined Lives.” The purpose of his email was to promote ODG’s Opioid Flyer (found here) and at the same time raise continued awareness for the epidemic our industry and this country is currently facing. ODG are of course evidence based guidelines and Michael Gavin has written on this same page a handful of times about how important it is to utilize evidence based medicine as a baseline for care.

But what struck a chord with me and what compelled me to want to share my thoughts is the passion and frustration that shows through in the way in which it was written. This is the same passion and frustration I know that a lot of us share on a daily basis when dealing with this issue. An issue that is front and center in our little corner of the world, and one where the problem is well documented everywhere else, but yet the adherence and desire to work together to combat the opioid epidemic is surprisingly lacking in our society.

It pains me to know that Missouri still does not see the necessity of having a prescription drug monitoring program.  It is frustrating that there are still physicians out there passing out painkiller prescriptions to patients’ outstretched hands as if Rx Halloween comes once a month. Especially considering the well documented cases of bad actors like Dr. Lisa Tseng who was arrested on murder charges and linked to at least 19 overdose deaths; or that of Dr. Rolando Lodevico Atiga who was arrested after writing a prescription for an opioid and a muscle relaxant to an undercover agent who presented him with an x-ray showing injuries to the neck and back … of a dog.

Perhaps what motivates me (and comforts me) is the fact that there are those willing to raise their hand when the questions is posed: What are we going to do? Dr. Andrew Kolodny, President of Physicians for Responsible Opioid Prescribing (PROP) is one such individual taking action against this epidemic. This group’s mission? “To reduce morbidity and mortality resulting from prescribing of opioids and to promote cautious, safe and responsible opioid practices.” We need individuals and organizations like this and we need more calls to action like the one that was expressed in Phil LeFevre’s email. And this is the advice given to the readers about the opioid flyer: “Share it, save it, print it, tape it to the wall if it helps you, your MPN providers, or your loved ones.”

That’s good advice because if you needed a reminder - this IS an epidemic and it is one that dwarfs the size of any we have seen in this country. Prescription drugs are now responsible for more overdose deaths than heroin and cocaine combined. But the transformation of this industry even in just the last couple of years to recognize this issue is commendable. And there is definitely a long way to go and a lot more that needs to be done, but every small effort like forwarding an email or typing up a blog rant is a step in the right direction.

Scott E Yasko
On Twitter @PRIUM1

Abuse-Deterrent Opioids: Great Solution, Wrong Problem

I was asked recently what PRIUM's plan will be when the "opioid crisis" passes.  My first thought was that I'll probably be dead and gone by then (I'm not that old, mind you).  The answer I gave (and which I wholeheartedly believe) is that workers' compensation is the ultimate tail claim business and whether it's opioids or something else entirely, the need for medical expertise on complex claims isn't going away.  Nevertheless, the question got me thinking about the fact that this particular medical management crisis is, in fact, different from past waves of over-utilization exhibited by providers treating injured workers. 

One of the significant factors perpetuating the current struggle with opioid over-utilization is the source of the pills themselves: giant, multi-national pharmaceutical companies with huge marketing budgets and armies of sales reps.  Pain meds are a $7.3 billion market projected to grow 15% by 2017 to $8.4 billion (according to Cowen & Co).  These companies are not inherently evil - in fact, any discussion regarding pain management medications must begin with the fact that there exists a legitimate need for these drugs in the world today.  There is little doubt, however, that our society is experiencing a public health crisis related to the misuse and abuse of these medications.  The pharmaceutical companies themselves, while perhaps suffering from a public relations fiasco, are nonetheless generating incredible economic profit driven, at least in part, by the inappropriate and medically unnecessary use of their products.  (Anticipating objection, let me point out that I am aware of the efforts being made by Purdue, Endo, Pfizer and others to stem misuse and abuse of opioid medications.  I find the effort laudable, albeit largely ineffective). 

This 15% projected market growth is driven by a simple equation that relies on two variables, price and utilization.   How much do the pills cost?  How many of the pills are sold?  If you know both variables, it's easy to arrive at the dollars at stake.  Billions of them, in this case.  In the world of pharmaceuticals, price is a function of patents.  And as Timothy Martin of the Wall Street Journal points out, those patents are being extended in the interests of medication abuse-deterrence. 

I wish to be perfectly clear on this point: I am 100% supportive of abuse-deterrent formulations of prescription opioids.  These formulations are effective in combating abuse and diversion (at least in the short-term - it seems drug addicts often find a way to crack the code of each newly formulated medication.  But that doesn't mean we should stop trying, nor does it mean we should eliminate the economic incentive for the pharmaceutical companies to develop such technology).  There is legitimate debate on this point.  I know several well respected clinicians who believe the work comp system would derive greater benefit from the drop in price of the drugs driven by generic conversion than from the protection of patents for branded drugs less likely to be abused by patients. 

To me, though, this conversation is a distraction.  While eliminating abuse and diversion would be great for the work comp system, these aberrant behaviors are not driving the bulk of the problem.  The vast majority of cases in which PRIUM intervenes involve legitimate prescriptions being taken as prescribed.  Very little pill crushing.  Very little intravenous injections.  Very little drug dealing. 

The problem as we see it is lack of medical necessity.  In most cases, it doesn't matter if the patient's opioid is abuse-deterrent or not.  If it's medically unnecessary, if it's leading to loss of function, if it's leading to dependence and addiction... it needs to go away.  The doctor will be better educated.  The patient will get better.  The cost of care will go down.  Everyone wins. 

Abuse deterrent technology is great, but if we focus on technology over medical necessity, we will have missed the mark and the crisis will continue. 

Michael
On Twitter @PRIUM1

On My Desk: A Litany of Legislation

The past couple of weeks have seen a significant number of legislative and regulatory efforts that warrant the attention of anyone working in our industry.  I couldn't decide which one to dig deeply into first, so here's an overview of what's sitting on my desk.  Look for deeper dives into each one over the next couple of weeks.

Florida has managed once again to snatch defeat from the jaws of victory in the battle over repackaged medications.  Senate Bill 662 (and companion House Bill 605) stipulate a compromise approach to pricing for repackaged drugs - 112.5% of the original manufacturer's AWP plus an $8 dispensing fee.  Setting aside for a moment the lack of logic behind differential pricing models for pharmacies and physicians, the larger impact of the legislation will be felt from the repeal of 440.13(12)(c) which smart payers were using to re-price these repackaged medications.  Senator Alan Hays is celebrating the compromise and while I give him credit for leading the fight over the last several years, the outcome is not a victory for Florida payers. 

Minnesota is attempting to update its approach to long term use of opioids.  Senate Bill 1603 (and its companion House Bill 1799) call for the adoption of "rules establishing standards for health care provider treatment."  Such rules are already in draft form and could quickly follow the adoption of the legislation.  Rules could govern such practices as opioid agreements between doctors and patients, frequency and content of follow up visits, and referrals to pain management specialists.

New York is asking for comment on newly proposed medical treatment guidelines for non-acute pain.  Comments are due by June 10.  At first glance, the guidelines appear comprehensive (the document is 90 pages with a sole focus on non-acute pain management).  The question will be: are they sufficiently specific to actually make an impact in prescribing behavior. 

Last, but certainly not least, is Oklahoma's Senate Bill 1062 (all 556 pages of it).  While I do not believe the adoption of this bill will lead to either widespread "opting out" within Oklahoma or widespread adoption of similar legislation in other states, it's nonetheless indicative of broader systemic issues and frustration around the workers' compensation. 

Michael
On Twitter @PRIUM1

Medical Treatment Guidelines: Evidence vs. Consensus

Senate Bill 200 is all but signed into law in Tennessee.  The bill brings broad reform measures to the state, some of which were desperately needed (e.g., the creation of an administrative dispute resolution system that will largely relieve the civil courts of the burden of work comp fights) and some of which will be deeply contentious (e.g., the revised definition of AOE/COE that will surely shift a material number of injuries that might have been covered by work comp historically into the commercial/group health insurance market). 

One seemingly minor point caught my eye.  The law gives the newly created position of Administrator of Division of Workers' Compensation, appointed by the governor, the charge to adopt medical treatment guidelines for the diagnosis and treatment of workplace injuries.  These guidelines need to be in place by January 1, 2016.  Assisting the Administrator in this task will be a medical advisory committee which will be assembled as soon as the law goes into effect and will expire on July 1, 2015.  Assuming the committee is formed over the next several months, it appears they'll have approximately two years to adopt medical treatment guidelines.

Two years? 

If Tennessee isn't careful, they'll end up with a Louisiana-like approach to the development and adoption of medical treatment guidelines - a process so fraught with lobbying, special interests, law suits, and covering of tracks that sections of the resulting guidelines more closely resemble instructions for Medtronic spinal implants than actual medical treatment guides. 

The choice for Tennessee's medical advisory committee is simple: they can choose evidence-based guidelines or consensus-based guidelines.  While it sounds reasonable that a group of Tennessee-based medical experts should assemble themselves and consider all stakeholder views to develop a set of guidelines for which there exists broad acceptance... the reality is that good politics often leads to bad medicine.  Before the citizens of Tennessee realize what's happening, lobbyists from pharma, medical device, and physician constituencies will take pen to paper to write sections of the guidelines - as a service, of course, to the very busy committee members. 

Instead, the role of the medical advisory committee should be to debate which set of existing, off-the-shelf, evidence-based, nationally recognized, constantly updated guidelines should be adopted by the state in their entirety with no edits, additions, or subtractions driven by special interests.  This will be tougher to accomplish politically, but will lead to the best, most consistent, most credible, and most reliable clinical and financial outcomes for the work comp system. 

(Note: See Texas.  This works.) 

Michael
On Twitter @PRIUM1

Closed Formulary, Coming Soon to Your State?

There's little doubt that the Texas closed formulary rules (instituted for new injuries as of 9/1/11 and forthcoming for all claims as of 9/1/13) is having it's intended impact.  Opioid scripts have dropped, spending on medication therapy has dropped, and prescription habits are clearly changing.  Washington State and Ohio, both monopolistic work comp systems, have also implemented closed formularies with apparent benefit (both clinical and financial). 

This morning's article in WorkCompCentral on California's forthcoming efforts around prescription drug management opens the door for the concept in California as well.  CA Insurance Commissioner Dave Jones explicitly suggested that a closed formulary concept should be explored.  This would make California only the second non-monopolistic state to adopt such an approach.

Obviously, we're a long way from the state legislature passing and the governor signing any such bill, not to mention the time it would take for DWC to implement such a measure.  In Texas, House Bill 7 - which called for the closed formulary to be implemented - was passed and signed in 2005; the rules went into effect in September of 2011.  Nonetheless, the notion isn't as far-reaching in California as it might appear. 

When plotting the potential geographic adoption of closed formulary concepts around the country, my view is that we're most likely to see such rules adopted in states that share several characteristics.

First, closed formularies will be particularly attractive in states that have a significant opioid issue.  California certainly fits this criteria.

Second, states that already have medical treatment guidelines with which the provider community is used to complying will find the concept of a closed formulary easier to swallow.  When Texas opted to use Appendix A of the Official Disability Guidelines, there was little push back.  ODG has been the guideline set governing care for Texas work comp patients for several years now.  California has its own Medical Treatment Utilization Schedule, but these guidelines are weak on opioids.  Interestingly, Department of Industrial Relations Director Christine Baker admitted as much to a panel of California lawmakers yesterday.  She noted that updating these guidelines is a "top priority" for DWC's panel of medical advisers.

Third, closed formularies will be most easily negotiated in states that already have clearly supportive utilization review (UR) statutes and regulations.  I recently reviewed the Texas rules as part of an education session in a non-UR state and suggested that I thought it might be a good idea for this particular state to give it a try.  Several audience members reacted quite negatively with one particular gentleman suggesting that all of the state's doctors would immediately cease taking work comp patients.  If your state doesn't have experience with UR, jumping right to a closed formulary is a tough sell to the provider community.  In California, UR is nothing new, though it's not a mandate like it is in Texas.  Nevertheless, I believe it's still a good leading indicator that adoption is possible.

Fourth, the state's politicians must exhibit the political will to adopt measures that are clinically and financially necessary, but not necessarily popular - particularly among physicians.  There are others in our industry who know far more about California politics than I, but I'm not convinced that a closed formulary concept wouldn't be changed beyond all recognition as it worked it's way through the deal making, negotiating, and bargaining that is a matter of course in Sacramento (and in many other state capitals around the country). 

California lines up well with respect to recognizing the opioid issue, moving toward more effective guidelines, and having plenty of experience with utilization review.  The open question: will the politics allow it to happen? 

Michael
On Twitter @PRIUM1

Addiction, Patient Rights, and Law Suits

The text of Nevada Senate Bill 75, authored by State Senator Tick Segerblom, is simple.  Here it is in it's entirety:

1.  Notwithstanding any provision of law, a person who suffers injuries as a result of an addiction to a prescription drug may bring and maintain an action for damages against:
a) The manufacturer of the prescription drug.
b) The provider of medical care who prescribed the prescription drug, if the provider of medical care knew or should have known of the person's addiction to the prescription drug. 
2. A person who prevails in an action brought pursuant to this section may recover his or her actual damages, including, without limitation, any costs associated with rehabilitation for the addiction, attorney's fees and costs of any punitive damages that the facts may warrant.
3. [definitions]

That's it.  Pretty straightforward.  But at the same time, incredibly complicated. 

To be clear, I'm in favor of the concept.  Patients that suffer the consequences of iatrogenic disease (including addiction... perhaps especially addiction) should have recourse against the responsible physician.  Addiction is a well-defined and legitimate diagnosis.  If a patient exhibits symptoms of addiction and the physician misses them or refuses to acknowledge them, that physician should bear responsibility for the consequences to the patient. 

That said, such broad language as included in Senate Bill 75 leaves lots of unanswered questions.  If the doctor is to blame, where does the liability of the drug manufacturer come into play?  How does such legislative language align with work comp's exclusive remedy?  What would passage of such a bill do to malpractice insurance?  I'm sure the plaintiff's bar loves this idea, but how do we separate the wheat from the chaff? (There will be no shortage of frivolous suits driven by this law).  Plus the hudreds of other questions you're thinking of right now as you read this...

I'm not sure that Senate Bill 75 is the panacea some hope that it will be.  But it's a bold suggestion in the face of a major public health issue. 

Michael
On Twitter @PRIUM1

Opioid Abuse: Is there a Role for Self Management?

Today brings a guest post from PRIUM's Founder and CEO, Jim Pritchard. 

There is little argument with the statement that injured workers are suffering from a high incidence of opioid abuse.

With such widespread recognition of the problem, why is it so hard to correct?  A partial explanation is reflected in the erosion of the “no fault” intent of workers' compensation.  We want the problem to be fixed back to the pre-incident status without cost to the injured worker (which is reasonable) and without effort (which is not).

Perhaps this is reflected by society’s perception of health.  Our society has tacitly defined health as indemnification against cost of health care procedures as well as our own poor personal choices, not just being of “sound mind, body and spirit”.  In my view, this is patently false.  Real health is a personal responsibility not a physician responsibility.  There is so much money (public and private) in this system with so many stakeholders continually attempting to gain their share of that money that we are encouraged and many times required to abdicate responsibility for our own health.

In workers' compensation, this is reflected by the attitude that the injured worker is indemnified against not only cost but also any pain, discomfort or effort in the recovery from incident or injury.  There are just too many perverse incentives at play.  Secondary gain, a busted legal system and little motivation to get back to work are just a few of such conflicting incentives. 

We at PRIUM have seen thousands of narcotics abuse cases.  Of these cases, obesity is the number one co-morbidity.  Psychological and other issues are frequently seen and mismanaged as part of the work incident, but obesity is still number one.  We all know that obesity brings with it a myriad of other co-morbid conditions such as hypertension, hyperlipidemia, diabetes, reduced level of activity, etc.  All of these issues tend to create a set of confounding variables that seriously complicate management of the case. Both narcotics and obesity tend to reduce desire for mobility which is probably the single best therapy for typical musculoskeletal workers' compensation injuries.

Instead of addressing this co-morbid condition (which admittedly requires an uncomfortable conversation), too many physicians increase dosage and medications to the detriment of the patient’s overall health.  We hear all too often “the patient is stable with a reduced pain score” as sole rationale for long term prescription of opioids.  We lose focus on function thereby creating a vicious cycle of reduced activity, increased caloric intake, feeling less well about one’s self, increased hypertension, potential onset of diabetes and more pain.  Removing these confounding variables should be pre-requisite to considering long term use of opioids for chronic pain.

In order to address this pandemic of prescription opioid abuse we must educate the patient as to the high risk and questionable benefit of long term opioid therapy in chronic pain treatment.  Patients must have sufficient information in order to exercise a responsible role in the decision making process for their own health.  Unfortunately, many in the physician community have displayed poor performance in addressing opioid abuse without such shared responsibility.

So, to answer the original question (why is opioid abuse so hard to fix?), not only should there be a role for self management in addressing opioid abuse, it should be a requirement.

JAP
On Twitter @PRIUM1

Medical Bills Are Killing Us

Normally, I find that Time Magazine isn't worth the paper on which it's printed.  Pretty cheap paper, too.  But the cover story of the February 20th issue caught my eye: Bitter Pill - Why Medical Bills are Killing Us. 

As I began to read the piece, I realized that this wasn't a typical, four-page, gloss-over-the-subject cover story.  This was 30 pages of in-dept analysis that took the author, Steven Brill, seven months to research, analyze, and synthesize.  The article balances the power of the anecdote with the realities of the data.  The conclusions are alarming.  For those of us that have spent a career in health care, the data, the stories, and the intricacies of the system are not news.  But Brill's cover story shines a light in a heretofore dark space for the vast majority of health care consumers in this country. 

This is the first mainstream piece of journalism I've read in which the concept of the illusive "chargemaster" is discussed in great detail.  The utter lack of logic on which the chargemaster is based is just the beginning of the problem.  The real issue is that a great deal of the negotiating that goes on between hospitals and insurance companies revolve around this massive database of fundamentally arbitrary codes and prices.   This isn't a fact most of us have to worry about - unless you are uninsured or underinsured.  Brill sums it up this way: "If you are confused by the notion that those least able to pay are the ones singled out to pay the highest rates, welcome to the American medical marketplace." 

Of particular interest to most regular readers of this blog will be the story of the $49,237 spinal cord stimulator from Medtronic.  Not a typo.  The patient was actually charged nearly $50k for a SCS (and this was for the device itself and did not include the outpatient surgery charges, the physician charges, or the blankets and surgical gown for which the patient was also charged).  And for those of you paying bills in the work comp space based on fee schedules driven off of Medicare rates, there's a lot of discussion about how CMS sets those rates and what it means for providers. 

We've spent a lot of time in this country over the last several years arguing about how to pay for growing medical costs.  I'm not going to weigh in on that debate.  But I do appreciate Brill's view on the subject: "When we debate health care policy, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?"

Worth a read. 

Michael
On Twitter @PRIUM1

Patient Education: Opioid Basics

PRIUM has put together a simple, one-page (front and back), graphically intensive, easy-to-understand education piece aimed at patients on opioid therapy for chronic pain.  We're offering this resource absolutely free of charge to anyone who wishes to use it: injured workers, adjusters, nurses, physicians, attorneys, etc.  While the PRIUM logo is shown on the page, we'd be happy to share an alternative version that doesn't contain our logo - just ask and we'll send it your way. 

You can find our patient education brochure here.

We spend a lot of our time here at PRIUM on the concept of education.  We conduct continuing education for claims professionals and clinicians.  We deliver informal education within the context of every peer-to-peer intervention we perform.  One of the purposes of this very blog is general industry education.  But we hadn't yet developed anything to engage the injured worker.  And that wasn't for lack of trying.  We had grand ideas about web sites, interactive tools, self-assessment techniques, etc. 

Then Dr. Pamella Thomas, our Medical Director, shared a glaring and critical insight about the need to create patient education that is simple.  Her rule: if the patient can't get through it while sitting on the toilet, it's probably not going to help.

Special thanks to Dr. Thomas for developing the content and to Marketing Works for turning the content into an engaging infographic. 

If this leads to even a single patient asking a single question that leads to better treatment of chronic pain, the effort will have been worth it.

Michael
On Twitter @PRIUM1

Physician Dispensing: Even More Expensive Than You Think

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

The statistics are compelling on many levels. 

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

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

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

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

Michael
On Twitter @PRIUM1

NCOIL Picks Up Where IAIABC Left Off

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

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

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

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

Well done, NCOIL. 

Michael
On Twitter @PRIUM1

Abject Failure at the IAIABC

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

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

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

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

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

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

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

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

They should remove that immediately.

Michael
On Twitter @PRIUM1

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

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

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

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

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

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

Michael

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

On Twitter @PRIUM1

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

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

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

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

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

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

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

No more deals.  Let's get to work. 

Michael
On Twitter @PRIUM1

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

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

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

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

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

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

Wow.

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

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

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

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

Michael
On Twitter @PRIUM1

Let the People Decide! Prescription Drugs and the Democratic Process

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

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

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

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

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

Michael
On Twitter @PRIUM1

Another Sad Story: Prescription Therapy Gone Awry

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

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

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

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

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

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

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

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

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

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

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

Michael   
On Twitter @PRIUM1

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