Tuesday, October 30, 2012

Treatment Guidelines, Prospective Review, and Patient Safety

New Mexico is currently working through the process of adopting medical treatment guidelines.  Thankfully, they appear to be leaning toward nationally recognized, evidence-based guidelines like ODG and ACOEM (vs. the Medtronic-influenced, politically-driven brew of guidelines that states inevitably end up with when they try to develop their own guidelines).  Also encouraging is the presumption of correctness that the New Mexico rule contemplates.  Holding treating physicians accountable to the guidelines (even if that means ensuring clear, documented rationale for treating outside of said guidelines) is the only way to improve patient care and reduce state-to-state, practice-to-practice, and physician-to-physician variability in care.

Less encouraging is the proposed elimination of the requirement for providers to obtain prior authorization for medical services that are recommended by the guidelines.  While that sounds logical and efficient, there may be unintended consequences.

Prior authoriziation (or pre-authorization or pre-certification) comes in several shapes and sizes.  In many states, it's optional - something the provider will utilize only in circumstances where high cost care is being rendered and the provider wishes to ensure future payment (i.e., for a surgery).  In some states, pre-authorization is mandated - something the provider must do prior to delivering care.  There are pros and cons to both approaches.  Optional pre-authorization is administratively simpler and less onerous on providers.  Mandated pre-authorization is the opposite - more demanding administratively and on doctors.

But the clearest and most compelling argument for mandated pre-authorization is patient safety. New Mexico may allow for retrospective review if a physician performs a surgery or procedure outside of ODG or ACOEM.  But by then, the care has been rendered, potentially to the detriment of the patient. 

Texas serves as a bright spot in this regard.  Texas has adopted nationally recognized medical treatment guidelines and still maintains mandated pre-authorization, which now includes pre-authorization for certain pharmaceutical treatment as well.  Does anyone doubt that measures such as these have made Texas one of the most cost-effective work comp systems in the nation? 

High marks for New Mexico regarding treatment guidelines.  Low marks for trying to remove mandated prior authorization.  This strikes me as a quid pro quo with the physician community ("we're going to adopt these guidelines... but you don't have to ask permission anymore..."), but I don't think this bargain is in the best interest of patient safety.

On Twitter @PRIUM1

Tuesday, October 23, 2012

Thanks to LexisNexis

PRIUM's Evidence Based blog has been named a LexisNexis Top 25 Blog for Workers' Compensation and Workplace Issues for 2012.  We're grateful to LexisNexis for the honor and humbled to be in such good company.  I've had the opportunity to not only read the content generated by the other honorees on a daily or weekly basis, but also to interact and collaborate with many of them.  I like the feeling I'm often left with... that we're pulling in the same direction.   

Writing about important health care and public policy issues is energizing.  Writing about issues I care about is a blessing.  Getting to do both simultaneously is pure joy. 

We're just getting started.  Plenty of battles left to fight.  If a simple but thoughtful blog post can inform an important debate, change a single mind, or influence even one decision maker... then that post was worth writing. 

Thanks for reading.

On Twitter @PRIUM1

Thursday, October 18, 2012

Prescription Drugs and Kids: This Will Make You Cringe

The New York Times published a piece last week that I find incredibly troubling.  While not directly impacting the workers' compensation system, the article sheds light on our cultural proclivity to rely on prescription medication for uses that were not intended and are not appropriate.  Further, it highlights the role of well-meaning medical practitioners who, in reality, are creating more harm than good. 

Dr. Michael Anderson, a pediatrician in Cherokee County, Georgia, noticed that some of his patients were performing poorly in school.  Unable to determine that anything was medically wrong with these children, Dr. Andersen assumed that the school itself was inadequate.  He may be right about that.  But his solution to the problem is shocking.

He prescribes Adderall. 

He admits, according to the NY Times, that the ADHD diagnosis that he makes is "made up" and "an excuse" to prescribe the drug for the express purpose of boosting academic performance (Adderall improves focus and impulse control).  Dr. Anderson goes on to say, "We've decided as a society that it's too expensive to modify the kid's environment.  So we have to modify the kid."


Later in the article, we come to discover that one of the kids prescribed Adderall began hearing voices that were not there and admitting to suicidal thoughts.  Dr. Anderson's solution?  A week in a psych hospital and a switch from Adderall to Risperdal.  Problem solved.  For now. 

Gradually over the last half century, we have become far too comfortable with the idea that there is a pill to solve every problem, even when legitimate medical diagnoses don't exist.  Struggling in school?  Take a pill.  We see this every day in workers' comp.  Pain? Take a pill.  Still hurts?  Take a stronger pill.  And take more of them.  We have to focus on non-pharmacological solutions to social, environmental, and even biological problems. 

Dr. Anderson acknowledges that no one knows the long term effects of pharmacological solutions like Adderral for academically under performing kids.  But, he says, "I am the doctor for the patient, not for society."  In reality, he is doing a disservice to both.

On Twitter @PRIUM1

Wednesday, October 17, 2012

Connecticut: A Simple Suggestion to Help Control Costs

There's a great post today by Jon Coppelman over at Workers' Comp Insider that compares and contrasts the work comp systems of Massachusetts and Connecticut in light of the recently released Oregon Rate Study.  (Side note: see David DePaolo's post on the Oregon study here - good data, but certainly needs to be read in proper context).

After a thorough overview of each state's woes (which happen to be equally painful, but polar opposite sets of issues), Jon suggests the following for Connecticut: "... regulators must confront entrenched stake holders and begin to exert control over runaway costs." 

Well said.  And I have a suggestion for where the good people of Connecticut might start: Let us talk to the treating physicians.

The employer/insurer community in Connecticut is severely restricted with respect to being able to initiate a peer-to-peer conversation with a claimant's treating physician.  Communication between payor and the attending physician where such communication would involve unilateral disclosure or discussion of material information is not allowed.

Payors, however, may request the physician to complete the "Employee Medical & Work Status Form" or provide progress notes. Copies of this communication, as well as any responses from the physician, must be provided to the injured worker or his/her representative (Payor and Medical Provider Guidelines to Improve the Coordination of Medical Services, 2010).

But there is no allowance for the insurer to engage a peer physician to launch a call to the treating doctor and say, "Hey Dr. Smith... can we chat about why Joe has been on Oxycontin for three years? The evidence suggests that might not be good for him. Are there mitigating circumstances? Do you need help with weaning? How can we be of assistance?" In Connecticut, that conversation can't happen. And that's a shame. 

The goal of a peer-to-peer conversation is not to coerce or connive our way to a cheaper treatment plan.  That is a disservice to all stake holders and peer review companies that conduct clinical conversations that way have no place in our industry.  Yes, we will challenge the current treatment plan if it falls outside of the medical treatment guidelines.  But we do that with a specific end in mind.  The goal of a well conducted peer-to-peer conversation (which is admittedly harder than it might initially seem) is to engage, to understand, to educate, to guide... in a word, to help

These conversations play an important role in the dissemination and adoption of contemporary research and best practices.  Without them, treating physicians are often left with an unattractive and biased alternative information source: the local drug rep. 

Allowing for peer-to-peer conversation in Connecticut is not a magic bullet that will, by itself, lead to significant cost reduction.  But it's a start.

On Twitter @PRIUM1

Tuesday, October 16, 2012

The Repackagers Pivot to Drug Screening

Legislative and regulatory action across the country is likely to put a dent in the P&Ls of drug repackaging companies.  They'll fight every step of the way and spend lots of money on lobbyists, but the fundamental business model simply isn't sustainable.  They're not going away tomorrow, but the writing is on the wall.  Some of the more strategically adroit drug repackagers are beginning to explore new revenue sources to replace the waning dollars earned from helping physicians dispense medications.  Where are they looking?

One clear area is drug screening.  Random urine drug monitoring for chronic opioid users is indicated in several sets of medical treatment guidelines and PRIUM believes strongly in the practice.  In fact, this is one of the standard areas we explore on every review we conduct.  The importance of random drug screening cannot be overemphasized given its impact on patient safety.   But any virtue taken to an extreme can become a vice. 

The logic trail here is similar to drug repackaging.  Take a therapy or procedure that the doctor feels the patient needs... allow the doctor to administer the therapy or procedure directly in the office... bill the insurance company for services provided... increasing patient convenience and compliance.  Sounds rational, right?

The devil, as they say, is in the details. 

Drug repackagers routinely develop novel NDC codes, allowing them to create arbitrary average wholesale prices.  This practice allows doctors to bill insurance companies significantly more than the insurer would have paid had the drug been filled at a typical retail pharmacy.  And there is no evidence to suggest that the practice increases safety or compliance.  Additionally, restricting this activity entirely (as several states do) does not appear to impact access to needed medications on the part of injured workers.  Not so rational after all.

We see the same trend coming in drug screening.  Keep a look out for excessive utilization and/or obnoxiously high bills for urine drug screening performed in the treating physician's office.  The drug repackagers are going to start teaching docs how to game this system as well.  A couple of examples: http://thephysiciansrx.com/toxicology.html and http://physiciandispensingsolutions.com/services-view/drug-toxicology/

Be vigilant.  Understand the services you're buying.  Ensure that the screening is truly random and within the treatment guidelines.  Get another clinician to look at the test results - is the money you're paying actually telling you anything about the patient's adherence to the drug regimen? 

On Twitter @PRIUM1

Thursday, October 11, 2012

Kentucky Revisited: Opioids and HB 1

Back in August, I wrote a post on the immediate impact of HB 1 in Kentucky.  I was a little surprised that most of the comments on that post (several of which I posted, some of which I didn't for reasons of either discretion or propriety) were negative in nature.  HB 1 was characterized as an overreach, dangerous to patients, and costly to the health care system in the state.  Further, the bill's basic constitutionality was brought into question (something along the lines of the KASPER database representing an invasion of privacy... shouldn't a citizen have a right to abuse drugs prescribed by multiple doctors without any consequences?)

This week, however, yields more data on the extent and severity of the opioid epidemic in Kentucky.  Turns out, Kentucky Medicaid patients are prescribed more narcotics than any other class of drug from 2000 to 2010.  According to this report from the University of Kentucky's Center for Business and Economic Research, the state spent $212 million on pain meds over this 10 year period for over 3.8 million prescriptions (just for Medicaid patients!). 

I understand HB 1 isn't perfect.  But I think the detractors owe us more than just a critique.  What's the specific set of alternative policies that could be implemented to help alleviate the epidemic of prescription drug use in Kentucky? 

HB 1 does inflict a greater burden on Kentucky medical providers and it does create a higher standard of care for chronic pain patients.  But I don't believe for one second that the increased cost to the state's health care system of these measures will not be easily overcome by the cost savings related to the mitigation of prescription drug misuse and abuse. 

On Twitter @PRIUM1

Thursday, October 4, 2012

WCRI Report on Opioids: Only Part of the Story

WCRI published a very revealing report this week on long term opioid use and adherence to medical treatment guidelines.  The findings were disheartening, though not terribly surprising. 

The 21-state median percentage of long term opioid users receiving psychological evaluations was 7%.  For psychological treatment the number was 4% (vs. 6% is the prior period studied two years before).  Claims with indications of urine drug testing stood at 24%.  This means that more than 9 out of 10 long term opioid users aren't receiving any kind of psychological screening or treatment.  Only 1 in 4 is being tested to ensure the drugs are being taken properly. 

What's potentially more interesting is what WCRI didn't measure (or perhaps more appropriately, couldn't measure).  The component of the "medical treatment guidelines" for which WCRI was able to collect and analyze data was limited to urine drug monitoring, psychological evaluation, psychological treatment, and physical medicine.  These components of the the medical treatment guidelines all have one thing in common: each can be associated with one or more CPT codes, making data collection and analysis feasible. 

But what about other components of the medical treatment guidelines that doctors should consider in light of chronic opioid therapy?  I'm thinking mainly about functionality.  You can't measure that via a CPT code, but all too often long term opioid use leads to decreased functionality, not improved functionality. 

The WCRI study, along with this basic issue of functionality, begs a broad and important question:

If, theoretically, medical treatment guidelines were properly considered and adhered to for 100% of claims where opioids might have been prescribed... what percentage of opioid spend would disappear from work comp?  What's your best guess?

On Twitter @PRIUM1

Tuesday, October 2, 2012

Fighting Fire with Fire: Kudos to Florida Payers

Back in March, I wrote a post about a little known corner of the Florida work comp regs that allows carriers and employers to reduce the price they pay for repackaged drugs. 

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

I'm not the only one that pointed this out.  The folks at workcompcentral and several other bloggers pointed to Florida statute 440.13 (12) as a potential tool for payers in the fight against repackaged drug pricing. 

Today brings news from NCCI that this tactic appears to be working.  NCCI has cut its estimate of savings from a proposed repackaged drug bill by half (from about $62 million to about $27 million) due to employers and carriers re-pricing obnoxious bills on their own. 

Predictably, AHCS (a software firm specializing in drug repackaging) says this is further evidence that NCCI's numbers are a moving target.  On the contrary, NCCI's numbers reflect the market reality of payers taking control of the situation in Florida and using any and all available statutes and regulations to stem the tide of inappropriately priced drugs. 

Way to go Florida payers. 

On Twitter @PRIUM1

Monday, October 1, 2012

An Important Message from Physicians for Responsible Opioid Prescribing

I received the following note from Dr. Andrew Kolodny and with his permission, I'm passing it along to all of you.  Please take 5 minutes and do your part. 

Dear Friends and Colleagues,
As you may know, PROP filed a request to FDA for changes to opioid labels. Specifically, we asked them to add a suggested duration of use, a suggested upper dose and to limit (on-label) use to severe pain. You can read about this here:

If FDA implements our request, opioid manufacturers will be prohibited from advertising long-term use of opioids for chronic non-cancer pain and the medical community will be informed that this practice has not been proven safe and effective. (However, clinicians will still be permitted to prescribe long-term opioids). We believe that this will help reduce overprescribing of opioids. And since it’s overprescribing that’s harming pain patients and fueling the opioid addiction epidemic, the label change could help bring this unprecedented public health crisis under control.

FDA is seeking public comment about the Petition. Thus far, they have received about 200 comments supporting the petition and 130 opposed to the petition. Not surprisingly, industry-funded pain groups (and pain patients misled to believe that this is an effort to ban opioids) have weighed in against the Petition.

Submitting comments to FDA is easy... just click here:

A couple of sentences is all you need. Please make sure to state clearly in the first or second sentence that you support the petition.

For example, you can write: 

I support this petition. Drug companies should not be permitted to advertise long-term and high dose opioids for moderate chronic pain because this treatment has not been proven safe and effective. The medical community should be informed  by a revised label that risks may outweigh benefits when opioids are prescribed long-term. 

Please try to do this ASAP. As soon as FDA takes an action on the Petition (which could be very soon), they will close the comment period.

If you are interested in reading comments that have already been posted, you can do this here:

Thank you for your support!


Andrew Kolodny, MD
President, Physicians for Responsible Opioid Prescribing
Chair, Department of Psychiatry
Maimonides Medical Center
920 48th St., Brooklyn, NY 11219
Tel: 718 283-7557; Fax: 718 283-6540

On Twitter @PRIUM1