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. 

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.

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.

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.

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.


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.

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.

On Twitter @PRIUM1