Tuesday, September 30, 2014

A World Without Work Comp

"I was carrying a steel pipe at work and it brushed up against an electrical wire.  When I woke up, I saw that everything was gone, and I just started crying... I've been begging for money in this same spot for 20 years.  All I can do is try to get my bread every day until God decides to take me home."

(If you don't follow Humans of New York on Facebook, you're missing something in your life.  This amazing project has gone from the streets of New York to a worldwide photo documentary of the highs and lows of human existence.  If you're looking for a little perspective, this is a great source.)    

This particular picture and quote was taken in Mexico City some time Monday afternoon.  On the one hand, it made me sad for this man and his circumstances.  On the other hand, it caused me to reflect on the positives of our workers' compensation system in the US.  Frankly, it's not hard to criticize the system.  But there's also a lot good that occurs and I'm grateful to know that should I ever brush a steel pipe against an electrical wire while on the job, my prospects would likely be better than this gentleman's.  

To paraphrase Churchill's thoughts on democracy: "Workers' compensation is the worst form of protection for injured employees... except for all those other forms which have been tried."  

On Twitter @PRIUM1

Friday, September 26, 2014

Hard Choices: Mental Illness vs. Medications

The recently released report and follow up webinar from the Workers' Compensation Research Institute (WCRI) shines more light on the complicated world of chronic pain.  (Full disclosure: PRIUM is a WCRI Core Funder... and proud of it).  WCRI doesn't take policy positions, they work hard to inject data and academic rigor into policy debates without taking a stance one way or the other.  As if often the case, however, the data in this report appears to speak for itself.

The report measures the utilization of modalities that should be used to support chronic pain patients in the healing process.  Physical therapy is the most common (moving from 87% of injured workers in chronic pain to 88%).  Still more work to do here - why are 12% still not getting PT? - but that statistic isn't particularly alarming.

Only 25% of injured workers in chronic pain are being monitored for compliance with drug therapy regimens.  From our vantage point, this statistic is slightly misleading.  We see pockets of extremely high and inappropriate utilization of drug testing among some physicians and virtually zero testing among others.  The net statistic is 25%, but we see a tale of two extremes in this area.  Again, this is our view from PRIUM - admittedly skewed by our focus on complex claims.

Finally, the dismal news.  Only 5% of injured workers in chronic pain go through psychological evaluation and only 4% receive psychological treatment of any kind.

We know why this is.  Adjusters: Raise your hand if you're willing to let a potential psych diagnosis get within 10 miles of any of the claims on your desk.  Seeing no hands raised, let's address the issue as candidly as possible.

On many long term complex claims, you are left with two bad choices: continue the meds or deal with the psych.  This is the proverbial "rock" and "hard place."  And years of training and bad experiences have left the work comp community with a clear answer to this quandary - under no circumstances are we to explore the psych.  Just pay for the meds, cross your fingers, and hope...

A favorite aphorism from one my business school professors comes to mind: "Hope... is not a strategy."

So what's the strategy?  I don't have all the answers, but here are a couple of ideas:

First, keep in mind that some modalities, like cognitive behavioral therapy (CBT), which are often used in support of the weaning process, do not necessitate or lead to psych diagnoses.  These are supportive and therapeutic modalities, not diagnostic.  And they can be billed under physical medicine CPT codes.  So don't freak out when you see a CBT recommendation.

Second, many treatment options require a psych eval to assess whether the option is viable for the injured worker.  Things like spinal cord stimulator trials, inpatient detox, and surgery often require (via medical treatment guidelines) a psych eval.  This can be complicated and you should consult with your supervisor and/or defense counsel on a case by case basis, but we've seen positive clinical outcomes as a result of a claims organization's willingness to choose the right clinical path, even if a psych eval has to be done first.

Finally, recognize the brutal fact that on some cases, the only way to reach resolution, the only way to for the injured worker to truly heal, is to deal with the underlying psychological issues faced by that person.  Note that according to the CDC, more than 60% of us experienced some kind of childhood trauma or abuse (verbal, physical, psychological, sexual, etc.)  We are a society of broken people.  Workplace injuries can trigger, exacerbate, or prolong our struggles with inner demons that have nothing to do with our non-specific low back pain.

I'm not declaring you should take on psych without regard to the potential consequences.  I'm simply suggesting that the first step to solving a problem is recognizing we have one.  And the second step is to have a real dialogue about the nature of that problem.

On Twitter @PRIUM1

Wednesday, September 24, 2014

Calls for FDA Commissioner to Step Down Over Opioids

Anti-addiction advocates have sent a letter to Secretary of Health and Human Services Sylvia Burwell calling for FDA Commissioner Margaret Hamburg to step down.  The letter itself is worth reading.

I was in the audience at the National Prescription Drug Abuse Summit here in Atlanta back in April when Dr. Hamburg attempted to address some of the decisions the agency has made.  I can understand the tension created by the need to balance public health with the FDA's role of approving medications on which million upon millions of R&D dollars have been expended.  My view: it's not that she doesn't get it, it's that she's erring on the wrong side of the issue.  Public health concerns should be the primary lens through which her agency assesses new pain medications and that's simply not the case right now. 

The letter is signed by many organizations, most notably Physicians for Responsible Opioid Prescribing (PROP).  This organization has worked tirelessly to push back against the tide of prescription drug misuse and abuse and the regulatory system that enables it.  If you haven't seen or taken advantage of their education materials, you absolutely should.  Every person in medical and claims management can learn something about opioid abuse here: PROP web site

While I don't think Commissioner Hamburg will step down, the press coverage of the letter shines a spotlight on the issue and calls into question the behavior of the key federal regulatory agency responsible for approving new pain medications.  I think this will help push us toward a more comprehensive and responsible view of opioid prescribing.  

On Twitter @PRIUM1

Monday, September 22, 2014

Unfunded Mandates and Patient Safety

Last week, several New Jersey state legislators convened a press conference to announce a legislative package intended to stem the tide of opioid and heroin overdoses in the Garden State.  And quite a package it turned out to be: 21 bills are included, covering everything from mandatory insurance coverage for behavioral health to the use of naloxone to prevent overdoses.  There appears to be enough in the package that everyone has something they like... and everyone has something they don't like.  Should make for interesting politics.

One key piece of legislation in the package caught my eye.

The bill requires the mandatory registration and use of the Prescription Monitoring Program (PMP) among New Jersey physicians.  Everyone likes the concept of the PMP, but the Medical Society of New Jersey has an issue with requiring doctors to consult the database prior to writing prescriptions. Should this bill pass, New Jersey would join Oklahoma, Kentucky, New York, Tennessee, and Massachusetts as the only states that require doctors to consult the database prior to writing prescriptions for pain management medications.  If New Jersey legislators are smart, they'll include provisions (like Oklahoma did) creating exemptions for hospice and other end-of-life care situations.  Additionally, they'll prohibit lawsuits against physicians for not checking the database.  While a patient can't sue a doctor for not checking the database, the doctor would still be in violation of the law and subject to sanctions, punishment, etc.

Doctors often refer to such requirements as an "unfunded mandate."  By that, they mean additional requirements are being placed on them with no additional remuneration.  But this is fundamentally about patient safety.  Are the pre-surgical verification steps outlined by JCAHO an "unfunded mandate"?  What about the commonly expected best practice of physicians washing their hands between patients?  These are things we do in the healthcare community to protect patients, physicians, and other stakeholders from the unintended consequences of care delivery.  I can't understand how that logic doesn't extend to opioid prescribing.

New Jersey is headed in the right direction.  I hope they don't screw it up.

On Twitter @PRIUM1

Wednesday, September 10, 2014

Medical Marijuana is NOT the Answer to the Opioid Problem

At least not yet.  But the conclusion being drawn by many a reporter in our industry would have you believe otherwise.  "Fewer Opioid Related Deaths in States with Medical Marijuana" read one headline.

A study published in the Journal of the American Medical Association at the end of August is causing a lot of confusion in our space.  The abstract of the study (which is, unfortunately, all that most reporters seem to have read) states the following: "States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate... compared with states without medical cannabis laws."  One has to crack the cover and actually read the study to understand this conclusion results from a multi-variate linear regression model that compares behavior of individual states that have medical cannabis laws to what the behavior might have been in that state without such laws.  I have absolutely no issue with the the methodology or the related conclusion.  I'm a data geek and I love a good linear regression model as much as the next guy.

But on page 3 of the study, you quickly learn that the actual observed historical data tells the opposite story. States with medical cannabis laws exhibit a consistently higher opioid overdose mortality rate vs. states without such laws.  Marcus Bachhuber, the lead author of the study, points out that its hard to compare states to each other and much more statistically relevant and reliable to compare states to themselves (what does California look like vs. what we would expect California to look like without a medical marijuana law?)  This is a perfectly valid academic exercise, but not one from which we should be drawing policy conclusions.  Dr. Bachhuber himself writes in the study, "In summary, although we found a lower mean annual rate of opioid analgesic mortality in states with medical cannabis laws [again, according to the linear regression model, not the observed historical data], a direct causal link cannot be established."

Kudos to Ben Miller at WorkCompCentral, who actually read the entire study and presented a balanced view of the issue in his article yesterday.  I was interviewed for and quoted in the article and stated the case much like I'm stating it here. I was impressed that Ben was willing to dig beyond abstract and take his story in a direction he may not have originally intended.  We need more reporters like him in our industry.

Bottom line: Medical marijuana laws cannot be said to lead to a reduction in opioid overdose deaths.  

On Twitter @PRIUM1

Friday, September 5, 2014

What's Actually Happening at the Pharmacy?

A lot, it turns out.  The local retail pharmacy represents another front, and a complicated one at that, in the battle against prescription drug misuse and abuse.  And you need to be aware of what some injured workers are facing when they take their prescriptions to the pharmacy.

Pharmacists are asking doctors questions about medical necessity... and doctors don't like that.  "They [pharmacists] call us sometimes and if (a prescription) is medically necessary," says Dr. Rafael Miguel, an anesthesiologist in Tampa.  "Well, if I write a prescription and it's got my DEA number and my signature on it, what do you think, I'm joking around?"

No, no one thinks this is a joke.  But pharmacists, insurance adjusters, case managers, other physicians, public health workers, and many others think you might be lacking key clinical knowledge regarding the appropriateness of certain prescriptions (yes, even doctors can be under-educated).  We don't think it's funny, we think it's tragic.

Then again, are pharmacists the right ones to be asking this question?  I have neither the clinical knowledge nor the courage to weigh in on that, but it's a question with which the healthcare industry is currently wrestling.  There is new tension in the traditionally high functioning relationship between doctors, pharmacists, and patients and pain killers are at the center of that tension.

For pharmacists and doctors reading this, nothing new here.  But for insurance industry personnel, it's important for you to get up to speed on the details of what's happening in the midst of an ordinary pharmacy visit.  We're revisiting some fundamental questions about the roles and responsibilities of various clinical constituencies.  I'm confident the pendulum (currently swinging at different rates in different directions in different places) will eventually come to rest where it should.

In the meantime, be on the look out for injured workers caught in the crossfire.

On Twitter @PRIUM1