Reviewing California’s draft opioid guidelines

California released their new opioid guidelines; not to put too fine a point on it but they are underwhelming.  That’s my layman’s perspective.

A good friend and colleague, who also happens to be the Medical Director of a worker’s compensation insurer, provided a professional’s perspective which is below.

I’ve taken the liberty of moving what I believe is a key takeaway to the top: “This DWC Guideline is a review of eight existing guidelines—it is not a de novo review of primary sources.

The DWC has posted for comment its guideline [link added] for the use of opioids in WRIs. It sets out to accomplish three goals:

  1. To provide a set of best practices for safe and effective prescribing of opioids in the context of WRIs in the acute, subacute and chronic phases;
  2. To prevent and reduce opioid-related long-term disability, morbidity, mortality and substance abuse and misuse; and
  3. To recommend opioid prescribing practices that promote functional restoration.

Its intended audience is clinicians, utilization reviewers and insurers.

Below is a summary and review of this 321-page document. It is not exhaustive, but I trust it will be useful as a starting point for discussion and further evaluation.

In my opinion, the best parts of this proposed Guideline are

  1. Discouraging the use of opioids in minor injuries
  2. Encouraging the use of other therapies before considering opioids
  3. Encouraging lowest effective dose, time limits on opioid use
  4. Encouraging the prescription of opioids for use at night and when the patient is not working
  5. Listing relative contraindications for the use of opioids
  6. Suggesting that current substance abuse (or illicit substance use) is a[n absolute] contraindication to opioid treatment
  7. Encouraging education and informed consent
  8. Encouraging education about safe storage and disposal of opioids
  9. Recommending that CNS depressants (including antihistamines, benzodiazepines and alcohol) should not be used concurrently with opioids
  10. Requiring the use of CURES [California's prescription drug monitoring program], treatment agreements and UDT
  11. Limiting UDT to baseline plus two to four times yearly; limiting UDT to prescribed and additional opiates, alcohol, amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, fentanyl, methadone and oxycodone
  12. Emphasizing the importance of documented functional improvement as a prerequisite to continued opioid use
  13. Giving criteria for discontinuation (lack of pain reduction or functional improvement; intolerance or severe side effects; or non-compliance)
  14. Recommending MED documentation at every patient visit
  15. Recommending opioid weaning semiannually for IWs on ≥ 80 mg MED

In my opinion, problematic parts of this proposed guideline are

  1. Although addressing opioids only (the MTUS addresses chronic pain separately), this Guideline includes “rest” as a treatment for pain (paradoxically, rest is considered a “physical activity” in this Guideline). Unless rest is clearly defined (for example, it may be appropriate to rest/immobilize a joint, depending on the clinical situation) and it is taken to mean bed-rest or inactivity, the “cure” may be worse than the disease.
  2. Likewise, this Guideline recommends complementary and alternative modalities “such as acupuncture”. What other treatments fall in this category? They do not elaborate and they do not address the requirement for effective, evidence based treatments and that’s a concern because it may open a door that providers will take advantage of—especially in California. Are they opening the door to massage, chiropractic, TENS, magnet therapy, hyperbaric oxygen, homeopathy, Chinese herbal medicine, etc.? You would have to reference the MTUS Chronic Pain Guideline to answer this question and this Guideline should point the reader to this fact.
  3. Guidelines as to when to discontinue opioids are absolute in some places, but very flexible in others. For example, the Executive Summary states that, “In order for opioids to be prescribed beyond the acute phase, there should be no contraindicated comorbidities…” In the Abbreviated Treatment Protocol and elsewhere the Guideline recommends that the prescriber “consider and document relative contraindications…If these conditions are present, written documentation must be provided to justify the use of opioids.”
  4. Aberrant use of medications or substances (as evidenced in an inconsistent UDT, for example) is indicated as an absolute disqualifier for further opioid prescribing in one section; however, another section invalidates that pronouncement (see below, footnote 9).
  5. The use of CNS depressants, such as sedatives, hypnotics, H1 antihistamines, benzodiazepines and alcohol seem to be an absolute contraindication in the Recommendations. However, Section 7 (Concurrent Use of Benzodiazepines and Other Sedative Hypnotics During Chronic Opioid Treatment) only recommends counseling the patient against using these substances concurrently and states that, “If, after careful consideration, the clinical decision is made to prescribe other sedatives or muscle relaxants to patients on chronic opioid treatment, counseling should be provided to stagger dosing to avoid excess sedation and potentially disastrous complications.” It seems to me that avoiding disastrous complications, including “fatal overdose events” should be a physician’s first priority. This also flies in the face of one of the three purported goals of the Guideline: “to prevent and reduce opioid-related long-term disability, morbidity, mortality and substance abuse and misuse.”
  6. Urine alcohol testing (as recommended as part of UDT by this Guideline) is not accurate and may not be clinically useful.

The proposed Guideline was completed before the publication of the new ACOEM Opioid Guidelines (March 2014) which, in my opinion, is far superior as a thorough and true evidence-based practice guideline. [emphasis added]

My colleague’s review provides necessary insight into the pros and cons with the Guidelines.  To DWC’s credit, they are looking for comments, and I’d encourage you to submit yours here; deadline is TODAY..

My layman’s suggestion would be rather simple – adopt ACOEM and be done with it.

 

Friday’s what-I-missed-this-week post

Another quick week is done, altho after the two inches of snow Tuesday I’m not sure that’s a bad thing.  So here’s what happened while we were digging out.

There’s a bunch of news re ACA enrollment and the impact thereof; I’ve picked out the key parts (as I see them) for your edification.

The latest projections on PPACA enrollment are out, and the Administration is touting a higher-than-even-originally-projected 8 million insureds. Notably, this does NOT mean all are newly insured, and does not exclude those who have not paid their premiums as of yet (for the newly-enrolled population, there’s no way to tell until their premium payment late period has expired.

Why aren’t GOP-led states jumping on the Medicaid block grant bandwagon?  If they are so sure they can do a better job (and I don’t doubt that some can) than the feds, what’s with the reluctance?  Bob Laszewski asks this vital question – and the answer is…

From investment research firm L.E.K. comes an excellent review of the impact of health care reform on hospitals.  Yes, it’s a complex issue, and no, don’t say you don’t have time to read it.  This is a very good piece, and relevant for work comp as hospital expenses are rising in many states. Of note – Medicare’s hospital expenses are projected to drop over the next decade – there may be an effort on the part of facilities to make that deficit up from…somewhere.

Health insurance premiums will be 15% less than predicted next year - so says a just-released study by the CBO, which did that initial prediction back in 2009, just before ACA became law.  The CBO study also lowered the total cost projection for ACA by $105 billion over the next decade.

Finally, with RIMS coming up in just over a week, there may well be a couple big deals announced end of next week or at the show in Denver. I won’t be there (too much client work, and work comp isn’t a big part of the show) but many will.  Expect at least one announcement; there may well be two deals completed by the time the show opens.

Here’s hoping the sun shines on your weekend.

NoDak state fund – be VERY careful what you ask for…

WSI, the North Dakota state work comp fund, is suing AON for an alleged failure to deliver a new claims system.

AON’s response included the statement “We look forward to telling our side of the story in court.”  This may seem innocuous at first read, but it isn’t; far from it.  WSI’s leaders are heading down what will likely be a very dangerous path.

The legal process will undoubtedly include substantial discovery efforts on the part of AON, efforts that will show WSI’s current senior management (with a couple exceptions) is in way over its head.  System change requests, poor oversight, and a lack of specificity on the part of management will be highlighted, publicized, and poured over.  Attempts will be made to place the blame squarely on the shoulders of former boss Sandy Blunt, but those attempts will show the process – which had just begun when Blunt was ousted – was moving along on schedule and on budget until he was terminated in a horrendous miscarriage of justice.

The suit will be very important to AON, as it will be highly visible to their customers, prospects, and competitors.  A loss, or even slightly unfavorable ruling, would damage the giant broker, while a well-documented win will show they did everything they could to deliver.

For AON, this isn’t be about the state fund in a tiny state, but about their reputation and brand.

Whether WSI’s decision to sue AON is due to a mis-guided attempt to save face, naiveté or political pressure is irrelevant; the outcome of the suit will further damage WSI.

I’m of two decidedly different minds on this.

I’ve come to know well and deeply respect Sandy Blunt, a true gentleman, workers’ comp expert and ultimate professional.  What current WSI CEO Bryan Klipfel and his cronies did to Sandy is a travesty, a character assassination that should make everyone’s blood boil.  For Klipfel and his buddies to be exposed for the incompetent fools that they are is, in some small way, payback for their sins.

Rest assured, AON’s discovery will make that all too obvious.

But.  That payback comes at a high cost.

WSI is responsible for workplace safety and claims for the vast majority of the state’s workers, and the agency’s continued downward spiral is a gross disservice to those workers, their employers, and North Dakota’s taxpayers, not to mention those WSI staffers who are really trying to do the right thing.

What does this mean for you?

Nothing good for NoDak’s employers and the many good folks at WSI.  And a well-deserved public humiliation for Klipfel and those who put him in the job.

(note – Klipfel was a state trooper who investigated Blunt, then got the job as WSI Executive Director)

The work comp service market’s response to consolidation

With OneCall getting ever larger, KKR buying TPAs and tech companies, EXAM Works’ consolidation of the IME business all but complete, and the private equity world’s seemingly insatiable appetite for work comp services assets, the continued consolidation of the work comp services business seems to be inevitable.

Perhaps.  But there’s another side to this big-getting-bigger story; there is a new crop of innovators beginning to emerge, one led by “cast off” execs from the “consolidated”, former business owners whose non-competes have expired, and newbies with great energy and a desire to do it better.

Ascential Care Partners is a relatively new regional company in the not-glamorous case management business.  Founder Cindy Whitehouse is one of the most delightful people I’ve met in the business; her passion, dedication, and desire to deliver the best possible service is beyond impressive.

curavita focuses on providing DME and related services for complex and cat cases; those really difficult, knotty situations where integrating all aspects of care is absolutely critical as is communicating with adjusters, family, and caregivers. Strong in technology and reporting, curavita was founded by long-time industry entrepreneurs (and good friends) Hank and Lisa Datelle and Mike Marsau. (I have a tiny stake in the company).

HomeCareConnect has a slightly different business model; they are a supplier of broad DME, soft goods, and home health care services – and only those services – and have a strong clinical orientation. 

LifeTEAM Health is also narrowly focused; They do “disability prevention” based on identifying and addressing psychosocial risk factors  - perhaps THE key factor in long-term, seemingly-intractable disability.  With providers around the country, they can and do bring a much-needed service to an industry that has yet to fully appreciate the importance of psychosocial issues.

What’s the common thread here?  It’s hard to discern, but there is one.

Case management is old as the hills; integrated complex case services with real-time reporting is cutting-edige ; DME/HHC with a clinical orientation is a different take on a common issue; psychological services are woefully underused in work comp.

But all are narrowly-focused companies working on knotty problems using unique (if not immediately apparent) approaches.

What does this mean for you?

Innovators take advantage of niches and their mega-competitors’ focus on “other” issues to solve tough problems.  You may well find they can help with yours.

 

 

Drugs and work comp – top issues are…

Opioids, ACOEM’s new guidelines, compounds, and, alas, physician dispensing.

Here’s a quick guide to the top issues and sources for additional info.

Opioids continue to plague the industry; while many PBMs and payers are having some success in reducing the use of opioids in new claims, there’s still a huge group of legacy claimants that have been on far too many pills for far too long.  Sandy Blunt and I conducted a survey on the opioid issue last fall (thanks to CID for sponsoring and the 400 participants for their insights) – The Survey of Opioid Management in Workers’ Comp can be downloaded here.

Last reminder – make sure you are going to Operation UNITE’s Prescription Rx Summit in Atlanta April 22 – 24.  The Summit is focused on all aspects of the prescription drug abuse problem.

Perhaps the best new tool in our armamentarium comes from ACOEM – their opioid guidelines were released last month and are available to subscribers here.  (you can also get a 14-day trial subscription).  A trio of highlights that challenge conventional wisdom merit attention:

  • No comparative trial shows that an opioid is superior to another medication (out of 28 trials.)
  • No evidence shows the long-term efficacy of opioids – the longest placebo controlled trial lasted only 4 months
  • 80-94% of opioid trials have industry conflicts (funding and/or conflicts of interest in the trials).

I’ll be posting an in-depth review of these guidelines later this week.  For now, my non-clinicians take is these are the best opioid guidelines out there; very well researched, highly credible, and desperately needed.

Express Scripts published a report on their work comp results; you can get a summary here. (hat tip to WorkCompWire)

CompPharma, the consortium of work comp pharmacy benefit managers (of which I am president), released a research paper on compounding medications in work comp; you can get a copy here (no cost, and no registration required)

I don’t see medical marijuana as a big issue; If anything it will be of occasional interest.  That said, in our upcoming Survey of Prescription Drug Management in Work Comp, we will be asking payers what their view of the issue is, and will report back on the results. Participants (previous reports can be found here).

Finally, we’d love to have you participate in the Prescription Drug Management in Work Comp survey; participants receive a MUCH more detailed copy of the report than regular people which includes a wealth of data points and statistics.  e-mail me at infoAT healthstrategyassocDOTcom (replace the caps with symbols first!) and we’ll sign you up (all responses are confidential and no company-specific data is shared).

 

Friday catch-up

Happy spring – hope the weather where you are is as great as it is in the northeast…we finally get to tell our friends in Florida that things are just fine, thank you.

Off we go to catch you up before you start the weekend

First, thanks to Billy Wynne for hosting the April Fool’s Edition of Health Wonk Review. There’s discussion of Obamacare’s status, the ICD10 situation, medical devices and pharma, and a great piece on hospitals and health systems’ future.

WorkCompWire’s got the very welcome news that the long-sought TRIA extension may happen sooner rather than later – good news indeed for the WC industry.  There’s a bill moving in the Senate to extend TRIA for seven years, raise the deductibles and make other changes necessary for bi-partisan support.

Pennsylvania’s House unanimously passed a bill limiting physician dispensing of drugs to work comp claimants to 15 days from the date of injury.  That’s great – but not as great as it seems.  Word is opponents are going to work to slow/stop the bill in the Senate.  Email your Senator and voice support for HB 1846.

 

The workers comp investment world is all abuzz; there are at least four pending transactions with two rumored to be looking for a pre-RIMS close date.  Whether they make it is anyone’s guess, but the opportunity to make a splash at the annual confab is plenty of incentive for all parties.  Expect hoop-la and trumpets blaring, announcements touting the wonders the new deals will have for all, and accolades for the geniuses who got them done.

Then ask yourself, this helps me how?

Quick update on health insurance enrollment

According to several recent analyses, insurance enrollment has increased significantly from last September to this April.

The latest, from RAND, indicates about 9.3 million more are insured, decreasing the uninsurance rate from 20.5 percent to 15.8 percent.

For several other estimates. the range is from 5.4 million to 9.5 million additional insureds; but – and it’s a big but, these are estimates from surveys of small populations.

From California Healthilne comes this [emphases added]:

Last month, the Los Angeles Times reported that at least 9.5 million previously uninsured U.S. residents gained coverage under the ACA during the initial open enrollment period for the exchanges. The analysis was based on various national surveys and enrollment data (California Healthline, 3/31).

Earlier this month, a study by the Urban Institute’s Health Policy Center reported that as many as 5.4 million previously uninsured residents gained coverage since the federal and state insurance exchanges were launched in October 2013 (California Healthline, 4/4).

Last week, a Gallup-Healthways Well-Being Index survey found that the uninsured rate had fallen to its lowest since 2008, with 14.7% of adults lacking coverage in the last half of March (California Healthline, 4/7).

I would quickly emphasize – again – that these are estimates, and likely to be somewhat off.  However, they are net of dis-enrollment/cancellation.

What does this mean for you?

Looks like this is here to stay; it would be very, very hard to tell 5 million people “never mind.”

Work comp’s new Coventry?

The work comp services market is consolidating - at a very rapid rate.  At this pace, pretty soon there will be relatively few entities providing a broad range of claims-related services.

And that scares insurers and employers.  A lot.

Work comp execs like to have control over their vendors; whenever possible they seek to have two (or more) vendors providing the same service, to “keep them on their toes.” Most execs (and desk-level folks too) want to dictate terms to their vendors, or if not “dictate” than at least “determine”.  That’s for two reasons; a) they’ve always been this way and aren’t likely to change; and b) a few years back Coventry work comp got very powerful and turned the tables on buyers.

A bit of history is helpful here.

Coventry Work Comp was built by combining the “old” OUCH network with Healthcare Compare, followed by an acquisition of Concentra’s WC services division, which had acquired NHR, which had acquired MetraComp, plus the acquisition of a few other bits and pieces.  Along the way, the company became the dominant work comp PPO.  A few years ago, it was the “must have” network for workers’ comp payers as it was the largest, had the best discounts, and had the most coverage in the most states. While other vendors may have had better networks in one or a couple of states, Coventry’s was the best (defined as largest number of providers and deepest discounts) and broadest.

Coventry’s management (since departed) used this market leader position very effectively.  They forced (yes, that’s the right term) payers to use their network – and other services – by raising their fees for payers who carved out specific states where another network was stronger.  In addition, they discounted other services (notably PBM) if the payer bought their network and bill review services.

This put payers in a tough position.  Try as they might to seek out the best-in-class network, PBM, or bill review offerings, insurers would have to pay a LOT more for Coventry’s network if they didn’t buy everything.

For Coventry’s erstwhile competitors, the playing field was anything but level.  If they built a great network in a state or two, one that far exceeded the depth, effectiveness, and discounts of Coventry, they’d often find the big buyers would tell them they’d won their business, only to learn a bit later that the deal had been undone and Coventry was going to keep it, having told the buyer that their fees were going to go up – often way up – if the state/s were awarded to the competitor.

Things got even more one-sided after Coventry bought Concentra’s work comp services business.

Coventry actually raised their prices, telling customers that the larger network delivered more value, and therefore a higher price was warranted.  Never mind that the larger network would deliver more revenue just by virtue of including more providers; Coventry management very successfully leveraged their all-but-monopolistic status to increase prices and beat out competitors.

According to several colleagues who worked with Coventry at the time (remember this was a few years ago), Coventry knew they had the leverage, weren’t afraid to use it, and was only too happy to let their customers know it.  Even more troubling, customer service and responsiveness got steadily worse.  Managed care execs used words like “arrogant”, “uncooperative”, and “dictatorial” when describing their interactions; many were very surprised, if not shocked, by the tone and tenor of discussions and negotiations.

Fast forward to today.

Coventry’s power has diminished markedly, the ancillary services are likely to be sold off soon, bill review is losing customers, and insurers and TPAs are only too happy to turn the tables as Coventry’s leverage has greatly diminished.  

Which brings us to the current state of the market; it is highly likely a very few vendors will hold leverage akin to that enjoyed by Coventry back in the late 2000′s.  Managed care execs at insurers, TPAs, and large employers are apprehensive/concerned that this may well mark a return to the “bad old days.”

Many of the private equity folks who are doing the consolidating don’t fully grasp this issue.  They say that their efforts will lead to lower costs, better service, improved outcomes, and are somewhat bewildered by payers’ concerns.  Make no mistake; that concern is real, it is pervasive, and it will definitely affect payers’ decisions about which vendors to use for what services.

What does this mean for you?

Insurers, TPAs, and large employers have been there, done that, and aren’t going back.

 

Friday catch up and idle speculation

Lots of big info out this week, and a few tidbits about pending deals in the workers’ comp services space too.  Here are the highlights…(for the latest on deals in the work comp space, scroll down)

There’s a lot of confusion about the Obamacare signups; I’ll cover this in detail next week, but here are the facts as of today…

  • more than 7.1 million signed up via the federal and state exchanges (we won’t know the total for a week or so as some state exchanges haven’t posted final March numbers)
  • a lot more – i’d guess a million to two million – bought insurance via the private exchanges
  • about 20 percent won’t pay the premium and there’s some duplication between all the exchanges and other enrollment methods for reasons we’ll discuss next week
  • more than 5 million MORE Americans have insurance today than at the end of 2013.

The net – Obamacare has increased coverage substantially; the uninsurance rate has dropped by 2.7 points.

Meanwhile, Fitch reports the P&C industry is doing just grand, thank you.  Profits are up, loss ratios declined, underwriting margins are improving, and revenue is too.  Thank the continued hard market and expanding economy.

Work comp is doing better as well, altho there’s still a negative underwriting margin.  It remains to be seen if pricing discipline holds, or if some big carriers cross the stupid line.

The “doc fix” is in; Congress passed and the President signed a bill that will increase Medicare reimbursement for physicians by 0.5% for the next 12 months. The bill also:

  • delays implementation of ICD-10 for a year till October 2015 – for an excellent discussion of how this will affect workers’ comp, read Sandy Blunt’s piece at workers compensation.com
  • and does some other stuff which you probably don’t care about and I won’t bore you with.

Work comp services Coventry is trying to sell their marginally-profitable work comp service business lines - we’re talking CM, UM, MSA, peer review, and likely pharmacy. They will NOT be selling the jewels – bill review and the network, because a) they make huge profits; b) bill review really isn’t sellable as the application is quite dated and would require the buyer to transition to a different platform likely resulting in customer defections; and c) they can’t sell the network.

Coincidentally, another large case management firm is also for sale; word is Apax/OneCallCareManagement is currently the leading contender; most likely they will add the asset to their ever-growing list of companies.

And I’d be remiss if I didn’t speculate that Apax is looking hard at the Coventry assets as well. OCCM CEO Joe Delaney has certainly proved himself a competent manager, but methinks the thought of adding these two to the portfolio would give even the best of execs pause…

Enjoy the weekend, watch some baseball, get out in the gardens, and ride your bike.

Sorry about that…

well, not really.

I’m referring to yesterday’s annual April Fool’s Day post, in which I “reported” Obamacare would include a single-payer federal workers’ comp system for small employers.  While some chalk it up to my sophomoric attempt at humor, (and they would be right), there’s another, more important takeaway, one that is particularly relevant in the work comp industry.

There’s a lot of mis-information out there, much in the form of reports, statistics, metrics, findings, research, and it often goes unchallenged.  Here are a couple examples.

“Research” published by benefits giant AFLAC claims companies that set up voluntary disability programs saw reductions in work comp claims.  Except the “research” is not credible, isn’t reproducible, is based on nothing more than opinion, and therefore is just marketing BS. (hat tip to Mark Larsen of WorkCompCentral for the info)

The key here is don’t believe “research” unless it is credible, which means there was a solid methodology (asking people their opinion then drawing a statistical conclusion from those opinions is NOT a solid methodology).

Vendor claims that they can “save” X% more than your current vendor on pharmacy/medical bills/provider costs/whatever are often – but not always – pure speculation.  Fact is, unless the vendor making the claim really, really understands what your current program/vendor is doing, how they are doing it, the methodology they are using to calculate results, and reviews the bill/provider/script data, their claims are suspect at best.

That’s not to say that some programs don’t deliver measurably better performance, but unless the vendor pitching you can provide a detailed analysis of why and how they can do better, they’re just blowing smoke.  How can you figure this out?  Simple – ask lots of questions – starting with how, when, who, how much, where.  Dig deep and do not be satisfied with generic marketing-speak answers.

You will find some vendors are only too happy to get into the details, while others get really uncomfortable.  And that tells you a lot about their REAL ability to deliver.

Finally, the April Fool’s post caught more than a few readers, so if you were one, you’re in pretty good company (there were several clients and a few regulators – all shall remain nameless – who fell for it).

What does this mean for you?

Don’t be an April – or any other month – fool.