WCRI – Opioids part three – Treatment Guidelines

Dr Dean Hashimoto’s talk on medical treatment guidelines covered what’s out there, what makes for good guidelines (my words not his) and what happened when MA implemented guidelines for chronic pain.  

We’ll focus on Massachusetts’ experience. (here’s a good synopsis of guidelines)  The state adopted those guidelines in part because there were an estimated 20 workers’ comp claimants were dying as a results of opioid poisoning (overdose).

Dr Hashimoto identified two impacts of Mass’ adoption of guidelines for chronic pain – these guidelines required use of the state prescription drug monitoring program, random drug screening, a written opioid agreement, and cautions when dosage exceeds 120 morphine equivalents per day.

While it is a bit early to assess results, here’s a couple preliminary findings:

  • “there was a leveling off of opioid prescriptions an deaths related to opioid poisoning.”
  • A WCRI study reported longer term use of opioids decreased from 11 percent of claimants to 7 percent after the guidelines were implemented.
Clearly evidence-based guidelines, effectively implemented, with strong UR features and “teeth”, work.  

 

WCRI and Opioids, part three – Interventions – a successful community approach

Operation UNITE’s Karen Kelly led off with some of the most disturbing data I’ve ever seen on the impact of opioids in Kentucky and the country.

  • average age of first drug use is 11.  Eleven.
  • in some counties, 50% of children are being raised with no parents in the home.
Operation UNITE is doing terrific work in Kentucky – sponsoring treatment, supporting narcotics enforcement and interdiction, buying drug lock boxes for homes, education of kids and others, sponsoring summer camps, building community coalitions, and drug-free workplace training – among many other initiatives.
And their work is paying off - there’s been a year over year decrease in dispensing of all controlled substances by 11.7% in their area.
There are a wealth of resources available on their site, from videos to educational materials  to news and updates on progress in the battle against opioid abuse.
(I’m moderating a session at the National Rx Drug Abuse Summit with Washington state’s Gary Franklin MD and Amy Lee of Texas DWC  addressing opioids in workers’ comp at their annual meeting in early April.) There are several other sessions addressing opioids, detailing what works, what doesn’t, strategies and results.

 

WCRI on Opioids – Part Two – Opioids in WC

Senior researcher Dr. Dongchun Wang’s presentation delved into the details, looking at data from 300,000+ non-surgical lost time claims, with scripts filled thru March 2011.  I emphasize non-surgical, as its entirely understandable that a patient just out of surgery would get some opioids to help them deal with post-surgical pain for a few days.

Takeaways…

  • Why are so many non-surgical claims getting opioids?  With rare exceptions, opioids are NOT indicated for these types of claims. Who’s prescribing these drugs and why is this allowed?
  • Building off yesterday’s discussion of variation in prescribing patterns, we’ve seen huge variations in prescribing patterns – dosage, duration, long-term vs short term usage.
  • The volume of opioids received per claim varied by a factor of four among the study states – lowest in Iowa, and highest in NY (on a morphine equivalent basis)
  • In four states, more than ten percent of claimants who received opioids were still getting scripts six months later – and remember, these are non-surgical cases.  While only 3% of AZ claimants were using drugs for more than six months, 17% of those in LA were…
  • 24 percent of drug claimants were tested in 2009/2011; a big improvement over the 14 percent from the previous two-year period – but still abysmal. (disclosure – Millennium Labs, a drug testing firm, is a consulting client)
  • As bad as that rate was, it was better than the use of psychological evaluations which should be done prior to prescribing – only 7 percent of claimants had psych evals…

 

WCRI – Opioids part one, the overview

Dr Karen Mack of CDC led off this morning’s discussion of opioids with a review of the opioid crisis and provided a lot of data on death rates, usage trends, and mortality trends. Pretty scary stuff.

The most compelling slide shows a strong correlation between opioid sales and overdose death trend rates  which, if not parallel, are certainly quite similar.  Encoouragingly, the rate of treatment has actually accelerated over the last few years at a rate that is much higher than opioid usage trends.

Here are a couple takeaways.

First, I was surprised that there were multiple “ooohs’ from the audience when Dr Mack presented info that I would have thought we all knew – e.g. currently there are enough opioids sold in the US to keep every one of us doped up for a month. Ok, I know I’ve been up to my eyeballs in this issue for several years, and others haven’t spent the time on this that we research nerds do.

But.  Come on folks!  This should NOT be a surprise.  The issue has been front-page news in most newspapers, featured on many news broadcasts, discussed by politicians, media, celebrities, not to mention the issue is so pervasive it’s hard to find someone who doesn’t know someone else who’s been directly harmed by opioids.

This is the single biggest issue in workers comp. Kudos to WCRi for dedicating most of day two to the issue.  

Now let’s stop talking about the problem and get moving on solutions.

Medical care variation among states – what’s the status and do guidelines help?

It has long been known that medical care delivery can vary dramatically from state to state, and even within a state.  Jack Wennberg and his colleagues at Dartmouth have reported deep and long on the issue, with the initial revelation – and it was that – coming forty years ago.  The latest work can be found at the Dartmouth Atlas of healthcare – and it is well worth visiting.

So, here’s the deal - medicine is as much art as science, driven by local knowledge and personal beliefs as much as by best practices and evidence-based clinical guidelines.  While we like to THINK it’s about science, it often isn’t.

WCRI’s Dr Rebecca Yang delivered the initial presentation at WCRI’s annual meeting focused on interstate variation in medical care.  Their analysis looked at surgery, MRIs, pain management injections, and physical medicine; a few highlights (for those not able or willing to make it to Boston this year) include:

  • Surgical rates varied from about 18 percent in Massachusetts to 38 percent in Indiana.
  • MRIs of the lumbar region had an even larger range, from 18% in MA to 50% (FIFTY PERCENT!) in Florida; Florida’s rate was 20% (8 points) above the next highest state.
These data raise multiple questions; do the UR requirements in MA have anything to do with the lower rate of surgery?  Could that rate be affected by Mass’ very low reimbursement for workers’ comp surgery?
Florida has (relatively) tight managed care provisions, yet their MRI rate was 250% of Massachusetts.  Both states have strong UR, and in FL employers can direct. And there’s no discernable variation in the types of injury.  Which begs the question – what are payers not doing that they should be doing in FL?
And another – are there too few MRIs in Massachusetts? ( I personally doubt this, as the rate may well too high even in MA).   Much more in Dr Yang’s presentation…
Ohio State Prof. Tom Wickizer followed Dr Yang.  He gave an excellent background on small area analysis and practice pattern variation.  he mentioned one of my heroes, Dr Jack Wennberg (noted above): and highlighted seminal research indicates “spending 50% – 80% more on health care did not lead to meaningful differences..”
Wickizer quickly pivoted to matters of specific interest to WC, discussing the wide variation in back surgery rates across the nation; there’s a nine-fold difference in the lumbar fusion rate between the northeast and the west…(which says don’t bother pre-certing in New England, but pre-cert every case in the southwest).
So, how does one “fix” this?  Well, guidelines can help improve results – if they are used.  Wickizer said adherence – the usage of guidelines – is often less than 50 percent.  There are a number of reasons for this, but not many are very good (a few are valid).  And, adhering to guidelines does lead to improvement in functional outcomes and better health – although it’s not a dramatic difference (Feuerstein study, 2003).  There was a larger impact in a study of the impact of PT guidelines, with costs and pain rating much lower and better outcomes as well.
All that’s well and good, and it indicates that guidelines can and do help – but they have to be used.  And getting providers to follow guidelines is very difficult – unless you force the issue.  The state of Washington did just that, and delivered better outcomes and lower costs way back in the early nineties… and those better outcomes included lower disability payments.  One can, and probably should, infer that better medical care delivers lower medical costs.
Thereby “proving the meme”…

Report from the Physician Dispensing Summit

Yesterday’s meeting in Boston was very, very productive.  The audience included trade groups, insurers, TPAs, large employers, physicians, researchers, regulators, analysts, PBMs, and media, all focused on the single issue of physician dispensing.

Among the sessions was a report on a just-completed study of the impact of dispensing on claim outcomes – very compelling and highly revealing.

Here were some of the other highlights:

AIA CEO Leigh Ann Pusey led off with the keynote; the fact that Ms Pusey took the time to prepare for and attend the Summit is revealing indeed; her members write over a hundred billion dollars of insurance premiums and are dealing with critical, industry-altering issues including Dodd-Frank, TRIA, and the sequester.  She was very knowledgeable and detailed the work AIA is doing both internally and with other groups and associations.  Suffice it to say that this is a very high priority for AIA and their members.

Dan Reynolds, managing editor of Risk and Insurance moderated an excellent panel on the issue of patient safety.  Pharmacists, a physician, and the nation’s leading authority on prescription drug monitoring programs provided insights into the risks inherent in physician dispensing.  Notably, John Eadie of Brandeis’ PDMP Center for Excellence revealed that most states require/request dispensing physicians access the PDMP prior to dispensing scheduled drugs.   He provided a guide for finding out how different states address the issue; I’ll provide a link in a later post.

Sedgwick’s Kimberly George noted that, where appropriate, the giant TPA uses physician dispensing as a data point in assessing and rating physicians. This can affect the volume of patients directed to specific practitioners.

For me, the major takeaway was CWCI’s analysis of the impact of physician dispensing on claim costs and outcomes.  Alex Swedlow’s concise presentation noted that after reform eliminated the upcharge for repackaged drugs;

  • each physician-dispensed repackaged drug prescription added $545 to the average medical benefit costs. 
  • paid medical benefits on claims with physician-dispensed repackaged drugs averaged $7,297, or 37.3 percent more than the $5,316 average for claims without these types of prescriptions.
  • indemnity payments on claims with physician-dispensed repackaged drugs averaged $5,039, or 28.2 percent more than the $3,930 average for claims without physician-dispensed repackaged drugs.
  • claims with physician-dispensed repacked drugs averaged 50.3 paid TD days – 8.9 percent more than the average of 46.2 days for claims without repackaged drugs.

The research, conducted by Swedlow, John Ireland, and Laura Gardner, destroys physician dispensers’ claim that better outcomes and lower costs result from physician dispensing.  

Undoubtedly, dispensing advocates will now roll out their PR flacks and physician shills in an attempt to refute CWCI’s study results, methodology, impact, and applicability to other states.

Good luck with that.

Swedlow, Ireland, and Gardner are three of the most respected researchers in this industry.  Their expertise, insight, intellectual rigor, and objectivity are beyond question.

With the release of CWCI’s excellent work, we can now refute every claimed benefit offered up by physician dispensers – leaving no doubt as to the only real benefit of the practice:

taking hundreds of million of dollars from taxpayers and employers to do nothing other than line the pockets of dispensing docs, dispensing companies, their investors, and their partners.

What does this mean for you?

Read the study here.

Send it to regulators, employers, policyholders, legislators, lobbyists, attorneys – anyone and everyone.  Get the word out.  

A very busy week – physician dispensing, WCRI, and the sequester

Here’s what’s up this week:

1. I’m at the Physician Dispensing Summit today in Boston hosted by PMSI and Progressive Solutions.  There are around a hundred attendees including regulators, payers, physicians,  researchers, retail pharmacy chains, and other stakeholders.

Among the sessions is the kickoff - Leigh Ann Pusey, CEO of the American Insurance Association – is doing the honors.  When the CEO of a group dealing with Dodd-Frank, the Terrorism Risk Insurance issue, flood insurance, and the sequester takes a day and a half to attend an event, you know the issue is vitally important.

Later on this morning CWCI’s Alex Swedlow will present the result of their research, which demonstrates the impact of physician dispensing on claim costs, outcomes, and disability duration. Tip – the research does NOT support dispensers’ claims that the practice improves outcomes…far from it.

2. WCRI’s annual meeting kicks off tomorrow – sure to be packed with timely info and research on cost drivers.  Nerd heaven…

3.  The sequester will affect workers comp – working on that post but no time to finish it before Friday (sorry!)

Opioids – the IAIABC responds, and others do too…

After failing to approve model language developed by many volunteers working many hours over many months, the IAIABC’s Executive Committee came out with a press release discussing their decision.

First, kudos to the EC for the release. This is a very contentious and highly visible issue, so the release helps explain the decision.  However, the explanation itself has done little to tamp down the furor over the non-decision.

Second, the entire workers comp world had this as a no-brainer; of COURSE the IAIABC would approve model language; opioids are widely recognized as one of if not the biggest problems in workers’ compensation, the model language development process had been going on for over a year, and there was no real indication from the EC that they had significant problems with the language.  As the trade group for WC regulators, the IAIABC absolutely would be out front on this.

The guidelines were going to be discussed in a session at Operation Unite’s National Rx Drug Abuse Summit in April, a session that has been cancelled.  They were also going to be reviewed in another session at the same conference; obviously that’s not going to happen either.

And that’s why the Executive Committee’s failure to approve the model language was such a shocker.

The press release did say the EC wants the language re-done;

“adopting model legislation and regulation on opioid use could be interpreted as too narrow and restrictive for jurisdictions. The Executive Committee was concerned the models could unintentionally create conflict in jurisdictions that may be already taking steps to initiate regulations for appropriate guidelines. However, they contain valuable information, and as such the Executive Committee is asking that the issues addressed in the drafts be re-framed to offer policy considerations rather than a single policy response.”

Michael Gavin, who worked long and hard on the guidelines wrote at PRIUM’s Evidence-based blog that the EC’s failure to approve the model language:

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?

Normally a reserved and diplomatic individual, Michael is saying what many others are thinking.  I’m guessing some members of the EC may have been surprised by the reaction to their decision.  IF they were, they shouldn’t have been.  This was, and still is, an opportunity for the IAIABC to lead from the front, to use its considerable influence to begin to stop the dying, the ruining of individual lives and families, the outrageous expense, the societal damage.

If the IAIABC moves quickly to publish comprehensive, specific, and definitive language, the damage – to the organization and its reputation – will be minimized. Call it model language, an example, a guideline, a framework; whatever.  If the process is extended and the result in any way nebulous, ambiguous, vague, or equivocal the damage done will be extensive and lasting.

The IAIABC has done much good work over its long history. The people who work at their offices in Madison, Wisconsin are dedicated, positive, very knowledgeable, and committed.  I’ve met and worked with several members of the EC and been impressed; these are individuals who’ve spent their professional lives working in a highly politicized environment yet succeeding more often than not in making progress on key issues.

To the EC members who blocked approval, I beg of you – get this done, and get it done now.

 

 

WCRI’s latest research says…

 

The good folk at WCRI were kind enough to send me their latest CompScope research which covers workers’ comp cost drivers, components, the impact of regulatory changes, and trends in 16 states.

Needless to say, there’s a LOT there.  And I’d be ‘less than truthful’ if I said I’d read them all.  So, here’s what I gleaned from reviewing what I could in between working on client stuff.  The reports examined data from 2005/06 to 2010/11 for lost-time claims, providing insight into trends, the impact of regulatory reform, and changes in provider practice/billing patterns

  • Inpatient hospital payments per episode – a measure of price inflation – were up 36 percent on average over that period.  Remember, price is but one component of cost – others include intensity of services (e.g. using an MRI instead of an X-Ray) and utilization (how many MRIs per episode) plus the percentage of all claims that get that service (frequency).
  • Outpatient hopsital average payments per claim were up about 31 percent – but fewer claims used outpatient services…
  • The average payment per claim for hospital outpatient treatment/OR/recovery room services increased about 62 percent.
  • The variation in the use of opioids was striking.  17% of Louisiana claimants who started using opioids were still using them 3-6 months later, compared to about 3 percent in Arizona.
  • Less than a quarter of all long-term opioid users were tested for drugs via urine drug screening.
  • Surgical claims were pretty interesting.
    • Average payment for claim for major surgery (not including hospital providers) increased 27.6 percent; however there was essentially no change in the percentage of claims that had major surgery over the study period
    • However, utilization – the volume of services delivered to each claimant who did have surgery – was up about 10 percent.
    • So, we have price and utilization up, but not frequency (the percentage of claims that had surgery)

So, what does all this mean?

Well, surgical costs were driven more by utilization and price than frequency.  Outpatient hospital costs look to be all-but out of control. Clearly, payers need to do a much better job addressing these cost areas.

There’s wide variation in drug usage, indicating one-size-fits-all approaches probably will be too much in some areas and far too little in others.  Payers and their PBMs who understand regional differences will be better able to address this critical cost driver.

A good chunk of the research period was undoubtedly affected by the Great Recession.  Teasing out the impact of the recession will help drive deeper understanding in two ways; the impact of that most powerful of external factors, and structural drivers v macro drivers.