How to prevent and stop opioid use in work comp

It can be done. And it is being done – by a state governmental agency, no less.

Ohio BWC (the state workers’ comp fund in Ohio)’s Medical Director gave background on just how bad things were at BWC in 2011, before just-hired pharmacy director John Hanna took over.

One patient was taking 4000 Morphine Equivalents per day.

40 million opioid doses prescribed in one year.

After five years, the number of opioid dependent patients, opioid doses, and patients taking opioids were all cut in half.

Here’s an even better view…

Ohio allows for treatment of opioid dependence for 18 months without it being allowed in the claim.

I can’t say enough about what Ohio BWC has done. While the data is telling indeed, I think of the families that are still intact, the moms and dads still alive, the employers still staffed by able and capable workers, the first responders somewhat less stressed.

Thank you, John Hanna, Dr Steve Woods, Dr Nick Trego, and Dr Terence Welsh – and your bosses at BWC and in state government, including Gov Kasich (R).

WCRI kicks off…with a deep dive into the future of labor

And we’re off!

Despite the weather, there are over 400 people here in Boston today. That’s an all-time high – even with the wet snow coming down outside. Kudos to Andrew Kenneally (Andrew handles the communications and marketing) and the rest of WCRI’s staff for putting together a conference that continues to draw people to New England in March.

For those unable to make it here due to weather, follow me on twitter at @Paduda, Mark Walls compilationLynchRyan’s Workers’ Comp Insider, ReduceYourWorkersComp, Sedgwick’s Don Lipsy at @UofADon, and of course @WCRI.

Erica Groshen, PhD of Cornell and former head of the Bureau of Labor Statistics led off with a deep dive into labor statistics, and a discussion on the future of work. Here are the takeaways…

  • over the last nine years, we’ve added 9.8 million jobs.
  • Healthcare and education has consistently been the biggest job-creator over the last year; last month construction led the way.

  • about one in five of the unemployed have been out of work for more than 6 months; employers are still pretty selective.
  • wage growth is flat over the last 12 months.

  • over the last 40 years, employee productivity has accelerated sharply, but compensation has not. This is a remarkable change from historical data; employees are creating a lot more value but are NOT getting paid for it.

With that, we move into where labor is headed.

There will be more of us in alternative work arrangements, that is, you work for a number of different entities, or you have a series of temporary jobs.

We don’t have any current data on employment in these alternative work arrangements (AWA) (due to a lack of funding for the research at BLS); the most recent information is over a decade old. However, look for new data that should be out in the next few weeks.

What we do know comes from the Current Population Surveys (CPS) – which look at about 60,000 households.

That data indicates there hasn’t been much of an increase in AWA employment over the last decade – in fact, it’s been flat.

I’m surprised about this; we all hear about Lyft and TaskRabbit and all the other web-enabled AWAs, and I’d assumed the number of us doing gig work was steadily increasing. It could be the CPS data is skewed due to mis-reporting or mis-identification (people like me who are self-employed may report they are “employed”).

A CWS report coming out in May will give us more info on this.

Dr Groshen made the case that Artificial Intelligence and other tech-driven changes (robotics, automation) will create jobs, noting there will be a “skills gap” as workers who lose jobs (think long-haul trucking) won’t be ready to take new jobs (programming AI). She went on to claim that regardless of the impact of AI and other technology, the economy will eventually return to full employment.

I admire her optimism. I’m skeptical of it as well.

Nothing ado about much

That’s the quick take on the White House’ plans to attack the opioid crisis.

Briefly, it amounts to:

  • harsher enforcement of existing drug laws,
  • education using advertising to prevent addiction,
  • helping fund treatment and
  • helping addicts find jobs while in treatment.

The latter two make a lot of sense; the first two are futile, stupidly expensive, and simplistic at best.

The “war on drugs” has resulted in millions incarcerated, trillions in costs, thousands killed, and, surprise, people still do illicit drugs.

These are just statistics, and therefore meaningless. But it isn’t meaningless for me or my family.  A family member in law enforcement died in the line of duty; much of his career was in drug interdiction and his death resulted from that work. The drug war is akin to Afghanistan; we’re never, ever, ever going to “win”, because the war isn’t winnable.

As for education, unless you’re older like me, you may not remember Nancy Reagan’s “Just Say No” campaign. Lucky you.  These “education” programs don’t work…according to an NIH study, the campaign: “had no favorable effects on youths’ behavior” and may have actually prompted some to experiment with drugs, an unintended “boomerang” effect.

While the latter pair make eminent sense, there’s nowhere near enough money – and without money they’re just talking points.

We need at least $10 billion more a year for treatment, plus additional funding for Medicaid which pays for a major chunk of treatment.

There’s an argument that former President Obama took too long to recognize the opioid disaster and start working on solutions – and I’d agree.

That said, the current funding level represents a real decrease in funding, at a time when death rates are accelerating.

What does this mean for you?

We’re on our own. 

Quick takeaways from CWCI’s annual meeting

One of the best conferences of the year is CWCI’s annual get together in Oakland California.

More information is packed into a morning than you’ll find in most multi-day events – and in a more entertaining format – and no one is more informative and entertaining than CWCI’s Alex Swedlow (I’m fortunate indeed to count Alex as a good friend and colleague).

First question – As Alex noted, way back in the pre-Triangle Shirtwaist fire days (no, I wasn’t around then), business claimed 95% of injuries were considered to be the fault of the workers – what is the actual number?

And why do many claims organizations/processes seem to operate as if that statistic is true today?

Okay, back to key takaeaways…

  • Average drug spend dropped 34% from 2012 to 2015 – Rx and DME combined amount to 8 percent of total spend of med payments at 24 months after inception
  • Opioid spend dropped dramatically, while NSAIDs went up.
  • Compared to all claims reported, Cumulative Trauma injuries have increased – a lot – since 2009. CWCI thoroughly debunked the contention by others that CT cases have decreased.
  • IMR decisions continue to uphold UR determinations more than nine times out of ten, a rate that’s held steady since 2014.
  • UR decisions on compounds are upheld in 99.2 percent of all cases.
  • Work comp administrative expenses are higher in California than any other state – by a lot. Part of the answer is the outright abuse of the IMR process by a handful of scummy providers in SoCal…and a couple up north too.

Gary Franklin MD gave a compelling, passionate, and pointed argument that opioid manufacturers are at fault for the disaster that’s killed more than 200,000 of us. Gary never hesitates, never waivers, and is the individual who has done more than anyone else to confront the opioid issue.

More to come next week.


Opioids – bad news and good

Patients taking opioids over the long term don’t go back to work, yet many long-term opioid patients can be weaned off opioids within two years.

Those are the quick takeaways from two studies that came out last week.

First, a study from WCRI validates earlier research, finding:

  • patients with multiple opioid scripts are out of work three times longer than patients with no opioid scripts, and
  • patients who lived in places where providers prescribe a lot of long term opioids…are more likely to get opioids for longer periods than individuals who lived elsewhere.

This is the first study that looked at ALL lost-time claims with a diagnosis of low back pain in a very large area – 28 states that represent 80% of claims – over a five-year period. This is important because it shows  cause-and-effect independent of so-called “severity” measures, which often use cost, treatment, or prescriptions to indicate medical severity, instead of actual clinical indicators. By looking at ALL low back claims with lost time, claims, it is clear that the driver of disability is long-term prescribing of opioids.

The takeaway is this – chronic use of opioids extends disability, and you can figure out where you need to focus your efforts by looking at publicly-available prescribing data.

California is one state with way too much experience in dealing with opioids in work comp; the graph below shows both the overuse, and the progress made in the Golden State since it got serious about reducing opioid usage.

source – WCIRB

Which brings us to the good news: weaning works, as research from California’s Workers’ Compensation Insurance Rating Bureau shows: 

47% of the injured workers demonstrating chronic opioid usage weaned off of opioids completely within the 24-month Study period. Injured workers who did not wean off completely over the Study period still reduced opioid dosage by an average of 52%.

The research included all patients with more than 50 morphine equivalents over at least 3 months within 24 months of the date of injury.

Yes, it is difficult, expensive, requires a lot of assistance from trained professionals, and does not always work. All that said, given the finding that patients taking opioids for longer periods are out of work a lot longer, it is well worth the time and effort to help these patients reduce or end their use of opioids.

Why isn’t anyone talking about health insurance costs?

A couple years ago, we heard endless stories about how “Obamacare” premiums were shooting up, individual health insurance was unaffordable, and families were going bare because the morons that came up with the ACA screwed it up.

Now, with average premiums up 30 percent, we hear…crickets.

The reason premiums have gone up by about a third is simple; President Trump stopped the payments that subsidized low-income folks and insurers are scared he’ll stop enforcing the individual mandate. Unsurprisingly, many people dropped coverage, and insurers had to raise premiums because their risk pools worsened.  

Chart credit Charles Gaba,

If CSR payments were still in place, and insurers assured the mandate would be enforced, premium increases would be less than half they are today.

What’s scary about this is how easily the media’s focus is influenced by outside efforts. Instead of informing us of this very real, and very important issue, the media is all wrapped up in arming teachers, death penalties for drug dealers, and Stormy Daniels.

What does this mean for you?

A reminder that all of us have to stay focused on the important stuff, not the shiny objects.



Stuff that affects work comp

Here are a few of the events/transactions/deals that may affect the workers’ comp industry, along with my take on that impact.

First – Trump’s steel and aluminum tariffs

Leaving aside the fact that China – Trump’s primary target – supplies just one-twentieth of all foreign imported metals, there are way more American jobs in other industries  that would be lost if the European Union and/or other trading partners impose retaliatory tariffs.  

Agriculture, autos, bourbon, bluejeans, and bikes are on the list of possible targets. Total exports amount to $1.4 trillion

Our cultural exports – fashion, film, music, sports – may fall out of favor as Asians and Europeans angered with Trump stop buying American.

My take – the Trump Tariff is going to cost jobs, unless it is quickly hollowed out by exemptions.

(an excellent discussion is here)

The Trump tax plan

First, if wages and hiring increase, as promised by the President, premiums will rise.

So far, that isn’t happening. The vast majority of the windfall is being spent on stock buybacks.  While this is inflating stock prices it isn’t going to have any material effect on the

With the added focus on deporting undocumented workers, industries that demand low-skilled workers for high-stress jobs such as meatpacking are often struggling to find enough workers. Jobs are usually filled with first-generation immigrants – as those jobs always have been.

Third, Employment changes.

The automation of both low-skilled and white-collar jobs is accelerating…over time many low-skill jobs are going to disappear – including burger-flipping, while white collar work including healthcare administrative jobs is being automated as well.

credit Daily Mail

The unemployment rate has improved  from 4.7% to 4.1% over the last year, while labor-force participation has remained flat (working-age people who’ve not looked for work).

Wages are up about 2.5% over the last 15 months, slightly more than inflation.

My take – hiring is strong, and wage growth may accelerate somewhat. This would generate more premium dollars over the near term. As Flippy and it’s relatives take over from Mary and Mike, we may well see average wages increase as there are fewer low-paid jobs available.

And Last-but-not-Least, changes in healthcare, specifically how and where healthcare is delivered.

Compare the revolution in retail – moving buying and delivery from stores to the home. That hasn’t happened at all in healthcare – but it will.

Enjoy the weekend.

Your baby isn’t that pretty. Really.

OK, got my cranky pants on today, so here goes.  I get about a dozen press releases a day, most of which breathlessly tell me about something I NEED to know about – like right now!

This is your baby in a PR release.

And of course, I NEED to tell you, dear reader, all about the new product/executive hire/office location/logo/study that is so damn important it makes North Korea’s nuclear threat totally inconsequential.

Like these…

  • Formaspace just unveiled a new virtual furniture designing tool that is going to shake up the world of office furniture procurement
  • I’m writing to suggest a story idea for Managed Care Matters on the top three “fake it till you make it” hacks for entrepreneurial millennials.

  • Below is VisualVault’s latest press release sharing the exciting news of their new Director of Healthcare Solutions, Kathy Biggers.

And those are just from today. Many are so far out of my (and probably your) area of interest it’s hard to imagine how they found MCM. I wish I knew, then perhaps I could hide from them.

I get it – the executive at company X thinks their news is really, really important. Ground-breaking. Game-changing. A Black Swan, Unicorn, or some other super-cool mythical beast. What they don’t get is the more they send, the less anyone pays attention.

A few suggestions…

  • Press releases should be about important stuff. Think of it this way; if you got your announcement from some random organization, would you care? Really?
  • STOP with the hyperbole and adjectives. The more hysterical you are, the less anyone cares.
  • Target your stuff precisely. DO YOU CARE ABOUT OFFICE FURNITURE?
  • Be brief, to the point, use short sentences and bullet points.
  • Personalize the release – use the addressee’s name and tell her/him why s/he should care.





Big changes in work comp pharmacy spend

Sometimes data is so compelling you have to get it out there immediately.

CompPharma’s annual survey of prescription drug management is underway; here are quick takes from the first ten surveys.

  • 2017 drug spend dropped 13.4 percent from 2016 – the biggest decrease in the 15 years we’ve been doing the survey
  • Opioid spend decreased twice as much – over 26 percent.

Note that the huge drop in opioid spend occurred BEFORE adoption of formularies and other controls in big states like Pennsylvania, New York and California.

Note also that this is the sixth drop in drug spend since 2010.

Graph from last year’s Survey, Public version available for download here.

There are a few other newsworthy findings;

  • compound spend is down dramatically in most areas – but has spiked in a couple of states.
  • the decrease in spend is attributed primarily to lower opioid utilization
  • despite the big drops in spend, respondents (typically the executive at a work comp payer with overall responsibility for medical management) see pharmacy as MORE important than other medical service types…because pharmacy drives disability and return to work

This is very preliminary; we expect another 15 or so respondents and I’d expect things to change with more data. (if you want to participate and receive a detailed copy of the 2018 Survey Report, email Helen Patterson at HKnightATcomppharmaDOTcom)

What does this mean for you?

The work comp industry’s decade-long focus on pharmacy is delivering far better care and lower costs.