What parts of Obamacare do you want to keep? eliminate?

The ban on medical underwriting and exclusion of pre-existing conditions?

The elimination of lifetime maximums?

The penalty for those who choose not to sign up for insurance?

The expansion of Medicaid to cover those with incomes up to 133% of the federal poverty level?

Requirement that Medicare control its costs or be subjected to stricter controls on useless or dangerous procedures and treatments?

The tax credit for small employers obtaining health insurance?

The requirement that preventive care is covered – at no cost to subscribers?

Tight restrictions on insurers seeking to cancel coverage when subscribers get sick?

It wouldn’t be good policy to eliminate many of these provisions, and, more to the point, it isn’t possible.

First, the policy problem facing Mr Romney.  Let’s take just one example; he’s said he

a) is going to repeal Obamacare on his first day in office, (let’s leave aside that he doesn’t have the ability to do that) while

b) ensuring anyone with pre-existing conditions can get coverage

I don’t see how that works.  In fact, Romney’s “assurances” about coverage for pre-ex are no more than what exists today; as long as you move directly from one insurance plan to another your pre-ex conditions are covered.  For those Americans who haven’t had coverage for a few months, you’re out of luck – insurers won’t have to offer coverage.

Oh, and there are no price limits on what insurers can charge you, so even though Romney says your pre-ex conditions will be covered, it may cost you two, three, even five times more than the list price for that policy.  Which means – really – Romney doesn’t guarantee pre-ex will be covered.

That’s just one provision that’s problematic for Mr Romney.  The reality is there’s a lot to like about Obamacare, as Romney has found – otherwise he wouldn’t be backpedaling on his earlier promise to kill the whole thing. Sure, most folks are only really interested in the one or two provisions that directly affect them – perhaps coverage of kids till they’re 26, or expanded coverage of Medicare drugs.  But he can’t – the practical reality is that unless he gets 60 senators to agree with him, he can’t overturn PPACA or significantly change any of its provisions.

So, the lack of any substantive discussion of health reform in the last debate was appropriate; it’s the law of the land and won’t/can’t be changed despite Romney’s occasional statements to the contrary.







We’ve recently completed the First Annual Survey of Utilization Review in Workers’ Comp, and some of the results are a bit surprising.

Sponsored by CID Management, there were 118 respondents, both front line and executive staff. While there were some consistent findings, once again it is apparent there are rather more disconnects than one would expect.

  • Execs are one-and-a-half times more likely than the front line to report their UM/UR system is integrated with their other medical management programs (e.g., bill review, networks, pharmacy). Interestingly, this is similar to the differences between executive and front line responses that HSA found in its most recent bill review survey; most executives thought BR was integrated with UM/UR, but most desk folks did not.
  • Execs appear to be more concerned with the execution of the UM/UR guidelines/rules by the state while the folks on the front lines appear to be more concerned with the state’s poor enforcement/accountability of their guidelines.
  • When asked what UR was utilized for, front line staff were more focused on controlling claim costs while management was most focused on delivering the right care at the right time.

Among those respondents using vendors for some or all of their UR work, the average vendor has been in place for five years – however most don’t see much of a barrier to switching vendors. In fact, two-thirds of both groups believe that it is neutral to very easy to make a UM/UR vendor switch. Further yet, approximately a quarter of both the FL and the EXs stated that it would be not hard or very easy to make the switch.

There’s much more detail to the Survey; we’ll be presenting results, and you can get a copy of the Survey Report, at the NWCD Conference in Las Vegas next month.  The presentation and Q&A will be held at CID’s booth; I’ll be posting the schedule next week.



Smarter patients = fewer procedures = lower cost

Educating patients leads to better outcomes – and lower costs.  A study found that over a quarter of the patients considering hip or knee replacement surgery decided against the procedure after learning more about the costs and consequences.

We’ll let Gary Schwitzer of HNR discuss the impact and implications below…

From a terrific piece in The Atlantic by way of Health News Review…

[the State of] Washington legislature recognized back in 2007 that decision aids are a valuable tool for improving medical care by helping patients make better decisions. They passed a law providing greater legal protection to providers who use shared decision making, rather than standard informed consent, and that law required the state to study the effects of shared decision making.[emphasis added] As part of that study, Group Health Cooperative (an integrated insurer and hospital system) gave all 660,000 of their patients access to decision aids when they were considering any of a dozen preference-sensitive treatments. They also made all of the doctors and staff watch the decision aids, and kept physicians informed of how many of their patients were choosing surgery.

If shared decision making is so wonderful, why aren’t we already using it in every hospital and every doctor’s office?

The results were striking. The paper, published in the September edition of Health Affairs, covers two orthopedic procedures — knee replacement and hip replacement for arthritis of those joints. During the year and a half immediately after they introduced the decision aids, rates of hip replacement fell over 25%; knee replacement went down 38%. Total spending went down 21% on patients with hip osteoarthritis and 12% for knee patients — not just on those patients who skipped surgery, but for the whole study population. That amounts to well over $1000 a year in true medical savings — money that can be spent on something else entirely, and isn’t just shifted from one payer to another.

Allow us to reinforce something from that last paragraph: over a quarter of patients were choosing not to have surgery once they were better informed. Looking at that one way, it’s great news: We can save a ton of money and make patients better off, just by doing a better job of targeting elective surgery. But it’s also a vicious indictment of our current practices: every day we continue not using decision aids, our medical system knowingly puts patients at risk of a wrong-patient error.

A series noted in Health News Review provides clear evidence that we Americans are the “worried well”; over-diagnosed and over-treated, often for conditions that aren’t very harmful in the first place.  The series, authored by a researcher in Australia, begins with this trenchant observation:

“over-diagnosis happens when people are diagnosed with diseases or conditions that won’t actually harm them. It happens because some screening programs can detect “cancers” that will never kill, because sophisticated diagnostic technologies pick up “abnormalities” that will remain benign, and because we are routinely widening the definitions of disease to include people with milder symptoms, and those at very low risk.”

Here’s the net.  Americans get far too much crappy information about health, health care, and treatments from media, friends, and [sometimes their] physicians.

But – and it’s a BIG BUT…

When Americans get GOOD information, they make smart decisions.


Parting can be sweet sorrow…

Even if you’ve just lost a client to a competitor.  

For those a few years removed from studying Shakespeare, “sweet sorrow” is how Juliet describes her feelings when Romeo leaves at night (the sorrow), anticipating their reunion the following day (the sweet).

Don’t walk away mad or cranky or spiteful – that’s the absolute wrong thing to do.  

People remember last impressions, and if their last memory of you/your firm/your service is a good one, you’ll benefit in the future.  Sure it’s tempting to lash out, but if you’ve gotten huffy and difficult, taken talent off the account, and pushed their requests to the bottom of the list, you’re going to have one bad reference.

If their last memory of you is poor, well, you will never know how it will hurt you, but rest assured it will.  This is a very small industry – people move all the time, everyone knows everyone else, and everyone talks to everyone.

So you’ve two options – give into your petulant side, take your toys and go home, or be professional, polished, respectful and service-focused.

Before you decide, think of what the client will say  – in the first instance, “man, those people turned out to be a whole lot different than I thought they were; they ignored us, refused to cooperate, and made the transition really difficult for me.”

Or, “gosh they were great; went above and beyond, really helped us move our business even though it was costing them money; can’t say enough good things about them.”

If you need more encouragement, there’s this.  Individuals make buying decisions, and each decision is risky.  When someone is thinking about what vendor to give their business to, they know that nothing is forever, that sooner or later the current vendor will be replaced by someone new.  If they hear you were professional and helpful when they moved the business to a new vendor, that’s a little less risk for the buyer, and a better chance you’ll win the business.

What does this mean for you?

You’ll never regret doing the right thing; you’ll all-but-certainly regret letting emotions get the better of you.

While the wait may be longer than Juliet’s overnight, the reunion will still be sweet.


Mutual Admiration Society

Normally, I am more comfortable calling attention to the issues rather than to myself… but I would be remiss in not thanking the IAIABC for their recent recognition of my efforts to address opioid overuse and physician dispensing in workers’ comp. I am quite honored to find myself in such an esteemed roster of industry professionals: to be mentioned in the same breath as Kathryn Mueller MD is humbling.

This is a good opportunity for me to tout IAIABC  because it’s a mutual admiration society; they do great work.

If you aren’t following their efforts, you need to be.

As the world’s oldest trade association dedicated to promoting the advancement of workers’ compensation systems throughout the world through education, research, and resource management, IAIABC has a distinguished history. The folks at IAIABC, and the stakeholders that do much of their work, spend untold hours working thru issues as mundane – and vitally important – as standards for electronic billing, the selection and deployment of medical treatment guidelines, and model regulations addressing the many arcane, esoteric, but nonetheless critical issues that make up workers compensation.

Regulators are a lot like sports officials – when things run smoothly you don’t even know they’re there.  But when they don’t, you get..the recent disaster known as the NFL.

Now that the “real” officials are back on the football field, we all know how good they are.

Let’s see if we can do the same for workers comp; as complex and complicated as it is, in many states it actually runs pretty well.

And if it isn’t, you can find a group at IAIABC working on a solution.


Meningitis, compounding pharmacies, and workers’ comp

There’s one good thing coming out of the horrific and rising death toll from possibly-contaminated drugs produced by a small drug compounding firm.  There’s nothing like a few deaths to concentrate the attention of policy makers. 

If that sounds heartless and cruel, it is nonetheless quite true.

Much more attention will now be paid to the practice of compounding, bringing much-needed focus on the very real dangers inherent in the practice.  To date, a dozen people have died as a result of the tainted drug, but the count may well increase: thirteen thousand people received the injections. Experts believe about 650 individuals will end up infected, up from 121 today.

Roberto Ceniceros reported that many of the facilities using the tainted drug treat workers comp patients. 

The reality is compounding is not tightly regulated; the FDA is responsible for ingredients but individual states handle manufacturing and oversight.  That’s not for a lack of trying; the FDA has repeatedly tried to increase its oversight of compounders, only to see those efforts blocked by compounders’ lobbyists.  (side note – think of this when you listen to politicians ranting about regulatory burdens).

The meningitis outbreak is only the latest in a string of what the FDA reports is 200 “adverse events” associated with 71 compounded drugs, one of which blinded two veterans at a VA facility.  Back in 2009, Dan Reynolds of Risk and Insurance wrote an extensive article on the problems with compounding, citing experts from PBM HealtheSystems.

Implications for workers’ comp

1.  The drug in question was typically injected into the back to relieve back pain.  The procedure, known as an epidural steroid injection, is all too common in workers’ comp.  It is highly likely that some of the victims were comp claimants.  Here’s hoping the insurers for the victim(s) vigorously pursue legal action against the compounder.

2.  As CWCI, WCRI, and others have reported, compounding is growing in workers comp.  There’s been a significant increase in California since the Golden State slapped controls on over-charging for repackaged drugs, one theory is the profiteers looked for another place to suck money out of the system. Hopefully regulators and legislators will now have the impetus they need to blow thru compounders’ lobbyists and put stronger controls on the practice.  


How profitable is the physician dispensing business?

This profitable.

That’s Gerry Glass on the left and Paul Zimmerman on the right, co-CEOS of Automated Healthcare Solutions

The two bought the jet, which is registered under the name “Boys from Dover”, back in May of 2010.  Other pictures are here and here.

The jet is a 1988 Cessna Citation III; similar planes go for upwards of a million bucks these days; hard to say what the “Boys” paid for their’s.  Of course, you gotta figure maintenance, fuel, pilot, hangarage, insurance, upgrades…

Hangarage runs about $40,000 per year

Insurance about $30,000.

Pilot, co-pilot, and flight attendant about $425,000.

Landing fees and associated charges – $20,000.

Cleaning should be $6000 or so.

We’ll lump the other operating costs – fuel, maintenance, upkeep repair and replacement of parts – into Direct Operating Cost – which is about $2,370 per hour, or, figuring average usage, $948,000 per year.

Total cost per year?  Hey, if you have to ask, you can’t afford it.  And after paying the inflated costs for physician dispensed drugs, you probably can’t.

But since you asked, it is just under $1.5 million per year.

On a possibly not-related topic, check your TIN data and see how many dollars have gone to Prescription Partners, affiliate of AHCS, which is also owned partially by the “Boys”.  

I know what you’re thinking…there are two “Boys”, so what if one wants to go to, say, Baltimore to appear at a hearing, and the other is headed out on vacation.  What’s to do? Well, no worries!  They’ll just flip a coin, and the loser takes the other plane -a Cessna 500.

Sure, it’s slower, and smaller, and can’t go as far, but hey! any private jet is better than flying commersh!



Florida’s failing drug program

WorkCompCentral’s Mike Whiteley reported this morning that Florida’s Prescription Drug Management Program (PDMP) is in danger of running out of money [sub req], just over a year after it got started, leaving doctors and dispensers with no way to monitor their patients’ access to  powerful, potentially addictive drugs.

PDMPs collect data on prescriptions for controlled substances from doctors and pharmacies, allowing both to access the database to find out if patients are getting conflicting, duplicate, or otherwise problematic scripts.

There are two main reasons for this debacle; Governor Rick Scott’s unfathomable decision to refuse state funding for the PDMP, and the incompetence and lack of diligence exhibited by and the chairman of the Florida PDMP foundation.

Scott rejected state funding for the PDMP, despite overwhelming evidence that Florida’s drug abuse problem was – by far – the worst in the nation.  As a result, the PDMP requires a mix of Federal and private funding to maintain its operations; according to Whiteley’s piece, there’s significant risk this isn’t going to be enough to keep the program functioning for much longer.

The chairman of the PDMP Foundation – responsible for funding the PDMP – is none other than Dave Bowen, president of physician dispensing company Automated Healthcare Solutions.  Evidently Bowen has been so busy spending millions lobbying Florida’s legislators to keep open the loophole that has AHCS rolling in cash he hasn’t had time to ensure the PDMP is adequately funded.  This despite his boss’s statement that “Information provided by the PDMP will be a powerful tool to make sure medication gets into the hands of people who truly need it…”


PDMPs aren’t intended to “ensure medication gets into the hands of people who truly need it…”; perhaps that’s the problem.  They are specifically intended to “reduce prescription drug abuse and diversion”; at least that’s what Bowen’s own Florida PDMP Foundation says they are supposed to do.  Those are very different goals; adherence to prescription drug treatment is quite different from making sure patients aren’t going to multiple docs and multiple pharmacies.  

According to Bowen’s PDMP Foundation website, there are calls scheduled each month; however – according to that same website – there are only notes for four calls so far this year, and none documented since June.  The website itself indicates funding is only assured thru June of 2011…

The opioid disaster has hit Florida as hard as any state. The PDMP is one tool that can go a long way to addressing the problem.  It is a travesty that a) the state can’t find less than a million bucks a year to fund the PDMP and b) the ostensible leader of the Foundation, one so committed to the PDMP somehow can’t find time to meet, much less actually get the program funded.

Note – this post was altered after Alia FarajJohnson, AHCS’ PR flack, complained that she’d been misquoted in the piece by Mike Whiteley.  I removed her quote.


Maryland’s medical miscreants coming to justice

The group of five Maryland physicians charged with inappropriate prescribing are getting their day in court – or rather, the court is getting their day with the docs.  

According to an article [sub req] in the Daily Record, “IWIF [Maryland state work comp fund] said an internal audit of prescription payments showed that from 2001 to 2006, the annual reimbursement fees for prescriptions at Maryland Orthopedics jumped nearly 1,700 percent, going from $12,489 to $212,170 over the 5-year period.”

As I reported a couple weeks back, “One physician, Raymond Drapkin MD allegedly administered pain injections and simultaneously prescribed – and dispensed – significant quantities of narcotics to patients.  One of Drapkin’s colleagues, Michael Franchetti MD, stands accused of the same type of inappropriate behavior, as do three other docs in the practice.”  Franchetti was the first of the (allegedly) Fraudulent Five to have a settlement hearing; word is he appeared at a settlement hearing in late August. Results are supposed to be released prior to 10/13 when one of the trials starts.

Word is two of Franchett’s colleagues are “going down swinging” while others are settling out.

A colleague was kind enough to provide insights into what the docs were doing with all the cash they were getting from dispensing, injecting, and allegedly over-treating.  Just shows that money does NOT equal good taste…

Can’t see the cement lions at the entrance from here…