Friday catch-up

Hurricane recovery

Thanks to NCCI for a very timely article by Chief Actuary Kathy Antonello on evaluating construction contractors based on information on experience modification rates.

Key takeaway – “It’s not appropriate to use E-mods to compare the relative safety of employers.”

Very interesting take on efficiency in construction; the Economist notes that the construction industry has become LESS efficient over the last few decades. While this may well be about to change, for those rebuilding in hurricane-ravaged areas, costs will be much higher, reconstruction take longer, and preparation to deal with the obvious impacts of climate change may not keep up with the speed of that change.

Blockchain continues to work its way into the insurance industry. An excellent piece in the Harvard Business Review notes that insurance is especially suited for blockchain. Both are predicated on spreading information, and in the case of insurance, that information deals with risk. Blockchain is uniquely suited to spreading risk as at its core it is a “trust and efficiency engine.”

Key takeaway…

it will require uncomfortable transparency [from established insurers] and price corrections in their business models. This will be toughest on the portions of the industry that are the least differentiated, where consumers often decide based on price: auto, life, and homeowner’s insurance. [emphasis added]

And there’s this telling point, which identifies a key reason insurers should be worried…

trust in business institutions, and the financial services sector in particular, is at an all-time low. While the large banks are at the center of this trust vacuum — with a seemingly steady stream of scandals, such as the recent Wells Fargo account rigging debacle — the erosion of trust is bad for everyone

Ignore at your peril.

Louise is the best.

Kudos to Louise Norris for her ongoing commitment to educate the rest of us about all things healthcare and reform related.

Today brings us her edition of Health Wonk Review – capping off a summer of never-ending health care legislative maneuvering with not one but TWO Senate bills that purport to fix everything.

One entry ruined my day – hookworm has returned to Alabama as many people can’t afford adequate sanitation – and the government there doesn’t give a rat’s ass.

Read it here!

Costs and benefits of disasters

Disasters are good for the economy – sort of. They are also very likely to be really bad for people.

Combined, Harvey and Irma will cost about $200 billion – or 1.5% of US GDP.  That’s a huge infusion of capital and cash into the economies of Florida and Texas – and the other affected southeastern states.

Those dollars will go to pay workers, buy new equipment, replace ruined houses, buildings, furniture, technology, and infrastructure.

What’s not accounted for in the $200 billion figure is the cost – both personal and financial – that these disasters will levy on people involved in rescue, clean-up, and re-building.

One example – the bacterial and chemical stew pervading many areas in Houston will lead to immediate and long-term health problems for residents and clean-up workers alike. Living rooms, offices, factory floors, nursing home rooms, healthcare facilities, schoolrooms and firehouses – many will be polluted, requiring thorough cleaning and decontamination.

The real concern here is will the workers tasked with this job have the training, equipment, and clothing required to do this safely.

caption from photo reads: The #HurricaneHarvey clean up crews at our homes that were hired by management number about 200 and notice that none of them were given #Hazmat suits

Several factors are greatly concerning.

  • Texas doesn’t require workers’ comp
  • Companies are desperate to find workers, any workers, who will go into dangerous places and do very hard work in brutally hot and humid conditions
  • Labor brokers are notorious for subcontracting work like this, shaving every possible corner, and in the process hurting workers and dumping the cost of their medical treatment on the public sector
  • There are far too few documented workers available in either state to get the necessary work done quickly, so labor brokers are going to be recruiting undocumented workers.
  • Given today’s political climate and past history, those undocumented workers are far less likely to report and injury or illness
  • Lastly, an illness brought on by exposure to chemicals or bacteria takes days, weeks, months or even years to present, making it a lot harder for any injured worker to prove it was work-related.

What does this mean for you?

While responsible non-subscribers in Texas will do the right thing, many other non-subscribers will not.

Florida’s a different story, but both states must be vigilant to catch unscrupulous labor brokers.

MedRisk is back on top.

Big doings at work comp physical medicine management firm MedRisk.

(MedRisk has been a client for over a decade)

Most significant, MedRisk is likely now the largest firm in the sector, passing OneCall’s Align Networks in total revenue. Two factors driving this result; Align dropped the ball on customer service, and MedRisk upped its game considerably.

As I wrote last year,

For years, [MedRisk] had the niche almost to itself, focusing its sales and service attention on corporate buyers. Along came Align Networks, a start-up that concentrated on the desk-level user, delivering stellar service to each and every adjuster and case manager.  Align was quite successful, eventually becoming the largest vendor in the PM management space.

A misstep by MedRisk helped Align.  Some years ago, MedRisk chose to outsource key functions, including some aspects of IT, billing, and outbound call center functions including patient scheduling. This did not go well, and the resulting dissatisfaction among desk-level users led some customers to switch from MedRisk to Align.

Confronted with the loss of business, MedRisk got back to basics.  The lesson was apparent; a dramatic change in customer service was critical. That involved a major shift in understanding about the central importance of the desk-level customer, the provider and the patient, and a recognition that those customers required, above all, personalized service.

MedRisk’s results prove the back-to-basics approach worked; the company has taken major market share from Align, and continues to add new business. Operations expanded, and the company had to lease new space to accommodate the hundreds of new workers.

Now, One Call is all-in on a technology solution, investing millions in a customized application intended to deliver on the “One Call” promise (currently the seven different services offered by OCCM have separate systems and processes). “Polaris” is slated to be “fully implemented” in Q1 2018, although it’s not clear what “fully implemented” means.

I don’t believe “automating” and off-shoring key customer-facing functions is the right answer, not in a high-touch business where adjusters, therapists, physicians, and patients all are key parts of the rehabilitation process.

While many MedRisk people made this happen – including COO (and fellow Syracuse grad) Michelle Buckman, CIO Vic Pytleski, and EVP Marketing Rommy Blum, the effort was led by President Mike Ryan.

Mike is one of the best-liked people in our industry, and most respected as well. Today, MedRisk will announce he is taking over as CEO from founder and Board Chair Shelley Boyce.

I’ve known Mike for years, worked with Shelley and her team for almost two decades, and am delighted for all. They traveled a long road and it is truly gratifying to see MedRisk back on top.

What does this mean for you?

It’s all about customer service.

Thursday catch-up

Genex acquires Prium…

Good move by Genex, as Prium’s portfolio of services including physician review and pharmacy management ties in well to Genex’ current offerings. I’m a big fan of Prium CEO Michael Gavin – he’s one of the most thoughtful, intelligent, and measured people in our business…good news is he’s sticking around.

Kentucky’s making big progress on opioids

Thanks to WCRI’s Vennela Thumula PharmD for her study on how new legislation (HB-1) helped to reduce the number of new work comp patients receiving opioids.

The legislation required prescribers to check the Prescription Drug Monitoring database prior to prescribing opioids, limited opioid prescriptions, and implemented mandatory educational and patient treatment practices.

Key Takeaways

HB-1 immediately reduced opioids prescribed to patients in the first 12 months after the date of injury.

Both the percentage of patients receiving opioids and the amount of opioids decreased by more than 15 percentage points.

Major surgical patients weren’t significantly affected by HB-1; not much change in prescribing to these folks.

Patients with back sprains and similar diagnoses had far fewer opioid scripts.

Thanks to Andrew Kenneally, Communications Director of WCRI, for the head’s up…

Opioid marketing practices

Kudos to Sen Claire McCaskill, D MO, for publicizing opioid manufacturer Insys’ alleged efforts to get approval for fentanyl product Subsys through misrepresentation. McCaskill’s report included an:

audio recording of conversations between an Insys employee and pharmacy benefit manager representatives related to a Subsys prescription for Sarah Fuller, who later died from an alleged fentanyl overdose. This recording suggests the Insys employee in question repeatedly misled Envision Pharmaceutical Services to obtain approval for Ms. Fuller’s Subsys treatment—heavily implying she was employed by the prescribing physician and misrepresenting the type of pain the patient was experiencing.

Sarah Fuller

This follows other reports of Subsys’ unethical and potentially illegal marketing practices, where other Subsys reps said they called payers, saying they were from doctors’ offices and were seeking approval for the drug.

Hell is too cold for these people. 

Finally, a very revealing piece in HealthAffairs provides more insight into just how powerful big healthplans are:

insurers with market shares of 15 percent or more (average: 24.5 percent)…negotiated prices for office visits that were 21 percent lower than prices negotiated by insurers with shares of less than 5 percent.

Differences in providers’ and insurers’ bargaining power are a major contributor to variation in commercial health care prices

Workers’ comp folks – you’re lucky if a generalist work comp PPO’s market share at a practice is 3 percent…

Back out onto the campaign trail!

Labor Day Special Edition

Happy Labor Day Weekend readers!

Make sure to thank the folks who work hard every day to make our lives better – teachers and support staff, building trades, healthcare workers, factory folks, agriculture and food workers, public safety, transportation, public works, and everyone else we often take for granted.

Here are a few articles of interest…worth thinking about as you watch parades, cook up your masterpiece on the grill, and enjoy the opening of the College Football season.

What’s been top-of-mind for me is how we’ve commoditized our workers, thinking of them as “expense” instead of an “asset”.  One of the most reprehensible anti-Semitic, racist, nasty people in business – Henry Ford – recognized employers need to pay their workers enough to buy the goods they make. Somehow we’ve forgotten this, along with the truth that workers are people, have intrinsic value, and deserve to be treated as such.

The best employers I know think of their workers as assets, not expenses. They know that when people feel valued and respected, those people do amazing work.

Here in upstate New York, one of the best employers I’ve ever come across is Tessy Plastics, a privately held company with about 900 workers that makes everything from those tiny plastic thingies that close ziplock baggies to surgical stapling devices used in gall bladder surgery.

Facing the loss of their largest customer fifteen years ago, Tessy relied on its workers to bounce back and become an amazingly successful company. I know a lot of Tessy employees, and they love what they do, work incredibly hard and smart, and as a result Tessy is doing very, very well.

We all can learn a lot from Tessy.

On the other hand, there’s a lot of worker risk and abuse out there.  First up, a reminder of how some workers are mistreated, abused, and oppressed by scummy bosses.  Thanks to workerscompensation.com for the heads’ up.

Law enforcement officials in New Jersey busted a company that was allegedly taking advantage of undocumented workers, cheating them and their clients in multiple ways, including money-laundering.

The explosion in the Arkema chemical plant outside Houston is another reminder of the risks faced by workers, risks that almost always are ignored by all of us until something catastrophic happens. Fortunately none of the 60 workers were at the plant when the storage trailers started exploding, but public safety workers were.

For those looking to help out with donations, the Greater Houston Community Foundation is one site that’s been thoroughly vetted.

Have a great weekend!

 

There’s no BIG problem in work comp pharmacy – and that’s scary.

In the fourteen years I’ve been surveying work comp payers on their views on pharmacy, I’ve never seen so little consensus among respondents on emerging issues.

In past years compounds, physician dispensing, opioids, price inflation, and new drug introductions have all been named by at least a plurality of respondents. Not so this year.

Here are some of the 24 respondents’ concerns:

legalization of marijuana – lots of talk about it but concern is what do you do about it, how do you handle it, pay for it, authorize it, etc. so many unknowns and little understanding
state regulations and how to bring information on those changed regulations and how to operate under the new regs back to adjusters and case managers at the desk level and to PBMs
I’m concerned we’ll see branded topicals increasing over the next few years despite a lack of efficacy and inflated prices. teracyn, speedgel, etc aren’t useful
advent of all new formularies, no one has grappled with legacy claims in that environment, thinking is formularies will get docs to taper it off – docs who prescribe all this don’t know how to taper, so finding the right docs and facilities is a real issue for legacy claims
acquisition of comp pbms and consolidation of the work comp PBM industry
Physician Dispensed Drugs and non-controlled home delivery – not just cost but formulary and safety and quality of care
what interventions can they do to to affect drug pricing, especially some of the drugs that have minimal alternatives
more problematic than opioids is the combination of benzodiazepines and sleep aids
watching very closely Evzio, naloxone prescribing practices as part of CDC
still a soft market so anything you can do to reduce costs is important

While payers are seeing good success in reducing opioid utilization and total drug spend, there are a host of troubling issues out there.

Here’s why this is a big issue.

Payers are all too used to getting screwed by unethical and very creative profiteers intent on sucking money away from employers and taxpayers by exploiting loopholes. Branded topicals, “independent” mail order pharmacies and novel drugs are all great examples of these tactics, often hidden under and supported by claims that these promote healing and health despite a total lack of supporting evidence.

In past years when doctor dispensing, the opioid crisis, or compounds were top-of-mind for most respondents, the industry joined together to come up with solutions. That obviously isn’t the case today, leaving patients exposed to crappy providers interested only in profits coming up with myriad ways to game the system.

What does this mean for you?

It’s not the one big problem that’ll get you, it’s the many small ones you may not even notice.

Big news in work comp pharmacy

Finishing up the Annual Survey of Prescription Drug Management in Workers’ Comp this week (I hope!).  24 payers responded this year – TPAs, Insurers, State funds, and very large employers. Each provided specific data about their pharmacy programs, data which provides remarkable insights into what’s really going on.

Something jumped out at me that I had to get out immediately…

Two big takeaways – drug spend dropped by almost 10 percent…

while opioid spend decreased even more – almost 14 percent.

Wrap your head around that.

Work comp PBMs and payers succeeded in eliminating one of every seven dollars spent on opioids; yes, overall drug spend was down a full 10 percent, driven in large part by lower utilization of opioids.

When opioids are eliminated, the drugs needed to counteract their awful side effects – everything from constipation to sexual dysfunction to gastrointestinal distress to depression – are reduced as well.

The programs, processes, analytical resources, clinical staff, research, and patient outreach that’s driven this stunning result are largely PBM-delivered (with some notable exceptions).  These services are clearly improving the quality of care delivered to work comp patients, while reducing costs for employers and taxpayers.

shipload of opioids has been taken out of circulation, eliminating the possibility of diversion, misuse, or abuse.

What does this mean for you?

Healthier patients, lower costs, reduced disability. 

 

Reducing opioids CAN reduce pain

Yes, patients can be weaned off opioids AND reduce their pain levels.

That’s the conclusion of a Vox article providing an excellent, detailed, and thorough review of a study published in the Annals of Internal Medicine Vox (thanks to Health News Review for the head’s up).

Here’s the abstract’s conclusion…

Very low quality evidence suggests that several types of interventions may be effective to reduce or discontinue LTOT [long term opioid therapy] and that pain, function, and quality of life may improve with opioid dose reduction.

Let’s parse this out.

The AIM study was based on a review of 67 clinical studies; it wasn’t “primary research.” Researchers found most of the studies on this issue had either a poor methodology or low sample size. And, relatively few were even of “fair” or “good” quality.

The 12.000 pain patients in these studies volunteered to taper off opioids; they were obviously motivated and wanted to make the change. So, it’s not possible to use this research when thinking about how to address non-volunteers as “involuntarily pulling patients off the drugs (may not) lead to similar outcomes.”

And this…

Crucially, the studies also looked at what happened when these reductions in opioid doses were paired with alternative treatments, including alternative medicines like acupuncture, interdisciplinary pain programs, and medication-assisted treatment for addiction. This is very, very different from a situation in which a patient is taken off opioids and effectively left stranded without any other form of care.

Conversely,

[the CDC concluded] there are simply no good long-term studies looking at the effects of opioids on long-term pain outcomes, while there are many studies showing that long-term opioid use can lead to bad results in other areas, including addiction and overdose.

Here’s a major point made in the study and Vox article – we HAVE to stop looking to opioids as a first-and-only line of treatment for pain.

the lack of access to non-opioid strategies may be one big reason that doctors resorted to opioids in the first place. The drugs offered an easy answer — if ultimately an ineffective one — to the many problems doctors faced, including patients who had complicated pain problems that physicians didn’t fully understand and tight schedules driven by the current demands of the health care system that made it hard to take the time to work through a patient’s individual problems. [emphasis added]

AND, we HAVE to allow/encourage/pay for alternative treatment.

What does this mean for you?

Suggest different initial treatments for pain, and get creative when helping patients who want to get off opioids.

Friday catch-up, innovation, and what kills it.

A few items of interest from around the work comp world…then a brief discussion of what works, and what doesn’t, in driving innovation.

Brian Allen’s now with Mitchell International’s ScriptAdvisor PBM operation.  A highly experienced government affairs professional, Brian’s been in the business for longer than he might admit.  Good pickup by Mitchell, which has rapidly grown its work comp pharmacy business and is likely the third largest PBM.

The fine folks at BWC Ohio have done exemplary work reducing overuse of opioids. Under the leadership of John Hanna MBA, RPh, over the last five years, BWC saw:

  • 44% fewer patients were taking opioids,
  • 48% lower opioid consumptiomn overall,
  • a prior authorization turnaround time of 4 hours (!) down from 2.5 days,
  • overall drug costs were down 7.7% year over year,

John and his folks have saved countless lives, prevented untold misery, significantly reduced employers’ and taxpayers costs, and done it all at a governmental organization. Yes, they have some significant advantages, but so do you.

John’s retiring this fall, but I fully expect BWC to continue to make progress as Nick Trego PharmD takes the reins…

And yes, I do have a man-crush on John.  I have huge respect for him. Thanks WorkCompCentral for the tip.

Innovation CAN happen in insurance – here’s a quick case study of one company’s pursuit of improvement via incremental, evolutionary, and disruptive innovation. 

Here’s the summary – but you really should read this.

Creating a culture of innovation is about much more than hiring a Chief Innovation Officer or creating a new department.  Culture change takes time and significant effort, and shifting culture toward innovation is no different. The process may start at the top, but it’s fundamentally about getting all employees involved.

But bureaucracy can frustrate innovation…

Also from Harvard Business Review, a piece on how bureaucracy screws up business and results and frustrates people.

(respondents) reported spending an average of 28% of their time—more than one day a week—on bureaucratic chores such as preparing reports, attending meetings, complying with internal requests, securing sign-offs and interacting with staff functions.  Moreover, a significant portion of that work seems to be creating little or no value.

But here’s the key takeaway – “Only 20% of respondents said that unconventional ideas were greeted with interest or enthusiasm in their organization. Eighty percent said new ideas were likely to encounter indifference, skepticism, or outright resistance.”