What its like fighting the opioid industry

I’m struggling to find an analogy that fits how one-sided this fight is.

it’s not a knife-to-a-gunfight thing; at least you could throw a knife and have a chance of injuring your adversary – then run away.

it’s not a David v Goliath thing, because big pharma is VERY aware of “David’s” capabilities and vulnerabilities.

The best I could come up with is an ant vs. a boot.


A couple recent articles highlight how bad our collective butt is getting kicked (thanks to Steve Feinberg, MD – a colleague and pain management doc in CA).

While publicly vowing to help roll back opioid usage, the opioid industry is spending millions to convince state legislators to slow-walk efforts to reduce opioid prescribing, weaken PDMP usage requirements.  One telling datapoint; Pharma spent $880 million on lobbying and contributions from 2006 – 2015, anti-opioid groups spent $4 million on contributions to state political campaigns AND lobbying from 2006 – 2015.

In New Mexico, efforts to curb opioid prescribing have been defeated, thanks to an overwhelming push by big pharma.  The opioid pushers hired 15 lobbyists, contributed to most members of the key Committee working on the bill, and got what they paid for.

And it’s not just overt lobbying by pharma; these bastards are funding “patient advocacy” groups like the Cancer Network, creating their own “astro-turf” patient groups, even stuffing wikipedia with opioid advocacy crap and changing entries to delete negative information about opioids.

What does this mean for you?



Opioids – you have no idea.

Two people very close to me are on the front lines of the opioid disaster.  Working in ERs and ambulances in the northeast, they see – multiple times every day – how bad it is.

You have no idea.

The toll this is taking is wide, deep, and devastating.  Some public safety workers are burning out, beyond frustration and anger to a place of fatalism.

Yesterday an unconscious woman was admitted after her kids told their dad she was taking a nap on the kitchen floor.  The nap was induced by a very heavy dose of benzos on top of heroin; when dad came home from work – he’s a public safety worker too – she was unresponsive.

Revived with a hefty dose of Narcan, the woman “justified” her dosage as needed due to some unspecified mental trauma.

This one example is playing out multiple times every day for every ambulance crew, in every ER, in every neighborhood.  NPR’s morning news greeted me with a piece about elephant-tranquilizer Carfentanil, a made-in-China chemical that is exponentially more powerful than fentanyl, which is exponentially more powerful than heroin.  Now spreading rapidly thru Ohio, Florida, and the midwest, carfentanil will soon find its way into your town.

If you think I’m being alarmist, you’re wrong.

Here’s how this is impacting us today.

  • parents are dying in front of their kids.  who’s going to take care of those kids, and prevent them from following in their parents’ tragic footsteps?
  • To some public safety workers, Narcan is NOT saving lives, it is a Get-Out-Of Jail-Free card, allowing users to “safely” push the limits of dosing in their quest to get ever higher ever longer.
  • opioids may soon be replaced by drugs such as carfentanil.  Why grow poppies when you can just order this pill from a chemical factory in China?
  • Public safety workers are at the end of their ropes.  How can they not be white-hot with anger at users when confronted several times a day with parents “justifying” their using after being revived with Narcan.

This started with legitimate “prescription” drugs pushed by pharma companies making billions.  Make no mistake, these bastards are the ones who started the ball rolling, a ball that has gotten ever-larger and is crushing more and more of us as it picks up momentum.

The great late David DePaolo penned a piece on Purdue just days before he died.  It’s well worth reading, and remembering.

But the disaster unleashed by Purdue and their ilk is way beyond what any of us thought it would become.  As powerful and necessary as the Surgeon General’s letter to physicians is, it is so, so late.

Will this epidemic be solved by public health measures far greater than anything we’ve thought of or funded to date, or, like smallpox among Native Americans or the Plague in Europe, is it fated to burn out only after it kills most users, leaving no one else to infect?

Have a great weekend.

More insured via Exchanges is good news for Work Comp

People who obtained private health insurance coverage thru the Exchanges in 2014 were less healthy than those previously insured. A just-published article in HealthAffairs provides details on their medical issues and conditions, more on this below. [sub req]

That’s not surprising; prior to ACA, many individuals and families weren’t able to obtain coverage at a reasonable price, and some couldn’t get any coverage at any price, due to insurers underwriting practices.

Now that medical underwriting and pre-existing exclusions are outlawed, folks with health problems can get insurance.  Before we jump into the implications discussion, here’s the specifics.

among those with individual private coverage, the likelihood of reporting fair or poor health and the likelihood of being obese increased by 1.5 and 4.2 percentage points, respectively (Exhibit 1). We also found that the likelihood of having at least one of ten specific chronic conditions5 increased by 6.7 percentage points for this group—a change that was driven by increases in the likelihood of having hypertension (a 4.0-percentage-point increase) and diabetes (a 2.9-percentage-point increase)

The good news is many of these chronic conditions respond well to relatively inexpensive treatment, and the cost of caring for these individuals is much lower if they have access to good primary care.

For work comp payers, the good news is a bit less obvious – but it is good news – for two reasons.

First, in general the working population will be slightly healthier – because more workers will have insurance, and the least-healthy are more likely to be improving their health status. Thus if they do get injured, they will likely heal faster as their overall health status is better.

Second, work comp insurers won’t have to pay to treat their non-occ medical conditions, as the patients are more likely to have health insurance.


Innovation in Insurance – we are soooo far behind

ACORD’s Bill Hartnett gave a compelling, entertaining, and pointed presentation on innovation, technology, and the impact of same on insurance (my title, not his).

You will be sorely tempted to ignore this and move on to the next email or project update; Do NOT do this.

His money quote – Insurance is the DNA of Capitalism.  Buildings and homes don’t get built or repaired…”

This set the stage for a discussion of the future that fortunately began with a back-to-basics primer on what insurance is for – risk assessment and management. One lightbulb went off for me – does big data give us great predictability, which obviates the “risk” issue inherent in the concept of insurance?

We will be able to predict weather events, identify medical conditions, greatly reduce “accidents”, deliver medical care designed specifically for that individual patient.

A few factoids – every minute, there are:

  • 4 million Facebook likes,
  • a million Vine users play videos,
  • 110,000 Skype calls,
  • 700 Uber rides scheduled, and,
  • 450,000 tweets

That’s a LOT of data.

And data mining uses this incredibly rich data trove to learn a LOT about you, about health issues, drug issues, crime, you name it.  Just by accessing, analyzing, and monitoring publicly available data.

Hartnett talked about vehicular changes dealing with autonomous vehicles – Ford and Tesla will have fully autonomous cars on the road before 2023. Given vehicular accidents are the single biggest cause of occupational fatalities, this is good news indeed – computers are better drivers than humans.  Yes, even me.

Moreover, frequency and severity will drop significantly within five years – this is going to greatly impact the auto repair business and auto insurance, but perhaps no industry will be more affected than long-haul trucking.

What will today’s drivers do?  How will they be classified for workers’ comp purposes? Will we get a spate of injuries as drivers see tech taking over the wheel?

New news to meGuardhat is a hard hat with technology specifically designed to avoid falls, notify when falls occur, and monitor other movement and risk metrics. Other technologies include wearables that address posture and monitor vital signs via a tattoo on the skin.

But hard hats may not be necessary, as 3-D printed buildings are coming – a 3-D construction printing rig can build a 2500 square foot house in 20 hours and needs 3-4 technicians to move it around.

I’ll stop with this – cognitive cognition – computers that can do pretty much everything we humans can in terms of pattern recognition, intuitive capabilities, and perhaps have emotions – exponentially faster and more consistently than we ever could.

Can you imagine the impact on health care?  Doctors? Diagnostics? Medical information? The health care delivery system will be revolutionized, with the potential to dramatically reduce costs as the role of people may well be greatly reduced.

Of course, I’ll be retired by then…oh, wait, I won’t be.

That’s how fast it’s coming.

Then there’s Distributed Trust

Monday catch-up

Happy Monday! here’s a few items you may have missed.

King v CompPartners – the California case may have implications for UR, IMR, and the “exclusive remedy” foundation of worker’s comp.

Here’s a very brief summary (see url above for more detail).

  • The underlying issue – did CompPartners’ UR reviewer do the right thing? is not in question.  The treating doc’s request was appropriately rejected as it was inconsistent with California’s evidence-based treatment guidelines.
  • However, the patient allegedly suffered seizures due to sudden cessation of the medication, and contended that the UR physician had a “duty of care” to inform the patient of that risk and recommend a weaning process.
  • The plaintiff took the case outside the work comp judicial process to civil court, where he lost.  It then went to Appellate Court, where the ruling raised this “question”: could Utilization Review be considered medical treatment, and the reviewer a treating provider?
  • This is contrary to all work comp precedent; the case is now before the State Supreme Court, which has stayed the Appellate Court’s ruling pending a decision.

Implications – talking to those who know better than I, the Supreme Court will likely reject the Appellate Court’s validation of civil court as an appropriate venue for the case, thereby reaffirming the “exclusive remedy” inherent in workers’ comp.

One issue that strikes me about this case; as the medication in question was prescribed by a physician for a condition deemed not covered by workers’ comp, why did the patient not a) pay for the medication himself or more likely b) get his health insurer to cover the script?

This would have allowed the patient to continue taking the drug and avoid the health issues experienced by the patient allegedly due to suddenly stopping the medication.

If you are in ChicagoLand and/or looking into value-based networks, read this. Really interesting piece on how a big provider system thinks about narrow networks, contracting, and what it wants to get paid for high-end services.  And will “eat” on commodities, such as MRIs for $100.

Here’s a shocker – media is all over reports on how chocolate helps athletes – even if the underlying study is pretty much nonsense. A much more important study that determined a very common spinal procedure is fraught with danger and likely counter-productive – was all but ignored.

From HealthNewsReview:

“Provocative discography” is a diagnostic procedure that’s used up to 70,000 times a year in the United States at great cost to the health care system. It’s commonly performed on patients with so-called “degenerative disc disease” who are considering spinal fusion surgery — a $40 billion per year industry”

If you have to rely on MCM to hear about critically-important research, there’s something really wrong with the mass media.

Looking forward to NCCI next week; will be on a panel moderated by Peter Burton with Mark Walls and Bob Wilson discussing regulatory issues.

Hope to see you there.

The impact of provider consolidation

Hospitals, health care systems, large multi-specialty groups – all are getting bigger by buying each other, merging, or snapping up smaller hospitals and physician practices. Providers smart/fortunate enough to be inside these mega-systems enjoy pricing power, strong brand recognition, and the negotiating leverage that goes with that.

Deal sizes are getting exponentially larger; a study by Deloitte indicates the average deal was $42 million in 2007.  Six years later, the average transaction was more than 4 times larger. Two were over $4 billion, and that was way back in 2013.

Last year, 940 transactions closed at a total value of $175 billion.  And it’s not just the mega-mergers that are influencing care delivery and pricing.  Small, “under-the-radar” deals are proliferating as those on the outside increasingly scramble for the crumbs.  Providers unable to join the big plans are pursuing out-of-network services, servicing smaller insurers, and trying to figure out how to remain viable.

Chicago is one such market; already quite consolidated, two of the largest systems, with over 6000 medical providers between them, are fighting to merge despite the Feds’ efforts to keep them apart. These mergers are increasingly coming under scrutiny from both federal and state regulators, as evidence suggests costs in “consolidated” regions are higher than in non-consolidated areas.

Meanwhile, DuPage Medical Group hasn’t been sitting by, closing 16 transactions that doubled it in size to 500 doctors. According to the NYTimes, “many of its acquisitions barely register — eight specialists last month, two small physician groups in February, a handful of doctors joining at a time. But it has been enough that DuPage now has ambitions of going national. Late last year, it teamed up with a private investment firm to provide it with $250 million for its goal.”

This is common everywhere; from Boise to St Louis to Boston to North Carolina providers are joining together, shifting the map or providers from one of thousands of tiny dots of ink to ever-growing Rorschach blotches.

What does this all mean for work comp?

Work comp is a tiny but very profitable line of business – so networks have limited bargaining power.

Prices are considerably higher in highly-consolidated regions; payers that don’t have contracts with the mega-systems must rely on non-contractual ways to address prices and utilization. This is particularly true in the South.

Where your patients get their care matters; a visit to a hospital-based provider costs about twice what the same visit to a privately-employed physician. Employer direction, soft-channelling, and variations thereof are key.

Tracking prices is key; make sure your internal analysts and external vendors are on top of the latest information on service prices.

Most importantly, factor outcomes into your evaluations.  Often the lower cost provider also delivers better outcomes; less use of opioids, better surgical results, faster return to functionality.

This last is key; price is easy to track and report. Outcomes are not.  Yes it’s hard; and yes it’s vital.



Health insurance, DOS, and Apple

Between a seeming inability to design a benefits plan that fits on one sheet of paper, a refusal to actually explain those benefits in terms normal humans can grasp, network arrangements that only a provider relations expert can understand, and a “explanations of benefits” that are dense and stuffed with jargon, health plans are way out of touch with consumers.
It doesn’t have to be this way.

If there’s one service that should be simple, easy to understand, and approachable for everyone it is health care.  What do I pay, where can I go, who do I have to call.

Health plans could learn a lot from the computer industry.  We old folks remember when only pocket-protector-people used computers; remember those big rooms with rows of metal boxes fronted by blinking lights and whirring tape drives? Those blue boxes were connected to green screens in the sea of cubicles outside the “computer room”, screens with horrible resolution requiring users to know what each of the dozen(s) of Function keys did and why.

The geniuses at Microsoft made computing much more user-friendly with Windows – and the PC industry exploded.

Then Apple got serious, designing their hardware and software around the non-nerdy user.  Macs were simple enough for schoolkids to use, and eventually even their parents got comfortable with Macs and PCs.

Now it’s smartphones, Siri, and google maps.  We don’t have to know anything about programming, or APIs, or backslash v frontslash.  The technology does it for us.  And “it” is pretty much everything.  We know the weather in Philly, score of the hoops game, whereabouts of our kids, monthly sales figures, meeting schedule for next week, and anything and everything else – instantly and in a format we grasp intuitively.

Which leads us back to health care.  Insurers and health plans need to take a lesson from Apple and Google; people want good health care that’s easy to access and fits their unique needs. They do NOT want to wade thru fine print stuffed with SAT-test words and jargon that’s murky at best. Blaming the consumer for misunderstanding a benefit plan is just nuts; write the plan so it’s understandable for everyone.

Give them the tools they need to use your health plan, tools that adapt to the consumer and their situation.  Tools that are intuitive, accurate, and user-friendly.

It’s long past time to scrap the “green screen” approach to health benefits.

What does this mean for you?

Some health plan(s) will figure this out.  And they will do very, very well.

Rx Drug Abuse Summit – key takeaways

I’ll keep this short.  Heading home from Atlanta and an incredibly disturbing Rx Drug Abuse Summit.  A few key takeaways.

  • The increase in the prescription opioid death toll is terrifying.  These are drugs ONLY AVAILABLE WITH A DOCTOR’S PRESCRIPTION.
  • cdc-us-overdose-deaths-2014_jr-2
  • Heroin is getting even worse – driven largely by the rampant over-prescribing of opioids.  75% of heroin users started with prescription opioids.cdc-us-overdose-deaths-2014_jr-5
  • We are making progress.  Lots of different approaches, very passionate people, truly impressive effort by the Feds.
  • There’s disagreement around the margins, but not with the central issue – opioid abuse is an unmitigated disaster.

The net is this.  There are far, far too many docs writing way more opioid scripts than they should.  Tens of thousands of people are dying, families are destroyed, kids left without parents.

You want to talk about treating pain?  

How about the pain of kids without parents, moms without daughters, sisters without brothers, communities without hope.

Who is treating their pain?

and who is causing it?

Obama, Pew, Landers and Paduda

Headed to Atlanta for Operation Unite’s fifth Rx Drug Abuse Summit, an event I’ve been privileged to participate in every year (this year Mark Pew of Prium, Michelle Landers of KEMI, and I are going to discuss formularies in work comp, an issue near and dear to my heart).

This year, President Obama is also speaking.

Think about that.

The leader of the free world is taking a day to fly down, talk, and fly back.  It’s not like the guy has nothing else on his plate – the Middle East, Apple v FBI, global warming, Congress, SCOTUS nomination of Merrick Garland, Pakistan, Iranian cyber attacks, China, trade policy…

and yet Pres. Obama a) decides to go to Atlanta; b) does the prep work necessary to speak on a panel about opioid policy, the FDA, drug approvals, law enforcement, heroin, treatment v incarceration; c) make the trip with all that entails; and d) speak on the panel.

While I’m pumped he decided to make the trip, I’m equal parts disheartened that the President of the United States has to do this.  Moreover, there’s a really impressive list of speakers; Governors, Congresspeople, the US Surgeon General, head of the FDA, Senators, head of the DEA, the CDC Director…

Those of us who’ve been up to our eyeballs in the crisis for a decade are gratified indeed to see the level of attention focused on the issue, and sad beyond measure that this has risen to the level that the President is devoting this amount of time to opioids.

What does this mean for you?

I’d suggest we focus on the positive here, as the negative is just emotionally crushing.

The Opioid Pendulum Swings

The CDC guidelines are out, and that’s a very, very good thing.

Yes, there’s an apparently-reasonable argument that the guidelines’ basis is not sufficiently evidence-based to stand up to the most rigorous standards.  There are two reasons that argument fails.

First, opioid advocates, manufacturers, and most prescribers did not worry about “evidence” when pills by the bucketful were prescribed and dispensed to anyone who presented with a sore back.  For advocates to caterwaul about science, evidence, and a lack of randomized controlled trials lasting more than 12 months is unfair at best.

Second, opioids kill more than 24,000 people a year – likely a lot more.  Mothers, daughters, sons, brothers, fathers are dying every day, causing destitution, devastated families, and disaster for communities. The time for half-measures is long past.

I understand this may lead to a few folks who ostensibly “need” opioids not getting their pills quickly or in the volume they desire.

Ask yourself this – how does this “need” stack up against the deaths, ruined communities, and parent-less children caused by rampant overuse of opioids?

I’d imagine the parents, siblings, and friends of those killed by opioids would be only too happy to wait a while or take another drug or try exercise or…