Sep
26

Watch out for gabapentin…

The CDC recently reported gabapentin was involved in one out of every ten fatal overdose deaths in reporting states.

Similar to opioids, gabapentin can cause severe breathing difficulties  – which are exacerbated when the drug is combined with other central nervous system depressants (CNS) (e.g. opioids, antidepressants, antianxiety meds).

Illicit use of gabapentin appears to be on the rise…from JAMA:

Gabapentin can produce feelings of euphoria and intoxication and can potentiate opioids’ effects. Individuals who misused the drug reported multiple reasons in a 2019 study, including a desire to enhance the effects of opioids; to achieve a “high” when preferred substances were unavailable, such as when they were living in a treatment facility or were incarcerated; or to self-treat withdrawal or pain. [emphasis added]

Gabapentin is a non-scheduled drug which became much more widely prescribed as opioid scripts declined.  Back in 2018 one out of five chronic pain patients were prescribed gabapentin (or its cousin, pregabalin). There’s some evidence that misuse of gabapentin – which is almost always prescribed off-label – often occurs after the consumer had a prescription for the drug.

And, Parke-Davis, manufacturer of Neurontin – the brand name version of gabapentin – pleaded guilty to promoting off-label use and paid a $430 million fine.

So, what to do?

First – learn more.  Start here – myMatrixx’ Shanea McKinney, PharmD penned an excellent overview way back in 2019.

Then…

  • Dig into your data – what’s been happening with gabapentin?
  • When and where possible, require prior authorization for gabapentin and similar drugs.
  • Educate patients and caregivers about potential risks of the drug.
  • Pay special attention to patients prescribed gabapentin off-label and in combination of other CNS depressants.
  • Consider recommending urine drug testing for gabapentin patients and include it in  the drug test panel.

What does this mean for you?

This looks awfully familiar. 

 


Aug
8

The Inflation Reduction Act’s biggest loser

For the first time in about forever, big pharma lost.

One can’t overstate the impact of the-about-to-become-law Inflation Reduction Act on pharma. The most powerful lobbying force in Washington got steamrolled – with one major exception.

Medicare will now be able to negotiate drug prices, a change that will lead to massive savings for seniors (a group I will join next year) and taxpayers alike. This didn’t come without a last-ditch effort by a horde of suits invading the Senate and House…but for once, the invasion was turned back.

Medicare part D was a huge taxpayer gift to big pharma as it covered seniors’ drugs while not allowing Medicare to negotiate prices. This was a giant boondoggle; Christmas, birthdays, anniversary and graduation presents all rolled into one 20 year giveaway. (historians will note this was entirely driven by Republicans – and added $9.4 trillion to the ultimate Federal deficit)

Imagine if you could a) add a huge new market for your services/products and b) set your own prices…why…you could buy that baseball team you always wanted!

Well, at least the insulin manufacturers won. Republican senators blocked a provision which would have capped diabetics’ monthly insulin costs at $35. 

1 out of 7 Americans that need insulin spend more than 40% of their income after food and housing on the drug.

What does this mean for you?

Just when you thought Washington couldn’t do anything – it does something really big and really important. 


Jun
17

Things work comp can/should learn

In addition to my focus on work comp medical management I’m deeply involved in governmental programs (Medicare/Medicaid/dual eligibles) and related businesses.

Here’s a few things work comp would do well to understand/explore/pursue.

  1. Auto-adjudication of medical bills – the standard target for auto-adjudication of medical bills is 90%.  That’s far higher than any workers’ comp bill process, and about twice as high as the average.
  2. Medical bill turn-around time (TAT) – average is at or below 20 days from receipt of complete “claim” (defined as a medical bill and needed documentation)
  3. Administrative expense ratio – <10%. yes, I understand work comp is a lot more litigious, blah blah blah. But seriously – 28-35%??
  4. Value-based care – is taking over the big governmental programs and corporate plans as well. Yes there have been a ton of misjudgments, errors, problems and failures, but make no mistake – in the near future VBC will be the dominant form of contracting and basis for reimbursement. (those who declare VBC isn’t going to happen in work comp may want to look outside their bubble)
  5. The impact of provider consolidation – this is one area where recent articles/briefs/research are starting to scratch the surface – but only just. Reality is consolidated markets are much more expensive and WC payers have way less ability to “manage” care in those markets. WC needs to get a whole lot smarter and more agile.

Whether this actually happens is up in the air. We veterans with decades in this business recall all too well what happens to claim counts/claimdurations when recessions hit.

What does this mean for you?

This is rarely helpful.


Nov
4

Reimbursement is changing – nerd alert…

CMS – aka Medicare – has published details on the pending cut to physician reimbursement and some physician groups are howling.  The cuts aren’t uniform; Any changes to the fee schedule done via rulemaking must be budget neutral; if some payments go up, others must go down.

Overall reimbursement is slated to drop by about 4%.

Surgery and radiology are two of the specialties especially vocal about the changes, which MAY be altered or retracted if Congress passes a law revising the reimbursement change.

(Details on this are here…)

A couple other things of note…

  • Of interest to workers’ comp are new codes (CQ and CO) and payment for services rendered by PTAs and OTAs supervised by PTs and OTs at 85% of the PT/OT rate. there are modifiers and time requirements, so make sure your BR entity has got this coded correctly.
  • The CPT Codebook listing of bundled services are not separately payable.  I’d note that this is NOT universally understood by work comp bill review entities; yes it is complicated and yes it changes, so payers would be well-advised to make darn sure they are handling these bills correctly.
  • Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Again, this is why reviewing provider notes is key, because facilities/practices often bill these separately in the hope that the payer won’t catch the “unrelatedness” issue. Separately, a denial of payment for critical care services should NOT result in an additional fee to the payer; that is basic bill review – or should be. Also, watch out for PPO fees attached to those separate charges – BR and PPO companies make money on those “reductions” while they DON’T make more $$ on just denying the critical care service as part of a code review.

So, what does this mean/what are the implications?

Watch out for creative billing/increased utilization as providers look to make up for lost revenue/lower reimbursement from Medicare and Medicaid.

Ensure that A)  your bill review program is prepared to handle these changes and B) you aren’t paying extra for that “management.”

(for more on the issue of how Sequestration effects reimbursement, go here.)

 


Jun
14

The future of telehealth

Is going to be a lot clearer when Congress finishes work on the Connect for Health Act.

The bill has Bipartisan backing from 57 Senators, and would:

  • permanently remove geographic restrictions on telehealth,
  • allow patients to do visits from their homes and
  • grant the Secretary of HHS permanent authority to waive telehealth restrictions.

It is possible a competing bill  – which would only temporarily extend telehealth waivers – will be passed instead of the Connect for Health Act. Regardless, it’s clear telehealth is going to be a major part of US healthcare going forward.

Emergency regulations that lifted restrictions on telehealth are likely to extend thru the end of this year; these were a response to COVID.

One key issue is whether phone calls will “count” as telehealth, a change that would certainly expand the availability of these services, as even today many patients don’t have access to reliable internet and/or a video-connected device.

One likely change is reimbursement; expect Congress/HHS to reduce reimbursement for telehealth visits.

Impact…

I’d expect most workers’ comp fee schedules to follow Medicare’s lead – even those that aren’t directly tied to Medicare.

What does this mean for you?

When Medicare does something, everyone else soon follows. 


Jun
11

Low prices every day = higher taxes

Cheap stuff isn’t cheap…you always pay way more than you think…because the hidden costs of that cheap stuff are damn expensive.

Two examples…

Walmart’s slogan is “Save people money so they can live better.”

McDonald’s mission statement includes “make delicious feel-good moments easy for everyone.”

The two giants (and McDonalds franchisees) employ over 4 million workers, paying wages that are significantly higher than the Federal minimum (which is $7.65 an hour) – but certainly not a “living wage.McDonald’s shift workers make less than $10 an hour; Walmart’s was a lot higher, almost $15 an hour.

In just 6 states, 15,000 Walmart and McDonalds workers and many of their families are on Medicaid. Undoubtedly tens of thousands more get their healthcare from free clinics or in hospital ERs. This is especially true in states that did not expand Medicaid – looking at you, Florida, Mississippi, Arkansas, Alabama, and a dozen more.

The median cost of Medicaid – which is NOT per employee, but the employee and dependents enrolled in Medicaid – is about $8000. If we figure just 20% of Walmart and McDonalds’ employees on Medicaid have dependents, taxpayers in those six states are paying $120 million a year for Walmart and McDonalds’ employee healthcare. 

Add to that the cost of uncompensated care for the uninsured – which is subsidized by overcharging privately-insured workers and workers’ comp payers – and its blindingly obvious cheap stuff is far from cheap.

This isn’t just Walmart and McDonalds; workers at Uber, DollarGeneral, Fedex and Amazon and many other companies get their health insurance – and supplemental food aid – from you, the taxpayer. In fact, more than half of Medicaid enrollees are employed by private companies.

Make no mistake – I’m not blaming McDonalds or Walmart or any other company for doing what they are doing – or rather not doing.  Americans are addicted to buying lots of stuff (a lot of which is redundant or really not needed) and demand low prices.

What does this mean for you?

These companies are giving us what we demand, and we are paying a hefty price for cheap stuff. 

 

 


May
7

Research Round-up – the Hospital Edition

Lots of good stuff…

Those darn facility costs…

WCRI’s latest survey of outpatient hospital costs, reimbursement, and all manner of related matters is just off the presses. There’s data about specific states’ costs, network penetration, facility cost trends, surgical costs in WC compared to Medicare, and pretty much anything you need to know.

One surprising data point – network penetration (for outpatient hospital surgeries) has declined in several states over the past 15 years…

HealthAffairs’ latest edition reports on a study showing health system consolidation increases Medicare’s costs.  I’m quite sure your costs increase as well. As health system consolidation continues, so will cost increases.

Another study analyzes the impact of private equity investments in healthcare facilities…

And here’s a state-by-state list of 1-star hospitals – and another for the 5-star ones.

What does this mean for you?

With facilities the fastest growing component of healthcare costs, these resources are valuable indeed.


Apr
23

Friday catch-up

Good to be back in the habit of regular posting…lots going on deserving of your attention.

Drugs

From myMatrixx, a very useful post from Phil Walls, everyone’s favorite pharmacist. Phil highlights three drugs in the pipeline that may well find a place in work comp.

Nalmefene was developed as the naloxone for fentanyl. While naloxone has saved countless people on the verge of dying from opioid overdose, a single dose isn’t strong enough to save someone on fentanyl. Read Phil’s post for details.

Two other meds – Molnupiravir and Ofev may help patients battling COVID. The former is an anti-viral, easily administered and offering the potential to reduce the length of infection.  Ofev is more narrowly focused on combating a very serious lung disorder associated with COVID.

Opioids

As if Florida, Mississippi, and other states needed yet another reason to expand Medicaid...individuals with Opioid Use Disorder referred by criminal justice agencies were more likely to receive  medications for OUD in states that expanded Medicaid compared with those in states that did not.

Considering overdose deaths dramatically increased after the pandemic started, legislators in non-expansion states need to get off their collective butts and do the right thing. Stop with the bullshit arguments and do something that actually helps people.

And the Biden Administration should do the same – fast track authorization for medical providers to prescribe buprenorphine. We’ve been waiting over three months, Mr President…

Hospital profits

Hospital and facility owner HCA reported profits more than doubled in the first quarter of 2021 over 2020. The really scary part is

“Same facility revenue per equivalent admission increased 16.6 percent in the first quarter of 2021, compared to the first quarter of 2020, due to increases in acuity of patients treated and favorable payer mix.”

In English – employers and taxpayers’ facility costs shot up. Here’s looking at you, workers’ comp…

Workers comp

Despite the rampant profiteering off workers’ comp by HCA and others, workers’ comp remains a very profitable line of business. That’s mostly because rates are still too high, frequency continues to decline, and medical trend remains flat.

National Underwriter reported WC was the fourth most profitable P&C line in 2019, at with a “relative net worth” of 12.2%. I’m not entirely sure what “relative net worth” is…perhaps the best way to compare margins across not-for-profit, mutual, and stock companies?

Anyone?

Finally – be Skeptical!

Did 4% of Americans gargle with bleach last year?

You may have read the news reports on a “study” that found a bunch of us were gargling with bleach. Bunch of morons…typical (insert demographic group here),

But, the answer is likely no.  In fact, the “study” had fatal flaws, flaws which came to the surface when a well-designed study followed up.

Takeaway – beware of clickbait, ESPECIALLY when it supports your own opinions and biases. Here’s looking…in the mirror.

Lastly, a request.

Smile at someone you don’t know today. Things are getting better by the day, and you can spread the joy.


Dec
6

AARP, healthcare costs and drug prices

AARP has rather strange positions on drug prices and healthcare costs.

AARP positions itself as an advocate for seniors (and no, while I’m eligible, I’m not a member). The latest PR effort by the huge organization touts its lobbying to “help Americans afford high healthcare costs.”

Rather than lobbying for extensions on tax breaks for healthcare costs, AARP would serve its members better by doing something to actually reduce the cost of healthcare. Here are a few suggestions:

  • vigorously promote value-based care with reimbursement more closely tied to valid outcomes including functional ability
  • aggressively regulate healthcare system expansion, and specifically require reductions in costs after mergers
  • promote higher reimbursement for primary care, reduced reimbursement for questionable specialty care
  • focus attention on transparency in drug pricing – including rebate payments to plan sponsors

On this last suggestion, I’d note that AARP consistently moans about the retail price of drugs, while refusing to acknowledge the very real impact of rebates on brand drugs – which aren’t passed on to consumers.

Frankly, AARP’s stance on drug prices is misleading.

AARP’s “research” doesn’t discuss rebates – and the fact that plan sponsors are getting rebates, which drastically reduces the prices those sponsors pay for drugs.

As a result, consumers pay the higher retail prices, while plan sponsors – AARP partners among them – keep the rebates.

(thanks to Adam J Fein, PhD, for his work on this.)

I emailed AARP, indicating my concern with this.  This was the response:

“While AARP appreciates the potentially distorting effects of rebates, evidence indicates that plan sponsors are sharing rebates with consumers in the form of lower premiums. For example, a recent CBO analysis of a proposal to eliminate rebates under Medicare Part D that found that premiums would increase for all enrollees and that federal spending would increase by nearly $200 billion, primarily due to increases in federal subsidies for premiums.

“Further, AARP has consistently said that it would be happy to run these analyses based on net prices. Unfortunately, no drug manufacturers have been willing to take them up on the idea.”

Well, no.

First, there’s a megaton of evidence out there that some individual/group health and Medicare Part D insurers are getting rebates, and are NOT passing them on to consumers.

This from the estimable Dr Fein; (note the rebate percentage accruing to Plan D (senior drug card) sponsors):

Second, AARP could easily ask its “partners” (Part D plan sponsors among them) if they are getting rebates (which they are), and if so are they passing the savings along to consumers and what is the impact on those consumers’ drug costs. That would allow AARP to ” run these analyses based on net prices.”

AARP positions itself as an advocate for seniors. I’d suggest failing to address this is not helpful to their members.

What does this mean for you?

Does AARP benefit from rebate payments? I dunno…

 


Nov
19

In which I read current research and summarize key takeaways so you don’t have to…

Stress over healthcare costs doesn’t go away when you are on Medicare

HealthAffairs reports that more than half of Medicare recipients with a serious illness reported “serious financial distress” due to medical bills. Drugs are the most common cause, followed by facility bills.

This is important because:

Medicare for All is NOT a panacea; politicians advocating for MFA should understand Medicare needs major improvements before it is “ready for prime time.”

Oh, and a third of all credit card holders are in debt due to medical bills.

Immigration and healthcare

If you or a parent have a healthcare aide, listen up. The bruising battle over immigration and the “Dreamers’ will affect healthcare – particularly for older Americans who rely on home health aides and other lower-level clinical support.

27,000 Dreamers work in healthcare and healthcare support, many providing individual care. The Trump Administration is trying to end this program and force Dreamers to leave the U.S.

The shortage of home health workers is particularly acute in older states such as Maine and the upper midwest. With immigrants filling one of every three home health positions, ending DACA and further restricting immigration would leave thousands of older Americans without care. 

What does this mean for you?

When a politician says something is simple, or their claims just seem to make sense, your alarm bells need to ring.

Medicare will need huge and expensive changes to work for all of us. 

If you don’t want immigrants in the US, then you get to care for your parents without any help.