A mass murderer brought to justice.

A California doctor, convicted of second-degree murder was just sentenced to 30 years-to-life in prison for overprescribing opioids that resulted in the deaths of 3 “patients”.

Dr Lisa Tseng’s apparent willingness to hand out scripts to anyone with cash was going on for years and reportedly resulted in the deaths of at least a dozen patients.  Worse, she knew her patients were dying; according to news reports the County Coroner called her office at least monthly to let her know one of her patients had died.

At least a dozen of her patients died of overdoses.

Let’s call her what she is – a mass murderer.

While her motives – apparently purely financial – may have been different than the Ted Bundys, John Wayne Gacys, and Jeffrey Dahmers, her death list is not.  Nor is the impact on the families and friends of her victims.

Her defense attorney complained that the verdict was already affecting other doctors’ behavior.  I should hope so.

Another physician bemoaned the verdict, saying:

“When you use the word ‘murder,’” said Dr. Peter Staats, president of the American Society of Interventional Pain Physicians, “of course it’s going to have a chilling effect.”

Staats said he believes an aggressive medical board — not prosecutors — should go after reckless doctors. But, he added, any doctor who is prescribing pills knowing that they are being abused or diverted shouldn’t be called a doctor.

Let’s understand what’s going on here.  Some in the medical community are totally missing the point.  Over a three-year period, this “doctor” wrote some 27,000 scripts for opioids and other very dangerous drugs.  That’s about 25 each day. 

Instead of whining about “chilling effects” and the impact on doctors, these protesters should be asking themselves why 28,000 people died as a result of “accidental poisoning” due to overdoses.

They should ask themselves why heroin use has exploded.

And why it came to this.

Fortunately, the Tseng case seems to be sparking some much-needed conversation in the pain physician community.  Here’s hoping it results in a lot more caution and far fewer opioid scripts.

Thanks to good friend and colleague Sandy Blunt of Medata for the heads’ up.

The Super Bowl of Drugs

Warning – rant follows…

The two main takeaways from last night’s SuperBowl are:

  • A really good defense and great defensive plan can beat a really good young quarterback.
  • Drugs are where the money is.

I’ll leave the first point to those more expert in football analysis and focus on the second for a minute or two.

In a sign of the imminent arrival of the Apocalypse, there were three ads for drugs shockingly none for life-threatening conditions.  Nope, we Americans must have way bigger concerns than diabetes and cancer – namely the coming open-toe shoe season and the inner workings of our lower digestive tracts.

Yup, there was an ad for a toenail fungus cure, (TOENAIL FUNGUS?!). another for diarrhea (DIARRHEA?!) and one for Opioid-Induced Constipation.  The cheapo fungus ad cost a mere $5 million for 30 seconds; the animated intestine discussing bowel movements graced our screens for a full minute; so did Astra Zeneca’s solution for the opposite problem.

The toenail fungus AND intestine ads came courtesy of Valeant, a name you may recall from news stories about Federal investigations into its pricing practices.  Over the last few years, Valeant has bought up the rights to at least four drugs – then jacked up the drugs’ prices by a factor of 10. (this is getting to be a common practice)

And opioid-induced constipation?

Okay, that’s a problem, but WhyTF are we taking so many opioids that pharma gets to make more hundreds of millions of dollars on a problem pharma created?

What a brilliant business plan; let’s create a drug that makes people feel really good AND is highly addictive, encourage doctors to prescribe it for everything from a sore back to cancer, then, when we have saturated the market so that there’s enough pills sold to give every American a month’s supply every year, let’s charge them three hundred bucks a month so they can poop.

When you watched those ads, did you think about all the zeros on your health insurance bill this month, realize that your family deductible is about equal to what you paid for your first decent car, and see that your choice of providers is best described as “few and far between?”

We are seeing a free market system running wild.

What does this mean for you?

If we stay on this path, we’re bankrupt.

 

 

 

Workers’ comp is leading the way on opioids

Welcome to the war, everyone.

Okay, so work comp is not the most progressive industry. We are – often justifiably – seen as slow-moving, overly conservative, reluctant to adopt change and averse to innovation.

Except when it comes to opioids, where work comp has been far in front – and continues to lead.  By advocating for treatment guidelines, restrictions of physician dispensing of opioids, formularies tied tightly to UR, analytics and clinical intervention, work comp has long been very active in a crisis that is only now getting real attention in the “real world”.

In a shocking statistic, opioid-related deaths in this country hit 28,647 in 2014, a 9% increase over 2013,

On the “What in hell took you so long”, it is wonderful to see the President call for $1.1 billion in funds to address the opioid crisis. The mainstream media is (finally) all over the issue.  Congresspeople are strident and passionate, finally joining Rep. Hal Rodgers R KY who has long been a leader, calling for action action action.  Presidential candidates are speaking out about the crisis.  It is an acknoledged public health emergency.  The CDC is promulgating guidelines.  Meanwhile, the opioid industry and their supporters are employing all their usual tactics in an effort to keep their profits flowing – expect them to spend whatever they need to.

For those of us in work comp who have been desperately working on the issue for years, this is welcome indeed.  We’ve been fighting this battle for at least ten years, thanks to research by CompPharmaCWCI, NCCI, and WCRI. Innovative efforts by a few insurers. Passionate and vocal leadership from pharmacists and medical directors. Washington State fund L&I’s Gary Franklin MD has been the industry’s leading voice on this issue for a decade, and the progress L&I has made under his direction (kudos to Jaymie Mai, PharmD as well) has been enormous.

The American Insurance Association’s Bruce Wood has been a forceful voice for common-sense, practical solutions, tirelessly bringing this issue to the attention of legislators, regulators, comp executives, and other stakeholders

A special shout out to PBMs, where diligent, targeted, persistent effort by execs, case managers, medical directors, clinical pharmacists, data analysts and account execs have actually led to a decrease in new claims with opioids for the last two years.

Think about that.   Working with payers, PBMs have been cutting opioid scripts for new claims by 5-7 percent per year for the last two years, likely significantly reducing adverse consequences – addiction, misuse, diversion, death.

PBMs make their money when patients are prescribed and dispensed drugs.  Yet PBMs, and their payer customers, have been working tirelessly to reduce the number of pills their patients take.

I’d be remiss if I didn’t acknowledge PBMs’ customers – adjusters and execs alike – have been a key part of the solution.  I recall a terrific program instituted by OneBeacon a decade ago that rewarded adjusters for identifying claimants on opioids and referring those claimants to a physician for review and treatment modification efforts.

Somehow the uninformed and unwilling-to-be-informed out there have not seen fit to allocate credit where credit is due.

Yes, work comp can be archaic, byzantine, frustrating, and even stupid.  And yes claimants can be mis-served for any number of reasons.

But what you’ve done about opioids is truly remarkable. Yeah, we still have a long way to go.  But we are well ahead of the rest of the world.

Note – I am president of work comp PBM consortium CompPharma.

 

Friday catch up

Made it home from warm and sunny Baton Rouge yesterday just in time to escape the travel disaster unfolding across the east coast.  Hope you and yours are warm and snug and home.

The big news-that-wasn’t was the completion of the acquisition of work comp PBM and specialty services firm Helios by OptumRx, United Healthcare’s PBM and ancillary business entity.  If you were looking for an announcement, there wasn’t one.  Although the deal was likely in the $1.5 billion range, Optum alone generated $67 billion in revenue last year, while the entire company totaled $157 billion in sales. Helios might be a blockbuster deal for work comp folks; it is not for United.

I was honored to speak at the Louisiana Workers’ Comp conference earlier this week, focusing on formularies and other tools payers use to ensure patients get the right drugs and don’t get the wrong drugs.  The audience was engaged, very knowledgeable, and had lots to say.  Good people looking to do the right thing despite what can be a very challenging environment.

Health care evolution

The canary-in-the-coal-mine that is California provides more insight into what will happen in your market – rapid and deep consolidation of health care providers into vertically-integrated delivery systems.  One market – the greater San Francisco Bay area – provides a view into the future for others.

This is especially important because these huge provider networks are critical to health care delivery, financing, access and cost and quality improvement.  Which raises the question – are they getting so big they are “too big to fail?”

Not surprisingly, a conservative view is the government is behind this, and the risk is high. The logic of that argument, while superficially valid, fails in the face of understanding.  What the author fails to note is the Co-Ops were established precisely to foster competition in a market dominated by hundred-billion dollar plus organizations.  More importantly, market consolidation has been going on for years – and while the ACA has likely sped up the process, this is an inevitable result of a maturing market.  This isn’t a government thing, this is a business thing.

Of course, if Sen Rubio et al hadn’t strangled the Co-Ops by cutting off their risk payments, there would be more competition…

Pharmacy

Interesting research published by the Pharmacy Benefit Management Institute, detailing the state of the PBM world over the last couple of years.  Not only does it have a cool picture of a women’s eight at the catch (that’s rowing talk), the pub has a wealth of information on what’s happening in the real world of pharmacy management. A few highlights:

  • driven by a near-20 percent jump in specialty med costs, overall trend was up over 10 percent.
  • most of the cost control efforts appear to be financial, with more payers adopting multi-level tiers for copays and the expansion of deductibles and other cost-sharing approaches.
  • the top goal across all respondents was managing the cost of specialty meds.
  • “The generic dispensing rate at retail pharmacies in 2002 was only 40%; today it is 78%”

Costs are going up at double digit rates despite more aggressive cost-sharing and a doubling of generic dispensing.

Work comp

NCCI is working on research aimed at tracking potential impacts of ACA on work ; their work includes monitoring time-to-treatment for comp claimants.  Kudos to Barry Lipton et al for this needed research.

Back at it next week – hope your team wins this weekend!

The Millennium Health settlement

Some weeks back, the Feds announced they’d reached a settlement with Millennium Health on allegations that drug toxicology firm Millennium Health was involved in illegal practices (my characterization, not theirs).

More recently, Millennium has been working through a reorganization wherein the company’s debtors will assume control of Millennium. This reorg (currently held up by legal wrangling) was driven in large part by a $256 million settlement Millennium agreed to pay to resolve allegations of improprieties.

Note: Millennium is a consulting client, has been for almost four years, and will continue to be a client for the foreseeable future.

A bit more detail on my relationship with Millennium.

I’ve worked very closely with Millennium to design and promote a work comp-specific program.  This program – a flat fee covering all drugs and metabolites tested by Millennium, coupled with a payer-specific outreach program and supported by clinical liaison personnel – has been widely accepted by and dramatically slashed drug testing costs for many payers. Everyone I’ve worked with at Millennium – their clinicians, researchers, operations, finance, executive, sales and account management staff – has been professional, highly ethical, and committed to their customers.  Over the last four years, I never encountered anything that remotely indicated a possible ethical transgression.

The drug testing program now being considered by Medicare – a flat fee for an entire panel of tests – is what Millennium has been offering work comp payers for over three years.

After extensive research into the allegations and legal wrangling among and between the parties, there appear to be two primary issues described in the DoJ statement referenced above – giving testing cups to physicians, and promoting/allowing physicians to have “standing orders” for drug tests.

Millennium was accused of violating Stark laws by giving docs test cups that the docs would use to collect urine specimens and send those specimens to Millennium for quantitative testing if further testing was required.  Millennium was also accused of inappropriately billing Medicare for drug tests by promoting custom “panels” wherein physicians would always request the same panel of drug tests for each payment.

First, the cups – and this is where things get a little confusing.  According to  Health Law Attorney Blog, 

Millennium initiated the practice of entering into “cup agreements” with physicians under which Millennium agreed to provide POCT [point of care testing] cups to physicians free of charge if the physicians agreed: (i) not to bill any insurer for the urine testing service; and, if further testing was required, (ii) to return each test cup to Millennium for lab testing of the urine specimen. If the physicians failed to comply with these requirements, then Millennium would charge them for the price of the cups.

There’s an illuminating discussion of the cup issue here.  It looks to me like the key issue is the government’s contention that by giving docs cups with immunoassay test strips attached, Millennium violated Stark laws.  If the cups did NOT have those test strips, this would not have been an issue.  I’m not clear as to how MH could have violated the Stark laws if the docs did not bill any payer for those cups and thus did not receive any remuneration, but it is clear that this was indeed a violation.   As the above-reference Blog notes:

quoting the government here – “whenever a laboratory offers or gives to a source of referrals anything of value not paid for at fair market value, the inference may be made that the thing of value is offered to induce the referral of business.” With that statement, the government clarifies its position that the fact the physician does not bill for the item or service does not, by itself, negate this inference.

So, just giving the cups away, even while requiring the docs to not bill for them, was a violation.

Now, the panels.  Drug test are supposed to be specific to a patient; the allegation against Millennium was that physicians and/or Millennium created custom panels of drugs and metabolites, specific to individual physician, panels that would be tested for every patient.  Here’s how the Department of Justice described this:

Millennium caused physicians to order excessive numbers of urine drug tests, in part through the promotion of “custom profiles,” which, instead of being tailored to individual patients, were in effect standing orders that caused physicians to order large number of tests without an individualized assessment of each patient’s needs. [emphasis added]

The DoJ also notes the agreement settles allegations that Millennium inappropriately billed Medicare for genetic testing.

Clearly, these were very significant issues. They have resulted in major changes at Millennium including an overhaul of the Board and significant changes to management and ownership.  There’s also a requirement that Millennium operate under a “corporate integrity agreement” overseen by HHS for five years.

The $256 million settlement addresses the Feds’ allegations, and there has been no determination of liability.  That said, some may well infer that Millennium’s decision to settle the case and essentially turn the company over to its creditors indicates the company was not confident it would prevail if things progressed to trial.

It’s been an ugly, messy, and at times repugnant story.  Here’s hoping the legal wrangling ends soon.  In the meantime, I will continue to work with Millennium to help them deliver on their commitments to the work comp industry.

Note: Millennium Health has not provided any information to me regarding this matter other than what is publicly available on their website.  Millennium has been aware of my intention to write a post on this topic once the legalities were resolved.  MIllennium has not reviewed, seen, edited, or otherwise been involved in this post.

Monday catch-up

CompPharma’s annual meeting was held last week; CompPharma is an association of workers’ comp PBMs of which I am president.  This year the focus was on connecting payers’ Medical Directors, PBMs, and regulators in an effort to broaden all parties’ understanding of each others’ priorities, issues, concerns, and constraints.

A few key takeaways;

  • Drug formularies must be evidence-based and supported by utilization review.  UR must incorporate a quick and intelligent way to resolve disagreements.
  • Formularies should NOT be restrictive – on either side.  That is, regulations should support payers’ ability to restrict access to inappropriate drugs and readily approve drugs that a formulary may deem inappropriate.
  • We continue to make good progress against overuse and abuse of opioids, but the biggest challenge remains long-term users of the drugs.
  • The regulator’s task is beyond complex. Rapid changes in medical knowledge, conflicting state and federal laws (e.g. marijuana), reduced staff in many jurisdictions, and an adjudicatory process built for far less complicated times combine to ensure very few answers are simple and straightforward.
  • Things are getting better in California, where the UR process has likely prevented serious harm in multiple instances.  That said, well over 95% of all medical procedures and treatments are approved, a result that may indicate too much leniency rather than too little.  

CDC’s draft opioid usage for chronic pain guidelines was obtained by an organization despite efforts to keep it closely held..  Notably, CDC’s researchers found precious little evidence supporting the practice.  Note the draft is just that.

Implementing reform

Things are getting contentious in the provider – health plan world.  As payers seek to promote narrower networks, some providers left out of those networks are not happy. While the most public airing of the dispute is in New Jersey, rest assured this is occurring in your state.

Expect a lot more in the news about this early next year; we’ll be all over this in January.

Meanwhile, both primary care and specialist physicians have seen a slight increase in pay since reform implementation.

Health insurance premium increases have been the subject of much reporting and even more confusion – some of it caused by the reporting.  Here’s a quick summary of what’s REALLY happened.  One key quote:

The average premium of the lowest-cost silver plan increased by less than 5 percent in five states, increased between 5 and 10 percent in five states, and increased by more than 10 percent in just four states.

Workers’ compensation

Jennifer Wolf-Horesjh, Executive Director of IAIABC has launched a podcast entitled Accidentally.  The initial effort is well worth a listen.

Along with former SAIF CEO John Plotkin, Bob Wilson, and Bob Reardon of ISG I participated in a panel discussion on Social Media at NWCDC, focusing on positive aspects of social media.  The video is up here.

Meanwhile, the US economy continues to improve, and the workers’ comp world is benefiting as employment increases lead directly to higher premiums.  While rates are decreasing in most states, the jump in payroll is more than enough to offset the rate drop.

NCCI’s out with the final report on how things went for work comp insurers in 2014.  Overall, ’14 results were pretty good despite low investment returns. The combined ratio (claims plus admin expense) stayed below 100, indicating insurers made money on an underwriting basis (not counting investment returns).

And t he good folk at WCRI have just published their latest research on Louisiana; you get order the publication here.  Key takeaway – after adoption of medical treatment guidelines, utilization of medical services decreased.  Remember, correlation is not necessarily causation…

The Anti-Opioid Movement is gaining speed and traction

The pushback on opioids has accelerated dramatically; every day there’s at least one major announcement about states, the Feds, or other entities taking major steps to attack the overuse of opioids.

We are starting to see some progress.  Perhaps most noticeably, a few weeks ago the CDC published draft guidelines re the use of opioids for treating chronic pain.

Unsurprisingly, the pain industry wasn’t happy. They’ve penned letters to CDC officials and Congress, with one complaining: “a lobbying organization that seeks to reduce the prescribing of opioids appears to have played a significant role in developing the guidelines.”

Allow me a moment to pick my jaw off the floor.  This is the height of hypocrisy.

This is coming from an industry that has used the billions it has made from selling opioids to:

  • lobby state and federal elected officials and regulators,
  • pack ostensibly unbiased review panels with drug company shills,
  • fund “research organizations” that published biased research supporting opioids, and
  • brilliantly and effectively promote the use of this incredibly dangerous and damaging drug.

I’m just stunned at the unmitigated gall of these people.

CompPharma (the work comp PBM advocacy organization of which I am president) has joined with the National Safety Council, Physicians for Responsible Opioid Prescribing, American Society of Addiction Medicine, National Coalition Against Prescription Drug Abuse and several other groups to support the DC guidelines.

The human cost of opioids is a constant and terrible reminder of the impact the opioid promotion industry has on each of us.

Yesterday the estimable Steve Feinberg MD sent one of his periodic emails re interesting issues related to work comp and the delivery of care in comp.. This one was a column by Bob Beckel, an editorialist who recounted how he had to check himself into rehab after a mere eight weeks post-op care involving OxyContin and Percocet had addicted him to the stuff.

Truly frightening.  And very common.

A truly awful side effect of the rampant overprescribing of prescription opioids has been the explosive growth in heroin use.  When patients can’t get prescription opioids, those addicted or dependent may well turn to illicit versions of opiates, namely heroin.

myMatrixx’ Phil Walls RPh has written an excellent synopsis of the history and current status of heroin. Detailed, thorough, readable; download and read on your next flight.

Perhaps the most trenchant observation appeared a couple weeks ago in an editorial in the New York Times entitled “How Doctors Helped Drive the Addiction Crisis”.  Here’s Dr Richard Friedman’s concluding paragraphs:

WHAT is really needed is a sea change within the medical profession itself. We should be educating and training our medical students and residents about the risks and limited benefits of opioids in treating pain. All medical professional organizations should back mandated education about safe opioid treatment as a prerequisite for licensure and prescribing. At present, the American Academy of Family Physicians opposes such a measure because it could limit patient access to pain treatment with opioids, which I think is misguided. Don’t we want family doctors, who are significant prescribers of opioids, to learn about their limitations and dangers?

It is physicians who, in large part, unleashed the current opioid epidemic with their promiscuous use of these drugs; we have a large responsibility to end it. [emphasis added]

Kudos to Gov Charlie Baker (R) of Massachusetts.  Gov Baker is calling for a strict limit on initial opioid prescriptions throughout his state.  Of course several docs are protesting this, noting problems of access for patients who need the medications.  It would be even better if these docs noted the problems inherent in opioid prescribing; perhaps they did but the reporter didn’t publish those comments… (thanks to Jake for the tip!)

Finally, there are many, many pieces and parts to ACA, including significant funding for clinical research, patient outcomes research, and research into improving the delivery of care. The Patient-Centered Outcomes Research Institute just closed it’s request for proposals for research into Clinical Strategies for Managing and Reducing Long-Term Opioid Use for Chronic Pain.

There’s nothing more important in the work comp world than this issue. 

This will make you stop and think.

In 2012, the entire US opioid market was $8.34 billion.

Workers’ comp paid about 17% of that bill.

One of every six opioid dollars was spent by the work comp industry. 

That’s a stunning statistic.

Recall that workers’ comp medical expenses account for about 1.5% of total US medical spend.  Sure, there’s a lot of pain in comp – but there’s a lot of pain in non-comp diagnoses as well.  Chronic non-cancer pain, end-of-life pain treatment, cancer-related pain, acute injuries, surgical recovery, dental procedures can all result in opioid prescriptions.

But few group health patients get opioids for non-skeletal back pain.

What does this mean for you?

We’ve accomplished a good deal in reducing inappropriate prescribing of opioids to comp patients.

But we have very, very far to go.  This is NOT the time to rest on our rather meager laurels.

 

Workers’ comp pharmacy costs – Survey says…

CompPharma, a consortium of workers’ comp pharmacy benefit managers, released the 12th Annual Survey of Prescription Drug Management in Workers’ Comp yesterday.  The Survey is an in-depth look at the issue based on telephonic interviews with 21 TPAs, insurers, state funds, and self-insured employers.

This year, we (I’m the author of the study) found that drug costs increased across all respondents.  Comparing total 2013 and 2014 drug spend across all respondents, costs climbed 6.4%.

However, that increase was driven by a minority of respondents as only 7 of the 21 saw costs go up.

Looking at inflation another way, we also calculated the average increase for each respondent; trend was essentially flat.

We offer these different metrics to provide readers with as much data as possible so they can draw their own conclusions.  One could argue that you have to look at cost changes across an entire industry to really understand what’s happening.  Another perspective focuses on individual payers. As the payer’s policyholder base doesn’t change that much from year to year, a payer-specific view is more accurate.

The big question is what is driving drug spend increases.  In that, respondents’ views were pretty consistent – physician dispensing, opioids, and compounds.  I’d note that the industry has had some pretty good success addressing opioids; PBMs that report on this have all been able to decrease opioid spend over the past couple of years.

Another cost driver, mentioned by a couple respondents, was likely a major contributor: price inflation for generic medications.  Fortunately, that has leveled off somewhat of late, although entrepreneurs will continue to look for opportunities to make their fortunes by buying up manufacturers (of little-used drugs) and dramatically increasing prices.

A couple points that bear making.

First, work comp pharmacy is about as different from group health/medicaid/medicare as chalk and cheese.  There are:

  • no deductibles, copays, coinsurance, or other cost sharing for patients
  • wide-open choice of drugs except in TX OH WA and OK
  • most spend is for pain; 24% of dollars go for opioids while about 84% of spend is for pain

Second, the PBM industry has done a remarkable job of bringing down the rate of inflation over the last dozen years.  Yes, there have been a couple spikes over that time, but ten out of twelve years we have seen a ‘decrease in the rate of increase.”

 

California’s going to have a work comp drug formulary

And that is good news indeed.

WorkCompCentral reported this morning that the state legislature passed the enabling bill late yesterday; the Governor will sign it.

California will join four other states that have formularies in place today, and it is highly likely others will follow suit soon.

As good as that is, please do not make the all-too-common mistake of declaring victory and moving on.  The formulary bill is just the first step.  Here’s what has to happen to make a formulary actually work for all stakeholders.

  • UR – binding utilization review processes and rules that require compliance.  Otherwise you have speed limits with no police or laws to enforce them.
  • Flexibility – enable payers and PBMs to use rule-based processes and procedures to ensure patients get the drugs they need and aren’t dispensed drugs that may be harmful or counter-productive.
  • Specificity – blanket Y/N formularies are blunt instruments – allowing percocet for all claims just isn’t good medical care.  Instead, the formulary should be disease/condition/injury specific.
  • Timing – Texas’ phased-in rollout of their formulary made a lot of sense.  Handling new claims differently from legacy claims is appropriate and sensible.
  • Assessment – Monitor, track, and report on changes in prescribing and dispensing patterns, single out potential irregularities, identify problems and publicize same.  Fortunately, California has the best state-specific reporting and analysis entity; CWCI will be instrumental in this process.

What does this mean for you?

Wait…are we seeing actual progress in workers’ comp?  Hope springs once again!