Work comp drug spend is going down

On average payers’ drug spend dropped 6.5% from 2014 to 2015.

And the bigger payers saw bigger reductions, with several cutting spend by double digits.

Those are the results for 30 large and mid-sized work comp payers I surveyed for CompPharma’s annual Prescription Benefit Management in Workers’ Compensation Survey.  State funds, large and mid-sized insurers, TPAs, self-insured trusts, and very large employers all participated in this, the 13th annual Survey.

The big question is – why?

Before we jump into that, allow me to address a potential criticism of payers’ drug management efforts.  This reduction is NOT because payers want to prevent their patients from getting the care they need.  Rather, payers – and their PBM partners – are focusing on ensuring patients get the drugs they need quickly and with minimal hassle, while blocking potentially problematic drugs.

This effort has paid off in the near term in lower costs for employers and taxpayers, and will almost certainly result in quicker healing and return to functionality; patients who don’t get unnecessary opioids get better a lot faster than patients prescribed these dangerous and often-misused drugs.

The Survey report, which will be out in August, will have details.  At this point in our analysis, several drivers seem to be at play here.

By far the most significant is the depth and breadth of pharmacy clinical management programs now in place at most payers.  The vast majority of payers rely on their PBM partners for most clinical management functions, with responsibility delegated to PBMs for some/most/all functions including:

  • patient enrollment
  • formulary development and management
  • prior authorization
  • pharmacist review of claims
  • prescriber outreach and follow-up
  • peer review and interaction
  • reporting
  • high cost claim assessment and intervention

This is somewhat unique in the work comp medical management world.  Unlike surgery, hospitalization, and other service types, most payers have delegated pharmacy management to PBMs.  There are several reasons for this.

  • Unlike other medical services, pharmacy is highly automated, requiring a unique electronic communication capability and expertise to accept, approve, process, and pay for the service.
  • Few payers want to invest the funds and management resources necessary to effectively manage pharmacy.  With the continued focus on reducing administrative expenses, overhead is an evil word at most insurers, so outsourcing it just makes financial sense.
  • PBMs have a lot more knowledge about pharmacy management as this is their core business.  Insurers, TPAs, and state funds have many other priorities on their collective plate, priorities that most view as more central to their core business.  They are insurers and claims handlers, not pharmacists.

That said, a handful of large payers have internalized pharmacy management – hiring pharmacists and nurses, instituting workflows specific to drug authorization, focusing on long-term opioid users, and tightening up drug formularies and approval processes.  These entities are also seeing solid payback on that investment, with costs dropping by double digits for these big payers too.

A final point that bears consideration.

Work comp PBMs, most of which are members of CompPharma (I am president of CompPharma), are doing a really good job and thereby reducing their income and profits.

They do this because this is how they win additional business; their value proposition is to ensure patients get the right medications and don’t get the wrong ones.

What does this mean for you?

PBMs are getting it done.

Work comp pharmacy – different indeed

The US spent $322 billion on outpatient drugs in 2015 – an 8.1% increase over the year before. (subscription required)

Over the next decade, CMS expects drug spending increases to outpace overall health care inflation by a significant margin at an average annual jump of 6.7%.

Things look remarkably different in the work comp world.

I’ve been surveying workers’ comp payers (insurers, state funds, TPAs, and large employers) for 13 years and the latest data indicates most are seeing a year-over-year decrease in drug spend.  I haven’t finished aggregating the data and checking the details, but this year looks like a continuation of the decreasing drug cost trend we’ve seen over the last several years (past Surveys available here).

More than 2/3rds of payers surveyed reported a drop in drug costs in 2015, and those that saw increases usually cited unique situations as primary drivers for those increases. Conversely, payers with decreases generally attributed their success to the same factors:

  • a strong focus on clinical management 
  • particular attention paid to opioid usage
  • ongoing, concerted effort to drive generic utilization

One other key driver – payers that work closely with PBMs on a variety of programs – retail network penetration, high risk patient identification, peer review, and outlier-prescriber outreach are seeing significantly better results.

I would note that work comp PBMs are spending a lot of money and resources to cut their revenues.  [I am president of CompPharma, a consortium of worker’s comp PBMs]

While there’s no question work comp can learn a lot from group health and other payers, the remarkable success workers comp payers have had in reducing the utilization of opioids shows that Medicaid and group health could and should carefully study what we’ve been doing.

What does this mean for you?

We are making progress, and work comp PBMs are leading the way.


Workers’ comp fast facts

Over the last few years I’ve had quite a few calls and meetings with folks in the investment community  looking to get up to speed on the workers’ comp industry and various aspects thereof.

While the volume of calls ebbs and flows, of late there’s been increasing interest, likely due to the credit market’s interest in OneCall Care Management and other transactions.

So, here are some key datapoints for anyone looking for basic information.

  1. Total workers’ comp premium and equivalents is about $85 billion.  That includes insurance premiums from private carriers and state funds, claims, administrative, and excess insurance costs for self-insureds, governmental programs e.g. FECA, and claims costs for minimum-premium or other “deductible” type insurance plans.
  2. Workers’ comp medical costs will be about $33 billion this year.
  3. That’s about 1.25% of total US medical spend.
  4. Medical costs account for about 60% of claims expense, with indemnity expense accounting for the remainder. (adding administrative costs to claim costs gets you close to total WC premium and equivalents)
  5. Claim frequency has been dropping by about 2-3% per year for more than two decades.  That will almost certainly continue.
  6. Drug costs will account for around 15-17% of that spend, with physical medicine in the same ballpark.
  7. Most states have some sort of medical fee schedule (FS) in place, however there’s MUCH variation among and between the states.  Some only have provider FS, others have provider, drug, facility, DME and other services covered by fee schedules.
  8. Almost all provider fee schedules are based on Medicare.  However, few states directly link their FS to Medicare, so when Medicare’s FS changes, it may – or more likely may not – change that state’s reimbursement.

There’s a lot more here; if you are looking for more information, try the search box on this page – it’s up there to the right.  With about 3000 posts on MCM, chances are pretty good there’s some discussion of pretty much every comp-related topic.

btw, good sources are: – see the workers compensation tab – everything workers’ comp – California-specific – their Annual State of the Line is really good.

We don’t need no stinkin’ science!

I think we’ve figured out why, in the face of compelling evidence to the contrary, plaintiff attorneys in California continue to argue the work comp system mis-serves a large number of workers’ comp patients.  

Before we delve into this, allow me to stipulate that many applicant attorneys are likely well-intentioned, seeking to do good, and may well believe that a lot of work comp patients are ill-served by the work comp system.  Since they only talk with work comp patients that have complaints, that would not be surprising.  And, a relatively few work comp patients are, indeed, ill-served by the system for a variety of reasons – a bad employer and/or boss, crappy doctor, under-trained and/or over-worked claims adjuster – even a lousy attorney.

That said, it appears their representative organization, the California Applicant Attorneys’ Association, is not conversant with research methodology, processes, or statistics – and that’s why they don’t understand that the work comp system is working pretty well.

I draw this conclusion after reading an article entitled “Calling all Applicants: The Injured Worker Survey” from a July 2016 CAAA publication. In the piece, author Richard Meechan argues:

“Nothing makes sense – up is down and they (the Committee on Health and Safety and Workers’ Compensation, or CHSWC) have graphs and charts to prove it.”  

The “Injured Worker Survey” Mr Meechan refers to will apparently enable the CAAA to:

“see how the system is working for the most seriously injured workers.  That would be workers that were out of work for more than a year, our clients, to be more exact.”

This is because the CAAA apparently doesn’t (want to) believe the myriad research studies published by research organizations about injured worker outcomes and related matters.

If you, dear reader, are puzzled by this, allow me to explain. Careful and valid data analysis by experts examining credible data sets can be, and often is, translated into “graphs and charts” to help the non-statistically-endowed understand what is really going on.

In the article, Meechan states he is skeptical of research finding “95 percent of medical requests were approved and that injured workers were satisfied with their medical treatment.”  That skepticism resulted in the CAAA’s enlistment of three attorneys to help the CAAA committee on Health and Safety figure out how to “respond” to these “tales” (referring to the research presented at CHSWC meetings).

While I could find no evidence that any of the enlistees have an educational or experiential background in statistics, statistical analysis, business analysis, the physical sciences, or operations management (heavy in analytics), one of the three did study economics back in the nineteen-sixties. This isn’t to denigrate the trio, rather to contrast their relatively modest scientific research and statistical analysis credentials with those of folks who actually do research.  Like CWCI. And WCRI. And RAND.

Using SurveyMonkey, the CAAA is conducting their “survey” and will likely publish “results” in an attempt to show the information presented at CHSWC meetings, based on reams of research published after hundreds of hours invested in very sophisticated analytical processes employing highly-refined datasets and tested methodologies vetted by actual, real, live, statisticians with decades of experience and darned impressive credentials in data analysis and everything that goes into it is, well, wrong.  

And CAAA will do this based on responses from an on-line, open access survey with no data validation or proof that you are actually an “Injured Worker” needed.

Hey, you can try it yourself, here.

So here’s where the problem lies.

In the article, Mr Meechan notes that fewer than one percent (33) of the 3700+ survey responses asserted they had been out of work for a year or more. Apparently that is concerning. Mr Meechan asks others to help get the word out, as “one hundred responses is the gold standard for surveys and we are short.”

That single statement demonstrates a complete lack of of even a basic understanding of statistics.  Mr Meechan is apparently confusing statistical validity with an arbitrary “gold standard”.  Further, there’s an assumption that all that is needed is 100 SurveyMonkey responses from respondents who claim to have been injured and out of work for more than a year, and he and his associates will have what they need to refute all that science stuff CHSWC throws up there on the screen.

As anyone who has one day of stats knows, without valid underlying data to start with, the whole exercise is pointless.

More directly, garbage in, garbage out.

And in this case, the underlying data is, indeed, meaningless. A gazillion monkeys could be typing away and deliver lots of “results”. Some whizkid could figure out how to program a bot to fill them out with no human intervention at all.  More prosaically, a bunch of law clerks could earn some extra hours banging away on laptops or iPads completing SurveyMonkey surveys.

In this instance it is indeed possible that some or most of the respondents at some point had an encounter with the work comp system. Or not.

I belabor this point not to embarrass the attorneys, for that is NOT my intent. Rather it is to point out an obvious conclusion:

As reform opponents think that a SurveyMonkey random survey will be more valid than real research studies conducted by experts, we now know why “nothing makes sense” to them.

They don’t have a clue.

They are totally, fundamentally, and blindingly ignorant of even the most rudimentary statistical terms and concepts.


Note – I don’t have a link to the original article.  sorry – ask CAAA for your copy.

Work comp pharmacy – early results of 2016 Survey

I’m up to my eyeballs in the 13th (!!) Annual Survey of Prescription Drug Management in Workers’ Compensation; the response from payers willing to devote time to the project has been gratifying indeed.

Previous Survey reports are available here; note these are the Public versions; respondents get a much more detailed and comprehensive version.

A bit of background first.  I conduct these surveys telephonically, speaking to the individual at the insurer/self-insured employer/state fund/TPA/trust who is directly responsible for the pharmacy program. In addition to asking their opinions and views, we get data on a variety of key metrics including:

  • drug spend for 2015 and 2014
  • opioid spend for 2015
  • compound drug volume
  • generic fill and efficiency rates
  • mail order usage

A few early findings.

  1. Pharmacy continues to be seen as more important than other medical ost areas, primarily due to the “downstream” effects of opioids on claim duration, return to work, and related pharmacy spend.
  2. Most respondents are seeing a decline in drug spend.  This is a bit of a surprise, as national research suggests drug costs are going up.  A possible explanation is that (most of) these payers are pretty sophisticated, have been working diligently on pharmacy issues for years, and most (but certainly not all) have employed a variety of programs to reduce unnecessary use of potentially dangerous drugs.
  3. The percentage of spend that goes to opioids varies greatly, from around 21% to over 50%.  Some of this is due to regional or state differences, but much is not. Much more to dig into here.
  4. Mail order continues to be woefully under-used, with most respondents reporting penetration rates in the low single digits.  Argh.
  5. Compound drugs are seen as highly problematic and payers have a wide variety of programs/efforts/mechanisms in place to address compounds.

Much more to come; when the Survey Report is done I’ll post a link.

Enjoy the weekend!


Monday catch-up

Summer’s arrived in upstate New York – and boy do we appreciate it. While I was watching all the trees turn green, I missed reporting on a bunch of stuff last week.

So better late than never, here it is.

P&C industry outlook

Let’s start with the macro stuff.  A couple weeks back, Fitch published a piece wherein they opined the P&C industry is in for a tough time this year. After several years of stellar performance, Fitch expects prices to decrease as competitors battle for market share. Here’s how they put it:

Renewal rates are flat or declining for most commercial market segments following a hardened market from 2011-2014. The price competition comes from underwriting success and market capacity expansion from earnings accumulation. As price competition intensifies however, this will likely be a drag on premium growth, according to Fitch. Commercial lines written premium volume grew by only 1.8 percent in 2015.

For work comp, Fitch identified prescription drug costs and continued low interest rates as problematic; the first increases costs while the second reduces investment income.


The number of opioid scripts in the US actually declined last year. And that was the third year in a row. That’s the best news we’ve heard in quite a while. Since 2012 – the peak year for opioid script volume – the number of scripts has dropped by 12% – 18% (depending on the data source).  

In case you’re interested, prescription opioids accounted for about $10 billion in total spend in 2015. Workers comp accounted for around 14% of that, a rather striking figure when you consider total work comp medical spend accounts for 1.4% of overall US medical spend.

Yup, work comp uses about ten times more opioids than other payers.

And how the bad news; the drop in scripts hasn’t been accompanied by a decrease in the death count, which stands at 28,000 for 2014.

California Workers’ Comp

Well, at least it hasn’t gotten any worse.  That’s my take on the just-released CWCI study on the UR/IMR process for Q1 2016.

  • IMR volume is about the same as last year at 160,000 determination letters per year;
  • the overall IMR uphold rate is the same as last year at 89%;
  • Rx drug requests still account for nearly half of all disputed medical service requests submitted for IMR (and 40% of the Rx drug IMRs are requests for opioids or compound meds);
  • and a small number of docs still account for the majority of the disputed  service request that undergo IMR (the top 10% of medical providers accounted for more than ¾ of the IMR service requests).  

My take – the IMR process is preventing people who don’t need opioids from getting scripts for opioids.  That’s a very, very good thing.  Yet the same docs keep prescribing this crap to patients knowing full well these requests will be rejected.

I’m very much looking forward to hearing all those “injured worker advocates” heaping praise upon the system for protecting their clients’ health and wellbeing, and that of their kids as well.

I’ll personally nominate each of them for a Comp Laude Award.

What’s with the gloom and doom?

“The economy seems to pulse — surges a little bit, pauses, surges a little bit, pauses,” said Kevin Logan, chief U.S. economist at HSBC. “And in the end it’s nothing.”

That’s the money quote from a very readable piece in today’s Washington Post, one that seems at odds with the doom and gloom emanating from some politicians and pundits.

Before my inbox overflows with tales of woe, I fully understand there are places where the recovery is halting at best.  And there are still too many who have decided to exit the workforce – although the number isn’t nearly as high as many think.

And, the percentage of the population that is without health insurance continues to decline – down to 11.0% in Q1, 2016. Deductibles are increasing for many – as they have for the last two decades – but it’s still far better to be insured than not.

Wage growth has increased, the unemployment rate is half what it was at the peak of the recession (and likely headed lower), manufacturing is growing, consumer spending is high, and most stock market indices remain relatively high.  Consumer confidence is in a six-month slump, but one wonders if that’s partially driven by the incessant drumbeat of negativity from Trump et al.

All that said, it’s abundantly clear the employment world is going to change dramatically over the next decade, and it is possible if not likely some of the unease is due to fears that automation and offshoring will continue to eliminate stable, good-paying jobs.

I bring this to your attention, dear reader, to add a bit of perspective and data to the discussion.

Enjoy the first weekend in June



Opioids and Workers’ Comp – a quick update

The rest of the world is beginning to catch up to the progress workers’ comp has made fighting the opioid scourge.  Kudos to PBMs, payers, regulators, researchers and some physicians for recognizing the incredibly negative effects of opioids years ago, and taking action to mitigate some of these effects.

That is NOT to say we’re anywhere close to getting this solved – far from it.

But we have seen some evidence of decreases in the number of new claims getting opioids in some areas and an overall decline in opioid scripts and morphine equivalents (MEDs).  We’ll have more information in a couple of months when CompPharma (a consortium of work comp pharmacy benefit managers) releases its 13th Annual Survey of Prescription Drug Management in Workers’ Compensation. (note I’m president of the organization and am conducting the research, past reports are available free for download here.)

A few factoids to give some perspective:

From CWCI’s most recent research:

  • Opioids declined to 27.2% of all scripts dispensed to California work comp patients in 2014, down from a peak of 31.8% in 2008.
  • Average number of morphine equivalents per script declined from 550 in accident year (AY) 2007 to 422 in 2012.
  • The % of work comp patients receiving opioids within 24 months of injury increased from 22.4% in 2005 to 27.9% in AY 2012
  • Express Scripts reported overall spend for opioids declined 4.9% in 2015, the fifth consecutive decrease.
  • Helios reported:
    • the percentage of work comp patients getting opioids declined by 1.6% from 2013 to 2014.
    • opioid utilization dropped 2.9% over the same period

What we have NOT seen is any significant progress dealing with the knottiest and most important problem – long term opioid users.

I can’t count the number of erstwhile start-ups, business ventures, and eager entrepreneurs I’ve spoken with who contend they’ve figured it out.

By definition, anyone who claims to have a universal solution most certainly doesn’t understand the problem.  Unlike reducing initial and secondary scripts, addressing patients who’ve been taking opioids for months is very much an

  • individual,
  • patient-by-patient approach
  • requiring flexibility,
  • a deep understanding of the disease state and chronic pain and addiction,
  • a willingness to experiment and fail, and
  • a very long term commitment to a business model that almost certainly will not be hugely profitable.

That’s not to say there isn’t opportunity – there most certainly is.

What does this mean for you?

We’re at the end of the beginning of the work to address opioids.  This will take focus, years, diligence, and unrelenting focus.

Workers’ comp – for hospitals, it’s where the money is

Two recent articles in Health Affairs highlight a growing issue for employers and taxpayers; some hospitals are increasingly looking to work comp as a profit maker.

Depending on the state, facility costs can account for anywhere from around 32 – 40% of total work comp medical expenses (different states classify locations-of-service differently).

Ge Bai and Gerard Anderson examined the fifty US hospitals with the highest charge-to-cost ratios and found their markups over Medicare-allowable costs were three times higher than the average hospital.

This is critical in work comp because state work comp regulations often base facility reimbursement on charges – despite NO evidence or requirement that those charges have any basis in reality.

Fully 20 of the fifty hospitals are in one state – Florida – that uses a percent-of-charges reimbursement methodology for hospital outpatient services (manual is here).

Bai and Anderson’s latest work provides a deeper dive into hospital profitability.  A few key quotes:

  • Hospitals with for-profit status, higher markups, system affiliation, or regional power, as well as those located in states with price regulation, tended to be more profitable than other hospitals.
  • Hospitals that treated a higher proportion of Medicare patients, had higher expenditures per adjusted discharge, were located in counties with a high proportion of uninsured patients, or were located in states with a dominant insurer or greater health maintenance organization (HMO) penetration had lower profitability than hospitals that did not have these characteristics.

The methodology used by Bai and Anderson is somewhat different from that used by other researchers in that it excluded income from non-patient care services. I infer that they did this to focus specifically on the actual care delivery cost and not factor in other revenues from services such as parking, gift shops, investment income, etc.

So, what are the implications?

  • Work comp is a soft target for facilities in many states
  • The percentage-of-charges methodology is a license to…profit
  • More profitable facilities have likely already figured out how to make the most revenue possible from every source – including workers comp
  • Less profitable hospitals are going to learn from their more profitable competitors

Correction – Are work comp medical costs really dropping?

Last week’s announcement at NCCI AIS that medical costs for lost time claims dropped for the first time ever was a shocker. Talks with experts and industry pros after Kathy Antonello’s talk led to much head scratching and wondering.

The likeliest contributor is…California.

My mistake – California is NOT an NCCI state.  I was under the mistaken impression that, while CA is not an NCCI state, CA does share data with NCCI and therefore was included in the data used for this research.

Today’s WorkCompCentral opened with the news that California’s work comp rates are dropping 5%, driven primarily by reduced medical costs.  In turn, that decrease was due to favorable medical development on older claims – which means those older claims are turning out to be less expensive than originally forecast.

As California accounts for more than 20% of ALL workers’ comp premium, it should not be a surprise that the reforms that have stripped out a lot of the egregious profiteering and waste (e.g. double billing for surgical implants, reduced reimbursement for certain procedures, reductions in costs for physician-dispensed drugs) have actually lowered cost for older claims.

What’s not apparent is the undoubted improvement in patients’ medical outcomes. By reducing incentives for too many surgeries and drugs, patients aren’t getting as much unnecessary care that prolongs disability and has dangerous side effects.

Notably, if Los Angeles was removed from the data, results would be a LOT better. That county has most of the worst physicians treating work comp patients.

What does this mean for you?

Don’t write work comp in LA County.