Opioids in workers comp – attacking the messenger

This morning’s WorkCompCentral had a piece by Greg Jones noting complaints by medical specialty groups about the study on physician prescribing of opioids recently released by CWCI.
I received a copy of the letter as well, and frankly was surprised – for several reasons.
What was most troubling was the statement that “Alone, the report’s findings do not indicate that there is anything inappropriate.”
I would argue that the findings absolutely indicate there is something very, very wrong going on here. In fact, a relatively few physicians are “handling the bulk of the prescriptions”; that was amply demonstrated in the analysis and results provided in the report, the details of which were discussed in detail therein.
In addition, the statement that “we are not surprised by these early findings” was quite troubling. I certainly was surprised.
Why was this not surprising to the medical society? Was it not surprising that a relatively few physicians were treating patients with low back sprains and strains for extended periods with relatively high doses of narcotics, when all evidence-based clinical guidelines do not support such treatment?
The letter suggested CWCI conduct a deeper analysis to determine whether the treatment was appropriate based on treatment guidelines.
Every treatment guideline I’ve heard of, including ODG, ACOEM, Washington State – none of them supports extended use of opiods for treatment of musculoskeletal issues. None.
I would also note that the letter called into the question the methodology itself. The author of the letter’s statement “it is clearly misleading to use
the initial diagnosis” is inaccurate
. Even a cursory review of the study
methodology reveals the researchers used a rather sophisticated clinical grouper to identify the PRIMARY diagnosis, which may well not be the initial diagnosis.
Finally, the letter asserted that others had mis-cited or misinterpreted the CWCI work, and requested CWCI somehow correct, clarify, or take steps to correct those misinterpretations. Studies are cited and discussed and reviewed and analyzed in the media and by individuals all day every day; I just don’t think CWCI has the time, resources, or obligation to monitor what everyone says about their research.
I guess is the net is I’m really taken aback by the letter.
There’s clearly abuse going on here, along with bad medicine and out of control prescribing of very addictive, dangerous medications that are ripe for diversion and abuse. I’m just very surprised that instead of taking this seriously, a medical society would attack the messenger. There’s something very rotten going on, and denying it is the wrong approach.


CWCI’s Opioids in Work Comp Study – more details

Yesterday I posted on the most recent CWCI study on Opioids in the California Work Comp system, noting that fewer than a hundred docs were responsible for prescribing 42% of the narcotic spend.
If that isn’t troubling enough, in an email conversation with lead author Alex Swedlow, I learned that the top ten physicians prescribe 17% more drugs than their peers in the top one percent of prescribing docs (93 docs are in the top one percent).
And, these top ten docs prescribe 34% more morphine equivalents than the others in the top one percent.
Recall that the top one percent of docs who prescribe narcotics are already prescribing far more than the average prescriber, so the top ten are outliers to the outliers.
Is it possible these outliers to the outliers are doing the right thing? Are they just treating the sickest, most pain-ridden claimants? Doing their best to alleviate high levels of chronic pain?
Highly doubtful. It is much, much more likely that these docs, who represent a mere one-tenth of one percent of all docs who prescribed Schedule II narcotics are a major problem, massively contributing to the addiction problem, adding huge costs to the system, and doing little to help their patients. As I said last fall in a post about CWCI’s research on narcotic usage in California’s work comp system;
“CWCI analyzed the impact of these drugs on claim costs, and found a strong correlation between increasing levels of Schedule II payments and adverse effects on injured worker recovery. Swedlow reported claimants that received the highest narcotic dosage levels had 200% higher medical costs than claimants receiving lower dosages.”
An earlier study reported by Business Insurance’ Roberto Ceniceros had similar findings:
“temporary disability claimants treated with opioids average 105 paid days off in contrast to the average of 30 days, than when narcotics are not prescribed.
The preliminary findings also show that when opioids are present in a claim, there is a 322% greater likelihood for litigation, a 264% greater likelihood for lost time from work, and 38% more likely for a claim to remain open longer and incur additional costs.” [emphasis added]
Kudos to CWCI for continuing to shine a very bright light on a very ugly problem, one that should be the highest priority for PBMs, regulators, payers, and prosecutors working in California.


Social media and workers comp

A colleague posed an interesting question last week –“does the proliferation of ‘new’ blogs, newsletters, and other internet-enabled communications vehicles pose a threat to the ‘brand’ and ‘market share’ of Managed Care Matters?”
No. In fact, the pie is growing, and it’s a better pie today than it was yesterday.

The new entrants are actually helping to expand the online media ‘market’, increasing the number of users and in many cases upgrading the conversation in the process. People who – a couple years ago – would not ever have considered reading a blog or accessing an online newsletter are now on MCM and other media outlets every day, checking to see what’s going on, voicing their opinions, taking the pulse of the market and staying abreast of their competitors.
Perhaps the most notable example of the explosive growth of social media is the Work Comp Analysis Group. Managed by Safety National’s Mark Walls, the WCAG now has over 8000 members, is constantly updated, and used by all and sundry for everything from finding out what an adjuster’s appropriate case load should be to posting jobs to coordinating social events at industry conferences.
CompTime, WorkCompWire, Workers’ Comp Insider, the dozens of state-specific WC law blogs (some of which are in the blog roll over there to your right), and the myriad other publications add a lot to the discussion.
In the olden days – three? four? years ago, most got their ‘news’ from printed media, which, while professionally assembled and of usually high quality, was limited to what the reporting staff could assemble – and the editorial staff deemed worthy of publication. Today, there is a lot more ‘news’ available a lot faster than in the old days of snail mail.
With that said, the instant news cycle – and opining on same – has it’s risks and downside as well. There’s a lot to be said for professional reporters, with high standards, specific training, and great contacts, especially when they are teamed with editors who, while working to deadline, have a LOT more time – and I’d argue ability – to consider, vet, rewrite, and factcheck than most of us in the online community enjoy.
There’s absolutely a need for that professionalism, perhaps more so now than in the past as they provide a kind of oversight, an ‘adult supervision’ role, one that adds seasoning, perspective, objectivity, and thought that may not always be present in those of us in the blog-o-sphere.


Guidelines – beyond the soundbite and marketing hype

Is medicine science, art, some combination of the two, or something else?
That’s not an idle question.
If you’re trying to get more scientific about how you practice medicine or what services/procedures/drugs/treatments you pay for, you are likely relying on clinical guidelines to help provide a little more perspective, hopefully one based on something other than best guess or generally accepted knowledge or tribal wisdom.
A recent study may well give you pause – the key finding is rather alarming – many guidelines are NOT based on solid research, but on work that is kindly described as rather more superficial.
Published in the Archives of Internal Medicine, the research found “More than half of the current recommendations of the IDSA (Infectious Diseases Society of America) are based on level III evidence [expert opinion] only.” [emphasis added] Note that the research focused solely on IDSA guidelines, which cover a relatively small fraction of all the guidelines in use today. Largely as a result of that conclusion, the researchers concluded “Until more data from well-designed controlled clinical trials become available, physicians should remain cautious when using current guidelines as the sole source guiding patient care decisions.”
This isn’t exactly new news. This from research on guidelines published in The Journal of the American Medical Association over a decade ago “Less than 10% of the guidelines used and described formal methods of combining scientific evidence or expert opinion. Many used informal techniques such as narrative summaries prepared by clinical experts, a type of review shown to be of low mean scientific quality and reproducibility.18​ Indeed, it was difficult to determine if some of the guidelines made any attempt to review evidence, as less than 20% specified how evidence was identified, and more than 25% did not even cite any references.”
The risk here is our sound bite-long attention span will lead some to use these studies to discount guidelines in their entirety, ignoring entirely the “Until more data from well-designed controlled clinical trials become available” recommendation.
Truth is there are lots of guidelines based on standards of evidence significantly higher than ‘expert opinion’. The pre-eminent organization in this area, and the one with the most rigorous standards, is the Cochrane Collaboration. And while not all will meet the randomized double-blind control methodology that most believe is the gold standard, many will indeed provide an ample and durable foundation on which to base medical decisions, treatment recommendations, and reimbursement.
With that said, there are organizations that trumpet their ‘guidelines’ as providing the basis for coverage and payment decisions, when a more-than-superficial examination indicates the ‘guidelines’ are built on mighty shaky ground.
The Agency for Healthcare Research and Quality maintains a database of evidence-based clinical guidelines; the listing is not comprehensive as many organizations choose to not submit their guidelines for business reasons. However, while not meeting the ‘gold’ standard described above, the standard employed by AHRQ is far superior to that of “expert opinion only”; AHRQ requirements include “Corroborating documentation can be produced and verified that a systematic literature search and review of existing scientific evidence published in peer reviewed journals was performed during the guideline development.” (while their science is solid, they really need to get some English majors involved in the whole writing thing…)
What does this mean for you?
If an organization or vendor is touting their medical criteria or guidelines, prepare – and ask – pointed questions about the methodology, development process, quality of the evidence, and staffing of the effort. The good ones will be only too happy to share their work, and the others will either not know why you aren’t impressed and/or be exposed.

A thoughtful piece on ranking the evidence used in medical guideline development can be found here. [opens pdf]
Lots more info on guidelines is available here.


What’s driving comp medical costs

Two things – facility costs and pharmacy.
We’ll get to pharmacy next week (I’m finishing up the Seventh Annual Survey of Prescription Drug Management in Workers Comp), but for now here’s a couple quick hits on the growing problem in facility expenses.
Today’s WorkCompCentral [sub req] highlights the results of a recent WCRI study examining cost drivers in North Carolina. a study that indicates the “average hospital payment per claim was about $9500 in North Carolina, the highest among all the states examined. The average charge for inpatient procedures was 49% higher than the median.” [emphasis added]
Note this was back in 2007; while WCRI does good work, the nature of their process is such that the results are somewhat dated.
The fee schedule was changed back in mi-2009, lowering the cap on inpatient hospital reimbursement from 77.07% to 75%, a whole 2.07 percentage points and outpatient from 95% to 79%.
If anyone thinks this is going to make any difference at all, they’re not thinking.
Gaming the ‘percentage off charges’ ‘fee schedule’ is ridiculously easy; this nominal decrease will have zero effect on actual payments to hospitals, and thus will do nothing to lower payers’ medical costs in North Carolina, costs which, according to WCRI, wer up 9% in 2007.
The fee schedule reduction was a complete waste of time. That may not endear me to the folks who, I am sure, worked diligently to address the issue, but that’s a fact. What NC should have done was change the methodology from a percentage off charges to something much more certain and fair – a cost-plus based system would have been a good, albeit imperfect, alternative.
We need a reality check.
Workers comp will pay about $31 billion in medical expense this year.
Health care costs will total about $2.7 trillion this year
I raise this often-overlooked fact to point out that employers and insurers will not be able to rely on networks to control costs, as work comp networks have little buying power, and thus little ability to influence price per service.
Therefore, regulators have to step into the breach, and provide real, actionable, metric-based fee schedules based on something much more solid than the facility’s charges.
What does this mean for you?
Higher facility costs will drive medical expense which will drive up combined ratios – and premiums.


The cost of forgoing care

A new report documents the impact of the recession on the health care system, and for many Americans, the news is proof of what they know all too well – higher deductibles and copays are reducing their ability to access care.
The report [fee req] does not document whether the forgone care would have been necessary/appropriate/supported by evidence-based guidelines, and it is likely some of the forgone care was unnecessary. That said, it’s only ‘some’, and it is highly likely Americans with slimmer benefits, or no benefits at all, are skipping visits, medications, therapies, and operations that will over the long term will have very serious implications.
According to a piece in the NYTimes, the researchers reported “We find strong evidence that the economic crisis — manifested in job and wealth losses — has led to reductions in the use of routine medical care.” 26.5 percent of respondents reported reducing their use of routine medical care since the start of the global economic crisis in 2007.
The report adds more weight to the increasing evidence that the recession, coupled with the unique American health insurance system, has had a significant impact on Americans’ ability to access care.
The importance of primary care in prevention is well documented; [opens pdf] timely use of primary care tends to reduce the need for interventional procedures such as CABG, thereby reducing cost and improving long term quality of life. Delaying or forgoing primary care will likely have the opposite effect, increasing future health care costs.
Impact on workers comp
Over the short term, this ‘side effect’ of the recession will likely increase work comp costs
and extend disability duration, as more injured workers will have poor health status due to forgone care. If diabetics aren’t controlling their blood sugar, asthma sufferers have more acute episodes, and hypertensives are taking their meds every other day, it is going to be more difficult, costly, and time-consuming to help these claimants recover functionality.
Over the long term, health reform will reduce work comp costs as many more individuals will have coverage. But until 2015 (or so), we won’t see this positive influence.


Work comp pharmacy – one company’s experience

The work comp pharmacy benefit management industry is growing increasingly sophisticated, and the release of PMSI’s Annual Drug Trends Report this morning adds to the trend.
Many of the larger work comp PBMs produce similar reports, providing deep insights into cost drivers, the effectiveness of solutions, and trends that anyone with any responsibility for med loss would be well advised to read.
Here are the quick takes from my admittedly not in-depth read of PMSI’s effort.
1. Price was up significantly last year, climbing 4.7%. This is heavily influenced by the price increases pushed thru by big pharma on brand drugs last year in anticipation of health reform.
2. Utilization was up only slightly, driven by more days supply per script.
3. Mail order utilization was up 3.6%, which undoubtedly contributed to the higher utilization as mail order scripts tend to include more days’ supply than those dispensed by retail stores.
4. The average number of scripts per injured worker was 11.1 in 2009. Yep, eleven point one. That’s a lot of drugs.
5. The report includes an interesting chart graphically illustrating the impact of the age of the claim on scripts per claimant; claims a year old typically had around three scripts at an average price per script of thirty bucks or so; in contrast ten year old claims had 23 scripts averaging over $180 each.

6. Generic efficiency (the percentage of scripts that could have been filled with a generic version) remained at 92%. This is driven by several factors, including state regulations (some have mandatory generic language and others are considering adopting it), PBM and payer intervention and outreach, and the ‘macro’ pharmacy market’s introduction of new brands. Generic efficiency and ‘conversion’ is key to cost management; according to PMSI (and consistent with other reports) each one point increase in generic utilization reduces cost by 1.4%.
7. Pharmacy in comp remains primarily, and I’d argue overwhelmingly, driven by pain. PMSI’s data suggests over three-quarters of drug spend was for pain management – one of the key differences between work comp pharmacy and group/Medicare pharmacy.
8. Our old nemesis OxyContin again accounted for a lot of comp dollars, with 9.9% of spend allocated to the brand and generic versions. On the good news side, Actiq and Fentora usage declined significantly (type ‘actiq’ into the ‘search this site’ text box above and to the right for plenty of reasons why this is a very good thing).
9. Finally, the average days supply of narcotic analgesicvs was up 6.4% while the number of claimants getting those drugs actually declined. This may be due to those claimants who could use alternative meds getting off narcotics (or not starting on them in the first place). As a result, the claimants still taking these drugs are more likely to need more meds.
There’s a lot more meat in the report, lots of detail on which drugs are driving how much utilization, changes in utilization by class of drug, and most importantly, the impact of clinical programs on utilization and drug mix.
What does this mean to you?
Two things.
While PMSI is one of the largest PBMs, remember that these data refer to their customers’ experience and therefore may not be exactly equivalent to your book of business. That said, don’t use that as an excuse if your stats aren’t up to snuff – instead look for ways to get better.
As you pack for that summer vacation, grab a copy of your PBM’s report (go to their site and find it there, or call your rep and have them send it over) and perhaps a couple others.
You know you want to, and you can always hide it inside a Cosmo or Men’s Health to prevent mocking stares from the knuckleheads on the next beach towel.


Cost-shifting – the practice of seeking higher reimbursement from some payers and patients to cover shortfalls due to low or no reimbursement from others – is rampant in the US health care system. Having worked with providers, health care systems, and payers, I can attest to the pervasive nature of the beast – it happens all the time, everywhere.
More evidence came across my virtual desk yesterday in the form of a study by the Insurance Research Council entitled “Hospital Cost Shifting and Auto Injury Insurance Claims” [available for purchase thru IRC]. The study compared auto injury hospital costs in Maryland to those in 38 other states that don’t have the all-payer hospital rates mandated in Maryland. Thus, whether a patient is covered by a health plan or auto insurer in MD doesn’t matter – all are reimbursed at the same level.
Here are a few of the highlights.
– the “percentage of a state’s population without health insurance was found to be the strongest predictor of average hospital costs for auto injury claimants”
– “another important predictor of average hospital costs for auto injury claimants is the percentage of a state’s population covered by Medicaid”
– IRC estimated of the impact of cost shifting to auto insurers totaled $1.2 billion in 2007.
It is clear that cost shifting is rampant, particularly to property and casualty payers. Work comp payers are particularly vulnerable as their network arrangements are under growing pressure from hospitals seeking higher reimbursement.
What does this mean for you?
Your hospital costs are headed up. What are you going to do about it?

predictive modeling
artificial intelligence


Ethics, clinical guidelines and profits

On Thursday I’ll be speaking at the Geisinger Clinic in Danville, PA on Comparative Effectiveness; the Payer’s ethical dilemma.
This is one of those ‘honored to be asked’, followed almost immediately by ‘I’ve a lot of work to do’ things. And a lot of work it indeed has been, but the deeper I’ve gotten into this, the more…gratifying it has become.
One example. In my research I came across Jim Sabin, MD. Dr Sabin, clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School; he also directs the ethics program at Harvard Pilgrim Health Care and writes an excellent blog, Health Care Organizational Ethics.
Here’s a few of the things I’ve learned from Dr Sabin.
1. Harvard Pilgrim may be the only health insurer in the country that has an inhouse ethics program that includes members, employers, brokers, community members, administrators and physicians. (If there are others out there I’d love to hear about them)
2, This isn’t a program set up merely for PR; rather it has studied significant issues, taken tough stands, and been public about its role and results.
3. The issue of ethics in medical research on effectiveness has another dimension, one that I hadn’t thought thru or explored in enough detail – health plans and health systems can be and in many cases are ‘sites’ for research; there are several ethical issues inherent in that role, issues that involve informed consent, public involvement and education, funding sources and use of those funds, the balance of cost and effectiveness, and the potential impact on the physician-patient relationship inherent in many research efforts.
4. Perhaps the most helpful discussion was around the not for profit status of HPHC. As a not for profit, Harvard Pilgrim doesn’t have to deal with the primacy of stockholder returns inherent in the for profit world; that’s not to say it doesn’t have to ensure financial stability and long-term viability. The difference is in what’s most important – profits or patients.
The primacy of stockholder returns influences ethical and business decisions, or rather should. For profit companies must consider shareholder returns first and foremost; to do otherwise would be an ethical problem. There are for-profit health plans and insurers that work diligently to deliver services ethically and responsibly, bending over backwards to do the right thing. Aetna is one that comes first to mind. And there are others that don’t bend at all.
Which is ‘right’? A compelling argument could be made for either position.


The ethics of clinical guidelines – the payers’ dilemma

In preparing for a talk on the ethics of comparative effectiveness I’m to give at the Geisinger Clinic in Danville PA in April, I’ve been interviewing medical directors from several health plans and workers comp insurers, along with physicians – both practicing and managing, in an effort to get their views on guidelines.
I’ve been somewhat surprised at what I’ve learned.
The real problem may not be payers’ efforts to deny medical care, but their willingness to ‘go along to get along’; to avoid making tough coverage decisions, and when in the slightest doubt, to approve the procedure/drug/treatment/therapy rather than run the risk of upsetting someone.
One would think payers would be keenly interested in supporting and using evidence-based clinical guidelines; costs would be reduced and outcomes improved, benefiting both patients and profits. And one might very well be wrong.
Payers operate in a market where public opinion matters a lot; if the payer has a negative image, it will be harder to convince employers and their employees to sign up for their health plan. It may also be harder to convince physicians and other providers to join and stay in their provider networks. And families may well be reluctant to carry an insurance card from a payer known for their tight controls on medical care.
We all know that restricting unnecessary care is not bad or immoral, but to the general public, it can certainly look like a profit-driven effort to cut costs, regardless of the effect on patients. To be sure, payers’ public efforts to terminate patients on the flimsiest of excuses and refuse coverage to anyone who might actually get sick haven’t helped their image. But the sense I get from the medical directors and practitioners I’ve spoken with is they are quite reluctant to deny treatment.
Part of this may be influenced by reality – when claims costs go up, so do premiums, and so does the health plan’s top line. There are few industries where built-in inflation results in near-double-growth same-store growth every year; health insurance is certainly one. This ‘reality’ is closely related to health plans’ motivations. Wall Street demands revenue growth, and for those health plans that are for-profit, their primary obligation is to their stockholders.
Allowing questionable treatments drives up revenues which benefits stockholders.
Of course, it isn’t anywhere near that simple or straightforward in the real world. Health plans’ profits are higher if medical costs are lower – at least over the short term. And most of the health plan execs I know are honestly trying to ensure their members get the care they need, care that they can’t afford if they approve any and all treatments no matter how ineffective.
But there is no question payers face an ethical dilemma, one complicated by patient demand, provider relations, market influences, and the obligation to their owners. (I’m not addressing the not for profits in this post)
A lot of Federal (taxpayer) dollars are going to be spent on comparative effectiveness research over the next few years, and if there’s a better use of my money I’m not aware of it. It is widely acknowledged that much of what we spend is wasted on unnecessary tests, advertising-driven consumer demand, unproven treatments and procedures that benefit device companies, specialists, and facility owners far more than patients.
It’s also equally clear that reining in those costs is going to be incredibly difficult, because much of it occurs in the somewhat grey area between procedures that are clearly useless or harmful, and those that are undeniably appropriate. And that grey area is where hundreds of billions are spent every year.
What does this mean for you?
Perhaps an ethical dilemma.