The contentious and misunderstood world of drug testing

Any time you have to mention urine in a blog post you know it’s going to be a tough one.

There’s a kerfuffle in the world of urine drug testing, one of the more litigious and contentious industries I’ve ever encountered.  The parties involved, Ameritox and Millennium Labs, have been involved in litigation for some time now.  [full disclosure, Millennium has been a consulting client for a couple of years; I work closely with them, and have found them to be great people who do the right thing consistently.]

A while back, Ameritox lost a suit brought by Millennium over alleged deceptive advertising; more recently a jury ruled Millennium had improperly given cups to docs in four states, a practice the jury deemed an unfair trade practice. Ameritox trumpeted their “win”, however the jury’s finding was inconsistent with the opinion of several experts in the area, all other charges were dropped, and the case is on appeal.  And there was a serious legal question raised when one of the key witnesses allegedly provided information that perhaps they had no right to.

Be that as it may, the case was noted by friend and colleague David DePaolo, who opined: 

While medical guidelines recommend drug testing for compliance purposes and to help ensure that drugs aren’t being diverted to the black market, we know those are specific case recommendations particular to a certain set of medical facts, not to be applied universally.

But the way medical suppliers stimulate sales with physician gifting and revenue enhancement programs tests the ethical and moral qualities of the individuals on the front lines, and physicians should not be placed in those positions, and we should not be placed into positions of having to pay for it.

Sometimes drug testing is warranted. Most of the time it is not.

A couple comments.

First, research from various organizations including WCRI clearly indicates there’s far too much testing going on of a small population, and far too little of most.  About a quarter of folks who should be tested are, while some unscrupulous docs test every patient every time, making bank.  I respectfully disagree with David’s statement that “most of the time” drug testing isn’t warranted.

Second,

What is correct is to say many more patients taking opioids should be tested, and that testing should comply with accepted evidence-based clinical guidelines; Washington State, Colorado, ACOEM, and others are all excellent sources.

Opioid abuse, misuse, diversion, and related problems have long surpassed crisis status – we’re now in a national disaster with more people dying from this than motor vehicle accidents.  Drug testing is a critical part of the answer.  Yes, there are vehement disagreements among stakeholders, and yes, they can get very contentious, and yes, I have a dog in this fight.  That said, I – and many others – have been working long and hard to bring attention to the opioid disaster, and we need to keep the focus on addressing the problem and not get distracted by tangential issues.

On that all parties should agree.

What doe this mean for you?

There’s a real danger that we over-react, over-simplify this issue, and in so doing make blanket statements that do more harm than good.

 

 

 

Latest changes in the work comp PBM world

Helios is the new name for PMSI/Progressive.  The idea is to have a single name for the two different firms, both of which had positive brand images in the work comp world.  In talking to the marketing folk, their take was that while both brands had strong equity neither legacy name would work for the combined entity.

It seems a shame to end PMSI’s decades-long run, especially after Eileen Auen, Jay Krueger, and their excellent colleagues rescued the PBM from what seemed like a sure path to oblivion.  Instead of watching over the demise, they turned it into one of the top players in the business.  That said, Progressive had a well-earned and well-deserved reputation as a VERY customer-focused PBM; beginning under founder Dave Bianconi (one of the best people in the business…ever). If anything that focus has grown under the current Auen-Young-Sisson triumvirate; customers are (with rare exceptions) universally pleased.

So, Helios it is.

That will be a d/b/a; due to legal, regulatory, compliance matters I would not expect to see the Helios name show up on provider contracts and other legal stuff as that may well trigger all kinds of re-filing and jumping-through-legal-hoops.  But what we’ll very likely see is a big re-branding push, with lots of PR, a new logo, and a splash in Florida next month and Vegas in the fall.

Meanwhile, Aetna’s much-discussed sale of its workers’ comp sub (I know, I owe a bunch of folks on my mis-call on this one) hasn’t been finalized – as far as I know.  In conversations with several potential financial buyers, Coventry WorkComp’s declining revenues and earnings, coupled with the problems inherent in re-contracting a provider network without mother Aetna’s market clout and concern over PBM First Script’s strong ties to network Express Scripts makes for a “sub-optimal-go-forward-scenario.

Yup, that’s a direct quote. I think it means the potential investor doesn’t think they can pay what Aetna wants and get a decent return on that investment.

Undoubtedly, someone else will come up with a different scenario; whether it’s enough is to-be-seen.

Side note - long time First Script exec Brain Carpenter has joined Healthcare Solutions as their top clinical pharmacist.  HCS has been dramatically increasing the number and expertise of their pharmacist corps and the addition of Brian is a big plus. Brian will report toy EVP Jim Andrews; kudos to Jim (who I am fortunate to consider a good friend) for successfully building HCS’ clinical programs.

What does this mean for you?

Stability at one PBM…

 

Compound medications – a killer scam

Compound drug use is exploding – so much so that Texas has changed their employee benefits program to limit reimbursement to $300.  They didn’t have much choice, as the Texas Employees’ Retirement System’s compound drug costs have gone up 4,600% over five years.

That was not a typo.

They’re now requiring prior auth and ONLY covering FDA approved drugs.

The only thing that may potentially slow down the growth is bad news – and that was delivered in spades last week with the news that a coroner’s report found the infant died after ingesting a topical pain cream.  After sustaining injuries at work, the baby’s mother, Priscilla Lujan, applied some of the cream to her knee and back, made a baby bottle, and some of the substance got on the nipple.  The story was broken by Karen Foshay of KPCC; Foshay reported the cream contained the

“antidepressant amitriptyline, the pain reliever tramadol and the cough suppressant dextromethorphan…

Workers’ compensation records show Jarminski’s office billed $1,700 for the initial 25-day supply of the cream. That is much more than the prices of various mass-produced medications, asserted McCann.

Jarminski [the mother's physician] was informed the cream was linked to Lujan’s son’s death but, according to McCann, that didn’t stop the doctor from sending more creams.

“Priscilla had expressed she didn’t want to see that cream anymore or use it anymore,” McCann said. “Despite that they continued to send her more creams by mail and bill workers’ comp for it.”

McCann said at least two to four more tubes of cream were sent to Lujan after her son’s death. It’s unclear how much Jarminski billed in workers’ compensation claims for those additional tubes.

As horrible as this is, this baby’s death may protect others from this deadly scam. The press is all over this, medical malpractice insurers are undoubtedly quite concerned, and law enforcement is getting more engaged.

While one would hope the mother’s doctor prescribed this medication solely for health reasons, the prescribing physician was one of those indicted in the California compound drug case.

Of course, the compounders have hired a PR firm to try to convince us with BS that which they can’t validate with science – and even started an astroturf group to “fight for patients rights”.  Like the right to have tubes of deadly cream lying around…

UPDATE From a colleague’s email -

One strategy that seems to work well in Texas is to approach every compound as Experimental and Investigational and require prior authorization for ALL. The Texas WC UR rules appear to allow for that approach since essentially none of the compounds has gone through specific FDA approval. Without high quality (or essentially any) studies to support their use compounds can only be viewed as E&I in Texas.

At least one large carrier I know of is approaching compounds this way in Texas and other jurisdictions.

For those interested in the current state of research into compounds and workers’ comp, CompPharma’s research paper can be downloaded here.

What does this mean for you?

DO NOT approve compounds without proof of medical necessity and safety.

Seven out of ten work comp adjusters say…

Senior Associate Jack Johnston joins us again, getting us up to speed on his research into work comp adjusters -

Over the past month or so I’ve been doing research on the claims adjuster profession to get a better understanding of what adjusters like, don’t like, and what their managers can do better – both in improving the adjuster’s lot and the companies they work for. From what I’ve gathered from various online sources, for the most part, adjusters aren’t the happiest, most fulfilled workers.

Gathering information from general websites such as www.glassdoor.com and adjuster-specific websites – www.claimspages.com, www.adjusterspace.org, and fromoneadjustertoanother.ning.com has produced a few positives and a lot of negatives.  Here’s what adjusters have to say about their job and the company they work for:

The Good:

Among those with good things to say, when it came to the pros a lot of them talked about the good benefits they received.  Getting paid during time off and having a 401k; can’t complain about that!  Another somewhat common pro was the flexibility of the work schedule.  Some adjusters stated that if they were doing well enough with work, they could get permission to work from home.  Other adjuster work-life positives included satisfaction with their compensation and the enjoyable camaraderie with co-workers.

The Bad & the Ugly:

While there were a lot of different complaints listed in the many sites I was researching, there were a handful that popped up repeatedly.

Let’s start with caseloads.  There seems to be a ridiculous number of cases handled by some adjusters, forcing them to work overtime (which they don’t get paid for).  Overall, most adjusters appear to be overworked; common complaints included: we are “always behind on work” and “There was an enormous amount of work that is expected of everyone, and it can be very defeating to have most of your days end without a feeling of accomplishment. (sic)” 

Even if an adjuster is doing a good job in the office (or at home), s/he probably shouldn’t expect much of a reward.  Promotions are scarce and raises tend to be paltry, with most getting a 1-2% increase (and that’s only if you are lucky enough to be given a raise).  The lack of ability to move up in the organization has upset many of the adjusters as they feel they aren’t rewarded for the work they put in with the heavy caseloads they deal with every day.

A fair amount of reviewers I read complained that instead of promoting within their company, the firm would hire someone from an outside company and place them in the higher position.  That’s a low blow to the employees who have been working there for years, expecting their effort and loyalty to lead to more responsibility and more income only to see the new person get the job.

Another common complaint is that managers are not qualified and don’t do a good job providing feedback to adjusters.  The adjusters never receive compliments or congratulations and are always told what they are doing wrong and how much more work they have to do.  They complain that they are not trained enough to handle some of their cases efficiently and they also feel that their offices are understaffed.  The adjusters want upper management to be realistic.

Conclusion:

I understand that this is certainly not the voice of all of the claims adjusters in the workers’ comp world but this is what I’ve found.  Websites like www.glassdoor.com can be easily accessed and false information, positive or negative, can be posted by bad actors. 

With that said, 69.2% of adjusters on the glassdoor website would not recommend their job to a friend.

Summary:

  • Adjusters like their benefits, salary, and co-workers… for the most part.
  • Schedules can be flexible (can work from home with permission).
  • No raises, room for growth, and no pay for working OT.
  • Overworked, large caseloads.
  • Always behind on work.
  • Lack of feedback from upper management.
  • And perhaps the most telling quote – “Run, do not work here”

Hartford changes Medical Directors

As of next Monday, Marcos Iglesias MD will be moving from Midwest Employers to the Hartford, where he will be taking over as Medical Director from Rob Bonner, MD.

I know both well, and the move is a good one.  Rob has done yeoman work at the Hartford, particularly in the areas of pharmacy, disability rating, and analytics.  He’s also been a leading voice in the effort to add more science to the practice of workers’ comp medicine, speaking out against physician dispensing, directing research on compound medications, and leading a key committee at the American Insurance Ass’n focused on workers’ comp. I’ve worked with Rob on a number of issues, and hope to work with him in the future on projects as he transitions to a less-full-time schedule.

Marcos is equally passionate about the right care for the right patient.  With extensive experience in occupational medicine practice as well as leadership roles at several insurers, he will bring an equally strong voice to the Hartford.

I’d be remiss if I did not acknowledge the insight shown by Midwest Employers in actually staffing a corporate medical director position.  I can’t think of any other reinsurers with MDs, and far too few primary insurers have full-time medical directors. Among those that do, many don’t have anywhere near the influence, responsibility, or authority they need and deserve. The Hartford is one insurer where the Medical Director does more than most; alas most workers’ comp payers don’t understand that medical is now approaching 2/3 of claims costs.

If they did, there’d be a lot more medical directors with a lot more authority and responsibility.

What does this mean for you?

Does your work comp insurer get it?

 

Mark Walls returns to Safety National

Well, done, Safety National.

As reported by WorkCompCentral, the reinsurer returned Mark Walls to the fold, but in a much more prominent position and one where his value will be maximized.

Kudos to Marsh for figuring out Mark was a valuable commodity and bringing him on board to run their Workers Comp Center of Excellence.  While obvious no-brainer, it was a brilliant move.  It paid off big-time for Marsh as they benefited greatly from the exposure and brand enhancement that came every time one of Mark’s 22,800 (!!) LinkedIn group members logged onto the group site.

Now that he’s back in the friendly halls of SN, he’s got the role, responsibility, and freedom he should have had all along.  When Mark Walls left Safety National to take a position with Marsh, I was rather critical of the reinsurer; now that they’ve brought him back I would be remiss indeed if I did not compliment them on the move.  According to their announcement, Mark will “oversee thought leadership activities and external communications, including developing content for white papers, social media, webinars and speaking engagements…”

In other words, he’ll be Mark – bringing his deep and broad market following, insights and intel, and his own particular brand of humor and rather unique dance moves and alter egos back to whence they came.

Reporting to the top gives Mark the access and SN the direct connection to the market needed to maximize his value.  One suggestion for Mark’s boss – now that he’s back, don’t get all “insurance” on him.  Recognize that his value is immediacy, exposure, his voice.  Don’t wordsmith, monitor, oversee, “manage” the guy – sure he’ll say some things (or wear some costumes) on occasion that will make you wonder, but that’s who he is and why he’s so damn good at getting you the recognition you want.

What does this mean for you?

Good for Mark, and good for Safety National.  And for the rest of you out there in insurance-world, wake up.  SN got a huge bargain, and you missed out.  

 

 

The Good, the Bad, and the Ugly

Who else but Clint Eastwood could fairly describe the current state of the workers’ comp services industry’s relationship with its employees.

People like Sandy Blunt, Mark Walls, John Plotkin (and many others) and a few service companies are the Good; doing the right thing, serving their customers, working with their employees to continue to improve, grow, develop.  I single out Mark because he spoke to this yesterday, making a plea for service companies to hire as many recently-terminated workers as possible.

If that were only possible – but we’ll get to that in a minute.

There’s also a Bad side; the folks who suddenly find themselves out on the street after working for years to help build a company.  Sure, some of them deserve to be out of a job – not everyone’s a star, and there are certainly more than a few knuckleheads in our business (just as there are in every industry and profession). But this is an inevitable if really bad effect of our business economy, and one hopes these folks can move on and perhaps even move up.

Except there’s the Ugly.

And oh is it ever.

Scores if not hundreds of work comp professionals have become collateral damage from the recent spate of mergers and acquisitions.  Forced/required/strongly urged to sign non-competes after which some were summarily discharged, now unable to find work in a business they actually know something about, they are forced to seek employment in areas where they have few contacts, little knowledge, and less hope.

Why?

Does a billing clerk, or recruiter, or intake specialist, or sales rep or account manager really represent that much of a threat to mega-huge-giganta-enormous-corp?  Sure, a sales rep or account manager might be reasonable expected to sign a non-compete for a limited time in a narrowly-defined niche, and a senior exec with lots of stock and a generous severance package isn’t going to elicit much sympathy.

But the effort on the part of some companies to prevent regular staff workers from getting a job in this business is way beyond the pale.  Many don’t fully realize what they are signing, and shame on them (and sympathy for them, too).  Others feel like the have to in order to keep the paycheck flowing, not realizing that signing a non-compete doesn’t provide them any guarantee that they will keep getting those checks.

Regardless, this isn’t the right thing to do.

Nor is it the smart thing.

Those clerks, sales reps, account managers, billing folks, intake staff all work with payers’  adjusters, case managers and other folks all day every day.  Once they’ve been laid off and their former contacts find out what happened to them, how are they going to feel?  How are they going to relate to mega-huge-gigantic corp? How motivated will they be to do all the little things necessary to get cases referred, bills processed, invoices paid, authorizations completed?  Especially when their fellow staffers read every day about how much money is being thrown around by the bigwigs?

More broadly, society is going thru wrenching changes as the gap between the very wealthy and the rest continues to grow.  This will be even more ammunition for those that believe the moneyed class doesn’t give a rat’s rear end about the rest.

It’s wrong, it’s dumb, and it’s mean.

What does this mean for you?

How would you want to be treated?

Work Comp PBMs – it’s drug trend report time

Today’s post is authored by Jack Johnston who is spending his summer interning at Health Strategy Associates; Jack is going to be a senior at Syracuse University (my alma mater); he’s studying Health and Exercise Science.

The three largest PBMs have sent out their annual drug trend reports to tell the Workers’ Comp world what’s been going on this past year.  Instead of you having to read through each entire report and finding out what’s new, I’ve bit the bullet and gone through them for you.  Coventry-First Script, Progressive Medical-PMSI, and Express Scripts have all made much progress and developed new ways to further develop their success.  Let’s give you the skinny…

PBM Goals:

Coventry-First Script has been working with physicians to eliminate the use of narcotics  – due primarily to widely known potential for misuse.  Increasing generic brand utilization to lower costs and helping the older workforce remain healthy enough to work have also been other tasks Coventry’s been working on.

Progressive has managed to accomplish their goal to decrease opioid usage by working with physicians, prescribers, and injured workers.  Progressive Medical is working to ensure injured workers will return to work healthy, as soon as possible, while employers (payers) are getting the lowest possible costs.

Express Scripts is focused on reducing drug costs, utilization, and abuse for workers and prescribers while increasing the use of more affordable generic medication wherever possible.

Summary Findings:

With all three PBMs reporting that OxyContin is once again the most prescribed drug (in terms of dollars) on the market, they’ve been working on ways to decrease the use of opioids.  Progressive reported a 5.0% decrease in opioid usage while Express also showed a decrease of 3.0%.  Progressive also reported that the opioid cost per claim dropped by 6.0% and the workers who were prescribed opioid analgesics this past year used lower dosages compared to 2012; with MEDs diminishing by 9.6% over the year as well.  (First Script did not show any indication of an opioid usage % decrease in their report) correction – First Script indicated utilization per claimant decreased 9.1%, the biggest decline among the three PBMs.

Progressive is using a “Multiple Prescriber Service” to identify injured workers that are getting drugs from more than one prescriber.  With the main focus on multiple opioid prescribers, Progressive notifies all prescribers treating the injured worker and offers guidance to address the issue.

Express Scripts’ MED Management Program allows clients to set max levels for the amount of narcotic medication prescriptions an injured worker can fill.  Once the amount is exceeded, the program employes a review process before additional medication is dispensed. According to Express, the MED Management Program has successfully reduced drug abuse, limited addiction, and controlled costs.

Express has also continued to developed their Physician Outreach Program to encourage the use of generics, which appears to be Express’s main concern.

The First Script network pharmacies are being re-credentialed under stricter requirements including background checks and site audits to ensure legitimate dispensing practices.  The network also blocks narcotics and other controlled substances through mail service to prevent potential drug overdose, diversion, and misuse.  This reduces risk to the patient and the community.

Summary:

  • Opioid use is the main focus of these PBMs.
  • PBMs are having success with decreasing opioid usage through a variety of targeted programs.

What Does This Mean For You?

  • Claimants have a lesser chance to become addicted to their medications (Yay!).
  • Medication costs have lowered over the years.
  • If you’re not using a PBM, sign up and reap the benefits!

Just when you thought it couldn’t keep going…

With Apax’ just-announced acquisition of Genex, the pending Coventry transaction, and ongoing consolidation in the PBM space, the work comp services industry will look much different at the end of 2014 than it did even a year ago.

OneCall Care Management, originally a one-service firm focused solely on imaging services, has become a behemoth, including in its portfolio (and among its sister companies):

  • the largest (in terms of revenue) PT network
  • the largest imaging network (OCM)
  • the largest case management firm (Genex)
  • the largest DME/Home Health supplier (MSC)
  • a strong regional PPO network (MagnaCare, owned by Apax) (note – in an earlier post I said Apax didn’t have other WC experience; this was incorrect) (edited  - Magnacare was sold some time ago)
  • transportation and translation (Stops)
  • the dominant dental network (Express Dental)
  • IME and peer review

A “big” work comp services company used to have revenues in the several hundred million dollars; now, the market has stretched out – and thinned out. One huge company has revenues of the $3 billion plus, there are several in the $250-$600+ million range, and lots of small firms with revenues under $30 million.  This is a bit of an oversimplification, but the market dynamic today is markedly different from we’ve seen at any time up till now.

And the market dynamic will undoubtedly change even more as OCCM consolidates. More on that later.  For now, the question is, what’s the strategy?

Key to understanding the OCCM strategy is the concept of “white space”, a term used to describe untapped markets.  There’s a sense among many investors that, despite the rapid growth and impressive success of OCCM (and many other companies) in capturing market share, there remains a lot more to be had.  Whether it is leakage from networks due to lack of focus on direction, poor electronic connections with bill review partners, inefficient processes, or entirely new customers previously untapped, the money folks are betting growth is a given.

I’m not quite so sanguine;  as a long-time executive in this business told me this morning, all the  easy, pretty easy, not easy, and pretty hard stuff has been done.  What remains is the really hard stuff; or, in investor parlance, the “really heavy lift.”

An example may be helpful; some payers service small mom-and-pop stores and businesses that may not have a comp claim but once in a decade. Their workers don’t know anything about work comp, much less understand claim reporting or compliance with direction. Add in states such as Illinois or New York where “direction” isn’t really possible, and the lifting becomes even more strenuous.

What does this mean for you?

I’d expect your friendly vendors to be calling a lot with helpful ideas on how to increase penetration.  This isn’t a bad thing, but their priorities may not be in the same order as yours.

Genex is sold, OneCall Care Management adds two more businesses

In a long-rumored-but-just-verified deal, OneCall Care Management is buying specialty managed care businesses Network Synergy and MDN from Genex.

Meanwhile, Apax, which also owns OCCM, is buying the rest of Genex.

Current Genex owner Stone Point Capital had been looking to sell the entire company, and they have succeeded, albeit in a deal that looks a bit convoluted at first blush.

The vast majority of Genex’ revenue comes from case management, and some from bill review.  The valuation on these traditional, relatively low (or no) growth businesses is much lower than we’ve been seeing for specialty businesses.  That said, at the proverbial end of the day, Apax is the one writing the check to buy Genex and its component pieces however different Apax funds may be funding the two deals.

Regardless, the transaction removes a competitor from the market, and prevents an erstwhile OCCM competitor from acquiring two quite small but nonetheless functional entry points into the PT and imaging sectors.

The question is why split CM and bill review off from specialty?

Allow me to theorize. Genex has a thousand or more case managers out there who can be distribution channels for the Align/Network Synergy and OneCall Imaging/MDN product lines.  Sounds great, right?  Who wouldn’t want a thousand WC field case management (CM) nurses doing that directing for them?

Well, not so fast.

First, field CM is a shrinking industry, with most CM handled telephonically – something Genex does little of.  Second, field CMs take direction from the adjuster and/or telephonic CM, and in most cases those in-house folks are the ones directing to specific provider networks.

Third, many payers have picked specific specialty vendors which are not tied to OCCM, and these payers may not want to use CMs that are directly linked to OCCM and their family of specialty network products.  The separation of Genex CM from the specialty products gives at least the appearance of neutrality and objectivity, possibly mollifying concerns of payers who don’t want their claimants directed to OCCM providers.

Finally, there’s also a significant-if-not-huge bill review business as well, which provides potential opportunities for retrospective discounting of imaging and PT via the BR process.  This is a bit more complicated and may require re-contracting of some or all providers, but retro discounting is hugely profitable for vendors.

All this sounds good, and while complex, do-able. However, the difficulties inherent in the real world make for a somewhat different picture.

First, OCCM is by no means integrated today; some of the companies that were merged into One Call several years ago are still not integrated for billing, sales, or service.  This deal adds yet two MORE companies and their different product offerings, operational flows, contracting processes, and reimbursement rules – as well as state regulatory approval and oversight burdens.

For a conglomerate that industry wags sometimes refer to as “Five Call”, the additional work of integrating two more companies while completing work on the current efforts may well be a challenge.

What does this mean for you?

Apax is moving up and down the claim process chain as it looks to get traction both earlier and later in the life of the claim.

But it’s all about execution.