You broke it, you own it.

A bill before the US House and Senate would have required physicians and pharmacists to check state databases before prescribing or dispensing opioids.

All available research shows this is the single most effective step to reduce opioid abuse and kill fewer people.

Now, thanks to “doctors and pharmacists groups”, that requirement has been stripped from the bill.  What’s left is some – but nowhere near enough – money for treatment and the hope that, against all evidence to the contrary, docs who are writing the scripts that are causing the opioid disaster will take the time to check the databases before they write the script.

Not going to happen.

I am sympathetic to the claim that mandatory Prescription Drug Monitoring Program (PDMP) checking can be time-consuming. States have to do a better job of figuring out how to streamline the process while protecting patient confidentiality – and many have done so.  Moreover, the four states with mandatory PDMPs have figured it out, and it is working pretty well.

I am a whole lot less sympathetic to the argument that somehow a moment or two of a doctor’s or pharmacist’s time is too much to ask, for the simple reason that these medical professionals’ failure to properly prescribe and dispense opioids is the proximal cause of the opioid public health disaster.

Pretty much every independent research organization studying the issue has recommended mandatory PDMP checking.  Here’s one.

More bluntly, that behavior is killing people, and the lobbying to strip mandatory use of PDMPs shows that’s not that big a deal.

Kentucky, New York, Ohio, and Tennessee all mandate prescribers access PDMPs – and all have seen dramatic reductions in doctor shopping and opioid script volume.

There’s a wealth of supporting data here.  Briefly, here’s what mandatory PDMP use does.

  • after Ohio ER docs checked the PDMP, they changed their treatment plan for 41% of patients; 61% had fewer or no opioids prescribed, 39% had more.  And doctor shopping dropped by over 2/3.
  • In Tennessee, doctor shopping dropped by 50% and the volume of opioid scripts decreased by almost half a million scripts.
  • Kentucky doctor shopping was cut in half, 30% fewer patients received the “holy trinity” drug cocktail, and benzo and opioid scripts dropped significantly.
  • in New York, doctor shopping was cut by 90%, and treatment admissions rose by 20%.

After spending a fruitless hour searching the web for an actual policy statement or testimony regarding mandatory PDMP use by the AMA, my conclusion is the giant medical society wants it both ways.

They don’t want their members to have to check PDMPs, but they don’t want to be public about that opposition.

What does this mean for you?

Refusing to support mandatory PDMP is unconscionable.  At some point an enterprising class-action firm is going to figure out how to make a shipload of money off the intransigence of “doctors and pharmacists groups.”

 

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.

Where work comp’s fraud problem REALLY lies

It’s not about the individual claimant who’s working while getting benefits, or the Sunday afternoon injury reported as on-the-job come Monday morning, or the migrating pain.

The construction premium fraud racket may well be a far bigger issue for workers’ comp than the sum of individual claimant problems.  That’s my conclusion after listening to several experts who deal with this issue every day, in every state.

I don’t pretend to understand this at anything other than a very high level, but suffice it to say it is massive.  Moreover, by far the biggest problem is on really big projects – we aren’t talking about the local sub who builds decks and redoes bathrooms.  Bridges, airports, office parks, malls, government buildings – all targets for fraudsters who under-report wages, fail to obtain valid workers’ comp insurance, and rely on horrendously short-staffed enforcement of laws that are often far too permissive.

Here’s how this works.  A contractor or subcontractors contracts with “facilitators” that obtain work comp insurance from agents and provide insurance certificates to labor brokers tasked with finding and paying workers.

The work comp insurance coverage is usually minimal, and is based on false payroll data.

Far too often these labor brokers cash their payments from the facilitator, payments that can run into the tens of thousands of dollars per week (and the facilitator may well get a % of the check as a kickback from the check cashing facility).  The broker may pay the actual workers in cash.

So, the general contractor has the paper that shows they have insurance and their labor costs are low (this is a highly competitive business, and construction contractors usually win or lose business based on their cost of labor).  The facilitator makes money on the front end and back end, the labor broker usually doesn’t pay the workers what they tell the facilitator the costs are, and the check cashing store makes anywhere from a couple percent to near ten percent in fees.

The folks who get screwed by construction work comp premium fraud are diverse – most importantly, it’s the worker.  They get caught up in the scheme when they get hurt, and either there is no workers’ comp insurance at all or the paper trail is, at best, inconclusive as to the worker’s coverage.  Often dumped at the door of the nearest ER, the worker is stuck for the cost of their care, or, more likely, the taxpayer is.

The original work comp insurer gets screwed too, with perhaps thousands of dollars of premiums foregone due to fraudulent reporting while the “insured” is deemed covered by state law.

And ethical contractors find themselves facing a very difficult situation; either lose bids to lower-cost competitors or play the work comp fraud game.

What does this mean for you?

We’re going to dig deeper into this in future posts, because we really need to.

 

The near-silence of the lambs…or, it’s still the work comp industry’s fault.

My post on the inability/unwillingness of work comp payers to talk publicly about the good work their employees do generated a bunch of emails and a few comments from the few payers that actually do try to get that message out.

Kudos to those payers for trying; doing something is far better than doing nothing. And I do NOT want the rest of this post to be seen as anything other than constructive criticism.  And thanks very much to the folks who got in touch and commented.

But…

Two issues – these folks are very much the exception to the rule.  Fact is the vast majority of payers rarely if ever share the positive news.

Which leads me to the second issue.  The folks that are doing some outreach almost without exception are bringing the proverbial knife to the gun fight.  YouTube posts, blog posts, and press releases are very few and very far between.  Some are pretty well done, but even the most prolific payers’ messaging is sporadic at best.

It is also rarely picked up by other media, so it sits there on their blog or YouTube channel, garnering a few hundred readers after a year or so.

Contrast that to the stories about heartless work comp insurers screwing injured patients in pursuit of the almighty dollar.  The media reach of bad news; ProPublica/NPR series, the Department of Labor’s discussion of work comp, and local media’s coverage of alleged bad behavior on the part of workers’ comp payers, adjusters, and medical management staff buries the good news about comp payers.

One other point; many payers’ press releases are rife with stories about their successes in catching claimants doing things they shouldn’t be able to, showing that the insurance company will find out if the poor “claimant” (I hate that word) is really able to walk without a cane.

While that messaging may discourage the occasional “fraud”, it’s more likely this PR effort does more damage than good.

Come on, folks.  While you may think this discourages the very few potential bad actors out there who are looking to game the system, the overall message is the giant, omnipotent, all-powerful insurance company vs the poor guy or gal trying to get by on a paltry average weekly wage that’s nowhere near enough to meet their financial needs.

So, what to do?

  • individual companies need to develop a strategy – a long-term strategy – to figure out how they want to be perceived and why.
  • commit to it, follow thru, and be consistent
  • work together in local markets and nationally to get that message out.
  • don’t be an insurance company – be innovative, interesting, engaging, occasionally funny, compassionate.
  • tell stories – about claimants, about the real, live, moms and dads that work for your company trying to make sure the patients they are responsible for get better and their families are protected.
  • don’t let execs’ fear of doing anything remotely risky stop you.

What does this mean for you?

If you don’t say who you are and what you stand for in a way that connects with people, you’re screwed.

 

It’s the workers’ comp industry’s fault.

Yep, it’s your fault that the popular press smacks you around, citing a few examples of alleged insurer screwups as proof that you’re all a bunch of cold-hearted, nasty, lazy incompetents motivated only by profit.

Gun-Point-Suicide-Attempt

When was the last time your company actually talked publicly about the good stuff you do?  The patients you help?  The above-and-beyond service you provided to the paraplegic who needed something expensive and special that you approved so they could get on with their life? The spouse you spent hours on the phone with, explaining how work comp works, when the checks would be there, how you’d make sure her husband would get the care he needed?

The hugely expensive inpatient drug detox to help a long-term opioid user get clean, get her life back, and perhaps return to work?

(update-  the good folks at Midwest Employers are sharing their work on YouTube.) Kudos to MWECC – and here’s hoping a) they do more of this and do more to publicize it and b) others follow suit)

The lengths you went to to prevent a young woman from being subjected to cervical implant surgery, knowing that the outcomes for patients with her condition were universally poor?

The dangerous drug interaction you prevented, despite the screams of protest from the claimant’s physician and/or attorney?

Wait…you never publicly talked about this?  Never once mentioned it, much less actually – God forbid – used this an example of the good work your people do?

Never published a case of the month, or sent out a release honoring one of your employees for going above-and-beyond in helping a work comp patient?

Then stop your bitching about ProPublica, NPR, the plaintiff’s bar, and muckraking journalists and bloggers.  Because it’s your fault.

There are a bunch of reasons why insurers, TPAs, and funds don’t do this – all of them short-sighted, ignorant, and indefensible.  Fact is, if you don’t tell your story, others will. And in the work comp industry’s case, those “others” have bludgeoned you near to death with some true, real life examples of major screwups, along with many mis-interpreted, mis-understood, or just plain BS examples of alleged incompetence and/or misconduct.  I’ve spoken with several industry executives, and all decry the silence – their employers’ silence.

We are in an election year, folks.  We are hearing about opt-out, about alternatives to workers’ comp, about a “broken system”, about how poorly you serve “claimants’ (I hate that word).

What does this mean for you?

Worker’s comp isn’t broken.  

But if you don’t get off your butt and show why, it damn sure will be.

 

 

That “oh, crap…” moment

It’s tough to find any thoughtful Brit on the “Leave” side who isn’t haven’t second thoughts about the vote to leave the European Union.  

With the pound taking a, well, pounding; equity markets down 5%+ around the globe, and the total inability of the leadership of either British political party to come up with anything coherent to say about what to do now, those thoughtful types have much to be thinking about.

It’s too bad this thinking wasn’t done before the referendum that is causing the clustermess in Europe, and will almost certainly hurt Britain much more than the EU.

There was a lot of fearmongering on all sides, a good bit of nasty nativism from Leavers, and a slew of unfounded statements about various and sundry awful ways the EU was ruining Britain.  Simplistic claims unsupported by facts or data ruled the day, and now there’s a shipload of buyers’ remorse. A few other complications…

First, there’s a nascent but forceful move in Northern Ireland to leave the UK and merge with Ireland – which is still part of the EU.

Second, Scotland may well vote to leave the UK as well, making the UK and “Union” of England and Wales.

Third, Gibraltar is now being claimed by Spain, and reportedly is in talks with Scotland in an effort to somehow stay in the EU as the UK’s representative.

Add this to the financial mess in the UK, and it is blindingly obvious that the Brexit vote was a really bad decision.

I could go on, but you get the picture.  What this has to do with we health care and work comp folks is this – when it comes to big decisions, such as overhauling healthcare, passing workers’ comp opt-out legislation, compromising on opioid limits, or otherwise legislating or regulating things that are big – at least for us – be thoughtful, ask lots of questions, look for facts, data, and logic in responses, and weigh things carefully.

What does this mean for us?

When it comes to big issues, do not get caught up in simple statements and black-and-white comparisons.  The world is more complicated than ever, and major decisions deserve major time and attention.

Friday catch-up

A busy week indeed!

Here’s what happened that’s worthy of your attention.

The Feds have been all over healthcare fraud for several years; earlier this week, Attorney General Loretta Lynch announced charges against 301 people accused of defrauding taxpayers – that’s us, folks – of almost a billion dollars.

Over the last decade, the Medicare Fraud Strike Force has charged “2,900 people with health-care fraud, who have billed Medicare for $8.9 billion.”  Note that doesn’t include Medicaid and private insurer fraud; I’d be surprised if the alleged miscreants weren’t going after every payer.

Workers’ comp

There’s been much talk of late about “broken” workers’ comp systems, a good bit of which has been hyperbolic and based on shrill trumpeting of anecdotal reports of payer screw-ups.  Rick Victor PhD, formerly WCRI Executive Director and now with the Sedgwick Institute provides a needed review of the facts in his latest missive.  A couple highlights:

  • The overwhelming majority of injured workers return to work and do so to their pre-injury employer at the same or higher pay
  • Most workers receive their first indemnity payment without dispute or substantial delay
  • By an overwhelming majority, most workers were satisfied with medical care received

I’d suggest that, like any and every other social benefit mechanism, work comp does have its issues, problems, shortfalls, and screwups, it works well for the vast majority of patients.

Yes, we can always do better.  Yes, there are bad actors.  But no, workers’ comp is NOT broken.

ODG delisting from National Guideline Clearinghouse

The kerfuffle about ODG’s removal from the NGC is a teaching moment that risks being overwhelmed by marketing-speak.

The central issue is NGC’s definition of and requirements related to assessing, documenting and applying scientific evidence.  An unrelated but still-relevant issue is applying for listing on NGC is discretionary, and by no means should a decision to NOT apply be construed as “evidence” the guideline developer is somehow lacking.

A quick summary of “evidence” is here; you may well think this is anything BUT quick, however like many critically-important but somewhat obtuse subjects, the devil is in the details.

Another excellent – and shorter – synopsis is from the Institute of Medicine. The IOM has eight standards for “trustworthy” guidelines:

  • Establishing transparency;
  • Management of conflict of interest;
  • Guideline development group composition;
  • Clinical practice guideline–systematic review intersection;
  • Establishing evidence foundations for and rating strength of recommendations;
  • Articulation of recommendations;
  • External review; and
  • Updating.

Suffice it to say that one person’s (or company’s) definition of “evidence-based” may well be different from another person’s – or generally accepted standards.

I’m hoping to continue the discussion of “evidence” in future posts.

Well worth a read

David Williams writes often and clearly about health issues; a recent post caught my eye and I’ve returned to it several times since. David discusses robotic surgery, making the case that technology may well hit surgery – and surgeons – just as it will affect long-haul trucking.

A stupid comparison, you say.

Before you do, read his post.

Finally, Health Affairs is looking for articles/research on various aspects of work and health for its February 2017 edition.  Details here.

Enjoy the weekend.

Exchange health insurance premiums up 10%…

ok, that’s the headline, but it’s so generalized that it’s all but useless. In fact, premium increases vary quite a bit around the country and even within markets.

Our plan is up less than 1 percent.  And here’s why.

The 10% figure is a very rough average of the price changes for the two lowest-cost “Silver” plans – the second-tier plans offered on the Exchanges in 12 states plus DC. In fact, premium changes for the benchmark second-lowest Silver plans range from a 13% decrease to an increase if 18% – and these are preliminary, before the state review process.

A couple other factoids.

  • 7 of the markets reviewed by KFF.org will have fewer insurers participating, while the other 7 will either stay steady or have more competitors.
  • Most of the plans that were the lowest-priced in 2016 will not be the cheapest next year. However, in most markets, consumers who shop around will be able to find plans with premiums below their 2016 rates.
  • On average, 5.5 insurers will participate in the 14 markets next year, down from 5.9 in 2016.

We buy our insurance thru the Exchange in upstate New York. Our premiums will increase about 1% in 2017 – for a platinum plan, narrow network, no out-of-network coverage for a three member family aged 58, 57, 24.  Very low deductibles, but a very limited choice of providers.

So, what does this all mean?

Clearly, the narrow network is working for Fidelis, our insurer.

Contrast this with UnitedHealthcare, which is exiting most markets after a financially abysmal couple of years.  Humana has also been hammered.  UHC (and to a slightly-lesser extent Humana) has long focused on the employed market, one where care management is far less of a priority than marketing to brokers, benefits managers, and folks with jobs.  Broad networks and generous benefit plans are absolute necessities, as moms – who are very influential in insurer selection – want their ob/gyns and pediatricians in-network.

Brian Klepper and Fred Goldstein said it very well when discussing Molina and Centene, two plans that are much like New York’s Fidelis:

[Plans with deep experience in managed Medicaid] have of necessity learned to manage risk more effectively than commercial plans. Medicaid plans receive a monthly rate for each enrollee, and then manage within that set budget. To accomplish this, they have become adept at understanding their populations’ clinical and financial risks, and putting medical management approaches into place that can mitigate those risks. In other words, when a plan with Medicaid experience moves into a fully insured (at-risk) commercial plan space, it is more likely to succeed.

The commercial plans, not so much. Most commercial plans have not been required to adhere to rigorous risk management disciplines and, if anything, their incentives are different. They can go light on large case management, for instance, allowing the costs of high-intensity patients to balloon, knowing that when costs exceed premium, they can recoup those costs through subsequent premium increases.

What does this mean for you?

Health insurance is changing, and plans that understand risk management are going to beat the pants off those who don’t – in the Exchanges.

 

Well, this makes NO sense…

The RFP will award the contract to at least two separate companies, yet the two “separate” companies that won the business are “partners” that work together quite closely.

And one has repeatedly failed to meet performance requirements and been accused of overcharging the client – while the other does not have the infrastructure or experience or basic functions required to meet the RFP’s requirements.

That’s the summary of the Veteran’s Administration contracting process for veterans’ disability evaluations, one that is now on hold pending protests from other bidders.  Yesterday Politico’s Ellen Mitchell reported that the contracting process is now on hold pending the resolution of the several protests, a delay that will cause further harm to veterans.

This is about the change the process for evaluating veterans for disability benefits, a highly-specialized service that long was the purview of the VA itself.  However, long delays in evaluations led Congress to launch a pilot program using non-VA entities to deliver the service.  The results were sufficiently positive to convince the powers-that-be to transition the evaluations to private entities.

And that’s where we are now – except the entities that “won” the vast majority of the business are either owned by or “partners” with Lockheed Martin – the giant defense contractor.

Despite a pretty shoddy performance record and demonstrated inability to meet the scheduling timeframes. So, the VA awarded most of the work to a company(s) that, to date, hasn’t been able to fix the problem that caused the VA to outsource evaluations in the first place.

After much work, three companies have protested the VA’s decision, and we’ll know more in a month or so.  (I’ve done work for one – Veterans’ Evaluation Services.)

In the meantime, veterans who need to get their evaluations done so they can start getting benefits and getting on with their lives are stuck in limbo.

Yes, the VA has been hampered by political enemies.  Yes, it has been damaged by the incredibly stupid sequester. But the failure of the contracting officials at the VA to consider their own standards when awarding this contract is a travesty, smacking of backroom deals for huge corporations.

HWR’s Pot Luck edition

hosted by Health Affairs and authored by REAL journalist Christopher Fleming is up here for your perusing pleasure.

Posts from Hank Stern, Louise Norris, David Harlow, Roy Poses, and Tom Lynch are among the insights you’ll find at this latest Health Wonk Review.