Insight, analysis & opinion from Joe Paduda

Mar
26

Value-based care in Work Comp

Randy Lea MD of the Dartmouth Institute (one of the nation’s leading healthcare research organizations, and my personal favorite) just completed research on value-based care (VBC) in work comp – a timely and much-needed project. Dr Lea presented at last week’s WCRI Conference.

Here are my takeaways.

Spoiler alert – value-based care is not getting much traction – and I don’t think it will.

First, the research was more of a survey of what stakeholders want, expect, can do, and think is necessary to bring VBC than a detailed description of what actually exists today. In that way, it’s helpful as it indicates what factors may/will lead to more VBC in work comp.

As much as I respect the Dartmouth Institute and appreciate Dr Lea’s insights, I found the presentation hard to follow. There was just too much information crammed into too little time.

Stakeholder readiness

Providers – only one engaged in a WC VBC pilot program; many were prepared and waiting, but “there’s no opportunity for them to engage at this time.”

Payers – only one is doing VBC – and that is bundled payments. Payers were more focused on high-performing networks, not real VBC. Also doubt the model will be sustainable.

Regulators – again, only one doing VBS, that one has seen positive results, and is ready to expand. access, quality, and are coordination. Not much going on, but many are at least thinking about it.

Now into the meat – their thinking about how VBC might actually occur in workers’ comp.

Conditions that were popular for inclusion in a VBC model included spine, shoulder, knee, CTS, and co-morbidities plus the condition.

First, we need a regulatory environment that is favorable to VBC. No surprise here, although all recommended employer direction, mandated medical treatment guidelines, reduced fee schedules (?!), reduced UR.

Second, providers need enough patients.

Third, there was a lot of concern around RTW, causation, and impairment and who is involved and how decisions around those key issues will be made and on what basis.

Development guidelines

  1. Need a set of values that are shared by the stakeholders that guide development
  2. Rewards for good performing providers
  3. Transparency across all stakeholders
  4. Outcomes focused, not discount-driven
  5. Adaptability to current programs and regulatory conditions
  6. Fair and quick reimbursement of providers
  7. Reimbursement based on guidelines and compliance w MTG
  8. Eliminate fee schedules
  9. Need real steerage of patients
  10. Tight definition of outcomes is mandatory, need real specificity around things like RTW.

Payment types – participants reviewed a variety of types of reimbursement, with most payers looking for bundled payments  – no surprise.

 

I also have to note that my main takeaway was thiswork comp is a couple of decades behind the rest of the world – and it isn’t catching up. If anything, we’re falling further behind.

I say this because this is some pretty basic stuff compared to what we see in Medicaid or Medicare.

My view is there are any number of reasons VBC is not going to happen in WC.

  1. There are not enough cases; providers won’t be interested in risk-taking if there aren’t enough cases to spread the risk.
  2. Providers don’t have to take risk; in many states there’s no or limited employer direction, so no guarantee they’ll get a minimum number of cases.
  3. Litigation – providers may have to provide documentation and perhaps testify, something no one wants to risk.
  4. Payers are far too wedded to the percentage of savings profit machine.

What does this mean for you?

Bundled payments aren’t really value-based care. And even those are few and far between, for good reason.


Mar
23

When people use cannabis do they stop using other drugs?

There’s been some good research into this – which may be THE key question when it comes to medical marijuana.

The answer appears to be – some do stop using other drugs. And, even better, fewer people die.

Key findings using Medicare data:

  • States with medical marijuana laws saw about 10% fewer daily doses of opioids than those without those laws.
  • States with dispensaries only (no home cultivation) saw a 14% decrease in opioid doses
  • Total savings to Medicare and Medicaid would be about $3.4 billion if all states adopted Medical Marijuana Laws – but the folks buying the marijuana would pay for their cannabis out of their own pockets.

Studies using Medicaid data saw somewhat greater reductions in opioid usage.

Couple observations – there have been massive changes in PDMPs, increases in naloxone usage, tighter state laws and federal guidance on opioids (CDC et al), which may well have had some impact on death rates and lower opioid usage overall (Brian Allen of Mitchell made this point just after I wrote this). Dr Bradford noted that their analysis considered these possible confounding issues.

My big takeaway – there’s a significant reduction in the number of deaths due to opioids when states have access to cannabis. Like a 25% reduction.

Dr David Bradford of the University of Georgia presented this information; he and Ashley Bradford published much of this in a piece in HealthAffairs two years ago; they used Medicare and Medicaid data.

Dr Bradford noted he and Ms Bradford hope to be working with WCRI on a workers’ comp-specific study soon.


Mar
23

WCRI on Physical Medicine

Physical medicine – chiropractic, occupational and physical therapy – accounts for about one out of every six dollars of workers comp medical spend.

Key takeaways from DR Rebecca Yang’s discussion of the latest CompScope(tm) report:

The location of PM services has shifted from hospital outpatient to non-hospital locations since 2003.

PM accounted for almost 18% of WC medical costs, with non-hospital totaling 14.6%.

Part of the reason is likely reimbursement; non-hospital care averages $41 per unit, while hospital is almost 50% more expensive at $60; this varies quite a bit by state.

Anecdotally, several payer clients have told me their PM costs have been increasing; some are concerned and others see this as likely – and not unwelcome. This latter group sees PM as a replacement or substitute for more invasive/riskier and expensive care – specifically surgery and opioids.

Don’t have any data to support these anecdotes, but hope to hear from anyone who’s looked into this.

What does this mean for you?

Increasing physical medicine costs may well be a good thing.


Mar
22

Opioids and disability duration

On a panel discussing opioids, Dr Bogdan Savych of WCRI opened with a review of WCRI’s latest research looking at the link between opioid prescribing and the duration of disability.

It is great to see WCRI spend a big chunk of time and research dollars on this – which I believe is the biggest problem in workers’ comp today – and will get worse long before it gets any better.

Couple quick data points…

  • One of 10 workers who get opioids are still taking them after 90 days.
  • And, between half and 85% of workers (not surgical cases) who had pain medications were still getting scripts for opioids 3 months later
  • There’s really significantly different prescribing patterns depending on geography – NOT evidence-based guidelines, severity, injury type, etc – but simply where the patient is treated. (so much for the science of medicine…)

That’s just nuts. (editorial comment)

Dr Savych’s study looked at low back pain cases, noting that most guidelines do NOT recommend opioids for low back pain – and certainly not for long term treatment.

Workers with longer-term opioid scripts had more than triple the duration of disability of those who did not use opioids over the long term.

Yet there is NO evidence that opioids are appropriate for long term treatment of low-back pain

Takeaway – Do everything you can to prevent workers from taking opioids over the longer term.


Mar
22

How to prevent and stop opioid use in work comp

It can be done. And it is being done – by a state governmental agency, no less.

Ohio BWC (the state workers’ comp fund in Ohio)’s Medical Director gave background on just how bad things were at BWC in 2011, before just-hired pharmacy director John Hanna took over.

One patient was taking 4000 Morphine Equivalents per day.

40 million opioid doses prescribed in one year.

After five years, the number of opioid dependent patients, opioid doses, and patients taking opioids were all cut in half.

Here’s an even better view…

Ohio allows for treatment of opioid dependence for 18 months without it being allowed in the claim.

I can’t say enough about what Ohio BWC has done. While the data is telling indeed, I think of the families that are still intact, the moms and dads still alive, the employers still staffed by able and capable workers, the first responders somewhat less stressed.

Thank you, John Hanna, Dr Steve Woods, Dr Nick Trego, and Dr Terence Welsh – and your bosses at BWC and in state government, including Gov Kasich (R).


Mar
22

WCRI kicks off…with a deep dive into the future of labor

And we’re off!

Despite the weather, there are over 400 people here in Boston today. That’s an all-time high – even with the wet snow coming down outside. Kudos to Andrew Kenneally (Andrew handles the communications and marketing) and the rest of WCRI’s staff for putting together a conference that continues to draw people to New England in March.

For those unable to make it here due to weather, follow me on twitter at @Paduda, Mark Walls compilationLynchRyan’s Workers’ Comp Insider, ReduceYourWorkersComp, Sedgwick’s Don Lipsy at @UofADon, and of course @WCRI.

Erica Groshen, PhD of Cornell and former head of the Bureau of Labor Statistics led off with a deep dive into labor statistics, and a discussion on the future of work. Here are the takeaways…

  • over the last nine years, we’ve added 9.8 million jobs.
  • Healthcare and education has consistently been the biggest job-creator over the last year; last month construction led the way.

  • about one in five of the unemployed have been out of work for more than 6 months; employers are still pretty selective.
  • wage growth is flat over the last 12 months.

  • over the last 40 years, employee productivity has accelerated sharply, but compensation has not. This is a remarkable change from historical data; employees are creating a lot more value but are NOT getting paid for it.

With that, we move into where labor is headed.

There will be more of us in alternative work arrangements, that is, you work for a number of different entities, or you have a series of temporary jobs.

We don’t have any current data on employment in these alternative work arrangements (AWA) (due to a lack of funding for the research at BLS); the most recent information is over a decade old. However, look for new data that should be out in the next few weeks.

What we do know comes from the Current Population Surveys (CPS) – which look at about 60,000 households.

That data indicates there hasn’t been much of an increase in AWA employment over the last decade – in fact, it’s been flat.

I’m surprised about this; we all hear about Lyft and TaskRabbit and all the other web-enabled AWAs, and I’d assumed the number of us doing gig work was steadily increasing. It could be the CPS data is skewed due to mis-reporting or mis-identification (people like me who are self-employed may report they are “employed”).

A CWS report coming out in May will give us more info on this.

Dr Groshen made the case that Artificial Intelligence and other tech-driven changes (robotics, automation) will create jobs, noting there will be a “skills gap” as workers who lose jobs (think long-haul trucking) won’t be ready to take new jobs (programming AI). She went on to claim that regardless of the impact of AI and other technology, the economy will eventually return to full employment.

I admire her optimism. I’m skeptical of it as well.


Mar
19

Nothing ado about much

That’s the quick take on the White House’ plans to attack the opioid crisis.

Briefly, it amounts to:

  • harsher enforcement of existing drug laws,
  • education using advertising to prevent addiction,
  • helping fund treatment and
  • helping addicts find jobs while in treatment.

The latter two make a lot of sense; the first two are futile, stupidly expensive, and simplistic at best.

The “war on drugs” has resulted in millions incarcerated, trillions in costs, thousands killed, and, surprise, people still do illicit drugs.

These are just statistics, and therefore meaningless. But it isn’t meaningless for me or my family.  A family member in law enforcement died in the line of duty; much of his career was in drug interdiction and his death resulted from that work. The drug war is akin to Afghanistan; we’re never, ever, ever going to “win”, because the war isn’t winnable.

As for education, unless you’re older like me, you may not remember Nancy Reagan’s “Just Say No” campaign. Lucky you.  These “education” programs don’t work…according to an NIH study, the campaign: “had no favorable effects on youths’ behavior” and may have actually prompted some to experiment with drugs, an unintended “boomerang” effect.

While the latter pair make eminent sense, there’s nowhere near enough money – and without money they’re just talking points.

We need at least $10 billion more a year for treatment, plus additional funding for Medicaid which pays for a major chunk of treatment.

There’s an argument that former President Obama took too long to recognize the opioid disaster and start working on solutions – and I’d agree.

That said, the current funding level represents a real decrease in funding, at a time when death rates are accelerating.

What does this mean for you?

We’re on our own. 


Mar
16

Quick takeaways from CWCI’s annual meeting

One of the best conferences of the year is CWCI’s annual get together in Oakland California.

More information is packed into a morning than you’ll find in most multi-day events – and in a more entertaining format – and no one is more informative and entertaining than CWCI’s Alex Swedlow (I’m fortunate indeed to count Alex as a good friend and colleague).

First question – As Alex noted, way back in the pre-Triangle Shirtwaist fire days (no, I wasn’t around then), business claimed 95% of injuries were considered to be the fault of the workers – what is the actual number?

And why do many claims organizations/processes seem to operate as if that statistic is true today?

Okay, back to key takaeaways…

  • Average drug spend dropped 34% from 2012 to 2015 – Rx and DME combined amount to 8 percent of total spend of med payments at 24 months after inception
  • Opioid spend dropped dramatically, while NSAIDs went up.
  • Compared to all claims reported, Cumulative Trauma injuries have increased – a lot – since 2009. CWCI thoroughly debunked the contention by others that CT cases have decreased.
  • IMR decisions continue to uphold UR determinations more than nine times out of ten, a rate that’s held steady since 2014.
  • UR decisions on compounds are upheld in 99.2 percent of all cases.
  • Work comp administrative expenses are higher in California than any other state – by a lot. Part of the answer is the outright abuse of the IMR process by a handful of scummy providers in SoCal…and a couple up north too.

Gary Franklin MD gave a compelling, passionate, and pointed argument that opioid manufacturers are at fault for the disaster that’s killed more than 200,000 of us. Gary never hesitates, never waivers, and is the individual who has done more than anyone else to confront the opioid issue.

More to come next week.

 


Mar
13

Opioids – bad news and good

Patients taking opioids over the long term don’t go back to work, yet many long-term opioid patients can be weaned off opioids within two years.

Those are the quick takeaways from two studies that came out last week.

First, a study from WCRI validates earlier research, finding:

  • patients with multiple opioid scripts are out of work three times longer than patients with no opioid scripts, and
  • patients who lived in places where providers prescribe a lot of long term opioids…are more likely to get opioids for longer periods than individuals who lived elsewhere.

This is the first study that looked at ALL lost-time claims with a diagnosis of low back pain in a very large area – 28 states that represent 80% of claims – over a five-year period. This is important because it shows  cause-and-effect independent of so-called “severity” measures, which often use cost, treatment, or prescriptions to indicate medical severity, instead of actual clinical indicators. By looking at ALL low back claims with lost time, claims, it is clear that the driver of disability is long-term prescribing of opioids.

The takeaway is this – chronic use of opioids extends disability, and you can figure out where you need to focus your efforts by looking at publicly-available prescribing data.

California is one state with way too much experience in dealing with opioids in work comp; the graph below shows both the overuse, and the progress made in the Golden State since it got serious about reducing opioid usage.

source – WCIRB

Which brings us to the good news: weaning works, as research from California’s Workers’ Compensation Insurance Rating Bureau shows: 

47% of the injured workers demonstrating chronic opioid usage weaned off of opioids completely within the 24-month Study period. Injured workers who did not wean off completely over the Study period still reduced opioid dosage by an average of 52%.

The research included all patients with more than 50 morphine equivalents over at least 3 months within 24 months of the date of injury.

Yes, it is difficult, expensive, requires a lot of assistance from trained professionals, and does not always work. All that said, given the finding that patients taking opioids for longer periods are out of work a lot longer, it is well worth the time and effort to help these patients reduce or end their use of opioids.


Joe Paduda is the principal of Health Strategy Associates

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