Health care – not a ‘system’ but an Industry.

To say we have a “health care system” is laughable; we actually have is a disconnected bunch of stakeholders who all view health care and the financing thereof through their own distinct lens.  There’s a:

  • heavy emphasis on profit and personal/corporate gain from individuals and organizations ‘serving’ the health care needs of Americans,
  • all subject to direction and oversight by an increasingly overburdened regulatory infrastructure that in turn is
  • directed by legislators who are often beholden to those
  • folks making a living off the “system”.

Any wonder it’s completely screwed up?

Yet we often lose track of these central challenges when thinking about/developing solutions to problems in health care delivery and financing.  Quoting Chris Brigham, M.D, “Many of the challenges we face in workers’ compensation are the results of flawed processes and wrong incentives – that drive certain behaviors – ultimately harming injured workers and society”.

There are a couple resources that help bring things back into focus.

First is the film, Escape Fire: The Fight to Rescue American Healthcare” This is a terrific documentary of a medical industry – not system – with profit-driven, rather than patient-driven care.  It has played on CNN several times during the past month and is available on ITunes and as a DVD.   Our health care costs are approaching 20% of our gross domestic product. We spend $300 billion on pharmaceutical drugs – almost as much as the rest of the world combined. 65% of Americans are overweight and 75% of healthcare costs are spent on preventable diseases that are the major causes of disability and death in our society. It is inexcusable. 

The second is an insightful article “Chronic Pain: Fundamental Scientific Considerations, Specifically for Legal Claims” by Robert J. Barth, PhD which was the lead article in the January / February 2013 issue of the AMA Guides Newsletter.  Barth’s article is an in-depth discussion of evidence and scientific findings indicating eligibility for compensation is the domi­nant factor for chronic pain claims.

With chronic pain the reef on which the ship of workers comp is increasingly likely to founder, Barth’s piece is well worth the read.  The key sentence – Barth quoting from a speech given by the author of a study on back pain – is this:

“Minor trauma was only associated with serious low back pain in a compensation setting.” [emphasis added]

Barth – “None of the surveyed participants who were NOT eligible for compensation developed serious low back pain after minor trauma.”

And there you have it: unequivocal evidence that there’s a huge amount of “secondary gain” driven medical care.

What does this mean for you?

Anyone who thinks there are simple answers to our health care mess is a simpleton. 



Just how dangerous is compounding?

Way more dangerous than we’ve been led to believe by compounding pharmacies and their supporters. A report in the Washington Post by two investigative journalists highlights shoddy practices and unsanitary conditions at three pharmacies that have sickened and killed patients.

Unfortunately compounding is a growing phenomenon, especially in workers’ comp.  Research from CWCI and other sources indicate that despite the lack of any evidence-based research justifying widespread use, compound meds are becoming a larger part of pharmacy spend.  Fortunately, we can observe what’s happened in California to forecast the future for compounding in other states.

California recently tried to address the issue thru bill AB 378, which specifically focused on the ingredient cost; the net? the number of scripts dropped 35% (from 3.1% of all scripts to 2%)…however the cost per script zoomed.  Compounds now account for one out of every eight dollars spent on drugs…

(see CWCI’s February 2013 report for details on what happened and why)

In his blog, David DePaolo reported on a criminal case involving payments to physicians for prescribing compounds;

“The complaint, filed by the owners of a medical billing company in the U.S. District Court in New Hampshire, alleges that Cyrus Sorat is a part owner of Health Care Pharmacy and Deutsche Medical Services in Tustin, Calif., and paid 208 doctors to prescribe compound drugs to injured workers needing topical analgesics. Sorat promised to pay the doctors an unreported fee for each prescription they wrote, and also agreed to handle billing and recover receivables on behalf of the physicians, according to the complaint.”

While cases such as these are unusual, the increased use of compounds, and specifically the changes in the compound drugs dispensed are clearly intended to maximize reimbursement.

Make no mistake – this isn’t about patient care or return to work or excellent medicine, it is about enriching a few at the expense of employers and taxpayers, while not caring one whit about possible patient safety issues.

Workers’ comp – the last refuge of scoundrels and charlatans.  Again.





The latest on workers’ comp physician dispensing in Louisiana

The good folks in Louisiana are rejoicing over a recent court decision in a case involving LUBA Workers’ Comp; here’s the interpretation from Jeffrey Napolitano of Juge Napolitano Guilbreau Ruli & Frieman PLC, a legal firm in Metairie, LA…

the court found “a wholesale pharmacy distributor, who contracts with physicians to provide pharmaceuticals to the physicians on a consignment basis for dispensing to their workers compensation patients, has no right of action to bring suit against the employer/insurer for payment for pharmaceuticals. [emphasis added] The court held that only the employee or healthcare provider has a right to brig suit for payment for providing medical services to an injured workers under the workers compensation act.”

While the Pelican State may have a reputation as a bit of a hellhole for workers comp payers, this latest shows that there’s always good to be found – if you have a good enough case and a smart enough attorney.

Kudos to LUBA for fighting the good fight.

Unfortunately, we can expect physicians to start billing for themselves, or figuring out some equally creative way to suck more money out of employers and taxpayers.

What does this mean for you?

The briefest of respites…




Among the top all time posts on MCM was the one a couple weeks ago about the right wing and nut-o-sphere’s claim that the feds are going to require anyone signing up for health insurance will be implanted with an RFID chip containing their medical and financial records.

As of this am, there were 12.386 views of that post.  I kid you not.

To repeat – there is NOTHING in the PPACA legislation or regulations about any RFID chip.

These conspiracy theorists either intentionally or ignorantly mis-read the PPACA’s Medical Device Registry language – which is clearly intended to track medical devices – hip replacements, pacemakers, spinal cages and the like – to “facilitate analysis of postmarket safety and outcomes data.” This language – which is quite simple and quite clear is mis-interpreted to imply that we all are going to get a chip implanted somewhere on our persons.

Of course we need to get these devices tracked – many fail, many are recalled, and there are many complications arising from these devices.  Rather than having no way to figure out who has an implant from the Acme Hip Bone Implant Device Co. by sorting thru paper documents, it only makes sense to have a central source that can identify the Acme patients.

Not only is there nothing in any document about this, but the tin-foil hat crazies propagating this rubbish cite a bill that was never even passed (HR 3200) and is not law as their source for this nefarious plot.  And, it has been refuted by Snopes and about a hundred other investigators.

But the monsters-under-the-bed crowd don’t let facts interfere with their claims – oh, no, not this guy.

There have also been a flood of comments from people claiming this is some part of a master plan of the Illuminati, or the FreeMasons, or some other obscure group bent on world domination.  After posting a couple comments, I’ve trashed the rest.


What business are you in?

The good folk at WorkCompWire asked me to contribute a piece this week; you can find it here.

The main point – Most workers’ comp executives – C-suite residents included – do not understand the business they are in. They think they are in the insurance business – and they are not. They are in the medical and disability management business – with medical listed first in order of priority.

Let the brickbats fly.


Wrapping up the workers’ comp week

Here’s the highlights from the week after the annual WCRI meeting and Physician Dispensing Summit…

The incontrovertible proof that physician dispensing of repackaged drugs extends disability and increases claims costs has raised the stakes in Maryland, Hawai’i, and Pennsylvania, states that are all working on legislation or regulations addressing physician dispensing.  The key takeaway – dispensing extends disability and raises medical costs – over and above the cost of the drugs.

It’s no longer about controlling the cost of the repackaged drugs, it’s now about the impact of dispensing on employers and taxpayers.

I’ve heard from multiple sources – including folks in Hawai’i –  that the new new thing in the repackaging/physician dispensing world is SpeedGel...developed and sold by the wonderful folks at Gensco Labs.  SpeedGel is currently available in both OTC and prescription strengths, but word is the over-the-counter version will no longer be available (amazing what you can learn when you talk to their sales reps).  Evidently some payers have been reimbursing the prescription version at the OTC price, and we can’t have that!!

As you can see from the link, Gensco isn’t resting on their laurels.  Nope, they’ve been busy filing trademarks for new and wonderful topical medications that are sure to solve myriad problems – to date Randy M Goldberg has filed for 43! Coincidentally, there’s a gentleman with the same name who’s affiliated with Automated Healthcare Solutions…

They sure are busy down there in Miramar, Florida!

Don’t worry about the disclaimer on their site…the one that reads “The products and the claims made about specific products on or through this site have not been evaluated by the United States Food and Drug Administration (FDA) and are not approved to diagnose, treat, cure or prevent disease.”

Finally, I’m going to be on holiday all next week in Italy.  See you in ten days.



Obamacare – criticisms considered

Over the last week I’ve had several conversations with folks opposed to Obamacare/the Affordable Care Act.  Their criticisms are focused in several general areas:

  • it doesn’t do enough to control costs;
  • it is too expensive and we can’t afford it;
  • it is socialized medicine and violates our country’s foundational free market principles; and/or
  • it is intrusive and injects government into the doctor:patient relationship.

As I’ve said ad nauseum, PPACA (pronounce Pea-Pak-A) is so obviously a product of our vaunted-but-deeply-flawed political system that it should serve as a warning to all future legislators.  It was NEVER supposed to pass and become law as-is; if the Dems hadn’t completely screwed up the Senatorial election in Mass, thereby losing their veto-proof majority in the Senate and therefore had to pass the reform bill already passed by the House in the lame duck session, this conversation never would have happened.

Alas, it did, and here we are.

So, on to the complaints.

We can’t afford it.

C’mon, folks, as if the US health care system was affordable BEFORE Obamacare.  And, the recent announcement by Ala. Sen Jeff Sessions that the ultimate cost will be $6.2 trillion was flat-out wrong; his projections assumed the cost-control provisions of PPACA would be ended.  In fact, the Hill reported:

“the U.S. deficit will decline 1.5 percent as a share of the economy over the next 75 years, according to the GAO. Auditors attributed 1.2 percent of this improvement to the Affordable Care Act.”

Fact is, there are cost control provisions in PPACA, and unless they are repealed, they will reduce the deficit.  Two, the IPAB for one and ACOs, are promising – if only because neither has been proven. But I see another part of PPACA as likely the most effective; the mandate and prohibitions against underwriting.   If we all have to get insurance, and insurers can’t make money by risk selection and actually have to manage care (horrors!!), they’ll actually have to work on improving health, reducing morbidity, and improving the delivery of care – and eventually controlling cost thru their creative approaches.

Dirty truth folks, back in the old days (which includes every day up till 1/1/2014) health insurers spent most of their time/brain power/resources not on managing care, disease management, population health, or any other “health care” thing – but on underwriting. Nope, they worked hardest on figuring out first – who was likely to incur a claim, then second – how can we avoid insuring them.

That game’s over.  Now, insurers are stuck with all of us – healthy, fat, diabetic, blind, fit, gluten-free yoga enthusiasts, old, young, pregnant, single, whatever.  And if they are going to survive, insurers damn well have to figure out how to keep us – all of us – healthy and out of the doctors’ offices/ER.

Their game has changed more than anyone could possibly understand.

Why? Cause the heavy hand of government (that would be a government elected by us, folks) essentially said “enough of this crap.  Figure out how to control costs and improve health, or you’re out of business.”

The PPACA essentially changed – and leveled – the playing field.  The rules are clear.  And so are the penalties.  

Is it perfect? Hell no.  Is any legislation ever perfect?  Same answer.  But it is a LOT better than what we had before. Which, for those with short memories, was a completely out-of-control health system with declining numbers of insureds and rapidly rising costs.



Smart move, CWCI

With long-time CWCI President Michael Nolan slated to retire in May, the Board named Alex Swedlow to replace Nolan, passing the torch to one of the leading figures in workers’ compensation.

Alex’ research rigor, insight into nuances and intricacies of the industry, and unparalleled ability to make complex and complicated information understandable for lay people has served the workers’ comp industry very well.  From ground-breaking research on the influence of provider’s workers comp claim volume on outcomes to their latest research demonstrating the link between physician dispensing of drugs and longer disability/higher costs/poorer outcomes, Alex and his colleagues have kept CWCI at the forefront of workers’ comp research.

It’s one thing to do great research; communicating the result of that research, making it understandable/approachable/usable for non-academics is an entirely different matter.  And that’s where Alex’ ability really benefits CWCI and the entire industry.  His dry sense of humor and straightforward presentation makes him a must-have for every conference.

I’d be remiss if I didn’t acknowledge the strides made at CWCI under Mike Nolan’s leadership.  He’s led the organization during a very tumultuous period marked by hard, soft, and rapidly-transistioning markets, keeping CWCI relevant and helping shape decisions in the nation’s largest workers’ comp market.

Kudos to CWCI’s board.  Smart move indeed.

(disclosure – I’ve counted Alex among my friends for several years, enjoy his company immensely, and will be speaking at CWCI’s annual meeting later this month.)



Mark Walls moves to Marsh

Good friend, colleague, and social media/marketing star Mark Walls is now at Marsh, where he’ll be “developing market research, insight, and other content for Marsh colleagues, clients, and prospects on emerging issues, trends, regulatory, and other changes that affect the workers’ compensation market.”

But mostly he’ll be doing what he does better than anyone; connecting people, commenting on current issues, generating dialogue, and taking positions.

This was a very, very smart move for Marsh.  They got themselves the guy who is arguably the best-known “brand” in work comp social media.  And they’re going to let him be himself: travel to and speak at conferences, help plan and participate in industry events; engage the industry and the various stakeholders.  The benefits for Marsh are incalculable; every time Mark posts, hosts, or toasts the Marsh brand will be there for all to see.

For Mark’s former employer, Safety National, this is a loss perhaps much bigger than they know.  Many in this industry associate SN with Mark; his work greatly improved their standing in the industry, opened many doors, and generated huge amounts of positive press.  Unfortunately, my sense is his bosses didn’t “get” Mark’s value to Safety National, did not understand how his market presence benefited the company, and as a result didn’t take full advantage of Mark.

That said, SN did encourage Mark’s activity and certainly benefited from that activity.  While many WC payers would have looked very skeptically on an employee engaged in social media, SN embraced that activity, generally supported it, and in so doing helped establish a presence for the company that is far wider and deeper than they’d have seen otherwise.

Mark’s WCAG group is the largest networked group in workers’ compensation.  He organizes several conferences, national as well as regional.  He’s a sought-after speaker and expert for media.  I have no idea what Mark is making at Marsh, but it’s a bargain for the return they’re going to get.

Congratulations Mark, smart move Marsh, and kudos to Safety National for getting this started.


WCRI’s research wrap-up

Only the thoroughly nerdy (and yes that includes your intrepid reporter) stuck around for the final session, a WCRI research sampler based on their CompScope research database for lost time claims from 2008-2011.

It’s not just medical benefits that vary wildly – indemnity benefits per claim ranged from almost $10,000 per claim in IN to $28,000 in NC.  The researchers broke this down into the various components and sub-components; temporary and permanent disability benefits.

This is NOT my area of expertise – so be warned.

One study looked at the Michigan workers’ employment after a lump-sum settlement of their claim.  19% of those claimants who didn’t have a job at the time of settlement found one within a year, most took their time.

Among those claimants who were working at their “pre-injury” employer, 41% left their job and were no longer employed a year later.  For those who had found a job at a new employer after their original injury, 75% kept that job.

About a third who had a job at time of settlement quit and weren’t employed a year after that settlement.

That’s it for me – time to get back get back to work.