Category: Health Policy

Jun
16

Massacres, mental health, and the Senate’s “plan”

Posted by Joe Paduda on Thursday, June 16th, 2022 | Comments

“Plan” is in quotes because as of now, it’s not legislation – just a list of programs and funding mechanisms that are very much a work in progress. It’s anyone’s guess if any legislation will actually become law…although as of now it seems a bit less likely.

Ed note – in my view the provisions of the legislation wouldn’t have much effect at all as they don’t address many of the core issues driving gun violence – except it would allow Dems to say they got a bill passed, and Republicans to tell independent moms that they care about kids.

Gun violence is a public health issue; it fits right into the purpose of public health, namely “reducing and preventing injury, disease, and death and promoting the health and well-being of populations through the use of data, research, and effective policies and practices.”

What’s appalling to me (a gun owner and hunter) is this:

  • More kids are killed by guns than by car accidents – child seats and restraints are the law in most if not all states because elected officials recognized kids were being killed and maimed in accidents.
  • This is especially true for Black kids – guns have been the leading cause of death for black boys over 15 for more than a decade.
  • Laws were passed decades ago to protect kids from lead paint.
  • Backyard pools must be fenced in most areas.
  • Kids can’t buy alcohol or tobacco products because of health risks.
  • When guns are present, suicides are far more likely to result in death; in fact there are far more gun deaths by suicide than homicide.

Yet most states do pretty much nothing to protect kids from gun violence – in fact in many states laws have been passed that increase the risk to children.

The holdup seems to be about two things; so-called red flag laws and the “boyfriend loophole”.

Red flag laws allow for/enable the temporary seizure of weapons and/or prevent weapons purchases by individuals deemed to be a danger to themselves or others. States with effective red flag laws have saved lives; “58 people who threatened mass shootings were disarmed during the first three years of California’s six-year-old red flag program. At least 12 school shootings were averted.”

GOP Senators are raising due process concerns; that is, they want to make sure individuals have their day in court before their guns are taken away.

More problematic is that there are 31 states without red flag laws; Sources indicate a GOP Senator assured his colleagues that “there would be no federal mandate to implement the laws”. Without that “mandate” the red flag provision would be pretty much toothless; states that have been busy making it easier for anyone to get and carry firearms wouldn’t be affected.

Sure those states wouldn’t get the federal funding needed to implement the red flag provisions, but elected officials would tout their willingness to refuse those dollars s evidence of their steadfast opposition to any gun control measures.

The “boyfriend loophole” is also problematic…today unmarried partners who commit domestic violence can buy/keep firearms while spouses who commit domestic violence can’t. (Note it’s not merely “threaten”…in most cases a spouse has to actually do something violent to potentially lose their guns.)

Health care payers

Behavioral health is how this affects health plans and payers.

All kids should be screened for BH concerns – no matter where they live. Care should be provided where needed. This will require additional funding, changes in benefit design for Medicaid, duals, and exchange/group health, and more behavioral health clinicians.

Of course this is politically driven…

Sen. Kevin Cramer, R-ND, on Tuesday. “I think we’re more interested in the red wave than we are in red flags, quite honestly, as Republicans and we have a pretty good opportunity to do that,” seemingly a reference to the possibility of Republicans taking control of Congress this fall.

Nice to see a politician publicly state that he cares more about votes than public safety.

What does this mean for you?

Depends – do you have kids? 

Jun
15

Single Payer health insurance and worker’s comp

Posted by Joe Paduda on Wednesday, June 15th, 2022 | Comments

A couple days ago NCCI’s Laura Kersey penned a piece about key legislative trends, one of which was Single-Payer health insurance. Good research work.

First, let’s define “single payer”. “Single Payer” – by definition – is government-financed and government-managed health insurance. (note Ms Kersey focused on state efforts; for reasons I’ll discuss below states CANNOT have a “single payer”.

Single Payer is a catch-all term for universal health insurance coverage. In some cases there isn’t a “single payer” in an entire nation – our neighbor to the north being one example, Switzerland and Germany are two others. In Canada, each Province is it’s own single payer; in the two European countries there are a variety of independent companies that provide health coverage. Taiwan has one payer for all residents.

There are a LOT of different versions of “single payer”; a discussion is here. Pretty much every country with Single Payer is unique, each with its own nuances. For example,

  • most don’t have government-employed healthcare providers; in many single payer systems, physicians, therapists, hospitals and other providers are private.
    • The UK is an exception; providers are (mostly) employed by the government
  • many are not government-operated; in many systems private insurers contract with the government to handle administration of health insurance – similar to our Medicare
    • Again the UK is an exception

Typically:

  • the government sets pricing/reimbursement policy and actual prices – similar to our Medicare
  • funding comes from some combination of employee, employer, and other taxes; in some countries, insureds pay some form of premiums – similar to our Medicare
  • it covers everyone
  • there is little to no paperwork for patients/consumers; all that is handled by the administrative agency
  • there are minimal or no deductibles, copays, or co-insurance requirements
  • people can buy into supplemental insurance through private insurers

Ms Kersey’s article notes several states have pending or tabled legislation related to single payer.

A key issue here is a very large chunk of spend in each state – as in more than half – comes from the Feds. Thus, unless a state gets waivers from the Feds (which will never happen) exempting Medicare and Medicaid from that state’s Single Payer program, most of the medical dollars aren’t going to be in that state’s program.

I’d suggest how Single Payer would affect comp depends on two core issues:

  • whether care for occupational injuries/illnesses is covered by Single Payer, and
  • whether there is a universal fee schedule.

If WC care is included under Single Payer, it is likely work comp would evolve to an indemnity-only system. This currently exists in several other countries, and seems to work pretty well.

If WC medical care is NOT included in Single Payer, the impact would be driven largely by the presence – or absence – of a universal fee schedule. 

Without that universal fee schedule, providers would likely continue to do their revenue maximization thing, although they’d supercharge those efforts. Why? Because reimbursement from all other payers would drop significantly, and providers would look to comp to replace as much of that lost income as possible.

What does this mean for you?

There will NEVER BE A STATE-BASED OR STATE-SPECIFIC SINGLE PAYER PROGRAM.

May
26

Moms, you can make this stop.

Posted by Joe Paduda on Thursday, May 26th, 2022 | Comments

Your kids will never be safe, not as long as pretty much anyone can buy and own and use guns designed only to kill people.

The slaughter has become commonplace…so “normal” that one can now buy casket wraps specifically for kids. 

credit Cara Anthony, Kaiser Health News

Guns were the leading cause of death among children in 2020 – more kids were shot and killed than died in car accidents.

This year alone 3,044 students aren’t going to graduate because they were shot to death. Thousands of parents and grandparents and neighbors and friends live with their loss – every minute of every day. 

The slaughter of little kids in Texas and elderly Black Americans in Buffalo tore away the comfortable numbness, replacing it with sadness beyond measure…yet somehow we pushed through. A colleague wrote this in an email; “I”m surprised at how much of business life just continued without comment.” That’s on us – each of us.

Here are two things that must be done.

  1. Make background checks effective.
    In the decade since Sandy Hook, we have made zero progress in improving or expanding background checks on gun buyers.  The current process is clearly an abject failure, rendered toothless by “compromise” in Congress. The reality is:

    1. minimal information is required
    2. Background checks aren’t done at gun shows or for private sellers, so anyone can buy a gun in a private transaction.
    3. there are loopholes and gaps that enabled multiple mass killings perpetrated by individuals who never should have been allowed to buy a gun
    4. “The bar for denying someone on mental health grounds is very high, requiring that a person has been declared unsound or involuntarily confined to a psychiatric institution by a court or other authority.”
    5. If the FBI (the Federal entity responsible for background checks) can’t make a decision within 3 days, the firearm purchase is automatically allowed.
    6. Many states, the US military, and other data suppliers tasked with sending information to the FBI fail to keep their records complete and up to date, rendering the information they supply to the FBI questionable at best.
    7. What you can do – Please sign this petition, and learn more here.
  2. Ban weapons designed to kill people.
    A good friend, former Green Beret and Vietnam combat veteran said this:As a nation we’ve got to come together and force our politicians to take up the challenge of eliminating the absurdly easy access by civilians to military weaponry and equipment. As someone who has owned guns for over 60 years and carried a shortened M-16 (actually called a CAR-15) for 19 months in combat, I’m saying that there is no reason for a non-military or law enforcement citizen to have a weapon that was intended only for killing other humans. What legitimate non-combat purpose does a 30 round stick magazine or 100 round drum magazine of 5.56mm ammunition have? Why are body armor and Kevlar military helmets permitted to be readily sold to the public with no questions about their intended use? How does one justify needing a 40 round magazine for a pistol? There truly must be a reckoning with our elected officials on both sides of the aisle to force the question of what their honest priorities are: the safety of our people or the continuance of their career funding by arms merchants, gun lobbies and a very small minority of highly vocal citizens who will fulfill their desires no matter what the cost to our society.
    What you can do: Support the Brady Plan.

What does this mean for you?

Take 5 minutes to help prevent a lifetime of grief. Support the Brady Plan

 

 

May
25

This is about your children.

Posted by Joe Paduda on Wednesday, May 25th, 2022 | Comments

Once again children have been killed.

Yesterday’s slaughter of little children cut me to the heart, coming the day after I spent hours watching our granddaughter. Hours of delight, wonder, love, joy and promise.  Sitting together in a swing as she munched on goldfish, picking dandelions, working on puzzles and learning more colors, doing nose kisses and picking out her outfit for the day (rain boots, shorts, and a favorite shirt, with a pretty awful ponytail (as it always is when grandpa does it)).

I cannot imagine the heartbreak suffered by families in Uvalde Texas, nor can I imagine how this reverberated among parents of kids killed in Sandy Hook Connecticut a decade ago, ripping open wounds painful beyond measure. That’s awful indeed – what’s worse – if that’s possible – is there have been dozens of mass shootings this year alone.

Look at your kids, your schoolyards, your sports fields, your graduation ceremonies and school plays and imagine the impact of a Uvalde/Sandy Hook/Buffalo/Laguna Woods/Milwaukee/Brooklyn/Sacramento.

If we do not do something about gun violence, some of you, dear readers, may come to understand all too well the heartbreak and utter devastation suffered by families victimized by gun violence.

Make no mistake, this butchery would not happen without grandstanding by vote-seeking pols, lax background checks, wildly inadequate mental health care, incredibly permissive concealed carry laws in some states and easy access to guns, many of which serve no purpose other than killing people.

What does this mean for us?

We are failing to protect children, loved ones, parents and family. This is a national disgrace. 

Note – I am a gun owner and hunter. Family members are first responders, former law enforcement and national security.

 

Mar
24

Optum vs the Massachusetts Attorney General

Posted by Joe Paduda on Thursday, March 24th, 2022 | Comments

Several weeks ago Massachusetts’ Attorney General’s office put out a press release noting work comp PBM Optum had settled a civil case by paying $5.8 million and agreeing to “implement additional procedures to prevent overcharges in the future under the workers’ compensation insurance system. Optum Rx has also agreed to cooperate with the AG’s Office regarding monitoring of future regulatory compliance.”

Several clients contacted me to get my take, and as I’m involved in audits of multiple pharmacy programs any insights into the issue might be helpful.

The net – Massachusetts’ work comp RX fee schedules’ regulations are ridiculously difficult/impossible to implement, and Optum was treated unfairly by the AG’s office.

[note I’ve spent way too much time digging into this, and it is entirely possible I don’t have the full story – largely because the AG’s office chose to be unhelpful.]

I reached out to the AG’s contact multiple times in an effort to better understand the issue; when I finally got a return call, it was, well, less than useful. The attorney told me he couldn’t say anything beyond the press release due to the involvement of a confidential informant. [that’s a pretty universal excuse for not engaging and one I found less than helpful; I wasn’t asking how the AG learned about this, but rather specifically what Optum allegedly did wrong]

here’s the key section of the AG’s press release:

The settlement, filed in Suffolk Superior Court, resolves allegations that Optum Rx, in some circumstances, failed to apply various regulatory benchmarks – like the Federal Upper Limit for Medicare and the Massachusetts Maximum Allowable Cost – to its pricing determinations for certain workers’ compensation insurance prescription drug charges.[emphasis added]

After some back and forth, in which I explained the release wasn’t clear, he informed me [paraphrasing here] that “anyone who knows the Mass work comp pharmacy fee schedule understands the significance of the ACA FUL and Mass MAC…”

I got a bit huffy with his borderline rude retort, and informed the gentleman that in fact:

  • A) I did “know” the Mass WC Rx fee schedule;
  • B) I have a pretty solid understanding of pharmacy fee schedules and reimbursement in general; and
  • C) if I couldn’t understand it, then I’m pretty sure most work comp payers and other stakeholders couldn’t either.

So, I called contacts at Optum to get their side of the story.

The net is, according to Optum – and other PBMs I’ve spoken with – the fee schedule wording is unclear, subject to interpretation, neigh on impossible to implement and therefore highly problematic.

From Optum:

  • Defining and Implementing the Commonwealth’s “Usual & Customary” definition – The provision as written is unclear and guidance on interpretation/implementation was not supplied in a manner that allowed all stakeholders to be successful.
    • 101 CMR 331.02  – “Usual and Customary Charge. The lowest price that a provider charges or accepts from any payer for the same quantity of a drug on the same date of service, in Massachusetts, including but not limited to the shelf price, sale price, or advertised price for any drug including an over-the-counter drug. If an insurer and the provider have a contract that specifies that the insurer will pay an average or similarly computed fixed amount for multiple therapeutic categories of drugs with different acquisition costs, the fixed amount will not be the provider’s usual and customary charge.”

      My take       – this is nonsensical and impossible to manage – for a whole host of reasons.
      Taking this literally, a PBM would have to A) know the amount accepted for reimbursement for B) each and every drug at C) each and every retail pharmacy. Note that the Commonwealth’s definition of U&C specifies the “lowest price that a provider…accepts from any payer…” As PBMs and other payers don’t instantly adjudicate claims and don’t know what amount a retail pharmacy ultimately “accepts” for a particular script, there is no way to comply with this requirement. [retail pharmacy bills are rarely paid on the day the script is dispensed, but paid in accordance with each PBM contract – it could be weekly, biweekly, monthly, or at another time.]Example – an Optum patient goes to Walgreens on Tuesday, gets her script for 30 tabs of 800mg ibuprofen. Did Walgreens know and transmit to Optum the lowest price it accepted for that drug on that day at that pharmacy?
      Of course not.

       

  • Understanding of contracts between the traditional triad of pharmacy/PBM/comp payor – The Commonwealth’s interpretation of how payment agreements (within the specific context of MGL c. 152, Section 13) should run between those entities is, frankly, unique in relation to how other jurisdictions operate.
    In English, what Optum is saying is the Commonwealth thinks contracts should be three-way – PBM, pharmacy, and payer/PBM customer.
    That is patently impossible; there are tens of thousands of employers and other entities contracted with PBMs, which in turn contract with thousands of pharmacies.

From the AG press release:

“Our workers’ compensation insurance system has specific processes in place to help ensure drug pricing is handled fairly, maintains transparency, and keeps costs down,” AG Healey said.

My view – well, no.

If I read this interpretation right, Massachusetts wants something no other state does to solve a problem that no other state seems to think exists.

I suspect the AG’s office is also pursuing similar litigation against other PBMs – and more’s the pity, because from what I have been able to learn, the AG did NOT handle this “fairly”.

If that’s a misinterpretation, it’s due to a lack of responsiveness and clarity from the gentleman from the AG’s office who chose to NOT be “transparent”.

What does this mean for you?

If you’re a PBM, make sure you’re on top of this.

[note – Optum is not a client, and we’ve actually crossed swords several times of late. Regardless, from what I can tell Optum did NOT attempt to drive “up costs and…unlawfully profit.”]

note 2 – happy to re-engage with the AG’s office at any time.

Dec
20

COVID update

Posted by Joe Paduda on Monday, December 20th, 2021 | Comments

Oh ^&%$*&^%^.  Here it comes again.

“IT” is the umpteenth wave/surge of COVID, a marvel of evolutionary adaptation.

IT has also killed 800,000 of our sisters, brothers, daughters, sons, parents and grandparents, friends and neighbors, co-workers and colleagues.

IT is also blowing up our healthcare system; 4 states are turning to their National Guard to staff critical services.

IT has driven healthcare costs over the $4 trillion mark as costs spiraled up almost 10 percent in 2020 – more than double the 2019 inflation rate. Taxpayers’ costs rose almost 4 times faster than the overall healthcare world – mostly driven by COVID.

Commenting on this, HealthAffairs noted;

OK, the good news.  Omicron seems to mostly infect the airways leading to and from the lungs, which helps make it more transmissible. It doesn’t get too deep in the lungs (in most instances); this may be one of the reasons it isn’t as deadly as other COVID variants.

Myocarditis occurring after vaccination is quite rare, according to research published in a UK Journal “However, natural infection from SARS-CoV-2 is linked to a substantial increase in the risk of serious outcomes from developing myocarditis, pericarditis, and cardiac arrhythmia, researchers say.”

What does this mean for you?

Get vaccinated AND mask up.

Nov
30

Facts vs beliefs

Posted by Joe Paduda on Tuesday, November 30th, 2021 | Comments

The medical community is wrestling with ethical issues arising from vaccines.

Simply put, should unvaccinated people infected with COVID be treated differently than the vaccinated?

This isn’t just an academic exercise; here in the Upper Valley of New Hampshire and Vermont, emergency rooms, critical care units, ICUs and Pediatric ICUs are stuffed full of COVID patients, almost all of whom are unvaccinated.

The Governor has issued an Executive Order intended to give hospitals more flexibility in setting up overflow units. At least two NH hospitals have postponed or halted elective surgeries as a result of the latest COVID surge.

Michigan may be in even worse shape.

The implications are real and potentially tragic.  Parents, friends, children or neighbors in car accidents, struck by heart attacks or strokes, suffering from kidney failure or pancreatitis or appendicitis or anaphylactic shock may find their local hospital doesn’t have an open bed and/or is operating short-staffed.

The latter is worsening by the day, as nurses, support staff, physicians and other clinicians are exhausted, frustrated, angry and despondent over long hours and the need to treat unvaccinated COVID patients. That and a relatively tiny number of healthcare providers have also bought into the lies perpetrated by antivaxxers, exacerbating the staffing shortage as they lose their jobs.

The exception to this discussion is for populations that have been mistreated, lied to, abused and misled by eugenicists masquerading as researchers.

The arguments for NOT treating those adults who are unvaccinated by choice (rather than due to a medical exemption) go like this…

  • the “slippery slope” argument – once we do this, then we’ll
    • refuse to treat obese people for heart disease, kidney disorders, diabetes, hypertension etc; smokers for heart disease, cancer or COPD; drinkers for liver disease – as if individual decisions with repercussions limited to that individual are the same as antivaxxers’ potential to spread infections, contribute to variant development and possibly kill family members, kids, health care workers and co-workers in the process.
      • as long as we’re talking about obesity…it isn’t
        • communicable,
        • preventable by vaccination, or
        • filling ICUs to over-capacity.
  • the false equivalency argument –
    • refusing to treat the “unvaxxed by choice”? than you shouldn’t provide care to women who have unplanned pregnancies – as if a one-time event is equivalent to a person’s brazen willingness to potentially infect dozens of us.
  • the “you are violating my freedoms” argument
    • if we can ban smoking in schools, restaurants, offices, airports and public transportation, we can certainly require immunization and penalize those without valid exemptions (if you think you should be “free” to smoke in a school or medical facility, that’s a whole different issue)
      • Oh, and pets are required to be immunized against dangerous diseases, as are kids.

Which leads us to the facts vs beliefs issue.

“Beliefs” – that you are a better driver than anyone else so should be allowed to drive at twice the speed limit through a school area and your child doesn’t need to be in a child safety seat and you don’t need to wear a seatbelt and you can hold your liquor so driving buzzed isn’t a problem for you; that you know more than 99% of the experts so you won’t get vaccinated, that children don’t die of COVID are NOT facts.

And when those beliefs are demonstrably false – as the anti-vaxxers’ arguments clearly are – the moral dilemma becomes more complicated.

“Freedom” isn’t free – if you want to be free to be unvaccinated, then you – no one else but you – have decided to accept the consequences of that decision.

Actually, that’s not right – because your decision is directly affecting your neighbors, family members, and co-workers. It is directly affecting my family members who work in healthcare, people you will infect, and lives you will disrupt.

In fact, freedom from disease, from economic disruption, from grief when loved ones die – comes at a cost – and that cost – however slight – is all of us getting vaccinated.

What does this mean for you?

Spare us the false equivalencies, the slippery slopes, the my freedoms nonsense, get the damn vaccination and wear a damn mask.

And when you get COVID, stay home and don’t interfere with our freedom to be free of COVID.

A more comprehensive discussion of the arguments against vaccination is here.

 

Nov
10

for hospitals, Cost ≠ Quality

Posted by Joe Paduda on Wednesday, November 10th, 2021 | Comments

Some hospitals are efficient – defined as delivering excellent care at relatively low cost, while others are quite inefficient – high cost, not great care.

Then there are the high cost and unknown quality of care facilities – but the net is this – cost ≠ quality, and quality does not cost more.

The Lown Institute has done some great research on this, and identified the nation’s 10 most efficient hospitals – the criterion being how much Medicare was charged compared to how many patients died 30 and 90 days from admission. OK, that isn’t by any stretch a comprehensive definition, but the results were revealing.

Costs ranged from $9,000 to $27,000 per patient…and if all hospitals operated as efficiently as the top 10, we taxpayers would save $8 billion each year.

Of course private payers are charged more, and pay more than Medicare. Nonetheless, efficient hospitals are going to be efficient for all payers.

Here’s the top ten.

  1. Pinnacle Hospital (Crown Point, Ind.)
  2. Saint Mary’s Regional Medical Center (Reno, Nev.)
  3. MercyOne Dubuque Medical Center (Dubuque, Iowa)
  4. Encino Hospital Medical Center (Encino, Calif.)
  5. Park Ridge Health (Hendersonville, N.C.)
  6. Oroville Hospital (Oroville, Calif.)
  7. Saint Michael’s Medical Center (Newark, N.J.)
  8. UnityPoint Health-Meriter (Madison, Wis.)
  9. East Liverpool City Hospital (East Liverpool, Ohio)
  10. Maple Grove Hospital (Maple Grove, Minn.)

Curious about another hospital?  Click here to find out how it ranked.

What does this mean for you?

Knowledge is power – but only if you use it.

Oct
6

Sticks, carrots, and vaccinations

Posted by Joe Paduda on Wednesday, October 6th, 2021 | Comments

Delta (my favorite airline) isn’t forcing employees to get vaccinated.  It is charging the unvaxxed more for health insurance.

Ochsner Health system in Louisiana is following suit, adding the same surcharge for spouses or partners that are not vaxxed in an effort to help cover the $9 million in costs the system spent on caring for workers infected with COVID – and pay for future expenses. The unvaxxed will have to pay $200 more per month and comply with strict testing requirements.

Financial giant JPMorgan will charge unvaxxed employees more for health insurance as of January 1 2022.

Those who come down with COVID are also going to see higher out-of-pocket costs as more insurers pull back on the first-dollar coverage they were providing for COVID care. Average out-of-pocket costs around $3,800 are expected for unvaxxed patients hospitalized for COVID treatment.

While a lawsuit has been filed by some Ochsner employees seeking to overturn the surcharge, legal experts dismiss any chance of success. CMS has told self-insured employers they cannot refuse to provide coverage for unvaxxed patients’ COVID care, but they can charge those members more. This is consistent with regulations regarding tobacco use, which can result in insurance surcharges.

Meanwhile, many of Delta’s competitors are mandating vaccines, perhaps in part because unvaxxed workers mostly comply with mandates. And all the data to date indicates the vast majority of workers are getting the shot rather than the heave-ho.

One expert noted the surcharges are a powerful emotional tool, stating:

“There is this idea of loss aversion, that losses are weighed more heavily than gains, so a $200 incentive will not have as much influence as a $200 fine.”

What does this mean for you?

Unfortunately, sticks seem to be more effective than carrots, at least for the most committed of the vaccine holdouts.

Aug
27

Friday update

Posted by Joe Paduda on Friday, August 27th, 2021 | Comments

Sorry loyal readers – been swamped w a big project; auditing the Federal work comp program’s pharmacy program.

Here’s what happened this week while I was immersed in data, workflows, job descriptions, reports and contract terms.

COVID

Florida – from colleague, master fisherman and good friend David Deitz MD PhD came this… anticipating more deaths among the unvaccinated, Florida hospitals are renting refrigerated trucks for temporary morgues.

The Sunshine State isn’t the only state with hospitals anticipating more deaths due to vaccine stupidity. Texas and Kentucky hospitals are also lining up rental trucks…

Most insurers are ending waivers for patient copays/coinsurance for COVID treatment. This means those who do have to get care  – or their heirs if that care doesn’t save their lives – may well face ginormous bills for treatment.  From Kaiser Health News:

 there’s logic behind insurers’ waiver rollback: Why should patients be kept financially unharmed from what is now a preventable hospitalization, thanks to a vaccine that the government paid for and made available free of charge?…

A harsher society might impose tough penalties on people who refuse vaccinations and contract the virus. Recently, the National Football League decreed that teams will forfeit a game canceled because of a covid outbreak among unvaccinated players — and neither team’s players will be paid.

But insurers could try to do more, like penalizing the unvaccinated. And there is precedent. Already, some policies won’t cover treatment necessitated by what insurance companies deem risky behavior…

I’m all in favor of personal responsibility – and no COVID isn’t the same as addiction treatment or lifestyle issues.

Those damn topicals

Topicals and compounds just won’t go away…Mostly because profiteering fraudsters are adept at figuring ways around regulations, insurers’ prior authorization requirements, network contract language, and system edits.

WCRI’s has just published a very useful report on the issue; this data point really got my attention:

payment share for topicals in the typical state increased from 9 percent in the first quarter of 2015 to 19 percent in the first quarter of 2020.

And don’t miss WCRI’s Dr Vennela Thumula and Te-Chun Liu research on off-label use of gabapentinoids, one of the other fast-growing and highly-questionable prescribing practices so damn common in work comp.

What does this mean for you?

Get vaccinated, and be very careful if you live in an area with a low vaccination rate.

And check your drug spend reports for topicals and gabapentinoid utilization. If your PBM can’t help you, get another PBM.