Sep
17

Where have all the work comp opioid patients gone?

Workers’ comp has done an admirable job reducing the volume and potency of opioids dispensed to work comp patients.

This from our latest Survey of Prescription Drug Management in Workers’ Comp…

The question is – how many work comp patients really stop taking opioids?

A Canadian study offers a sobering possibility – many likely did not.

those injured workers that received…120 MED or more at the end of their claim were likely to have post-claim opioid use in approximately 80% of cases. [emphasis added]

Caveats abound – different country, different system, different approach to opioid management. Yet we need to ask ourselves questions that are deep and uncomfortable.

Did we really help these patients?

Were they addicted, dependent, and/or have serious chronic pain that we failed to adequately address?

Have we looked deep enough into what happened to those patients taking opioids after they stopped?

Perhaps most important – What is our responsibility to those patients?

This is not – an any way – justification for the opioid industry’s twisted and misguided attack on efforts to reduce opioid over-prescribing. It is crystal clear that industry has killed hundreds of thousands of people, devastating communities and families.

Rather, we need to make very sure we are doing the right thing for patients. In some instances this will involve telling patients what they don’t want to hear; we need to be prepared to do that and help them thru the process, while understanding that process is very difficult.

What does this mean for you?

Do you know whether patients no longer getting opioids via work comp are still taking them? What responsibility do you bear?


Sep
13

The Purdue Opioid “settlement” – key takeaways for workers’ comp

Reportedly Purdue Pharma, the fine folk behind OxyContin, is nearing a settlement with 23 state attorneys general and thousands of other governmental entities.

Here are the key takeaways:

  • this does NOT appear to be a universal settlement; other state AGs, local governments, employers, and other affected entities will almost certainly seek their own compensation from Purdue.
  • The Sackler family, Purdue’s owners, will lose up to $3 billion of their personal fortunes estimated to total $13 billion – most of which came from OxyContin sales.
  • Purdue Pharma will enter bankruptcy and future earnings will go to addressing the awful repercussions of the opioid crisis

What wasn’t included are criminal charges for the Sacklers; that is an outrage.

It is crystal clear many members of the family were intimately involved in Purdue’s efforts to shove more and more opioids down more and more throats. Not satisfied with those billions, the arrogant bastards were going to make yet more treating the addicts they created. (Note not all of the Sacklers were involved in the opioid disaster)

This from NY’s opioid lawsuit (credit Vox)

The unmitigated gall of the Sacklers is stunning; they knew their drugs were killing tens of thousands, and now wanted to profit from the untold damage they had done.

For workers’ comp, there are a couple of implications.

First, as the tort industry dives deeper into this, they will sue more and more participants. My informed opinion is payers are pretty safe for several reasons;

  • state regulations are the primary and ultimate driver of work comp coverage;
  • work comp entities led the charge to reduce opioids when they first grasped the size of the problem;
  • payers did not receive rebates from opioid scripts so there was no financial benefit to allowing the scripts; and
  • payers were damaged by the opioid industry due to much higher medical costs, extended disability duration and death claims.

I haven’t heard of any workers’ comp entity being sued for damages related to opioids – but it is possible.

Second, work comp payers have been damaged by the Sacklers and their ilk. While state funds may be involved in some of the suits seeking compensation for damages (it’s impossible for me to unpack all the plaintiffs in all the filings), I have yet to hear of any suits involving commercial insurers or reinsurers.

I’ll admit to being surprised at the work comp insurance industry’s seeming lack of interest in taking on the opioid industry. Every day:

  • Insurers go after claimants for double-dipping and false claims,
  • Insurers go after employers for falsifying payroll data,
  • Insurers go after providers for fraudulent billing for practices, and
  • Insurers sue each other over coverage issues and reinsurance claims.

Before anyone else could spell opioids, work comp payers saw the damage being done and took action.

What does this mean for you?

Work comp insurers must be a highly visible part of the solution; we owe it to policyholders and taxpayers, we owe it to patients, and we owe it to all of the insurer staff, regulators, researchers, and other stakeholders who’ve dedicated untold hours to fixing the damage done by the Sacklers and their ilk.

Need more incentive? Here’s David Sackler’s $22 million Bel Air mansion your workers’ comp dollars helped pay for.

 


Aug
7

Work comp vs. opioids – how we’re doing

It’s been a decade since work comp payers and PBMs got the big wakeup call, the one that changed the industry.

From looking at drugs just as an expense, the industry began to see how devastating these drugs were to patients, families, employers, and taxpayers. Instead of fighting over the price of each pill, payers started to push PBMs to figure out ways to slow down the spread of these incredibly dangerous drugs.

Today, we’re on a roll. While anyone with any sense of the issue knows opioids will remain a top 3 issue for years to come, we’ve made a lot of progress.

After surveying 30 workers’ comp payers, we’ve learned this:

  • Opioid spend dropped 19.7 percent from 2017 to 2018.
  • For the first time on record, opioid spend represents less than a fifth of total drug spend
  • By a long shot, opioids are not the biggest problem in workers’ comp pharmacy. (3 respondents out of 30 said they are)
  • Payers believe the’ve made more progress dealing with initial opioid scripts vs chronic
  • By far the most important tools have been more internal resources and focus on the opioid issue, followed by new regulations and legislation and payers adopting a comprehensive approach to the issue.

We’ve got work to do, to be sure.

But we should take a minute – or a day – to stand back and revel in what we’ve accomplished. 

The industry has cut opioid usage probably in half, and it’s headed further down. People haven’t died, families haven’t been destroyed, pills haven’t found their way into kids’ hands.

What does this mean for you?

A welcome opportunity to reflect on a very hard job done well.

 


Jul
17

The latest data on opioids in work comp

We’ve just about completed the 16th (!!) Survey of Prescription Drug Management in Workers’ Comp, and there are two key findings you need to know.

First – total opioid spend in 2018 dropped 23.2% across all 27 respondents (ranging from very large TPAs to state funds to insurers to small state-specific payers). The average decrease among respondents was just over 22%.

That dramatic reduction comes on the heels of a 16% reduction from 2016 to 2017, and a 13% decrease in 2016.

From last year’s Survey; each numbered column denotes a respondent’s results (2019 Report will be out in August)

Over the last few years, payers and PBMs have cut the amount of opioids dispensed to work comp patients by more than half.

While cost reductions are good news for employers and taxpayers, when you talk with payers its mostly about patient safety and return to functionality. Patients taking opioids over long periods aren’t getting better, aren’t going back to work, and most (but not all) are not functioning very well. That means they aren’t the parents, friends, daughters or sons, grandmothers or grandfathers they can or want to be.

Second takeaway: payers are anything but satisfied or complacent. All the 27 people I’ve talked with to date remain focused, committed, and completely engaged in continuing to fight the good fight against overuse of opioids. They’ve asked me what other payers are doing, what they can do differently, what works and what doesn’t.

That’s a great relief. One would understand if payers’ focus was shifting to other issues, now that they’re seeing massive progress in the battle over opioid over-prescribing.

With some exceptions, the knottiest problem remains how to help chronic opioid patients find other ways to handle their pain, to help them function at a higher level even with chronic pain. Payers are very creative and dedicate lots of dollars and time to solving chronic opioid usage. This focus will continue to help patients get better, while reducing costs for employers and taxpayers.

I’d be remiss if I didn’t note – once again – that work comp is leading the rest of the world on solving the opioid issue. You knew about it sooner, took drastic action much faster, and are delivering much better results than Medicaid, group health, or Medicare. 

Yeah, the workers’ comp industry is often maligned for its many faults and challenges. But this is one area – and a damn important one – where you’ve got much to be proud of.

What does this mean for you?

Well done. Stay focused. 

 

 


Jul
11

With 20+ interviews to date, we are starting to see some patterns in responses.

For those unfamiliar with our annual survey, click here to get access to public versions of the last dozen-plus Survey Reports.

Respondents are the folks in charge of the pharmacy programs at major work comp insurers, TPAs, state funds, and self-insured employers. Drug spend ranges from $200 million plus to $1 million.

Quick takeaways:

  • Spend continues to decrease; haven’t totaled up the numbers yet but my guess is it’s a high-single-digit drop from 2017 to 2018.
      • A big cut in opioid spend is a major contributing factor
  • Transparency is the biggest single issue in work comp pharmacy; respondents aren’t happy with the level of transparency, are frustrated with the lack of clarity around AWP, and want more detail on pricing.
  • That said, respondents generally acknowledge it’s fine for PBMs to make a margin, they just want to make sure that margin is reasonable.
  • Opioids remain perhaps the biggest issue, but many payers have made remarkable progress in reducing both initial and chronic opioid usage.
  • Compounding is seen as all but dead, crushed by aggressive moves by payers, regulators, and legislators.
  • Specialty medications while not yet much of an issue, may well be especially if assumption laws for pubic safety workers gain more acceptance.

There’s a lot more to come; we’ll be wrapping the data collection part of this year’s effort in a few days.  If your organization’s pharmacy program management person  wants to participate – and get a detailed, respondent version of the Survey report, let me know via the comment box below this post…


May
31

Drug price fixing – the impact on workers’ comp

The generic drug manufacturers’ price-fixing scheme raised prices by up to 1,000 percent. There’s good news for workers’ comp payers as the impact has been minimal.

Here’s why.

Workers’ comp is mostly about trauma treatment and pain management; relatively few drugs are involved. Contrast that to Medicaid, Medicare, and health insurance which cover all conditions – and have a much broader “formulary”.

Contrary to what others have opined, this didn’t have any significant impact on workers comp, because there were very few “work comp” drugs affected by the price-fixing.

Here’s more from my conversation with Jim Andrews, RPh.

MCM – In your view how did the alleged price fixing affect workers’ comp payers?

Andrews – Since WC utilizes specific drug classes the impact of these 100 drugs could/would be significantly less than that of the commercial and governmental markets (especially Medicare and Medicaid). A quick scan of these drugs (without reviewing the larger WC PBM annual drug trends) reveals that there are blood pressure medications, antibiotics, birth control, dermatological , blood thinners etc. I do not see (might have missed it) – narcotic pain medications.

So the overall cost impact from this companies’ activities do not significantly impact WC by themselves.

MCM – What medications commonly used in workers’ comp may have been involved?

Andrews – Generic Celebrex (celecoxib), generic Neurontin (gabapentin) and generic ketoprofen represent some of the more commonly prescribed drugs utilized today.

[These drugs] didn’t seem to detail the same level of price support that some of the other drugs had e.g. pharmacy and GPO involvement.

[MCM – note data from workers’ comp PBMs indicate the these three drugs account for about 7% of total drug spend].

MCM – There’s a difference between drug reference price (AWP, etc) and the actual price paid. Does the report provide any insight into whether the price fixing actually affected the price paid?

Andrews – It is unclear to me whether the purchase price for these channels actually increased or whether the drug reference price e.g. AWP increased.

MCM – this from Vox shows changes in overall drug costs over time.

What does this mean for you?

Yes, the price-fixing affected workers’ comp, but not much.


May
30

Drug price fixing…the details

A massive price-rigging scheme that drove up drug manufacturer profits by inflating drug prices has been exposed in a lawsuit filed earlier this month by 44 states.

Rather than compete in an open market, manufacturers including Teva, Pfizer, Novartis and Mylan conspired to split up market areas, allowing them to increase prices for more than 100 generic drugs by up to 1000%.

Are you angry yet?

NYTimes:

“A key element of the scheme, the complaint alleges, was an agreement among competitors to cooperate on pricing so each company could maintain a “fair share” of the generic drug markets. At the same time, the companies colluded to raise prices on as many drugs as possible, according to the complaint.”

The Times’ piece added:

“Rather than enter a particular generic drug market by competing on price in order to gain market share,” the complaint states, “competitors in the generic drug industry would systematically and routinely communicate with one another directly, divvy up customers to create an artificial equilibrium in the market, and then maintain anticompetitively high prices.” [emphasis added]

I asked Jim Andrews, RPh, for his thoughts on the suit; here’s the first part of our discussion. [Jim has been working in retail pharmacy and PBM for decades and understands this stuff as well as anyone]

MCM – In your view is the suit filed on solid ground?

Jim – Yes, it is obvious from the volume of materials collected, referenced and cited – that this investigation has been going on for multiple years. I think the sheer volume is indicative of the seriousness of the lawsuit. Many areas of the lawsuit that I found were redacted so I assume they are the most damning.

MCM – What were some of the key claims made by the plaintiffs that caught your attention?

Jim – Hyperinflation of common generic drugs, especially after 2012. Fair share territories maintained between competing generic manufacturers that preserved current drug pricing and prevented price declines. Collusion between competing generic drug companies in the form of sharing confidential information on drugs, pricing, customers and strategies.

MCM – It appears that the alleged behavior has been going on for some time – do you think this type of behavior has occurred before?

Jim – I assume that this had been going on prior to the 2012 time frame referenced in the lawsuit but the 2013/2014 hyperinflation indicates a period of increased strategic cooperation.

What does this mean for you?

The alleged criminal behavior cost consumers – and some payers – millions. 

Tomorrow – what this means for workers’ comp.


May
28

Hey work comp payers – Do Your Job.

Has any workers’ comp insurer, excess carrier, or state fund, any self-insured employer sued opioid manufacturers, distributors, or dispensers?

Have you?

Generic opioid manufacturer Teva just settled a lawsuit with  Oklahoma, paying the state $85 million. Purdue Pharma – in my view the worst company in the world – had already agreed to pay $270 million –  $70 million from the founding Sackler family’s coffers. Next up is Johnson and Johnson subsidiary Cephalon.

Sounds like a lot, right? Well, no.

The annual cost to the rest of us – in taxes, insurance premiums, lost wages, higher drug costs – is in the hundreds of billions of dollars ANNUALLY.

Meanwhile, a massive lawsuit involving 1600 cities, counties, other governmental entities, and Native American groups is headed to trial later this year in Ohio.

And, Massachusetts’ Attorney General Maura Healey’s suit against Purdue is pending. The massively detailed complaint is comprehensive and terrifying in its detail; here’s the AG’s record of the billions the Sacklers made from OxyContin.

I’ve asked dozens of work comp execs about this, and with a couple of exceptions, none have reported they are suing anyone in the opioid business.

Why not?

Is it because it’s too much work?

Or insurers don’t really care as they can just increase premiums to pay opioid-related costs?

Neither is remotely acceptable.

Workers’ comp payers – all of you – have a fiduciary responsibility and an ethical and moral duty to recover as much money as possible for their policyholders from the companies and people who’ve addicted, killed, and destroyed work comp patients. Those dollars should go back to the taxpayers and employers harmed by the opioid industry.

What does this mean for you?

Yes it’s going to be hard. Stop making excuses and start doing your job.

 


May
24

Research Roundup

In which I drop a “Nerd Bomb” into your email folder…

Here’s this week’s research-that-impacts-you I found compelling…

From WCRI, a report analyzing the relationship between prices for medical services and patient outcomes. More specifically, authors Olesya Fomenko and Bogdan Savych and ask the question “What happens to worker outcomes when prices increase or decrease?”

The authors used a comparison of workers’ comp medical prices for common office visits to group health, with the latter used as a proxy for adequate or benchmark compensation (my words, not the authors’.)

Key takeaways:

  • Medical prices are “not strongly related to measures of recovery of physical health and functioning, speed and likelihood of return to work, or duration of temporary disability.”
  • But…as all healthcare is local, there are some unexpected (at least to me) findings.
    • in areas where WC pays less than group health, raising WC prices results in more care delivered to WC patients, increased temporary disability (TD), but no significant change in access to care – and no impact on outcomes
    • where WC pays MORE than group, increasing WC prices results in more care delivered to WC patient, less concern about access – but NO meaningful impact on outcomes

Changing bad health behaviors

If you’re using financial incentives to change people’s health behaviors, you may be disappointed. Research published in NEJM indicates support from loved ones and clinical support are  more effective.

Pharmacy costs

Lost in the mostly-incoherent squabbling about drug prices is this: Net prices – that is, what insurers/healthplans/employers/payers paid AFTER rebates – for “traditional” drugs DROPPED last year (specialty med prices increased marginally).

Dr Adam Fein’s analysis of PBM trend rates showed the overall increase across all PBMs was in the low single digits; individual PBM results varied somewhat.

I’d encourage all to read Dr Fein’s post – and to subscribe to Drug Channels.

Speaking of drugs, the American Pain Society – the fine folks partially funded by opioid manufacturers looks to be filing for bankruptcy. 

Finally, how important is clinical care to a person’s overall health?

The answer – not much.

Your family income, environment, whether you take care of yourself – all these are WAAAAAY more important than the quality of care you get.

Which ties in pretty well to the research above about health behaviors.

What does this mean for you?

Get out and take a walk, and lift some weights too!

Note – this is me getting some exercise while on the boy’s annual mountain bike trip in Moab, Utah. Fortunately the “healthy behavior” of riding my bike a lot wasn’t outweighed by my inability to avoid crashing a few times…


May
13

Explaining pharmacy pricing, part 4

Do you have any idea if you are paying your PBM what you should?

Work comp payers’ PBM pricing is based on AWP; typically it is a percentage below AWP. Brand drugs are discounted 10-16%, and generic pricing is typically below AWP -40% .

The PBM is making its money on the “spread”; the difference between what it pays the pharmacy, and what it charges you.

Your PBM contracts with retail pharmacies, chains, food and drug purveyors (think Walmart), and independent pharmacies. In some cases third party billers are also contracted, along with physician dispensers and mail order pharmacies.

Here’s where it gets funky.

The PBM’s contracted rates with those pharmacies are all over the place and may even vary by region or drug. That’s fine; you are getting a discount, and the PBM is betting it will – overall – make a profit.

That is, it’s fine IF your average discount is equal to or better than what you were promised.

Reality is, very few workers’ comp payers review their PBM’s bills to make sure that the average discount is what they were promised. 

Workers’ comp insurers and TPAs audit claims, case management performance, reserves, bill review, hospital bills, network discounts, legal bills…pretty much everything BUT pharmacy.

The Russians said it best.

That is NOT to say PBMs purposely mess with the numbers/bills/codes to increase their reimbursement. Rather, like any entity, mistakes can be made, lapses occur, updates lag.

Unfortunately, in the audits we’ve seen these errors usually benefit the PBM.

What does this mean for you?

If you’re looking to ensure you’re paying what you should, let’s talk.