Mar
2

The CDC’s Opioids for Chronic Pain Guidelines; Myths and facts

After my posts last week it is clear there’s a lot of misinformation and misunderstanding about the CDC’s opioid and chronic pain guidelines. At MCM we take the old-school approach to these things; we focus on the facts.

So, here they are.

The CDC’s guidelines mandate strict limits on dosage and require tapering  for patients on long-term opioids.

False.  As Dr Beth Darnall of Stanford University noted recently;

some health care organizations and states have wrongly cited the 2016 CDC Guideline as a basis to substantiate prescribing “dose-based limits” or to mandate that physicians and prescribers taper patients taking long-term opioids to specific thresholds (eg, < 90 mg, or < 50 mg). Such dose-based opioid prescribing policies are neither supported by the CDC, nor do they account for the medical circumstances of the individual patient. [emphasis added]

Further;

The CDC [issued] a clarifying statement that derided the misapplication of the opioid guideline and discouraged the dose-based policies and practices that fall outside of its scope, as well as use of the guideline to substantiate tapering.

The Guidelines for Prescribing Opioids for Chronic Pain were developed in secret.

False.  The process fully complied with CDC and AHRQ requirements and standards, and the results were shared with the public and public comment sought prior to promulgation of the final guidelines in 2016.

The Guidelines aren’t working; look at all the opioid-related deaths.

False.

  1. The big increase in drug poisonings (technical term for overdosing) is driven by a rapid increase in the use of synthetic opioids, both prescription and non-prescription. The synthetic opioid death rate increased over 1000% from 2013 to 2019, with the biggest increase in the western US. Fentanyl and Tramadol are examples of synthetic opioids
  2.  There’s been a small but measurable decrease in the death rate (4.4 to 4.2) from prescription opioids that correlates with the guidelines’ publication date.  Of course, correlation is not causation, but clearly the guidelines have been impactful.

3.  Further, when you count the deaths due solely to prescription opioids, the drop in the prescription opioid death rate is even more remarkable. The bold line is prescription opioid-only; the guidelines were introduced in 2016.

The net is those who claim the guidelines are somehow “failing” are conflating law enforcement issues with public health issues, and are ignoring the very real post-guideline decline in deaths from prescription opioids.

The guidelines are killing people.

The guidelines are just that – guidelines.

The guidelines do NOT require or mandate dosage restrictions or tapering. Blaming the guidelines – and those who developed the guidelines – for physicians not following the guideline’s explicit recommendations is wrong, and does nothing to solve the problem of bad legislation and poor physician behavior.

Here’s what the CDC actually said:

Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. [emphasis added]

There are a lot of anecdotal reports of patients unable to get prescriptions renewed or otherwise forced off their opioid regimen, many with awful consequences. Yes, the guidelines did suggest/encourage/support these tools in certain circumstances, but – as you can read above – these are NOT requirements and require clinicians to evaluate and balance risk and harm.

What does this mean for you?

The real problem with Opioid Guidelines is states, insurers, and other entities – as well as prescribing physicians – failing to use the guidelines as intended.

reminder to commenters – valid email addresses are required, and disagreements are welcome as long as they are supported with credible citations.

 


Feb
18

The prescription opioid crisis is far from over

There’s still lots of money in the peddling of opioids, and lots of misinformation out there about opioid control efforts going too far.

Correlated? You tell me.

The American Medical Association sent a letter to the CDC claiming  “the nation no longer has a prescription opioid-driven epidemic...the AMA urges governors and state legislators to take action [to] remove …. arbitrary dose, quantity and refill restrictions on controlled substances.” [emphasis added]

In a letter sent to the AMA that was also published in the British Medical Journal, Physicians for Responsible Opioid Prescribing took the AMA to task, noting the AMA’s position is misguided at best:

 There is compelling evidence that many of those currently struggling with opioid dependence and addiction were introduced to opioids through use of medically prescribed opioids used to treat chronic pain. Medically prescribed opioids remain a common gateway to illicit opioid use and are themselves frequent causes of opioid addiction and overdose, even if illicit opioids currently cause the greater number of deaths.

PROP’s letter goes on to state:

Suggested dose and duration restrictions are not “arbitrary”, they are based on considerable evidence of when harm far exceeds benefit.

I do not know why the AMA is mischaracterizing the CDC guidelines. I do know opioid manufacturers are very, very good at working the levers of power, expert at manipulating government officials, and extremely generous in their political contributions.

The AMA’s anti-opioid guideline stance is kind of bizarre, bizarre as in Through the Looking Glass. On the one hand, it is mischaracterizing and decrying CDC guidelines that have been instrumental in mitigating the opioid disaster.

On the other, the AMA is claiming credit for reducing opioid use, deaths from overdoses, and various other positive trends, stating “the [AMA Opioid] task force’s recommendations have led to significant progress…”

That’s rather bold, considering:

And, of course, those CDC guidelines have been widely adopted by states, and are widely credited with reducing the damage done by opioids.

At times the guidelines have been misapplied, doctors have arbitrarily applied them, and patients have been abruptly cut off. That is NOT the fault of the guidelines, that are just that – guidelines. Rather, it is the fault of those mis-applying them to patients.

What does this mean for you?

The opioid crisis is far from over.

Controlling inappropriate use of prescription opioids is as important today as it has ever been.


Feb
9

We have a very long way to go.

The first step to recovery is admitting you have a problem. Well, America, we have a problem. That problem is our healthcare delivery and payment system/industry.

Our healthcare system is a mess.

It is unfathomably complicated, far too expensive, and delivers results that are generally good for wealthier White people and not so good for poorer and non-White people.

This is just the high level stuff…

But wait, Medicare is simple…right??

Then there’s our crappy results.

Americans’ life expectancy has dropped while people in every other developed country are living longer.

Oh, and it’s stupid expensive…Americans spend twice as much on healthcare as the average developed country.

But our healthcare is great…right??

Not for Black babies.

But all of us get far fewer doctor visits…

From far fewer doctors…

While Purdue and the rest of the opioid industry make tens of billions of dollars killing our relatives and friends

The result  – we pay waaaay more than other people and die sooner.

What does this mean for you?

Demand better. And do something about it.


Feb
4

Workers’ comp is still in the dark ages.

With extremely rare exceptions, workers’ comp payers – and PPO networks – are doing next to nothing about “quality”.  An illustration.

Let’s compare two hospitals near Jacksonville Florida.

Using publicly available, free data (thanks to RAND), Baptist Medical  is pretty good; it has 4 out of 5 stars on the CMS Hospital Star Compare rating system – the most widely accepted quality rating metric.

Over the bridge is an HCA facility – Orange Park Medical Center – with 2 stars, below average on CMS’ scale.

Both facilities are in multiple workers’ comp PPOs…none of which indicate the large gap in quality between the two. Or any other quality measures for any other facilities.

You’ll note there’s a cost difference as well. And no, you don’t get what you pay for.

The higher-rated facility costs less –  Baptist gets paid about 2.6 times Medicare’s rate for care delivered by private insurers, Orange Park is 4x Medicare.

What does this mean for you?

Want to show you care about the quality of care delivered to injured workers? Send them to good facilities.

 

 


Feb
1

MCM is back – and so is the damn coronavirus

After a brutal three weeks of 12 hour work days, finally came up for air late yesterday. The water is receding, so should be able to get back to my posting duties on a regular basis.

Let’s get right into it.

COVID’s mutations are likely to put off a full recovery till late summer or even fall.

While quite rare, viruses mutate during replication – genetic material gets shuffled around, mixed up, and re-ordered. In most cases the result is pretty minor, or “fatal” to the virus’ replication (as viruses are not technically “alive”, “fatal” isn’t exactly the right term, but close enough.)

Mutations are even rarer for the coronavirus.

So that’s the “good news”.

The bad news is this – with hundreds of millions of people infected, each producing hundreds of millions of individual viruses, there are lots of opportunities for the virus to mutate.

That’s why we now have at least three separate instances of a mutation that appears to make COVID more transmissible. While only one – the UK variant – appears to be slightly more deadly, the overall impact is not good.

Even more worrying, these mutations also appear to make antibodies (one of the immune system’s tools to attack viruses) and perhaps one of the vaccines less effective.

The good news is the Moderna and Pfizer vaccines appear to work almost as well against COVID mutations as they do against the “original” virus. So far.

Meanwhile, vaccinations in the US are few and far between. With only one out of 12 Americans vaccinated to date, we have lagged far behind the world leader – Israel – which has vaccinated over a third of its population.

Amazingly, there are idiots seeking to stop or prevent COVID vaccinations; these people are complicit in the deaths of the 440,000 Americans who’ve died from COVID. (photo credit halperry)

What does this mean for you?

  1.  Wear an FDA-approved N95 or KN95 mask. Not a cloth mask, not a bandanna, not a “surgical mask. (Thanks Mary!)
  2. Prepare for at least six and maybe nine more months of COVID. It stinks and no one likes it and all that – we all need to suck it up, stop whining, help each other out, and power through.
  3. If you can, help out the less-fortunate. Be kind and be generous.

 


Jan
22

COVID update – good news and bad.

The good.

David Colon and Raji Chadarevian of NCCI have produced an excellent summary of COVID’s impact on workers’ comp medical treatment.

Colleagues Brittni Moore and Vicky Mayen have authored a companion piece that provides an early projection of 2020 financials. While not COVID-centric, there’s no doubt COVID is a main driver of the 8.1% decline in private carrier premiums. Moore and Mayen also note final premium totals may well be lower due to pandemic-driven declines in payroll.

As we projected back in the summer, profits remain robust. The pandemic-driven decline in claims plus carryover from inflated pricing due to the opioid factor are likely chief contributors.

A few takeaways from the COVID study:

  • Among COVID claims that had medical expenses, one-fifth had an inpatient stay. Note that this is only for accepted claims WITH medical expenses.
  • Among those claims with an inpatient stay, one-fifth – or 4 percent of all claims with medical expenses – were in an ICU at some point.

graphic courtesy NCCI

My takeaway – medical costs are relatively low.

Meanwhile Johns Hopkins University researchers studying Accident Fund data report there’s only one industry likely to be significantly impacted by occupational claims for COVID – you guessed it, healthcare.

The highlight – “This suggests that the vast majority of workplaces will not be subject to a high frequency of COVID-19 related WC claims over the course of the pandemic.”

Now, the bad news.

Long Haulers are COVID patients with persistent and often strange symptoms that can persist for month. Possibly related to an immune response gone awry, these conditions include (quoting the NYT):

  • fatigue,
  • pain,
  • shortness of breath,
  • light sensitivity,
  • exercise intolerance,
  • insomnia,
  • hearts that race inexplicably,
  • diarrhea and cramping, and
  • memory problems.

While most patients improve over time, one researcher estimates about one in ten have issues that persist for months.

What does this mean for you?

We have a lot to learn about COVID.


Jan
15

COVID’s impact on workers’ comp

Premiums and injury claims are way down; profits remain really high.

Those are the key takeaways from just-released analyses of COVID’s impact on comp from NCCI and WCRI (WCRI report free to members, fee for non-members).

That’s also what Mark Priven and I predicted last summer. I highlight that not to crow but rather to point out that these findings were quite predictable. And others’ grave concerns about COVID hitting profits were completely off the mark.

First, the qualifiers.

  • NCCI’s report includes private carrier data reported by NAIC through September 2020. Things got a lot worse late in the year, so it is highly likely premiums and injury claim drops increased somewhat.
  • WCRI data covers results from 27 states during the first half of 2020

Claim decreases

WCRI’s data shows a stunning decline in non-COVID claims (MO and LT) across the 27 states from Q2 2019 to Q2 2020…a 30% + drop in the vast majority of states.

Not surprisingly, the decrease in LT claims – while still dramatic – wasn’t as large.

The net – overall, claims dropped by more than a quarter in the vast majority of states.

Also, WCRI found that the severity of the outbreak was strongly correlated (my word not their’s) with the decline in non-COVID claims.

Implications

  • TPA revenues suffered as claim counts declined
  • Medical management revenues in the second half of 2020 almost certainly dropped significantly (compared to 2019). Fewer new LT claims = fewer bills, fewer network encounters, less need for case management and UR

What does this mean for you?

  • With COVID infections exploding – and the criminally inept vaccine rollout – we will almost certainly see a reprise of Q2 2020.
  • You can expect this reprise started in December and will continue thru April.

 


Dec
23

COVID update pre-holidays

First – stay careful and smart – this is NOT the time to take risks; hospitals in many states don’t have room in their ICUs or ERs. Drive carefully, mask up (see below for info on the most protective mask), and DO NOT hang out indoors with people outside your “pod”.

To that point..

“Excess” death counts are used to better understand the real impact of COVID. In California, the pandemic is not only leading to tight capacity in hospitals, it is correlated with a significantly higher death rate, especially among Blacks and Latinx people.

This isn’t surprising; people of color are:

  • less likely to have health insurance and
  • thus are in generally poorer health;
  • more likely to live in urban areas with denser populations;
  • have less access to testing; and
  • more likely to work in “essential” industries and in “essential” jobs that place them at higher risk.

This from an NYC physician:

As a physician in an urban pediatric ED, I have worked with families who fear losing their jobs and medical coverage or exposing their children because they cannot work from home; families who feel abandoned by their primary care clinicians after their offices closed down; and families with language barriers or limited internet access precluding their use of telemedicine services, which are not always covered by insurance.

Also notable – the group that had the highest increase in excess deaths was people under 24 years old.

It’s not just California. A national study of excess deaths among 25-44 year-olds showed just over a third were from COVID.

Workers’ comp claims

COVID-related claims in California hit an all-time high last month.

A quarter of all claims in November were COVID-related.

BUT…claims are down by almost 17% for the year.  One out of every six claims disappeared…

double But – only (!) one of every 10 projected claims didn’t happen. (claims counts are on a decades-long structural decline)

Other key metrics:

  • about 1/3rd of all COVID claims are denied
  • over half of all WC COVID claims are for people under 40
  • to date, one of every eight claims is COVID-related

CWCI has led the way in reporting, documentation, and accuracy in all things COVID claim related.

Insurance execs are concerned.

As well they should be. The fine folks at NCCI report that COVID is the top concern amongst the insurance execs they polled.

I still don’t get fears about  presumption (the number 2 concern). COVID claims are cheap, resolve relatively quickly, and rarely become cat claims. Yes a very small percentage of patients may become Long Haulers, but even then they don’t/won’t represent a lot of dollars.

Concern about rate adequacy is even more puzzling.  Rates have been too high for years, driven largely by declines in opioid-related costs and disability. While that may change w the uptick in opioids, to date we’ve seen nothing that indicates the long-running gravy train that is workers’ comp is headed off the tracks.

What does this mean for you?

Prevention is the best cure – the most protective cloth mask is a two-layer woven nylon version.

If you don’t have one, use your regular mask this way:

See you next year.

 


Dec
21

Florida’s hospitals win big. Employers and taxpayers lose big.

Defying statutory requirements, logic, common sense, good government, fairness, basic math and the facts, Florida’s workers comp regulators just hammered the state’s employers, taxpayers, and physicians.

This is NOT yesterday’s Three Member Panel meeting, altho it bears a striking resemblance…foregone conclusion after a lot of theatrics

In a regulatory process resembling a Soviet show trial, the Three Member Panel slammed through a reimbursement scheme that will raise costs for employers and taxpayers while making sure Florida’s docs are among the lowest paid in the nation.

Allow me to list a few of the TMP’s many errors.

  1. The TMP failed to comply with the law that established the TMP, which reads in part:
    Paragraph 440.13(12)(d), F.S. further 4 states: In establishing the uniform schedule of maximum reimbursement allowances, the panel must consider: 1. The levels of reimbursement for similar treatment, care, and attendance made by other health care programs or third-party providers; [note that several organizations gave the TMP data comparing WC reimbursement to Medicare and others; the TMP ignored it] 2. The impact upon cost to employers for providing a level of reimbursement for treatment, care, and attendance which will ensure the availability of treatment, care, and attendance required by injured workers…”
    The TMP said the scheme would reduce facility costs by 23%, citing an NCCI analysis that indicated the revised hospital fees. HOWEVER, the comparison data used in the analysis was from 2019, when hospitals were able to game the system by over-charging work comp patients. After a court ruling some months ago, many payers started denying outlier payments – and that continues to this day. [edit after hearing more from NCCI]
    Thus, the comparison does NOT reflect the actual difference between current and future costs due to the TMP’s new reimbursement scheme.
  2. The TMP refused to even consider the impact of rampant price-gouging by facilities with high charges on employers and taxpayers. This is very well documented, yet somehow escaped the TMP’s consideration.
  3. An incredibly naive comment by one TMP member illustrated his total ignorance about medical costs in work comp. According to a piece authored by William Rabb in WorkCompCentral, “worker representative” Jason Robbins said that in his experience, since few workers end up in the hospital, it’s not a big deal. [Why read WCRI studies when you can just rely on your own “experience”?)
  4. The estimable Mr. Robbins also noted excess insurance protects the insurers from high costs. Of course, employers and taxpayers have to pay premiums to excess insurers, which are driven by facility costs, a reality that appears to have escaped Mr. Robbins.
  5. Then there’s the hospital lobbyist noting that the law doesn’t require reimbursement to be “reasonable”…looks like the TMP bought into HCA attorney Jennifer Hinson’s opinion on what the law says.  Attorney Hinson’s opinion is – to be kind – not supported by the actual law, which states:
    “The uniform schedule of maximum reimbursement allowances must be reasonable, must promote health care cost containment and efficiency with respect to the workers’ compensation health care delivery system…”[italics added]
  6. Even the employer “representative” on the TMP, one Tamela Perdue, also voted in favor of hospitals. Perdue is an attorney employed by Sunshine Health, a Florida health insurer owned by Centene.
    I’m a bit surprised Perdue is a) on the TMP and b) voted; there’s a potential conflict of interest here as her vote favoring hospitals could be seen as a favor to hospitals in Sunshine Health’s network.

Finally, there’s a wealth of research indicating Florida’s reimbursement of physicians is way too low.  Rather than take a stand on this, the TMP just said it wasn’t anything they could do anything about.

Leadership at its finest, no?

What does this mean for you?

This is a not-very-well-hidden tax on Florida employers and taxpayers.

[note – I asked the Dept of Workers’ Comp for comment; as of this time they did not respond]


Dec
15

COVID – quick takes on the latest research

A solid study found that the US infection rate is likely way higher than the official reports. The brainiacs at The Economist estimate almost one in every five of us has had the disease.

Coincidentally, I was talking with a client yesterday about his bout with what sounded a lot like COVID. Turns out his wife had it as well.  This is just one of several stories I’ve heard from folks who got sick as far back as last December or January.

The Economist has a very well done COVID tracker that provides data on excess deaths during the pandemic era, as well as a description of potential reporting issues and causes.

Before you scoff, read the article; the evidence is compelling that the pandemic has led to many more deaths than expected.

A study examining hospital readmission rates for COVID patients found more than a quarter died or returned to the hospital after their initial discharge. This sounds pretty high, but it is actually lower than longer-term death and readmission rates for heart failure and pneumonia patients.

Thanks to WorkCompWire for the piece on CWCI’s report on claims for public self-insureds for the fiscal year ending June 30, 2020. Recall that COVID hit California in early March, so the reports’ findings reflect 8 months of a “normal” year and 4 pandemic months.  Top takeaways:

  • Claim counts dropped over 6%
  • Indemnity expenses zoomed up almost 17%.

My view – it is highly likely the pandemic drove increased disability duration as patients couldn’t access care, facilities postponed elective procedures, and newly-injured workers found it harder to get appointments.

You’ll likely hear much more in a few months if you Save the Date for CWCI’s Annual Conference – on Thursday, March 11, 2021 the brilliant minds and best-presenters-in-the-industry will once again inform and enlighten.  Details forthcoming…topics to include a discussion on how the industry reacted to COVID and the results of current research.

Sticking with workers’ comp, a Kimberly George/Mark Walls piece in National Underwriter noted TPA Sedgwick has handled:

45,000 COVID-19 workers’ compensation claims for their clients. 78% of those are closed with an average paid of $1050. 54% of the claims had no payments made.

That’s pretty consistent with findings from my firm’s June 25 survey of 35 payers and service providers (summary report download at no cost); from an interview back in June:

a lot of claims are filed with no payments…[a] respondent stated “96% of claims cost less than $3,500, but 4% are expensive.”

Finally, the news that Moderna’s vaccine will likely be approved for use this week is excellent news indeed. The company participated in Operation Warp Speed, the Trump Administration’s effort to jumpstart vaccine development by funneling $18 billion in taxpayer funds to organizations and companies working on vaccines.

One of the most positive signs is Moderna’s vaccine showed equal effectiveness among white and non-white subjects. As COVID has been particularly devastating in communities of color, this is critically important.

This from the NYTimes:

There was also no significant difference between its protection for men and women, or between healthy volunteers and those at risk of severe Covid-19 who had conditions like obesity and diabetes. For people 65 and older, the trial provided an estimated efficacy of 86.4 percent, lower than the overall estimate of 94.1 percent. But the apparent difference was not statistically significant.

So far, two potential differences between the vaccines have emerged from the F.D.A.’s reviews, but the findings may [emphasis added] reflect a shortage of data rather than genuine differences. The Pfizer-BioNTech trial showed that their vaccine started to protect against the coronavirus within about 10 days of the first dose. The trial of Moderna’s vaccine, by contrast, did not reveal such a striking effect after the first dose.

What does this mean for you?

Wear the mask and be very careful. This is  very far from over.