Oct
1

Friday catch up

Let’s spend a minute on all things workers’ comp – and one COVID note.

First up, the fine folk at WCRI – in particular the eminent Bogdan Savych PhD – are putting on a free webinar on the

Effects of Opioid-Related Policies on Work-Related Injuries

– register here. This is particularly helpful for me; I’m helping out on a Federal research project comparing outcomes, impacts, and patient experiences from opioid programs and regulations in Washington and Ohio. Thanks to all taxpayers for helping fund this project – this is some really interesting work that I am quite sure will increase our understanding of opioid management.

NCCI just released their annual analysis of work comp industry reserves… And boy oh boy are there are a LOT of extra reserves sitting in payers’ coffers.

Key takeaway – NCCI-projected industry loss and LAE ratios continue to be below those reported by carriers.

Said another way, carriers are NOT releasing these excess reserves in the form of dividends or credits or whatever. My take – carriers are salting away dollars to protect their future profits from the inevitable – but much delayed – market turn.

While one may think this is a one-time difference between carriers and NCCI, the data clearly shows otherwise.  Over the last decade insurers have consistently over-estimated claims and admin costs  – especially from 2014 to 2017. (graph courtesy NCCI)

So here’s my take – carriers are over-reserving because their actuaries haven’t yet figured out the rapid decrease in opioid utilization is having a major impact on claim duration, indemnity expense and medical costs. Carriers were well behind the curve when opioid use exploded in the middle of the last decade, and they are repeating that error now on the downside.

As a long-time – as in 27 years – consultant, I’m always on the lookout for advice for clients about working with consultants. Great piece in Harvard Business Review on that topic…key takeaways are consistent with my experience:

  • first and most important, spend the time to define the problem(s) you are looking to solve for. That will save untold weeks – and thousands of dollars billed
  • all parties should be humble and very open-minded – including the consultant
  • don’t assume you know the solution; going to RFP should be an option, but not the first one to address a market need, performance issue or vendor problem

File this away and pull it out next time you look to engage a consultant – me or anyone else!

One COVID fact check…I’ve heard from a couple folks that migrants on the southern border are a major source of COVID infections – partially because they aren’t being tested. Well, all are being tested, and the test positivity rate is actually much lower than among residents of border counties.

(note that a recent report indicating 18-20% of migrants leaving Border Patrol custody tested positive specifically includes ONLY those migrants targeted for “expedited removal” and thus is not a complete sample of all migrants)

While those two data points don’t completely address the assertion that migrants are the cause of infections (and there’s no way to prove or disprove that assertion) – it is clear that COVID infections in those border counties would be a lot lower if more residents wore masks and were vaccinated.

What does this mean for you?

Always check your sources, be humble, and do your research.


Sep
9

The state of the industry – pharmacy management in workers’ comp.

29 payers responded to this year’s Survey, ranging from very large TPAs to small state funds, from small guarantee associations to large insured employers and insurers. As always, no individually-identifiable information is disclosed or contained in the Survey report.

Here’s the key takeaways from our 17th Annual Survey of Prescription Drug Management in Workers’ Comp.

  • Total work comp drug spend for 2020 was about $3 billion, or about 10% of total medical spend.
  • That’s down from $4.8 billion a decade ago.
  • Opioid spend decreased 19.3% from 2019 to 2020
  • Pharmacy management remains important despite these decreases, primarily due to respondents’ view that drugs have a disproportionate influence on claim outcomes and disability duration.

You can download your copy of this year’s Survey here – just click on “resources” at the top. Previous Surveys are also listed and all are free to download.

Note that the public version at the link is not as extensive or detailed as the respondent version. As respondents invest time, energy, and brain power helping with the Survey, they get the detailed version.

 


Aug
30

Help me understand…

Why some people refuse to get vaccinated, but are fine with taking large doses of drugs commonly used for horse de-worming.

Out of 163,000,000 people fully vaccinated, there have been 1,263 COVID deaths…yet anti-vaxxers still refuse to do the easy, safe, and smart thing.

Yep, in just one state, Missouri, there’s been a big jump in calls to the poison control center due to people in distress from taking ivermectin; at least two Mississippians have been hospitalized due to overdosing on the drug…. and 7 out of 10 calls to the center have been for ivermectin.

Ivermectin is also a big problem in Texas…

Ivermectin “tablets are approved by the FDA to treat people with intestinal strongyloidiasis and onchocerciasis, two conditions caused by parasitic worms.”

News flash – COVID is NOT transmitted by parasitic worms. Nor is there ANY credible evidence it protects against COVID or has any meaningful effects.

Yes, there is a research paper based on a meta-analysis authored by several scientists but these “scientists”:

  • didn’t disclose they are members of a group promoting ivermectin;
  • ignored the fact that most of the studies cited had “incomplete information and significant methodological limitations, which make it difficult to exclude common causes of bias,”
  • views were rejected by the leading scientific society focused on infectious diseases; and
  • another meta-analysis rejected the ivermectin-supporters’ “conclusions.”

Oh, and “The few existing higher quality clinical trials testing ivermectin against the disease uniformly have failed to find a positive result. It’s only the smaller, lower-quality trials that have been positive. This is a good indication that the drug probably doesn’t work.”

Double Oh, and the rest of the scientific world isn’t having their BS.

Triple Oh... after internet sleuths raised concerns about plagiarism and data manipulation, the preprint server Research Square withdrew the paper because of ‘ethical concerns’.”

And one more Oh…

Not only is ivermectin very much unproven, it is also dangerous when taken in large doses. From the FDA:

You can also overdose on ivermectin, which can cause nausea, vomiting, diarrhea, hypotension (low blood pressure), allergic reactions (itching and hives), dizziness, ataxia (problems with balance), seizures, coma and even death.

There are multiple reports of people taking horse-level doses of ivermectin;

Again the FDA:

animal drugs are often highly concentrated because they are used for large animals like horses and cows, which can weigh a lot more than we do—a ton or more. Such high doses can be highly toxic in humans.

Moreover, FDA reviews drugs not just for safety and effectiveness of the active ingredients, but also for the inactive ingredients. Many inactive ingredients found in animal products aren’t evaluated for use in people.

Meanwhile, reality is “less than 0.004% of fully vaccinated people had a breakthrough case that led to hospitalization and less than 0.001% of fully vaccinated people died from a breakthrough Covid-19 case…”

So we have knuckleheads overdosing on horse de-worming drug while they refuse to get vaccinated because…why?

They’re suicidal?

No – it’s actually because their “tribe”/”clan’s” views are more important to those individuals than ANYTHING else – including their lives and the lives of their loved ones, babies, grandmothers and spouses.

What does this mean for you?

Belonging to the tribe, and being accepted by the tribe, is the dominant force in the life of anti-vaxxing ivermectin-takers – and no amount of science, marketing, education, compassion or reason is going to get most of them to change.


Aug
27

Friday update

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 thisanticipating 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. 


Aug
12

Hypocrisy and Hippocrates

A physician posting on MedPage blamed many of the problems in healthcare on private equity…and for-profit insurers.

That takes some…[insert anatomical reference here]. While his assault on Private Equity does have some merit, I can’t let his assertion that the profiteers are insurance companies stand.  What makes me nuts is Liu’s mindless and demonstrably false assertion, coupled with his complete inability to see that he is part of US healthcare’s cost problem.

Dr Mitchel Liu stated “For-profit insurance companies have long been regarded as the ultimate offenders in medical profiteering.”
Wow. Coming from a physician, who make more than docs in any other country, that is ballsy indeed.
Reality is physician compensation is a key driver of healthcare costs, and one of the reasons our healthcare costs are so much more expensive than other countries’. For-profit healthplans do make billions…but their margins are tiny compared to healthcare providers.
Liu also says:
“It’s time for medicine, including individuals and professional societies, to restore the integrity of the physician-patient relationship by taking a strong stand against all forms of corporate greed.”
Well, docs are often partners in Ambulatory Surgical Centers and hospital outpatient surgery centers.  Many docs belong to big multi-specialty groups that are quite profitable.  And, docs make a lot of money.
What does this mean for you, Dr Liu?
How about taking a stand against physician greed, Dr Liu?

Aug
10

Opioids, tapering, and risks – what you need to know

WorkCompCentral’s Mark Powell penned an excellent piece on just-released research on tapering long-term opioid patients.

One finding demands our attention; researchers found a statistically significant increase in overdoses and mental health crises in the 12 months after tapering was concluded. On average, these adverse events (science talk for bad stuff) happened 6 months after tapering concluded.

From the JAMA article:

In the current study, tapering was associated with absolute differences in rates of overdose or mental health crisis events of approximately 3 to 4 events per 100 person-years compared with nontapering. These findings suggest that adverse events associated with tapering may be relatively common and support HHS recommendations for more gradual dose reductions when feasible and careful monitoring for withdrawal, substance use, and psychological distress. (emphasis added)

The study included 114,000 patients who had been on stable, higher doses (50+ morphine equivalents) of opioids over an 11-year period. It came on the heels of two chronic pain studies published earlier this year; one addressed opioid treatment for chronic pain and the other was a meta-analysis of 190 studies focused on non-opioid treatment. I wrote about both here.

Tapering is an opioid management approach involving a steady decrease in opioid dosage over a prescribed time. The decreases in dosage and how fast patients were tapered varied significantly among the patient population; patients who were on higher doses before tapering were at increased risk for adverse events.

There were some limitations in the study including; the population was Medicare Advantage and commercially insured; individual patient tapering may have varied after the initial decrease; and the data didn’t indicate if the prescriber or patient initiated the tapering.

A thoughtful and detailed discussion of tapering is here…in part the paper states:

The authors emphasize that any medical action taken should involve as much patient buy-in as possible and should not be driven by rigid opioid dose cutoff s and misinterpreted guidelines. The authors of this paper also support sustaining patients on their existing medication at its existing level if patients are continuing to benefit from use, are not experiencing significant side effects, and express the desire to remain on their current medication as opposed to pursuing a taper. In such cases, the risks of a taper would outweigh the potential benefits.

Regardless, this is a wake-up call to the industry. Yes, workers’ comp – once the addiction creation industry – has made great progress in reducing inappropriate opioid usage and some progress in helping long-term opioid patients reduce or eliminate opioids.

That said, there are a variety of opioid management approaches, and we should be considering – and open to – any and all.  Medication-assisted therapy involving methadone or buprenorphine, physical therapy, acupuncture, yoga, and talk therapy are among the approaches that have shown promise.

I’ll end quoting myself from a post back in 2019;

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.


Jul
23

Well, I got that one wrong…COVID-related treatment delays

Didn’t happen.

That’s the result of a just-published study conducted by Olesya Fomenko PhD, one of WCRI’s talented researchers.

Not only were there no delays during the first half of 2020, when the pandemic was raging – but there was a slight improvement in waiting times for some services.  This may have been due to non-COVID patients actively avoiding medical treatment facilities (that’s my speculation, not Dr Fomenko’s).

This was true even in states hit hard in the early months of the pandemic; of note the waiting time for surgeries decreased by 1/3.

The same held for pretty much all injury types; soft tissue injuries, fractures, lacerations, you name it, none had delays in treatment. 

The report documents decreases in emergency room visits in Q2 2020 for lost time claims – again this may well be due to patient reluctance to go where COVID may be present. It’s also a reminder that all employers should do everything they can to ensure workers with non-emergent injuries DO NOT SEEK TREATMENT AT ERs.

ERs are way more expensive than occ med clinics, often exhibit abusive billing practices, don’t understand workers’ comp, and are where sick people go.

Other findings…

Non-COVID claims plummeted in the 27 study states during Q2 2020…

There was little difference in the type of injuries incurred during COVID’s worst times…

There’s a lot more in the 63 page report, but my main takeaway is this – I was pretty sure there would be treatment delays – and that was wrong.

Sure, logically my assumption made sense; people would avoid care because they were scared of being near COVID patients. And that was certainly true for most medical care; visits to doctors’ offices dropped 70-80%.

But that “logical” assumption didn’t take into account that when you get a nasty cut, or fall off a ladder, or break your leg, you need medical care.

What does this mean for you?

Question your assumptions.


Jul
22

The hospital war is ramping up.

The Biden administration is clamping down on hospital mergers and ramping up enforcement of surprise billing laws. 

Meanwhile, most hospitals are pretty much ignoring the requirement that they post prices. and are going to the mattresses to fight over mergers. (going to the mattresses is what Mafioso did back in the day during major turf battles)

I’ve written extensively about the impact of mergers on cost – it goes up, a lot – and quality – no evidence that it improves. But this isn’t just about hospitals, it is about the entire healthcare system and where it is headed.

Hospitals accounted for $1.2 TRILLION in spending back in 2018

Price is the reason healthcare is so damn expensive here compared to other developed countries; and price is driven more and more by hospitals. Pricing power is how hospitals and health systems generate ever margins, pricing power is what they get when hospitals merge and reduce competition in markets.

This from Cooper and Gaynor:

A number of studies have examined individual hospital mergers and found price increases of greater than 20% (e.g., Town and Vistnes 2001, Krishnan 2001, Vita and Sacher 2001, Gaynor and Vogt 2003, Capps et al. 2003, Capps and Dranove 2004, Dafny 2009, Thompson 2011, Tenn 2011, Gowrisankaran et al. 2015).

The FTC has conducted a series of merger retrospectives. These analyses have found price increases of 20% to 50% (Haas-Wilson and Garmon 2011, Tenn 2011, Thompson 2011).

There has also been work analyzing “cross-market mergers” of hospitals that are not geographically proximate competitors (Dafny, Ho, and Lee 2019, Lewis and Pflum 2017). These studies have observed cross-market merger effects that raised prices between 10% and 17%.

That’s how Tenet reported record profits last quarter, it’s why Michigan’s two largest systems are merging.

The merger thing has gone on so long that 4 out of 5 hospital market areas are “highly consolidated” – meaning the locally-dominant health systems have pricing power, and can use that to dictate prices to payers of all kinds. Mergers peaked several years ago – not because they are losing popularity, but rather because there just aren’t that many merger targets any more.

Because hospitals thrive on profitable services, we’re seeing cutbacks in less-profitable lines, cutbacks that are limiting the availability of services especially in rural and under-served areas. 

What does this mean for you?

We have got to get control of the hospital beast before it eats us alive.


Jul
20

Transparency in drug pricing

One of the top issues in work comp pharmacy – heck in all pharmacy – is transparency.

More than half of the 27 respondents to our latest Survey pf pharmacy management in workers’ comp want more transparency, while several others “need more transparency as I don’t feel comfortable not knowing if pricing is fair.”

The question is – what exactly is “transparency?

Is it the customer knowing what the PBM paid for the drug?

What about rebates?

Is it knowing what the pharmacy “charged” the PBM for that drug (which may or may not be what was paid)?

What about MAC pricing (Maximum Allowable Cost), where the PBM fixes the price it pays for a type of drug, say ibuprofen 800 mg, at a flat rate regardless of the drug manufacturer’s AWP price (there are lots of companies making ibuprofen 800mg)?

Net is “transparency” isn’t quite transparent.

What does this mean for you?

If you are evaluating PBMs, make very sure you understand exactly how they define transparency.  The best way to compare is to have them reprice specific drugs from the same pharmacy dispensed on the same day.

 


Jul
14

Latest data on WC drug spend, opioids, generics and PBM ratings

27 payers were kind enough to participate in this year’s Annual Survey of Prescription Drug Management in Workers’ Compensation.  I’m working thru the data now…here are a few highlights. (The Survey falls under CompPharma, a workers’ comp pharmacy consultancy; as always, responses are confidential and not shared with anyone or any entity)

Overall, pretty darn positive (but premature as some data is still coming in) results…

Opioids

Across all 27 respondents, opioids accounted for 18.7% of drug spend, a drop of half a point over the last 2 years.  That’s good news indeed…but there are caveats which we will get into in a future post.

One thing to note – there was a good bit of concern last year that the COVID thing might/would increase opioid usage; that didn’t happen. Again, good news.

Drug spend 

Overall drug spend decreased 12.3% from 2020 to 2021; about half of the respondents attributed the drop at least in part to fewer claims. In turn, most tied the drop in claim count to COVID.

Over the last decade, work comp pharmacy costs have dropped 9 out of the ten years.

Generics

Generic drugs accounted for 89.3% of all scripts, with generic efficiency ( the percentage of all drugs dispensed as generics that could have been generics) averaging just under 98%.

Again, an improvement over 2018’s 87% generic fill percentage.

PBM ratings

Once again respondents rated myMatrixx as the top PBM with 3.7 out of a possible 5 points, with market-share leader Optum trailing by a half-point. Mitchell is tied with Optum, while Coventry’s First Script lags another half-point behind. (Mitchell recently acquired Coventry)

Again, data is preliminary and subject to change.

More to come; as always a big thank you to the respondents who will each received a detailed copy of the Survey report; a public version will also be prepared and available at no cost to all.

Note – myMatrixx is an HSA consulting client; myMatrixx was not involved in conducting the Survey.