COVID19 and Chloroquine – what does the science say?

The President and the Governor of my home state (New York) are all in on chloroquine and variations thereof.

Spoiler alert – there is no credible evidence that chloroquine is effective in treating COVID19.

And lots of evidence that the drug can be quite harmful.

Let’s unpack the “science”.

First, it’s important to note that this drug has been tried on numerous viral diseases; “Researchers have tried this drug on virus after virus, and it never works out in humans. The dose needed is just too high,” says Susanne Herold, an expert on pulmonary infections at the University of Giessen. source here

There appear to be two sources of “information” that chloroquine advocates cite as justification for using the drug.

Neither meets basic standards of credibility.

One is s tiny “survey” from France; you can read it here. The study’s authors concluded:

our survey shows that hydroxychloroquine treatment is significantly associated with viral load reduction/disappearance in COVID-19 patients and its effect is reinforced by azithromycin.

Well…no.  The “survey” has many flaws, which combine to make it impossible to draw any meaningful conclusions.

(The primary author, one Didier Raoult has been widely criticized for various misdeeds…this is a detailed and quite damning profile)

  • the study was tiny – 42 patients in total at the outset, of which 26 received the drug and 16 did not (these were the controls)
  • out of the 26 who got the drug, 6 were excluded from the reported results, and 4 of those 6 did not do well:
    • 1 died
    • 3 were transferred to the ICU
    • 1 stopped taking the drug due to nausea
    • and 1 left the hospital
    • “As several people wrote sarcastically on Twitter: My results always look amazing if I leave out the patients who died, or the experiments that did not work.” source here
  • the survey’s authors claimed it was a 14 day study but that doesn’t fit between the 12 days from when the study was approved till the day it was concluded
  • the study was not randomized; that is, the separation of study patients wasn’t statistically random which could lead to selection biases (for example, the control group was much younger than the study group, which reflects non-random sampling
  • the “outcome” wasn’t consistently identified or measured;
    • many control patient outcomes are presented as Positive vs Negative, rather than a count (of the actual virus load) vs Negative, as they are for patients in the active treatment group
    • instead of a typical result e.g. 28 day post-treatment mortality (death) rate, for some patients it was the presence or absence of the virus in a nose-swab test.
    • most problematic, some patients tested “negative” one day then “positive” the next; others showed the opposite results...since the final test was a single snapshot and no follow-up was done, we don’t know if the patients that were “negative” at the end of the survey didn’t subsequently become “positive”…or vice versa
    • the outcome also wasn’t specific as it didn’t indicate how much of a “viral load” existed, only if it was present or absent (defined as viral load under a certain threshold)
    • so, “negative” patients could have had the virus, just not enough to trigger a “positive” test result
    • “It would have been better if the authors would use clinical improvement (e.g. fever, lung function) as the outcome, not a throat PCR. The virus could still be rampantly present in the lungs, and the patient could still be very sick, while the virus is already cleared out of the throat. If PCR is an outcome, it would be better measured as e.g. at least 2 or three consecutive days of PCR negativity.” source here
  • There’s a lot more to this – you can read a critique here.

Next – reports from China, which were cited by the French study’s authors as a reason to consider using versions of chloroquine.

The reports included

a) opinions from Chinese physicians that were based on their personal observations, not on actual studies.  A key source for this was a letter published that did not provide any details, data, or credible evidence as to the efficacy or safety profile of chloroquine and related drugs.

Remember…a letter – often cited by opioid promoters as evidence of the drug’s safety and efficacy – helped spark the opioid epidemic, I’d be careful relying on the Chinese letter as a rationale for using chloroquine.

b) many of the clinical trials that were started some time ago were canceled or suspended, leaving no data or substantive conclusions

Fortunately the WHO has begun several major scientific studies to evaluate various drugs’ efficacy and safety…we can be hopeful that they will yield actual credible information that will help us defeat COVID19.

Here’s a handy cheatsheet you can use to evaluate news reports and Facebook posts about COVID19 “cures”,


Finally, this stuff can be dangerous if not deadly. Doses of chloroquine and related drugs just slightly above recommended levels can kill. The drug can damage vision, appears to be dangerous for anyone with cardiac arrhythmia, and has a host of other nasty side effects, many of which occur even when patients are taking doses far lower than “recommended” by French and Chinese doctors.

What does this mean for you?

To quote Karen Masterson, author of THE MALARIA PROJECT;

We should learn from past mistakes. Federal officials after World War II failed to listen to public health experts about the limitations of chloroquine. Our top political leaders today should avoid the same error.


Coronavirus/Covid-19 update

WCRI’s annual meeting was well attended…timing is everything. Many other events have been cancelled or postponed, especially those on the west coast – not to mention Italy, Iran, and Asia.

Here’s what we know about Covid-19 (the disease caused by the coronavirus) so far.

Those are the facts – here’s stuff that may be true, or is uncertain as of now.

  • the death rate for confirmed cases appears to be between 2% (apparent rate in China) and 1% (researchers speculating). Note the italics; it is possible, if not likely, that there are many more unconfirmed cases or untested patients that are not dying, thus the death rate may be significantly lower. Also, note that the death rate derived from the number above is significantly higher; that may well be due to lack of testing that would have identified many patients early on who did not die.
  • if these figures hold up, Covid-19 will be much deadlier than most other flu varieties which have a mortality rate of 0.1% – again much higher in vulnerable populations
  • the growth in the number of confirmed cases varies greatly by country – in general, it is doubling every week or so.

What does this mean for you?

Don’t over-react.  This isn’t Ebola or the Black Death – and may be significantly less deadly than the Spanish Flu of a century ago.

Travel isn’t a no-no.  I’m headed to Florida today  – so it’s not just happy talk from your loyal reporter.  And the WHO agrees.

What IS stupid/irresponsible/selfish is engaging with other people or being in public spaces if you feel ill.  A jackass did just that last week – he happens to work at Dartmouth Hitchcock, where our eldest daughter is also employed. Needless to say, he’s on the poop list.

Mostly, chill. 


Dr Vennela Thumula led off a panel discussing the latest research on changes in opioid prescribing in workers’ comp.

Many factors have contributed to the decline, PDMPs, changes in prescribing guidelines and enforcement via legislation, public education and workers’ comp drug formulary adoption are among the contributors.

Key takeaways from research looking at two time periods; 2014-2016 and 2016-2018.

Opioid use decreased in nearly all study states

The average volume of opioids dropped in almost all states too.

There was more use of non-opioid pain medications as opioid use decreased.

Finally, overall, fewer workers are getting pain meds these days, a positive outcome indeed.

Panelists discussed the information in depth an dove into specifics; Dr Albert Rielly of Mass General Hospital noted that at one point the number one cause of death for workers’ comp back patients receiving surgery was opioid poisoning. He also described a situation in Germany where a person was surprised when they didn’t get Vicodin after major dental surgery; ibuprofen was deemed enough. And, it was.

Dr Rielly rarely prescribes opioids to treat occupational injuries, and provided insights into alternative treatments for pain. He noted when one starts PT is key; it may not be appropriate to begin PT right away, just as it usually isn’t helpful to delay for several weeks.

John Christian, a practitioner who runs an assistance program for the construction trades in Massachusetts indicated there is good news and bad. Fewer patients are testing positive for inappropriate drugs, and the death rate for opioid overdoses has declined. The bad news is, opioid use may not be going down, rather there are fewer patients dying due to the increased availability of Narcan.

Mr Christian noted the death rate for opioid poisoning remains high; he also noted that massage and acupuncture is becoming more common among his patient population – and he’s a fan of cognitive behavioral therapy. The longer the patients are in treatment, the better the outcomes,

A somewhat-new problem is emerging – topicals intended to treat pain. Dr Thumula noted the use appears to be increasing, particularly in Illinois.  Nina McIlree MD of Zurich echoed Dr Thumula’s point, indicating Zurich is seeing more prescribing of dermatologics.  Pain kits have been growing as well; these are branded compounded kits that may include tape – plus over-the-counter medications to deliver those “medications”.

What’s coming…

Dr McIlree opined that we need to be watchful especially regarding invasive procedures, potentially inappropriate use of spinal cord stimulators, and the old favorite – epidural steroid injections.

Dr Rielly suggested prescribers need to focus on quality of life and functionality when speaking with a patient in pain, along with a quick determination of the efficacy of treatment, the idea being to stop doing stuff that isn’t working quickly and move to something that may help.

The key takeaway is that pain is a symptom, not a cause. Therefore if you don’t address the underlying issue, you’ll never be able to affect the pain…increasing opioid dosages, trying expensive and unproven novel treatments, wrapping limbs in fancy athletic tape all focus on the wrong thing.

What does this mean for you?

  • Opioid use is declining- and that is a very good thing.
  • Be really vigilant about “alternative treatments” with scant solid research backing up any claims.
  • Chronic pain management is difficult, time-consuming, often not linear, and requires a very long term commitment; these patients do not “get better” quickly.
  • Be patient and persistent – and don’t get discouraged.


Heading to WCRI – practice “safe conferencing”

Don’t be offended if handshakes aren’t offered and hugs avoided…it’s all part of “safe conferencing”, my name for the guidelines posted by the fine folk at WCRI.

Things kick off tomorrow, but most are getting in this afternoon – me included. I’m looking forward to the discussion of economic cycles and their impact on the labor market. Economists have been predicting a significant slowdown in growth for months and things are looking shakier due to the coronavirus’ impact on travel and supply chains. 

Here’s an excellent piece by one of the best news sources – The Economist – on how things will be different in the next recession than in past versions, and why.

And another from the Wharton School on the virus, how business is reacting to it’s many effects, and thoughts about long-term impact(s).

(I’ll be posting on this issue next week)

Got dinners, lunches, and breakfasts all confirmed, along with a cocktail catch-up or three.

Good to see colleagues aren’t over-reacting to the coronavirus thing.  Yes it’s a concern, but it is not a reason to stay home.



Coronavirus, Monday update

Until things calm down we’ll do an occasional post on the biggest health story out there – coronavirus.

Thanks to Larry – here’s the latest numbers (as of 10 am EST 3-2-20) on cases, recoveries, and mortalities by nation. Source link here.

Note that all views/opinions/takes are based on what we know nowwhich will change as time goes on.

First, how afraid should you be?

Quick take – it’s worse than the flu, but way less dangerous than other diseases.

This isn’t Ebola – which has an 80% death rate.  It’s not MERS (death rate of 34.7%) or the plague (death rate of 15% if patients are effectively treated).

Based on very incomplete data, it looks like the death rate is equal to or less than the Spanish Flu – somewhere less than 2 percent. No question – that is a relatively high death rate – but it is based on very preliminary data.

Here’s a datapoint – in the US 18,000 people have died from the flu in the current flu season – and over 300,000 have been hospitalized.

So far, logic says you should be a heckuva lot more afraid of the regular flu.

More to the point, it appears those with compromised respiratory systems, or in poor health, or with other serious health problems are at much higher risk than healthier folks.

BUT – and it’s a big but – that mortality rate may be much lower, because:

  • a significant percentage of people that test positive for corona don’t have any symptoms
  • tests  – especially the one initially used in the US – weren’t very accurate

How contagious is it?

Probably about the same as a “regular” flu; again initial reports indicate corona is more contagious, but that may be because it was a brand new disease, wasn’t managed well at the outset, and started in a very densely populated area.

What are the symptoms?

Initially, fever and a cough; some victims go on to contact pneumonia.

Will corona go away when it gets warmer?

We have no idea. There is no scientific basis for President Trump’s claim that warmer weather will end the epidemic; this is a brand new virus and no one has any idea if or how it will be affected by weather.

Lastly – be very careful about information sources.

The World Health Organization is the best I’ve seen.

One that pops up at the top of google searches is RT. RT is funded, staffed, and written by the Russian government.  RT highly exaggerates death rates, here’s one example: RESEARCHERS DISCOVER MERS HAS A 65% FATALITY RATE

This is categorically false.

To date, White House announcements about corona haven’t been much better. White House statements have downplayed the risk of corona, the number of cases, how fast it is spreading, and claimed the flu’s death rate is the same as corona (it isn’t; so far corona looks to be 14 – 20 times more deadly than the flu).

What does this mean for you?

Science is important.



Coronavirus Part One, the Bad News and the Good.

Just chill.

Several readers have suggested I post on the coronavirus issue and how it relates to workers’ comp.

My quick takeaway – it’s highly unlikely coronavirus will be contained – but the death rate (percentage of people who die from it) will be pretty low.

Now, where things stand today.

First, there’s little hard, irrefutable evidence about coronavirus.

It’s so new that scientists and epidemiologists (scientists who study the spread of disease) don’t have any historical data to study. So, we do not know a lot – and much of what you hear is based on pretty sketchy information.

Second – do NOT just read the headlines; this one is a great example.

StatNews is a very credible source, but even here the headline “New data from China buttress fears about high coronavirus fatality rate, WHO expert says” is misleading.

While one expert avers that the mortality rate is relatively high, other experts refute that assertion, noting there just isn’t enough data to draw any credible conclusions.

Moreover, even in China the mortality rate varies greatly, with the death rate among those infected in the province where the virus originated 3 to 6 times higher than outside that province.

I get this is confusing and frustrating and scary – but it’s critical that we read objectively and question declarative statements especially those from people who aren’t scientists. [that includes me, dear readers]

Example – yesterday the Secretary of Homeland Security said the death rate from coronavirus and the flu is the same – 2 percent. That’s flat-out wrong; the worst case estimate for coronavirus’ death rate is around 2%; that’s 20 times higher than the flu death rate (0.01% – one out of 10,000).

Third, it appears – at this moment – that the corona virus is much less deadly than the worst strains we’ve seen in the past.  [please refer back to #1 above…]

Reality is, flu-type diseases that are really deadly don’t spread very fast because infected people die pretty quickly – which means they don’t infect many others. You may remember the deadliest one in memory – the avian flu. It killed more than half the people infected, yet only 455 people died.

Remember SARS and MERS?  They are different strains of coronavirus than the current one, and quite deadly. Yet less than 1000 people died from each of these strains.

Fourth, some people infected with the virus don’t have any symptoms. 

This isn’t surprising, as about 1 of every 7 people who have a “regular” flu are also asymptomatic.  It also supports #3 above. But that’s also why it’s so hard to contain coronavirus – a bunch of infected people are walking around undiagnosed, spreading the virus to others.

Fifth, there will NOT be a vaccine for at least a year.

And likely longer than that. Vaccine development is tricky, frustrating, and marked with lots of false starts and stops and dead ends. And vaccine safety is a critical issue.

What does this mean for you?

There are about a gazillion things more worrying than coronavirus – including the flu.  Take a step back, relax, and read critically.

Excellent fact checking here.


Work comp medical costs – the real story

Workers’ comp medical costs are not increasing…

Even close followers of the industry would get the opposite impression; pretty much all industry “news”, marketing pitches, industry executive poll results and investor reports talk about rising medical costs or the fear thereof.

The best data out there indicates medical costs have been flat for at least five years – as in, no increase, inflation, or rise. According to NASI’s annual report on workers’ comp, total medical costs actually dropped – albeit marginally – from 2012 to 2017 (the most recent year available). (disclosure – I am a member of NASI, but am not involved in any of their research)

I’ll be the first to admit I was under the impression costs were going up every year – that’s what NCCI and others report, and based on their data and methodologies, that was generally accurate.

Here’s the issue with those metrics – most look at cost per lost time claim, or use actuarial projections to estimate fully-developed claim costs by accident year.

The cost per lost time claim is helpful, and according to most credible research costs are up slightly – on a per-claim basis.

Actuarial projections are much less so; over the last few years NCCI has consistently projected future costs would be higher than they turned out to be. That’s no slight on NCCI; actuarial methodologies and assumptions are based on historical results, and the impact of opioids is the proverbial black swan (one hopes).

This is a reminder that questioning one’s long-held beliefs on a regular basis is healthy, useful, and, yes, often humbling.

And that’s not to say costs aren’t increasing in places – facility costs in Florida and California and physical medicine are among the problem spots.

What does this mean for you?

We’ll dive into implications tomorrow. For now, check your business plan’s assumptions…


NO, higher indemnity payments ≠ longer disability

A recent piece in WorkCompCentral highlighted research that ostensibly said paying injured workers higher indemnity benefits results in longer disability duration and higher costs.

At least that’s what one might conclude from the headline – and the research report itself.

Except the research is preliminary (as noted in William Rabb’s article) , and actually reading Rabb’s WCC article – and the study itself – and doing a little Googling – reveals significant problems with the research.

To the researchers’ credit, they make it clear their conclusions are preliminary and “comments are welcome” but I fear many will read the headline, tweet it out, and use it as justification to reduce workers’ indemnity benefits.

Reality is, the study has multiple flaws, rendering the authors’ conclusion that:

“increasing the generosity of wage replacement benefits does not impact the number of claims but has a large impact on claimant behavior, leading to longer income benefit durations and increased medical spending.”

is baseless at best.

Among the multiple flaws in the study is the failure to account for other factors that may well have driven an increase in disability duration and medical expenses. The researchers based their analysis on workers’ compensation reforms in Texas and data from 2005 – 2009. The reforms, which increased disabled workers’ wage replacement levels, also affected many other parts of workers’ compensation regulations and benefits.

For example, medical reimbursement in 2008 spiked due to changes in the Texas WC medical fee schedule – which were largely driven by increases in Medicare’s fee schedule.

Then there’s the 2008 – 2009 recession, which significantly affected employment opportunities in the Lone Star State. I’d suggest that the recession affected employers’ desire and ability to return injured workers to jobs that no longer existed or where hours had been greatly reduced. It also limited re-employment opportunities for workers who no longer had jobs to return to.

2008 saw a steep decline in jobs towards the end of that year…

And the forecast for 2009 was even worse…

(for more discussion, here’s the Dallas Fed’s analysis. Evidently the authors didn’t read this, or if they did, did not reference it in their footnotes or references.)

What does this mean for you?

I’m no PhD economist – but I can do a Google search. And so can you – I’d encourage all to question “research” that makes bold assertions.

Especially when those assertions support one’s long held beliefs.


What’s up with WCRI 2020?

I asked WCRI President John Ruser PhD for the scoop on the upcoming WCRI annual conference…here’s the interview.

  1. What is different this year (format, topics, approach)?

Same credible WCRI research, but different topics (e.g., How Injuries, Claims, and Outcomes Change with Age; Alternatives to Opioids for Pain Management; Readmission and Re-operation Rates among Workers’ Compensation Patients, etc.).

Same focus on the pressing issues of today, but different ones compared to 2019 (e.g. Generational Differences and Stereotypes in the Workplace; Economic Cycles and Their Impact on the Labor Market; Prioritizing Mental Health for Workers Injured on the Job, etc.).

  1. What are the issues your members are most concerned about?

The issues on this year’s agenda (e.g., opioid alternatives, generational differences, the impact of the economy on the workers’ compensation system, and mental health) are issues that all of our diverse membership is concerned about and would benefit from learning more about, which is why the theme of our conference is Gaining Clarity Through Research.

  1. There are some deeper dives into aspects of medical care delivery and outcomes (e.g. readmission rates), which appears to be a change from previous conferences, can you talk about that?

We are continuously looking to help all stakeholders understand the most significant issues in the workers’ compensation system today. Naturally, these are going to change from year-to-year based on what we are seeing; external actors and factors (i.e., business cycles, elections, etc.); new technologies; and new research, etc.

  1. What are the work comp issues that are least understood and most impactful on employers that will be addressed by this year’s conference?

Although many of the topics our sessions delve into may not be new to employers, they will benefit from the independent research and expert perspectives that is the hallmark of our sessions and conference.

That said, one issue that we could all stand to better understand is our panel on prioritizing mental health, since serious workplace injuries can lead to anxiety, depression, and other mental health issues. Indeed, new research from Boston University (BU) Professor Les Boden found that an injury serious enough to result in at least a week off work almost tripled the risk of suicide among women, and increased the risk by 50 percent among men.

To help us better understand the challenges workers face to their mental health after a workplace injury, as well as to learn about initiatives to address those challenges, we have assembled a distinguished panel: Prof. Boden; President Steven Tolman of the Massachusetts AFL-CIO; Dr. Kenneth Larsen of the New England Baptist Hospital; and Mary Christiansen of Southern California Edison.

  1. What has been the most significant change in the conference over the last five years?

We seek to continue to identify those topics that are of greatest interest to attendees.  An indication of our success is that our conference keeps growing, and based on registration today compared to last year, we are on course to do so again.

Those who attend value that this a research-based conference, that there are high-level networking opportunities, and that the conference is of appropriate length.

This combination brings a diverse and dedicated (senior-level) crowd of people who are interested in understanding the trends that are occurring in workers’ comp and learning actionable items they can use in their jobs.

I’d add that the Conference always sells out.  To make sure you’re not this guy, register here.



Now’s the time to fix that roof.

Barring some catastrophic exogenic event (war with Iran, pandemic, sudden recession) – workers’ comp premiums will continue to shrink.

Meanwhile, despite compelling evidence work comp execs are worried about the opposite problem – that they won’t be able to raise rates high and fast enough if something bad happens. This at a time when industry profits have never been higher, insurers are awash with cash and all indicators point to continued low combined ratios.

Claim frequency continues to decline (yes there are increases here and there but these are NOT altering the decades-long trend). I penned a four-parter on frequency a while back that provides more detail.

The large and mid-sized payers I speak with are seeing declines in claim counts.

Medical costs are flat – and have been for several years.

Yet NCCI’s poll of workers’ comp execs finds these folks are worried about rate adequacy. (that means claims costs will go up faster than insurance premiums, leading to financial losses for insurers)

Wrong problem, folks.

The real issue facing C-Suiters is declining premium dollars – which means less money to pay for administrative expenses – which means fewer dollars to invest in:

  • IT and new IT projects
  • revamping claims systems
  • electronic connections to providers, vendors, and other third parties
  • adjuster training and retention
  • innovation

I get that CEOs have to do worse-case scenario planning – but the chances of that worst-case (claim costs increase and rate increases can’t keep up) happening are minimal. Yet this “problem” is top-of-mind (according to NCCI) – so execs are:

investing in predictive analytics to help with pricing and dedicating more resources to actuarial research and analysis. Insurers are closely evaluating and monitoring risks for the purposes of acceptability, pricing and coverage.

There is compelling evidence that rates are too high now – and will remain too high for some time to come.  The cause is the steep drop in opioid usage among work comp patients, a drop that is slashing claim duration, increasing claim closures, and reducing reserves.

Opioid users’ claim costs are more than double non-opioid users. As usage plummets, rate decreases lag far behind. The result – today’s rates are based on what happened years ago – not what’s happening now.

Graph courtesy CWCI, p 19, The Impact of Declining Opioid Use on Lost-Time Claim Development & Outcomes in California Workers’ Compensation 

While the impact of rapidly decreasing opioid usage – and concomitant reduction in claims costs – is real indeed, rating models and methodologies haven’t caught up to this reality.

This is the problem execs should be devoting most of their time to – how will they manage their business with less revenue than they have today.

The time to fix the roof is when the sun is shining. Work comp execs would be well-advised to invest their record profits in ways that:

  • improve efficiency,
  • automate low-value tasks, and
  • most importantly – assure effective medical care.

What does this mean for you?

You don’t want to be on a roof in a rainstorm.

More on this in a free webinar hosted by WorkCompCentral February 27. Register here.