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.


Jul
12

I haven’t seen any proof that it isn’t…and, well, if one believes the Left is a secret cabal of demons chasing kids, it sure looks like it could be.

Two very interesting data points.

First, residents of counties that voted for Trump are significantly less likely to have been vaccinated.

Same holds true for states…

Second, almost all recent COVID-related deaths are among folks who aren’t vaccinated; fully-vaccinated people account for less than one out of a hundred COVID-related fatalities.

And, the ones who stand to gain if more Trump voters die from COVID are Democrats and Leftists.

Of course this is utter nonsense, but no less nonsensical than accusing Hillary Clinton of leading a child-sex ring headquartered in a pizza restaurant.

What does this mean for you?

Satire has lost its impact.


Jul
8

The Delta Variant – key facts

What you need to know about the Delta Variant

  1. Delta is more transmissible than the original COVID and the Alpha variant.
  2. It may be more dangerous as well; a Scottish study found Delta victims were about twice as likely to be hospitalized than those infected with other COVID versions.
  3. Various studies indicate full doses of the various vaccines are quite effective at preventing COVID infections, reducing hospitalizations and deaths.
    1. Canada – Pfizer is 87% effective.
    2. UK – Pfizer is 88% effective in preventing symptomatic disease; Astra Zeneca 60% effective against symptomatic disease
    3.  Israel – Pfizer 64% effective at preventing infections, 93% in preventing serious problems from COVID infection (note I was unable to locate the actual research; source is the Israeli government.)
  4. Delta is responsible for the vast majority of new cases in the UK.
  5. Countries with relatively low Delta infection rates continue to see declines in overall COVID infections.

What does this mean for you?

Get vaccinated.


Jun
29

You bet your life.

For my friends out there who remain unconvinced COVID vaccinations are a good idea, please think again.

Breakthrough infections – fully vaccinated people contracting COVID – accounted for only about 1 in every 700 hospitalizations.

Put another way, people who haven’t been vaccinated accounted for 699 out of 700 hospitalizations.

A similar dichotomy holds for COVID-related deaths; fully-vaccinated people account for less than one out of a hundred COVID-related fatalities.

Not surprisingly states with lower vaccination rates are seeing higher infection, hospitalization and death rates.

Great source for tracking state-specific data

Arkansas, Oklahoma, and Missouri are among those states likely to experience increases in COVID infections, hospitalizations, and deaths.

There is another factor in play here – unvaccinated people are far more likely to get infected, become a COVID host, and pass their germs on to others. So not only do they risk their own health, they also endanger many more people.

And – and it’s a BIG and – the more people infected, the more likely COVID will mutate and become more transmissible and deadlier. We’ve already seen this with the Delta variant; transmission rates are increasing rapidly especially in the South.

What does this mean for you?

Please – get vaccinated.


Jun
24

The Delta Variant

You are as done with COVID as I am.

COVID is not done with us.

Here in New York’s Finger Lakes everything is open; had a great family night out yesterday, no masks required for those of us fully vaccinated, hiring signs are all over, and the joy that is upstate NY in summer is in full swing.

While we are blissfully enjoying life, the Delta Variant is:

That’s the bad really bad news.

The good news is vaccinations – especially the ones based on mRNA (e.g. Pfizer) are still “spectacularly effective” against the Delta variant. 

As in 96% effective in preventing hospitalizations.

However, that’s after both doses; a single dose is just 33% effective at preventing symptomatic illness.

Here’s the thing. The more of us that get infected, the greater the chance that the damn virus morphs into a deadlier, more transmissible, and thus even bigger problem. So far the vaccines we have are working.

But – and it’s a damn big “but”, far too few of us are vaccinated. That’s particularly true of southern states, where a combination of misinformation,  awful treatment of minorities by some governmental entities and segments of the medical community (the Tuskegee experiment being a prime example) and resulting mistrust, and difficulty with the J&J vaccine have combined to drastically slow vaccination rates.

click here for detailed state-specific data

Here’s a great graphic detailing state progress towards full vaccination…

All this is to say that the fewer vaccinated people there are, the more likely COVID will mutate into something even worse.

What does this mean for you?

Get vaccinated.

Note – if you want to debate or disagree, cite credible sources for your statements. Period.


Jun
17

Thursday catch-up

Doing my best to avoid work on Fridays…so moving this occasional catch-up post to Thursdays…

COVID

Promising news on the effectiveness of a drug to help infected patients fight off the virus was reported by the Economist. The good news – Regen-Cov:

saved the lives of many of those unable to make their own antibodies in response to SARS-CoV-2. Such “seronegative” individuals constituted about a third of the 9,785 hospital patients in the study…compared to a control group given standard treatment … 20% more patients survived

The bad news – it’s stupid expensive, and supply chain issues are hampering production.

A study conducted by the National Institutes of Health indicates COVID may have been in circulation earlier than originally thought. Blood samples from Illinois, MassachusettsMississippi, Pennsylvania and Wisconsin indicate the virus was in those states in December 2019. An earlier CDC study found similar evidence in California, Oregon, and Washington.

These findings indicate a better and more thorough process to identify disease outbreaks may well be warranted.

Comp drugs

WCRI is hosting a timely webinar on Interstate Variations and Trends in WC Drug Payments on June 24. Register here. Gotta say I’m darn impressed by the researchers’ ability to obtain, analyze, and report on payments as recent as Q2 2020. This makes WCRI’s information much more actionable for regulators, clinicians, and payers alike.

Dr. Vennela Thumula and Dongchun Wang of WCRI will be guiding us thru their findings; the webinar is free.

I am finishing up the latest Annual Survey of PBM in WC which will have 2020 and 2019 data; last chance to participate and receive a detailed, respondent-only version of the report. If you want to participate let us know in the comment section below (there’s no cost to participants).

Couple interesting – and very preliminary – takeaways…

  • growing interest in transparency, along with an increased awareness that this isn’t a simple issue.
  • spend continues to decrease, with respondents attributing some of the decrease to COVID.
  • opioid spend continues to drop, but most respondents are still struggling to help chronic pain patients/long-time users of opioids reduce usage.
  • there’s a growing awareness that the PBM pricing model needs to change. With spend declining and a push for transparency, knowledgeable payers understand that paying PBMs less year after year is not sustainable.

Previous public versions of the Survey Report are available here for download at no cost.

 

 

 

 

 

 

 

Hospital pricing

Hospitals are supposed to be publishing their prices – at least Federal regulations require them to. But those smart, sneaky administrators are figuring out all kinds of ways to avoid telling you how much it will cost for that MRI, drug, band-aid, or lung transplant.

From JAMA:

hospitals must publish discounted cash prices (applicable to uninsured patients) and payer-specific negotiated rates. Second, hospitals must display price data, including expected out-of-pocket costs, for “shoppable services” that can be scheduled in advance (eg, office visits) in a consumer-friendly manner that facilitates service-specific comparisons across hospitals (eg, price estimator tools). [emphasis added]

As of early March, only 17 of 100 randomly selected hospitals were complying with the regulations. The penalty for non-compliance is…wait for it…

$300 a day.

Perhaps if the Feds charged hospitals the same way hospitals they charge us, we’d have a bit more compliance. 

How about…the Feds tell the hospitals after the fact what the cost will be, based on a “compliance chargemaster” that takes into account the hospital’s margin, quality scores, number of collection suits it has filed, and medical error rate.

Thanks to the estimable David Deitz MD PhD for the head’s up.

Wellness works

Finally, HealthAffairs reports wellness programs don’t really improve population health, reduce healthcare spending, or improve employment outcomes. 

Almost 40 years ago, I was halfway through a Master’s of Science in Health/Fitness Management when it became obvious this was NOT going to be a lucrative career…quite the opposite. Not saying I was prescient, just that employers sensed this was a nice-to-have and not a got-to-have, and that lack of importance showed in salaries.

Dodged that bullet.

And really finally, congratulations to my favorite baseball team – the White Sox have the best record in baseball after taking 2 of 3 from Tampa Bay. I

know my friends in the Bay area will be heckling me when the Rays surge again…hey, you gotta take advantage of good news when it comes!