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
5

Why don’t workers’ comp execs embrace change?

The short answer is – they have little incentive to do so.

Here’s why.

  1.  Workers’ comp insurance is mandatory in all states save Texas. Pretty much all employers have to carry workers’ comp coverage, so sellers of insurance and self-insurance services (albeit to a lesser extent) know their prospects have a budget, timeline and decision process, and selection criteria. It’s not IF they buy, it’s whose they buy. That removes a big problem in sales – finding prospective customers.
  2. For most of the last decade, insurance rates have been dropping. Workers’ comp costs are at or near historical lows in almost every state. As a result, with rare exceptions, buyers aren’t focusing on workers’ comp – it is way down the list of things CFOs and Treasurers are worried about. So, they aren’t pushing insurers or TPAs to improve, get creative, develop new products and solutions and improve existing processes.
    No problem – no need for a new solution.

  3. That’s driven primarily by two key factors – frequency and medical cost.
    Frequency – the percentage of workers suffering an occupational injury or illness – has been dropping pretty steadily for decades. With fewer people hurt or sick every year, there’s fewer problems to solve. And yes, claim counts trended up till last year, but that upward trend was driven by increased employment.
  4. Despite what some vendors claim, medical cost trends are very much under control. Sure facility costs are increasing, but the decline in drug costs and related medical expenses seems to have offset that…so far. So, little incentive to come up with creative/fresh/different medical approaches.
  5. Risk:reward. With some notable exceptions workers’ comp execs are pretty satisfied with the status quo. Put another way, they are highly risk-averse. Most have ascended to their executive positions by not taking risks, by avoiding mistakes. Any new, creative, different approach is inherently risky and therefore anathema to folks who have succeeded in part by tightly managing risk.

By no means is this true of all execs; I’m privileged to be able to work with several payers that are pushing the boundaries, working very hard to come up with new and much better ways to help the injured workers and employers they work for.

What does this mean for you?

Workers’ comp buyers are mostly not interested in innovation or change. 


Jan
14

Haven Healthcare’s demise – lessons for workers comp

Haven Healthcare – the Amazon-JPMorgan-Berkshire Hathaway joint venture intended to re-invent healthcare – is no more. The quest to improve access to primary care, simplify insurance coverage, and make prescription drugs more affordable ended after three years.

We don’t know why Haven is now in heaven; it could be that three of the most powerful and well-run organizations in the world could not figure out how to build a better healthcare system.

Or it could be that they each had different motivations, different needs, and different priorities and could not figure out how to work together. That would not be a surprise. Or that their well-known, accomplished, and brilliant CEO was not an effective CEO (that’s not a slam; I’m no operator either).

Or more likely – all of the above plus more.

Regardless, it’s dead. Workers’ comp execs can learn three lessons from Haven’s failure.

CEO Atul Gawande MD lacked the intimate, deep knowledge of healthcare infrastructure, reimbursement, regulations and management required to be successful. A brilliant writer, insightful analyst, and highly visible public figure, Gawande didn’t have the management chops. He also didn’t give up his other jobs and had no experience as CEO of a start-up.

Implications – Two things – knowledge and commitment.

Do you know anyone in workers’ comp with deep knowledge of healthcare? Someone who understands reimbursement, infrastructure, process, the regulatory environment? Medical drives workers comp, and very few comp execs have that knowledge and understanding. 

Many who think they do – don’t.

Then there’s commitment. Gawande was committed to Haven – and frankly the three founding companies were as well – like the chicken is committed to breakfast.

If you want to take on something as daunting as reforming healthcare, you’d best be committed to the task like the the pig is committed to breakfast.

Second, market share. With about 1.6 million employees – and perhaps 5 million insureds – the three giants had a lot of lives to cover, a lot of healthcare dollars to leverage (about $24 billion in employer costs and a total of about $30 billion). BUT, the proverbial mile-long-and-inch-deep problem meant Haven didn’t have local scale.

Healthcare is local – facilities and medical practices want insured bodies, the more the better. Outside of a very few markets where Amazon has big distribution centers, Haven didn’t have enough bodies to leverage big changes.

Implication – Total annual medical spend in workers’ comp is about the same as Haven’s – $31 billion. That is less than 1 percent of US medical spend. Haven tried to leverage all those dollars. It failed.

Unlike Haven, there are lots of workers’ comp networks all trying to negotiate deals – the largest may have $8 billion in spend nationally.

That is small potatoes indeed…A mere tablespoon of hash browns.

What does this mean for you?

The workers’ comp industry cannot “solve” healthcare. But that’s not the point.

The point is this – organizations and leaders that know more about healthcare, that are more committed to doing better, will far outperform their competitors.


Jan
12

I wish I could.

It is times like this that determine if people have souls.

To those who say stay out of politics, I say – I wish I could [see comments at link].  What happened last year, and last summer, and last week make that impossible.  We can’t just continue on as if nothing had happened.

Our country – lauded by self-described “patriots” as the greatest country in the world:

photo credit Daily Mail, circled object is fire extinguisher thrown by rioter that struck and killed Officer Brian Sicknick

 

American Carnage indeed.

I get that people are upset when their candidate loses a critical election – millions of Americans – your fellow citizens – were crushed when Trump won in 2016. I was – and still am – among them.  As much as it hurts to say it, Trump won in 2016 – and we accepted that victory. We did not riot, lie, provoke, build scaffolds on the Mall, threaten to hang the Vice President and shoot the Speaker of the House. We did not file 60 lawsuits seeking to overturn our fellow citizens’ votes.

I accept and understand that Trump supporters are distraught, angry, even terrified – as I was in 2016 (and still am of the damage Trump has done and will do). I do not accept and cannot allow the anti-American behavior of many to pass unremarked and unchallenged.

I applaud the businesses that have stopped contributing to politicians lying about election fraud. Among those organizations fed up with Trump and his enablers are AirBnB, Amazon, BestBuy, the Blue Cross Blue Shield Association, Commerce Bank, Dow, Marriott, GE, Hallmark, AT&T, MasterCard, Verizon.

I decry CVS, Berkshire Hathaway, Facebook, Goldman Sachs, JP MorganChase, Microsoft, Google, BlackRock, Charles Schwab, VISA and others who have suspended all political contributing to all politicians – this smacks of false equivalency when it is blindingly obvious that the Ted Cruzes and Josh Hawleys are guilty of fomenting insurrection – not the Sherrod Browns and Jason Crows.

My family has agreed that we must do more. So, I will contribute 10 percent of my income to organizations dedicated to righting wrongs. The Southern Poverty Law Center, BLOCbyBLOC, FairFight, and the Native American Rights Fund are the ones we’ve chosen.

This may well cost me readers, business, income, and prominence – and I am totally fine with that. What we are on the verge of losing is immeasurably more important.

[to unsubscribe just respond to this post with unsubscribe in the subject line]

Tomorrow – back to health care and related topics.


Nov
17

Despair, anger, or action

Winter here in northern New England is long and cold, with short days too often grey. Sunday night sleet driven by  howling winds pounded the house, leaving a layer of ice on everything.

We are all facing a northern New England winter – long, cold, dark, with far too little sunlight. 

Which leaves each of us with a choice – we can rail against nature, furious that our lives are disrupted, mad at the world. We can scream at each other, curse each other, denigrate and demean, as if this is going to solve anything or be in any way remotely helpful.

Or, we can succumb to lethargy, going through the motions in survival mode, making no difference, taking no responsibility, endlessly waiting for…something.

Or, we can make that something happen.

We can do something positive, something helpful, something neighborly, something kind. Like…

Get takeout, and tip way too much.

Add a few extra things to your shopping list and drop them off at the local food pantry.

Shop for an elderly neighbor, get their mail, shovel their driveway.

Smile at everyone you see – not to worry, they’ll see it in your eyes.

Buy $5 gift cards from local merchants and give them to teachers, aides, neighbors.

Be extra patient.

 

 


Nov
3

here’s hoping this ends soon.

We interrupt this healthcare blog to bring you a few moments of humorous relief…

Here’s for enthusiastic voters…

Gotta love Steve Schmidt et al…

Colbert is always so helpful!

Yeah, I don’t get it either…

Ouch.

And calls, and posters, and signs, and…

 

Oh God NOOOOOOOO!!!!!

What does this mean for you?

Everything.


Oct
2

Trump tests positive – initial takeaways

President Trump has tested positive for the coronavirus; we’ll divert from our usual focus on healthcare matters to highlight what we know now, and potential implications.

It is important to understand that most people with coronavirus have no symptoms or  relatively mild cases. Statistics favor a positive outcome for the President.

Infection source

We do not know how the President become infected. We do know that one of his closest advisers, Hope Hicks, tested positive. Reports indicate Hicks has multiple daily encounters with the President, traveled with him on Air Force One, and accompanied him on his latest trips.

The President’s health

Implications

CDC data indicates that one out of ten people in their 70’s with positive diagnoses of COVID19 died. The report did not separate data by sex; it is likely men are at higher risk of death. (note there are no credible reports that Trump has COVID19 – he has tested positive for the coronavirus which may lead to COVID19.)

The same study indicated almost one out of three COVID19 patients 70-79 with an underlying medical condition died; note that obesity was not specifically identified as a medical condition.

Near-term implications

First, the President will suspend his campaign schedule during a two-week quarantine period. Events will be canceled for the time being as his campaign awaits developments.

If his health is severely impaired, his powers as President can be delegated to the Vice President under the 25th Amendment to the Constitution until such time as he is able to resume those duties.

Worst-case implications

If a sitting President dies at any time during his/her term, the Vice President assumes the Presidency.

If a major political party’s candidate dies after being nominated by her/his party, and during the election campaign, that candidate’s political party would nominate a replacement candidate. The process differs by party; for the GOP, the Republican National Committee would oversee the process which gives each state the same number of votes it has at the party convention.

[Note the Democratic Party’s process is generally similar]

It is unclear what happens if the Party’s candidate is medically incapacitated at the time of the election.

There is no Constitutional provision to delay a Presidential election in the event of a candidate’s illness, incapacity, or death after nomination and before the election.

For more information on the latest details on COVID19 treatment, click here.

What to watch for

There will be a lot of political maneuvering and posturing , most of it just noise.

Rely on credible news sources – the major broadcast networks, NPR, and major newspapers – and ignore nonsense from YouTube, twitter, and the like.

And there are already lots of ridiculous conspiracy theories – ignore them too.

 

 

 


Aug
28

Another whirlwind week is just about over, and with it the summer of 2020.

Here’s important/interesting news that came across my virtual desktop this week.

COVID and Comp

More data on workers’ comp COVID19 claims is coming in; Virginia’s Workers’ Comp Commission has published data; key takeaway is to date, only 8.3% of COVID19 claims reported have resulted in benefit payments. That will certainly increase as claims develop.

More info on state COVID reporting is here – you can watch a recorded webinar on the subject here – Mark Priven and I dive into data from California and Florida and discuss the implications thereof.

Meanwhile, employment took another hit as last week more than a million Americans filed for unemployment. This continues a five-month run of claims at or above the million mark. 14 million of us are still without jobs.

COVID19’s impact on health insurance coverage

Several million people have lost their health insurance due to COVID19-related job losses.  We don’t know the specific number – and it is certainly increasing – but it is likely between 3 and 12 million. (download the report for details).

Another perspective is here.

Most of those folks are lower-income workers and many are minorities; some may be eligible for Medicaid however states that did NOT expand Medicaid such as Texas and Florida will see an increase in uninsured care costs.

Congratulations to myMatrixx and new Chief Sales Officer David Dubrof; David is one of the very few “A” players in work comp services sales; myMatrixx will benefit greatly from his sales leadership. David and his colleagues are equally fortunate; payers have consistently rated myMatrixx the top workers’ comp PBM. (myMatrixx is a client)

NCCI published a report on the impact of fee schedule changes on outpatient facility costs.  Good to see this rapidly-rising cost driver getting attention.

Implications

  1. Fewer jobs = lower payroll = lower work comp premiums
  2. Things are tough and getting tougher for lower-wage workers, which are disproportionally people of color.
  3. More uninsured = more need for facilities to get $$ from those who are insured.

Jul
10

Friday funday!

Ok, it’s been another terrific week…although my definition of “terrific” has changed a lot since January.

This being Friday, it’s time to lighten things up.

Today seems like…yesterday.

Therefore, it is time to look for a present for that special friend…

Some states are going back into lockdown, which is too bad cause you’re going to miss out on stuff like this.

SPORTS!

With worries about football season, baseball scheduled to play just 60 games, and the NBA playing in a bubble, it’s time to expand our horizons and consider other sports.

Baseball may not be it for this young player…

Looks like the SEC was practicing social distancing before we knew it was a thing.

This just in from Chicago…

That “other” football has to change too.

From an Eagles fan…

Finally, as a recovering Catholic, this brought back lots of memories.


Jun
26

Masks and IWP gets hammered.

So, who knew masks could be so dangerous?

In our continued effort to keep us all honest about “science” and “research”, I have to weigh in on a recent piece wherein some folks seem to be concerned about mask wearing’s impact on a person’s health. The Risk & Insurance piece noted:

A study (italics added) conducted by PN Medical, and as reported in The New York Times, found that extended mask wearing could lead to improper breathing, which could result in possible negative side effects such as anxiety, headaches, increased heart rate, dizziness and fatigue.

This wasn’t a “study”; it was a “small investigative trial”. Details are here.

The person who described it is not a clinician.

There’s no information on how many subjects were involved, if there were any controls, the demographics of the test subjects, the methodology used, how the multi-site “trial” was conducted to ensure consistency, weather conditions, temperature and humidity, time of day, and the many other factors that could influence a person’s post-mask behavior and physiology.

The story goes on to describe all the bad stuff that “might” happen, all of which are assumptions based on assumptions based on what is most definitely not credible research.

Further, the story is based on another reporter’s failure to accurately describe the “small investigative trial;” a New York Times reporter at that.

It is entirely possible that masks cause some issues…but they’ve been in use for decades and this is the first report I’ve seen that there is any concern.

We need to do better, folks.

IWP gets hammered by Massachusetts’ Attorney General

Finally, IWP Pharmacy, long the bane of many adjusters, agreed to a Consent Decree that requires major changes at the Massachusetts-based mail order pharmacy. Mass AG Maura Healey announced that IWP will pay an $11 million settlement and make major changes to resolve:

allegations that it failed to implement adequate safeguards against unlawful and dangerous dispensing, resulting in the shipment of thousands of potentially illegitimate controlled substance prescriptions across the country.

In perhaps the most stunning example of spin I’ve yet seen, IWP’s statement doesn’t even mention the settlement… in a post entitled “IWP Expands Compliance Program” the multiple changes to staffing, operations, compliance, and sales were characterized as:

steps…developed in collaboration with the Attorney General of Massachusetts, as part of a recent review they undertook of past business practices.

The AG’s statement read in part:

“Injured Workers Pharmacy created an illegal operation that put dispensing speed and volume over patient and public safety…They dispensed thousands of prescriptions for dangerous drugs, including opioids like fentanyl, with a shocking lack of regard for whether those prescriptions were legitimate.”

What does this mean for you?

Question reporting and go to the primary source.

Check your files for IWP patients.