Author: Joe Paduda

Apr
23

Workers’ comp drug trends – good news at last – Part 1

Posted by Joe Paduda on Tuesday, April 23rd, 2013 | Comments

There are three workers’ comp drug trend reports out this week; we’ll look at each one (in order I received them).  A cautionary note; it is difficult to compare PBMs’ performance on the basis of their reports; the metrics and basis for those metrics varies, their books of business are different (some have lots of very old claims, others have more state funds than national clients and there are also other differences in payer mix with some payers much more aggressive and willing to work with their PBM on specific issues).

First up is Progressive Solutions’ version. The big PBM saw an average reduction in spend per claim of 0.5 percent, driven by a combination of fewer days’ supply per script and fewer scripts per claim.  Progressive has invested heavily in predictive analytics; the payoff has been a significant drop in opioid usage for targeted claims (15% decrease in morphine equivalents).  The data shared in their report parses out the various factors driving claim cost and risk, with “pharmacy behavior”(number of prescribers, number of pharmacies, medications) becoming increasingly significant as a claim ages.

Progressive’s clients are seeing a reduction in opioids as well, with both long- and short-acting opioid script volume down. This has cut per-claim costs for opioids by 4.2 percent.

The report has an extensive and accessible section on legislative and regulatory trends, with discussions of state regs on repackaging, compounds, and physician dispensing.

The takeaways are this:

  • Analytics and modeling can drive much better results by focusing resources on the big problems. The PBM and WC industries need to continue to up their game, and get smarter about where, when, and how to address cost drivers – generic, one-size-fits-all approaches are costly, inefficient, administratively burdensome, and annoy claimants and physicians.
  • The impact of regulations and legislation on WC pharmacy, and thus workers’ comp costs and outcomes, is increasingly important.  Physician dispensing and compounding are two of the biggest profit-creators for those interested in sucking money out of the comp system.  It behooves all stakeholders to thoroughly understand these issues and get involved.
  • Opioids are being addressed – there’s much to do but a strong focus and assertive programs can and do deliver results.

Finally, Progressive’s report is well-designed and well-written.  Kudos to the folks who actually took all that research and translated it into language the rest of us can understand.

 

 

Apr
22

A tough week for work comp in Florida

Posted by Joe Paduda on Monday, April 22nd, 2013 | Comments

Florida’s legislature is working thru several workers’ comp bills – and the news isn’t good.  A PDMP bill has been emasculated; Florida’s prescription drug monitoring program won’t require physicians check the system before prescribing drugs.

And while there’s ongoing negotiations on a bill addressing physician-dispensed drugs, at this point it looks like Florida’s employers will have to pay more for physician-dispensed drugs than they would if those drugs were dispensed by retail pharmacies.

This is a fluid situation and may well change – and we can only hope it does. We are also wondering where the retail pharmacies and food/drug combos are in the discussion; there is no evidence that physicians pay more for their drugs than drug stores do, so forcing employers and taxpayers to cough up millions to line the pockets of dispensers and their enablers is nothing more than extortion.

That said, it is clear that the Florida Medical Association has once again ignored their Hippocratic oath to do no harm; according to Mike Whitely’s piece in WorkCompCentral the FMA  got the bill’s sponsor, Rep. Mike Fasano R New Port Richey, to “drop a requirement that Florida physicians consult the PDMP before prescribing drugs on Schedules II and III of the US Drug Enforcement Administration’s controlled substances list.”

Notably Rep. Fasano appears to have removed that requirement in hopes that in so doing the bill would have a better chance of passage.  That said, the FMA’s position is short-sighted and self-serving.  According to the vice chair of the FL PDMP Foundation, it “makes sense for doctors to check the database and it takes 30 seconds.” [emphasis added].

So.  Thirty seconds is more important to the FMA – and their members – than preventing doctor-shopping, reducing criminal behavior, and saving lives.

Lest you think I’m being hyperbolic, doctor shopping kills people. And speaking about the Tennessee law requiring docs check the PDMP database before prescribing, “There’s no question the law there will reduce overprescribing and doctor-shopping, said Gary Zelizer, director of government affairs for the Tennessee Medical Association. Yet reducing over-prescribing, doctor-shopping, and the resulting deaths and injuries is less important than saving 30 seconds.

For those interested in doctor-shoppers’ views on PDMPs, read this.  Abusers hate PDMPs that mandate physician checks of the PDMP before prescribing.

Apr
18

Screw up and get paid more – only in America’s health care “system”

Posted by Joe Paduda on Thursday, April 18th, 2013 | Comments

Privately insured patients with post-surgical complications – infections, surgical errors, generate 2 – 3 times more margin for hospitals than patients without complications.

To be precise, the average surgery with complications generated $39,017 more “contribution margin” than those without errors or complications.  

According to the authors, “Depending on payer mix, many hospitals have the potential for adverse near-term financial consequences for decreasing postsurgical complications.” [emphasis added]

The authors – quite clearly – noted that there is no evidence, nor do they believe, that hospitals aren’t focused on eliminating these complications despite the obvious negative financial consequences.  And that’s not my point.

The point is this is yet another example of what happens when you pay providers to do things and not on the basis of how well they do them.  If you get a lousy meal in a good restaurant, they’ll usually comp it.  Bad hotel experience?  On the house.  Defective car?  It’s fixed under lemon laws.

But not health care.  If we based payment – at least in part – on the result, we’d likely see much more focus on that result.

What does this mean for you?

Why are you paying providers to fix problems they caused?

 

Apr
16

Opioids’ long term impact on workers’ comp – WCRI reports

Posted by Joe Paduda on Tuesday, April 16th, 2013 | Comments

Opioids will be the biggest problem the workers’ comp industry faces over the next few years.  WCRI’s hosting a webinar on the issue later this month, and I’d encourage you to sign up (do it fast, there’s a limit on attendees).

For those unaware of recent research on the issue, here are a few of the issues:

  • there’s huge variation among and between the states; according to WCRI’s latest research,  17% of Louisiana claimants who started using opioids were still using them 3-6 months later, compared to about 3 percent in Arizona.  Clearly the risk of addiction/dependency in LA is much higher than in AZ.
  • Less than a quarter of all long-term opioid users were tested for drugs via urine drug screening.  When you factor in drug testing data that indicates a substantial percentage of claimants prescribed opioids don’t have evidence they’re taking them, it is clear employers and insurers are paying millions for opioids that may not be used for the intended purpose (to be generous).
  • In California, claimants prescribed opioids are off work 3.6 times longer; litigation is 60 percent higher, and their claim costs are twice as high as claimants who don’t receive opioids.

If opioids aren’t on your radar, they soon will be.

If not, you must be in Arizona.

What does this mean for you?

Sign up for the webinar

Apr
15

Sequestration’s impact on health care

Posted by Joe Paduda on Monday, April 15th, 2013 | Comments

For most, the federal budget sequestration (that’s the event, sequester is the verb, as in “to sequester, thanks Gary) has yet to make itself felt.

For some, it’s all too real; one person’s waste is another person’s livelihood.

Here’s a few ways the sequestration stalemate in Washington is affecting health care.

So, what does this mean for you?

Well, reduced reimbursement for hospitals, doctors, and drug companies may mean more cost shifting to privately insured patients.

That’s the macro issue.  On a personal level, cuts will affect individuals relying on free vaccinations, wages from medical research funded by NIH, Medicare reimbursement for their salaries, jobs for newly graduated nurses, and residency programs for newly-minted MDs.

There will also be a long-term, downstream impact that we won’t feel for some years – the FBI will not have any new agent classes for at least two years.  That’s not good for health care fraud investigations.  

Apr
12

Drug compounding’s continuing problems

Posted by Joe Paduda on Friday, April 12th, 2013 | Comments

According to the NYTimes, the FDA’s ongoing investigation into compounding pharmacies:

“found numerous unsafe practices at about 30 compounding pharmacies, the same type of facility responsible for the tainted drug that caused a deadly meningitis outbreak last year.

Among the problems found were unidentified black particles floating in vials of supposedly sterile medicines, rust and mold in clean rooms where such drugs are made, improper air flow, and clothing that left workers’ skin exposed.” [emphasis added]

If they aren’t, workers’ comp payers and medical management firms should be paying very close attention to these inspections.  There are three problems with compounds – they tend to be very costly, there is zero evidence that they help the healing process, and there is a wealth of evidence (see above) that compounds can be very dangerous – if not lethal.

Workers’ comp claimants harmed by compounds will incur expenses to address that harm – expense that will have to be covered by the workers’ comp payer.

The payer may also have to provide death benefits for claimants killed by compounds.

States that currently have a compounding problem are likely to see it grow – as it has in California.  States enjoying a compound-free experience are almost certain to be targeted by compounders and their enablers.

The list of FDA-inspected compounders is here.

Apr
10

“Disability” is increasing…why?

Posted by Joe Paduda on Wednesday, April 10th, 2013 | Comments

Are we suffering traumatic injuries from falling trees, collapsing scaffolds, dangerous industrial machines?

Is it because so many of us work at jobs requiring intense physical labor, and we are working long hours long past middle age?  Conversely, is it the very sedentary nature of many jobs that saps energy and wastes muscle?

Could it be we are just living longer than we ever have, and our bodies, programmed by evolution to live long enough to procreate, just aren’t built to stay strong, flexible, and resilient for decades?

Or are we way too fat, get far too little exercise, eat lousy food, and blame everyone but ourselves for the consequences?

Is it the continuing high unemployment rate and dearth of good-paying jobs?

And/Or – and here’s the scary thought – is it the definition of “disabled” that’s changed – both the public one and the way some view themselves?

This is becoming an increasingly critical question – as the number of Americans on Social Security for “disability” has increased rather dramatically – doubling from 1985 to 2005. In 1984 2.2% of the working-age population was receiving Social Security Disability Insurance (SSDI); 4.1% was in 2005.  This increase was, according to a paper published by the National Bureau of Economic Research, driven by a change in the definition of disability:

The most important factor is the liberalization of the DI screening process that occurred due to a 1984 law. This law directed the Social Security Administration to place more weight on ap-plicants’ reported pain and discomfort, relax its screening of mental illness, consider applicants with multiple non-severe ailments, and give more credence to medical evidence provided by the applicant’s doctor.

These changes had the effect of both increasing the number of new DI awards and shifting their composition towards claimants with low-mortality disorders. For example, the share of awards for a primary impairment of mental illness rose from 16 percent in 1983 to 25 percent in 2003, while the share for a primary impairment of musculoskeletal disorders (primarily back pain) rose from 13 per-cent in 1983 to 26 percent in 2003.

The number of working-age folks receiving SSDI reached 8.8 million at the end of last year.  That’s about 4.4 percent of the working age (18-64) population, an increase of 0.3 percent over the last seven years.

There’s been an increasing amount of attention paid to this issue; that’s both warranted and appropriate.

Yet I’m reminded of something Jennifer Christian MD told me years ago; “there’s no condition so disabling that there isn’t someone in the US with that condition working full time today.”

So, what is it?

My sense is it is all of the above. Some are really hurting or unable to work at jobs they can perform, others lazy, some dispirited, some enabled by physicians, many just getting older and wearing down, many unable to find good-paying jobs.

What does this mean for you?

Big, knotty problems aren’t fixed by simple answers or assignment of blame.  They are fixed by understanding drivers and the various moving parts needed to assemble solutions. 

 

Apr
8

Medicaid expansion – waiting for the alternatives

Posted by Joe Paduda on Monday, April 8th, 2013 | Comments

Lost in the political arguments over whether or not to accept federal dollars to expand Medicaid is a rather basic question – what happens if you don’t expand Medicaid?

This is especially important in states such as Florida and Texas, Louisiana and New Mexico, states where over a quarter of the working-age population don’t have health insurance.

If these states don’t expand Medicaid, those people will remain uninsured, safety-net providers will not be able to provide care for them, and hospitals’ financials will deteriorate, some drastically.

In Texas, Louisiana, and Florida, there’s little chance that Medicaid will be expanded, yet there are no alternative solutions proffered by opponents. The politicians in opposition seem content to allow hospitals to fail and people to suffer and die.  Some do this in the name of freedom, others fiscal prudence, yet the result is the same in both cases.

People who can’t afford or can’t get health insurance need solutions, yet all they are getting from expansion opponents are sound bites.  Where’s the leadership, the courage, the bold and innovative solutions?

I’m pretty sure “freedom” to a single mother with kids suffering from asthma and diabetes means freedom from worry, from the gnawing fear that she’ll have to quit her job because she earns too much to qualify for Medicaid in Texas/Louisiana/Florida.  But it’s either that, or go bankrupt when her kids need care.

What does this mean to you?

Depends on your concern about others and your definition of freedom.

 

Apr
4

A worthy research project.

Posted by Joe Paduda on Thursday, April 4th, 2013 | Comments

How many work comp claimants died from opioid overdoses last year in your state?

How many of your claimants died?

As far as I can tell we only know this figure for one state – Washington.  And we only know that because Gary Franklin, the state fund’s medical director did a lot of analysis of a lot of data. That analysis was a major factor in the state’s adoption of strong laws around opioid prescribing, laws that have been directly responsible for a 50 percent reduction in the number of opioid-related deaths of work comp claimants.

So. How many claimants are dying in your state?