Author: Joe Paduda

Apr
3

Rx drug abuse summit – who’s not here

Posted by Joe Paduda on Wednesday, April 3rd, 2013 | Comments

There are almost 900 people attending the second annual national Rx abuse summit, and many are workers comp stakeholders. There are PBMs, UR firms, testing companies, drug companies, a few clinicians from large payers: but no executives no C-suite residents, no actuaries.

That is precisely why opioids are the single biggest problem in workers comp.

Executives don’t grasp this. With a very few exceptions (Aig’s Benmosche is one, SCIF’s Tom Rowe another), the leadership the workers comp is not paying attention. I suppose this is understandable as they have yet to see the real impact of opioids on their financials. Sure they are aware of the growing influence of opioids and are sorta/kinda focused on drug costs, but most are much more cognizant of other more traditional issues: settlement rates, TRIA, admin expense ratios, market cycles. All important and significant, but I’d suggest nowhere near as important as opioids.

The reality is claimants on opioids for more than six months are at high risk for addiction, are not going back to work, and run up high medical costs. Many of these claimants have nothing more serious than back sprains and strains, conditions that should rarely – if ever – merit opioid treatment.

Until and unless those execs start paying attention, focusing their staffs and resources and government affairs people, the problem is going to get worse.

And until and unless actuaries tell them how much more costly these claims are that’s not going to happen.

 

 

Apr
1

Sequester’s impact on hospitals – only CMS could come up with this

Posted by Joe Paduda on Monday, April 1st, 2013 | Comments

The budget sequester is going to cut reimbursement rates for many providers – starting today many will see a 2 percent reduction for Medicare.  That’s going to hurt, but there’s good news as well – for some providers.

According to CMS, the most recent guidance from Congress on implementation of the sequester for Medicare providers requires CMS to “ensure reductions in reimbursement are not based on any currently-in-force profiling, bonus, ACO, e-billing or other reimbursement-altering methodology or process…”  CMS’ Office of the General Counsel’s interpretation of this guidance is it prohibits any staff-based input into “determining, deciding, or selecting which or to what extent bills, providers, locations, or procedures” will be affected.

As a result, as of today, CMS will begin implementing the “random sequenced reimbursement reduction program”, or RSRRP.  While the final details of this have yet to be worked out, early indications are it involves setting reimbursement at zero for every fiftieth provider bill; bills so affected will be pended and routed to the “further action required” queue (typically utilized for bills with missing data elements or demographic.

In this instance, the RSRRP bills will be held until such time as “adequate funding exists to complete the adjudication and reimbursement process.” [emphasis added]

Hospital organizations are, understandably, up in arms over the cuts, asserting they are arbitrary, capricious, and will cause significant harm to many hospitals, including the most vulnerable safety-net institutions.  An American Hospital Association report indicates the sequester will reduce spending by some $10.7 billion in 2013 alone, noting: “Sequestration is a blunt and indiscriminate instrument. It is not the responsible way for our nation to achieve deficit reduction” An AHA spokesperson went further: “Hospitals will have to make tough choices about which services to maintain because of potential cuts since hospitals will maintain the highest quality for whatever services they provide…”

Responding to the criticism, HHS Sec Kathleen Sibelius noted that her hands were, in effect, tied as Congress “effectively prevented HHS from taking any action to ameliorate the effect of the sequester.  Quoting from the report, Sec. Sibelius said: “the “blunt and indiscriminate” effect of the sequester calls to mind an HL Mencken quote; “the people get the government they deserve, and they deserve it good and hard.”

When asked how long the RSRRP bills might be held in limbo, a spokesperson responded: “ask Congress, and encourage your readers to do the same.”
What does this mean for you?

Likely more cost-shifting from hospitals seeking to make up lost revenue.  

Mar
29

The new compounds and who’s making them…

Posted by Joe Paduda on Friday, March 29th, 2013 | Comments

Gensco Labs has been busy filing trademarks for new and wonderful topical medications that are sure to solve myriad problems – to date they’ve filed for 46!  They sure are busy down there in Miramar, Florida!

There are a LOT of Genscos down in Inverness Florida…and the trademarks Gensco holds have been filed by Randy M Goldberg., Esq.  One wonders if this is the same Randy M Goldberg who is listed on his LinkedIn profile as Chief Legal Counsel of…wait for it…

Automated Healthcare Solutions!

If it is, one wonders if ABRY Partners, the private equity firm that has a stake in AHCS, is getting a piece of the pie.  Of course, two of ABRY’s other holdings, York RSG and Gould and Lamb, might not be too excited about that.

As long as we’re wondering, how do Gensco’s scientists get the time to do all that ground-breaking research work as they work tirelessly to bring the wonders of medical genius to injured workers around the country, working side-by-side with selfless people striving to ensure those terrific new medications get in the hands of as many dispensing physicians as possible.

Their medications include such wonders as SpeedGel, TranzGel, InflaGesic, LidoGesic, TranzGesic, and other xxx-Gesics.  Perhaps they’ll make a superduperGesic, or maybe even a TranzLidoSpeedInflaGesicGel…wouldn’t that be GREAT!!

No word if any of these wonder-drugs compounds have made their way to California or if they are some of the medications that have driven the average price per compounded med up some 68 percent.

SpeedGel has a wealth of wonderful ingredients; echinacea purpurea, echinacea angustifolia, aconitum napellus, arnica montana, calendula officinalis flower, hamamelis virginiana root bark/stem bark, atropa belladonna, bellis perennis, chamomile, achillea millefolium, hypericum perforatum and comfrey root gel.

No eye of newt or bat wing extract, but perhaps in a future version…

I’ve heard that the OTC version of SpeedGel is going to or has been pulled from the market – evidently some payers have been confusing it with the prescription version and reducing reimbursement.  Shame on you, payers!  Bad payers!  Fortunately, the REAL SpeedGelRx is going to continue on.  

Alas, some payers don’t see the benefits – this from Summit Holdings in Florida:

“In the first months of 2012, several new creams have entered the market. Again, these are formulated with common over-the-counter ingredients and, interestingly, are marketed exclusively to physicians who see workers’ comp patients. They are assigned National Drug Codes, along with corresponding Average Wholesale Prices.** SpeedGel is priced at $700 for 3 ounces, and TranzGel is listed for $695.

While your patients may not get the bill for these products, these costs have a major impact on the workers’ comp system. Our clients (your patients’ employers) end up paying these costs in increased premiums and, in many cases, actual medical costs.

In most cases, we are denying coverage for these products…” [emphasis added]

What doe this mean for you?

To find out of your claimants are lucky enough to be getting SpeedGelRx, search for NDC 35781-0200-5 and 35356-0647

Mar
27

The Health Care Social Media Review

Posted by Joe Paduda on Wednesday, March 27th, 2013 | Comments

In the “why didn’t this happen sooner” category is Louise Norris’ new review of health care social media blogging – you can find it here.

Brilliant and needed.

Mar
27

Health care – not a ‘system’ but an Industry.

Posted by Joe Paduda on Wednesday, March 27th, 2013 | Comments

To say we have a “health care system” is laughable; we actually have is a disconnected bunch of stakeholders who all view health care and the financing thereof through their own distinct lens.  There’s a:

  • heavy emphasis on profit and personal/corporate gain from individuals and organizations ‘serving’ the health care needs of Americans,
  • all subject to direction and oversight by an increasingly overburdened regulatory infrastructure that in turn is
  • directed by legislators who are often beholden to those
  • folks making a living off the “system”.

Any wonder it’s completely screwed up?

Yet we often lose track of these central challenges when thinking about/developing solutions to problems in health care delivery and financing.  Quoting Chris Brigham, M.D, “Many of the challenges we face in workers’ compensation are the results of flawed processes and wrong incentives – that drive certain behaviors – ultimately harming injured workers and society”.

There are a couple resources that help bring things back into focus.

First is the film, Escape Fire: The Fight to Rescue American Healthcare”  www.escapefiremovie.com This is a terrific documentary of a medical industry – not system – with profit-driven, rather than patient-driven care.  It has played on CNN several times during the past month and is available on ITunes and as a DVD.   Our health care costs are approaching 20% of our gross domestic product. We spend $300 billion on pharmaceutical drugs – almost as much as the rest of the world combined. 65% of Americans are overweight and 75% of healthcare costs are spent on preventable diseases that are the major causes of disability and death in our society. It is inexcusable. 

The second is an insightful article “Chronic Pain: Fundamental Scientific Considerations, Specifically for Legal Claims” by Robert J. Barth, PhD which was the lead article in the January / February 2013 issue of the AMA Guides Newsletter.  Barth’s article is an in-depth discussion of evidence and scientific findings indicating eligibility for compensation is the domi­nant factor for chronic pain claims.

With chronic pain the reef on which the ship of workers comp is increasingly likely to founder, Barth’s piece is well worth the read.  The key sentence – Barth quoting from a speech given by the author of a study on back pain – is this:

“Minor trauma was only associated with serious low back pain in a compensation setting.” [emphasis added]

Barth – “None of the surveyed participants who were NOT eligible for compensation developed serious low back pain after minor trauma.”

And there you have it: unequivocal evidence that there’s a huge amount of “secondary gain” driven medical care.

What does this mean for you?

Anyone who thinks there are simple answers to our health care mess is a simpleton. 

 

Mar
26

Just how dangerous is compounding?

Posted by Joe Paduda on Tuesday, March 26th, 2013 | Comments

Way more dangerous than we’ve been led to believe by compounding pharmacies and their supporters. A report in the Washington Post by two investigative journalists highlights shoddy practices and unsanitary conditions at three pharmacies that have sickened and killed patients.

Unfortunately compounding is a growing phenomenon, especially in workers’ comp.  Research from CWCI and other sources indicate that despite the lack of any evidence-based research justifying widespread use, compound meds are becoming a larger part of pharmacy spend.  Fortunately, we can observe what’s happened in California to forecast the future for compounding in other states.

California recently tried to address the issue thru bill AB 378, which specifically focused on the ingredient cost; the net? the number of scripts dropped 35% (from 3.1% of all scripts to 2%)…however the cost per script zoomed.  Compounds now account for one out of every eight dollars spent on drugs…

(see CWCI’s February 2013 report for details on what happened and why)

In his blog, David DePaolo reported on a criminal case involving payments to physicians for prescribing compounds;

“The complaint, filed by the owners of a medical billing company in the U.S. District Court in New Hampshire, alleges that Cyrus Sorat is a part owner of Health Care Pharmacy and Deutsche Medical Services in Tustin, Calif., and paid 208 doctors to prescribe compound drugs to injured workers needing topical analgesics. Sorat promised to pay the doctors an unreported fee for each prescription they wrote, and also agreed to handle billing and recover receivables on behalf of the physicians, according to the complaint.”

While cases such as these are unusual, the increased use of compounds, and specifically the changes in the compound drugs dispensed are clearly intended to maximize reimbursement.

Make no mistake – this isn’t about patient care or return to work or excellent medicine, it is about enriching a few at the expense of employers and taxpayers, while not caring one whit about possible patient safety issues.

Workers’ comp – the last refuge of scoundrels and charlatans.  Again.

 

 

 

Mar
25

The latest on workers’ comp physician dispensing in Louisiana

Posted by Joe Paduda on Monday, March 25th, 2013 | Comments

The good folks in Louisiana are rejoicing over a recent court decision in a case involving LUBA Workers’ Comp; here’s the interpretation from Jeffrey Napolitano of Juge Napolitano Guilbreau Ruli & Frieman PLC, a legal firm in Metairie, LA…

the court found “a wholesale pharmacy distributor, who contracts with physicians to provide pharmaceuticals to the physicians on a consignment basis for dispensing to their workers compensation patients, has no right of action to bring suit against the employer/insurer for payment for pharmaceuticals. [emphasis added] The court held that only the employee or healthcare provider has a right to brig suit for payment for providing medical services to an injured workers under the workers compensation act.”

While the Pelican State may have a reputation as a bit of a hellhole for workers comp payers, this latest shows that there’s always good to be found – if you have a good enough case and a smart enough attorney.

Kudos to LUBA for fighting the good fight.

Unfortunately, we can expect physicians to start billing for themselves, or figuring out some equally creative way to suck more money out of employers and taxpayers.

What does this mean for you?

The briefest of respites…

 

Mar
20

There is NO OBAMACARE RFID CHIP!

Posted by Joe Paduda on Wednesday, March 20th, 2013 | Comments

Among the top all time posts on MCM was the one a couple weeks ago about the right wing and nut-o-sphere’s claim that the feds are going to require anyone signing up for health insurance will be implanted with an RFID chip containing their medical and financial records.

As of this am, there were 12.386 views of that post.  I kid you not.

To repeat – there is NOTHING in the PPACA legislation or regulations about any RFID chip.

These conspiracy theorists either intentionally or ignorantly mis-read the PPACA’s Medical Device Registry language – which is clearly intended to track medical devices – hip replacements, pacemakers, spinal cages and the like – to “facilitate analysis of postmarket safety and outcomes data.” This language – which is quite simple and quite clear is mis-interpreted to imply that we all are going to get a chip implanted somewhere on our persons.

Of course we need to get these devices tracked – many fail, many are recalled, and there are many complications arising from these devices.  Rather than having no way to figure out who has an implant from the Acme Hip Bone Implant Device Co. by sorting thru paper documents, it only makes sense to have a central source that can identify the Acme patients.

Not only is there nothing in any document about this, but the tin-foil hat crazies propagating this rubbish cite a bill that was never even passed (HR 3200) and is not law as their source for this nefarious plot.  And, it has been refuted by Snopes and about a hundred other investigators.

But the monsters-under-the-bed crowd don’t let facts interfere with their claims – oh, no, not this guy.

There have also been a flood of comments from people claiming this is some part of a master plan of the Illuminati, or the FreeMasons, or some other obscure group bent on world domination.  After posting a couple comments, I’ve trashed the rest.

Mar
19

What business are you in?

Posted by Joe Paduda on Tuesday, March 19th, 2013 | Comments

The good folk at WorkCompWire asked me to contribute a piece this week; you can find it here.

The main point – Most workers’ comp executives – C-suite residents included – do not understand the business they are in. They think they are in the insurance business – and they are not. They are in the medical and disability management business – with medical listed first in order of priority.

Let the brickbats fly.