Apr
5

Compounds – the stench of corruption

There’s a bill in the US House of Representatives that would greatly expand compounding, drastically reduce the FDA’s ability to oversee compounding, and eliminate many of the desperately-needed controls on this occasionally-deadly and often-abused practice.

Why anyone thinks this is good idea is beyond me, but someone convinced Rep. H Morgan Griffith (R VA) to write a bill and introduce it in Congress, and Rep Henry Cuellar (D TX) and others to co-sponsor Griffith’s bill.

That “someone” may have deep pockets.

Griffith has received over $100,000 in donations from “health professionals” and pharma entities; Cuellar got money too.

Griffith also got more money from the “International Academy of Compounding Pharmacists” than any other candidate for any Federal office.  The IACP has spent millions lobbying Congress to strip the FDA of authority and eliminate controls over compounding.

The IACP and other organizations are seeking to rewrite regulations issued after the New England Compounding disaster, a tragedy that saw hundreds of people sickened and scores killed by contaminated compounded medications. These medications were prepared and shipped by the NECC, a business in Massachusetts that happened to be located right next to a recycling center owned by the same family.

(This is relevant because ventilation systems were one of the problems identified by investigators looking into the causes of contamination in NECC’s products.)

The regulations were issued to implement a law passed by Congress in response to a Congressional inquiry into the disaster.

From wikipedia:

In a congressional hearing the FDA Commissioner was asked why regulators at the FDA and the Massachusetts Board of Pharmacy did not take action against the pharmacy years earlier. The legislators were told that the agency was obligated to defer to Massachusetts authorities, who had more direct oversight over pharmacies.

Yet Griffith’s bill would overturn many of the desperately-needed controls now in place:

The bill exempts from interstate distribution limits the dispensing of a compounded drug from the facility where it is compounded to a patient or health facility.

The scope of Food and Drug Administration (FDA) inspections of compounding pharmacies is limited to pertinent equipment, materials, containers, and labeling, which is the same scope as inspections of pharmacies. (Currently, the scope of inspections of compounding pharmacies is the same scope as inspections of drug manufacturers.)

The bill eliminates the requirement for compounding pharmacies to register with the FDA as drug manufacturers.

As a side note, we’re seeing a dramatic decrease in compounds in workers’ comp, driven by payers’ refusal to pay outrageous charges for “medications” with no proven efficacy. In our annual Survey of Prescription Drug Management in Work Comp, respondents are reporting they paid for far fewer compounds last year than the year before.

That decrease could reverse if Griffith’s bill is passed, and we could well see a return to the days of poorly-regulated profit mills masquerading as compounding pharmacies.

What does this mean for you?

Elections have consequences, and campaign finance laws are killing us.


Mar
30

Cirillo takes over at myMatrixx

myMatrixx, Express Scripts’ workers’ comp PBM brand, will name Mike Cirillo President on Monday April 2.

Cirillo most recently led Injured Workers’ Pharmacy’s effort to enter the PBM space. He has deep experience in work comp claims from his days at the Hartford’s SRS TPA, along with 5 years’ pharmacy experience at IWP.

He will replace myMatrixx CEO Artemis Emslie, who, as we’ve noted previously, announced her decision to step down at the end of last year. Those are some big shoes to fill, as Artemis is universally well-liked and well-regarded for her depth of knowledge and long experience in work comp pharmacy and related businesses.

The changeover comes at a critical time. Currently there are multiple payers deep into the RFP process, more so than I’ve seen at any one time in recent years.  Several are seriously evaluating switching PBMs.

IWP’s effort to launch a new work comp PBM started just over a year ago. The PBM, branded SpecialtySolutionsRx, did not gain much traction, perhaps due to payers’ views of IWP as part of the problem, not part of the solution to work comp drug issues. There is no current information available about Specialty Solutions on IWP’s site.

It is likely SSRx is in a holding pattern for the time being.


Mar
28

919,400 people aren’t working because of opioid use

My best guess is about a quarter of those are work comp patients.

Opioid use disorder (OUD) drains the workforce of qualified, experienced workers, costing our economy $40 billion.

Healthcare costs for OUD alone were $28 billion in 2015 – and all but $2 billion of that was paid by insurance – mostly Medicaid (which is taxpayer funded).

If you are 50 or younger, you’re more likely to die from opioid use than anything else – not a car accident, not cancer, not a heart attack, not diabetes.

Solutions

Medication-assisted therapy (MAT)- using methadone, buprenorphine, vivitrol to help victims get off and stay off opioids – is, for most folks, a key part of recovery. Yet most states have far too few MAT facilities, and many facilities only provide one or two of those medications (not surprisingly, different people seem to do better on different therapies).

Yet there are far too few providers trained and able to provide MAT.  From Inflexxion:

Data shows that less than half of privately funded treatment programs offer any form of medication-assisted treatment. That number falls to 23% in publicly funded programs. According to the 2013 National Survey on Drug Use and Health, of the 2.5 million opioid-dependent or opioid abusing Americans, fewer than 1 million received MAT.

MAT, coupled with counseling and patient-centric, individualized treatment plan can be quite effective.  A solid study found over well over half of patients using MAT were not using the illicit drugs 18 months into treatment – a remarkable success.

However workers’ comp payers are often unable to find MAT facilities, lack the understanding needed to develop a comprehensive, long-term treatment approach, and are loathe to go down that path, as they’re afraid it will make the employer liable for all manner of additional services.

What does this mean for you?

States can and should come up with novel ways of encouraging treatment while limiting future liability.

This will save thousands of lives and billions of dollars for employers and taxpayers.


Mar
22

Opioids and disability duration

On a panel discussing opioids, Dr Bogdan Savych of WCRI opened with a review of WCRI’s latest research looking at the link between opioid prescribing and the duration of disability.

It is great to see WCRI spend a big chunk of time and research dollars on this – which I believe is the biggest problem in workers’ comp today – and will get worse long before it gets any better.

Couple quick data points…

  • One of 10 workers who get opioids are still taking them after 90 days.
  • And, between half and 85% of workers (not surgical cases) who had pain medications were still getting scripts for opioids 3 months later
  • There’s really significantly different prescribing patterns depending on geography – NOT evidence-based guidelines, severity, injury type, etc – but simply where the patient is treated. (so much for the science of medicine…)

That’s just nuts. (editorial comment)

Dr Savych’s study looked at low back pain cases, noting that most guidelines do NOT recommend opioids for low back pain – and certainly not for long term treatment.

Workers with longer-term opioid scripts had more than triple the duration of disability of those who did not use opioids over the long term.

Yet there is NO evidence that opioids are appropriate for long term treatment of low-back pain

Takeaway – Do everything you can to prevent workers from taking opioids over the longer term.


Mar
22

How to prevent and stop opioid use in work comp

It can be done. And it is being done – by a state governmental agency, no less.

Ohio BWC (the state workers’ comp fund in Ohio)’s Medical Director gave background on just how bad things were at BWC in 2011, before just-hired pharmacy director John Hanna took over.

One patient was taking 4000 Morphine Equivalents per day.

40 million opioid doses prescribed in one year.

After five years, the number of opioid dependent patients, opioid doses, and patients taking opioids were all cut in half.

Here’s an even better view…

Ohio allows for treatment of opioid dependence for 18 months without it being allowed in the claim.

I can’t say enough about what Ohio BWC has done. While the data is telling indeed, I think of the families that are still intact, the moms and dads still alive, the employers still staffed by able and capable workers, the first responders somewhat less stressed.

Thank you, John Hanna, Dr Steve Woods, Dr Nick Trego, and Dr Terence Welsh – and your bosses at BWC and in state government, including Gov Kasich (R).


Mar
19

Nothing ado about much

That’s the quick take on the White House’ plans to attack the opioid crisis.

Briefly, it amounts to:

  • harsher enforcement of existing drug laws,
  • education using advertising to prevent addiction,
  • helping fund treatment and
  • helping addicts find jobs while in treatment.

The latter two make a lot of sense; the first two are futile, stupidly expensive, and simplistic at best.

The “war on drugs” has resulted in millions incarcerated, trillions in costs, thousands killed, and, surprise, people still do illicit drugs.

These are just statistics, and therefore meaningless. But it isn’t meaningless for me or my family.  A family member in law enforcement died in the line of duty; much of his career was in drug interdiction and his death resulted from that work. The drug war is akin to Afghanistan; we’re never, ever, ever going to “win”, because the war isn’t winnable.

As for education, unless you’re older like me, you may not remember Nancy Reagan’s “Just Say No” campaign. Lucky you.  These “education” programs don’t work…according to an NIH study, the campaign: “had no favorable effects on youths’ behavior” and may have actually prompted some to experiment with drugs, an unintended “boomerang” effect.

While the latter pair make eminent sense, there’s nowhere near enough money – and without money they’re just talking points.

We need at least $10 billion more a year for treatment, plus additional funding for Medicaid which pays for a major chunk of treatment.

There’s an argument that former President Obama took too long to recognize the opioid disaster and start working on solutions – and I’d agree.

That said, the current funding level represents a real decrease in funding, at a time when death rates are accelerating.

What does this mean for you?

We’re on our own. 


Mar
13

Opioids – bad news and good

Patients taking opioids over the long term don’t go back to work, yet many long-term opioid patients can be weaned off opioids within two years.

Those are the quick takeaways from two studies that came out last week.

First, a study from WCRI validates earlier research, finding:

  • patients with multiple opioid scripts are out of work three times longer than patients with no opioid scripts, and
  • patients who lived in places where providers prescribe a lot of long term opioids…are more likely to get opioids for longer periods than individuals who lived elsewhere.

This is the first study that looked at ALL lost-time claims with a diagnosis of low back pain in a very large area – 28 states that represent 80% of claims – over a five-year period. This is important because it shows  cause-and-effect independent of so-called “severity” measures, which often use cost, treatment, or prescriptions to indicate medical severity, instead of actual clinical indicators. By looking at ALL low back claims with lost time, claims, it is clear that the driver of disability is long-term prescribing of opioids.

The takeaway is this – chronic use of opioids extends disability, and you can figure out where you need to focus your efforts by looking at publicly-available prescribing data.

California is one state with way too much experience in dealing with opioids in work comp; the graph below shows both the overuse, and the progress made in the Golden State since it got serious about reducing opioid usage.

source – WCIRB

Which brings us to the good news: weaning works, as research from California’s Workers’ Compensation Insurance Rating Bureau shows: 

47% of the injured workers demonstrating chronic opioid usage weaned off of opioids completely within the 24-month Study period. Injured workers who did not wean off completely over the Study period still reduced opioid dosage by an average of 52%.

The research included all patients with more than 50 morphine equivalents over at least 3 months within 24 months of the date of injury.

Yes, it is difficult, expensive, requires a lot of assistance from trained professionals, and does not always work. All that said, given the finding that patients taking opioids for longer periods are out of work a lot longer, it is well worth the time and effort to help these patients reduce or end their use of opioids.


Mar
7

Big changes in work comp pharmacy spend

Sometimes data is so compelling you have to get it out there immediately.

CompPharma’s annual survey of prescription drug management is underway; here are quick takes from the first ten surveys.

  • 2017 drug spend dropped 13.4 percent from 2016 – the biggest decrease in the 15 years we’ve been doing the survey
  • Opioid spend decreased twice as much – over 26 percent.

Note that the huge drop in opioid spend occurred BEFORE adoption of formularies and other controls in big states like Pennsylvania, New York and California.

Note also that this is the sixth drop in drug spend since 2010.

Graph from last year’s Survey, Public version available for download here.

There are a few other newsworthy findings;

  • compound spend is down dramatically in most areas – but has spiked in a couple of states.
  • the decrease in spend is attributed primarily to lower opioid utilization
  • despite the big drops in spend, respondents (typically the executive at a work comp payer with overall responsibility for medical management) see pharmacy as MORE important than other medical service types…because pharmacy drives disability and return to work

This is very preliminary; we expect another 15 or so respondents and I’d expect things to change with more data. (if you want to participate and receive a detailed copy of the 2018 Survey Report, email Helen Patterson at HKnightATcomppharmaDOTcom)

What does this mean for you?

The work comp industry’s decade-long focus on pharmacy is delivering far better care and lower costs.


Mar
2

What the %$#(*& is going on with opioid policy?

I’m somewhat encouraged, but mostly confused.

Briefly, this is the problem with national opioid policy.

There’s a major disconnect in DC on what to do about opioids – criminalize addicts, incarcerate them, kill drug dealersor expand treatment, go after opioid manufacturers and distributors, increase funding for solutions, change Medicaid policy to allow more treatment options.

While these aren’t mutually exclusive, the messaging coming from the White House is wildly inconsistent.

[HHS Secretary] Azar’s emphasis on medication-assisted treatment for opioid abuse also stands in stark contrast to Trump, his boss, who typically focuses heavily on law enforcement whenever he’s addressing the epidemic. That’s the approach Trump took yesterday, telling summit attendees that cracking down on drug dealers is a key to solving the problem — and even suggesting that imposing the death penalty on them would be helpful.

“Some countries have a very, very tough penalty — the ultimate penalty,” the president said. “And, by the way, they have much less of a drug problem than we do. So, we’re going to have to be very strong on penalties.”

While there’s lots of press out about the recent White House confab on opioids, what’s really happened behind the scenes is a lot less exciting. It sure looks like the policy experts are being sidelined from the real work, which is being handled by, you guessed it, political types…

from Politico

[Senior White House Advisor Kelly Anne] Conway’s role [as chair of the WH “opioid cabinet] has also caused confusion on the Hill. For instance, the Senate HELP Committee’s staff has been in touch with both Conway and the White House domestic policy officials, according to chairman Lamar Alexander’s office. But lawmakers who have been leaders on opioid policy and who are accustomed to working with the drug czar office, haven’t seen outreach from Conway or her cabinet.

“I haven’t talked to Kellyanne at all and I’m from the worst state for this,” said Sen. Shelley Moore Capito, a Republican from West Virginia, which has the country’s highest overdose death rate. “I’m uncertain of her role.” The office of Sen. Rob Portman (R-Ohio), another leader on opioid policy, echoed…

Of course, there’s still no Director for the Office of National Drug Control Policy, but at least it isn’t being run by a 24 year old.

I’ve talked to professionals deeply involved in national drug control initiatives and policy; some are convinced Trump et al are serious about the opioid disaster and are focused on it; others say it’s all a sham, the Administration is either unable or uncaring about this, and just bounces from policy statement to policy statement without getting anything done.

My takeaway is this.

Good people in the Administration know the opioid disaster is a disaster, and want to help address it. But they can’t.

The complete and total managerial incompetence, institutional attention deficit disorder syndrome, and lack of understanding of how to govern on the part of the White House’s current occupant and his staff hamstrings any and all efforts to develop and implement solutions.

What does this mean for you?

Big problems require thoughtful and diligent approaches.


Feb
8

Pennsylvania’s work comp formulary – the real story

There are honest disagreements about policy matters, and there is ignorance and fear-mongering.

That’s what’s happening in Pennsylvania’s House of Representatives, where a bill to mandate adoption of a formulary failed to pass yesterday.  It appears some politicians are being swayed by mischaracterizations by those who should know better, including “several unions joining with…trial lawyers.”

What’s especially disturbing is these unions and “plaintiff advocates” are claiming to defend injured workers, yet their opposition to this bill risks patient safety and does nothing to improve patient care.

(Note: this is NOT a slam against all plaintiff attorneys or organized labor)

One plaintiff lawyer characterized the bill as “just a cost-savings package for insurance companies.” That claim is blatantly false. Wording in the bill, SB 936, “expressly requires regulators to make sure any savings form a formulary are passed on to policyholders via reduced rate filings” (quote from WorkCompCentral)

Opponents of the bill say they’d support a bill that only addressed opioids.

This is nonsensical and naive at best.

Why are a comprehensive formulary and UR necessary and appropriate? 

Formularies have been in place in Medicare, Medicaid, Group and individual health insurance for decades. Workers’ comp PBMs use formularies and utilization review to ensure patients get the right drugs for their conditions, protect patients from potential ill effects from inappropriate medications, and streamline the approval process.

Second, it’s not just opioids that are potentially dangerous or deadly. Benzodiazepines, muscle relaxants, anti-depressants: all have significant risks, can be mis-used, and represent clear risks for patients.

Third, combining a formulary with utilization review is essential for patient safety. A formulary alone is just a set of guidelines; UR is how these guidelines are applied.

The compound drug scandal in Pennsylvania is prima facie evidence of the need for a strong formulary and tight utilization review. This from the Inquirer:

Three partners at [law firm Pond Lehocky] and its chief financial officer are majority owners of a mail-order pharmacy in the Philadelphia suburbs that has teamed up with a secretive network of doctors that prescribes unproven and exorbitantly priced pain creams to injured workers — some creams costing more than $4,000 per tube.

Pond Lehocky sends clients to preferred doctors and asks them to send those new patients to the law firm’s pharmacy, Workers First. The pharmacy then charges employers or their insurance companies for the workers’ pain medicine, sometimes at sky-high prices, records show. [emphasis added]

Formularies and UR are not the entire answer. In addition, Pennsylvania – and other states – should:

  • adopt mandatory reporting to and checking of a drug monitoring program (PDMP),
  • require a comprehensive approach to opioid prescribing (Washington State’s example is one of the better ones),
  • vigorously enforce drug distribution reporting requirements, and
  • demand manufacturers and distributors pay for the damage they have and continue to cause.

Note – as I’ve opined before, I have concerns with closed or binary formularies, and strongly believe payers and PBMs should have the flexibility to adapt formularies to match the needs, conditions, and co-morbidities of individual patients.

What does this mean?

We are doing everything we can to ensure patients get the drugs they need quickly, while protecting those patients from potentially dangerous medications.

It’s not about costs, it never was, and it never will be.