Any time you have to mention urine in a blog post you know it’s going to be a tough one.

There’s a kerfuffle in the world of urine drug testing, one of the more litigious and contentious industries I’ve ever encountered.  The parties involved, Ameritox and Millennium Labs, have been involved in litigation for some time now.  [full disclosure, Millennium has been a consulting client for a couple of years; I work closely with them, and have found them to be great people who do the right thing consistently.]

A while back, Ameritox lost a suit brought by Millennium over alleged deceptive advertising; more recently a jury ruled Millennium had improperly given cups to docs in four states, a practice the jury deemed an unfair trade practice. Ameritox trumpeted their “win”, however the jury’s finding was inconsistent with the opinion of several experts in the area, all other charges were dropped, and the case is on appeal.  And there was a serious legal question raised when one of the key witnesses allegedly provided information that perhaps they had no right to.

Be that as it may, the case was noted by friend and colleague David DePaolo, who opined: 

While medical guidelines recommend drug testing for compliance purposes and to help ensure that drugs aren’t being diverted to the black market, we know those are specific case recommendations particular to a certain set of medical facts, not to be applied universally.

But the way medical suppliers stimulate sales with physician gifting and revenue enhancement programs tests the ethical and moral qualities of the individuals on the front lines, and physicians should not be placed in those positions, and we should not be placed into positions of having to pay for it.

Sometimes drug testing is warranted. Most of the time it is not.

A couple comments.

First, research from various organizations including WCRI clearly indicates there’s far too much testing going on of a small population, and far too little of most.  About a quarter of folks who should be tested are, while some unscrupulous docs test every patient every time, making bank.  I respectfully disagree with David’s statement that “most of the time” drug testing isn’t warranted.

Second,

What is correct is to say many more patients taking opioids should be tested, and that testing should comply with accepted evidence-based clinical guidelines; Washington State, Colorado, ACOEM, and others are all excellent sources.

Opioid abuse, misuse, diversion, and related problems have long surpassed crisis status – we’re now in a national disaster with more people dying from this than motor vehicle accidents.  Drug testing is a critical part of the answer.  Yes, there are vehement disagreements among stakeholders, and yes, they can get very contentious, and yes, I have a dog in this fight.  That said, I – and many others – have been working long and hard to bring attention to the opioid disaster, and we need to keep the focus on addressing the problem and not get distracted by tangential issues.

On that all parties should agree.

What doe this mean for you?

There’s a real danger that we over-react, over-simplify this issue, and in so doing make blanket statements that do more harm than good.

 

 

 

Helios is the new name for PMSI/Progressive.  The idea is to have a single name for the two different firms, both of which had positive brand images in the work comp world.  In talking to the marketing folk, their take was that while both brands had strong equity neither legacy name would work for the combined entity.

It seems a shame to end PMSI’s decades-long run, especially after Eileen Auen, Jay Krueger, and their excellent colleagues rescued the PBM from what seemed like a sure path to oblivion.  Instead of watching over the demise, they turned it into one of the top players in the business.  That said, Progressive had a well-earned and well-deserved reputation as a VERY customer-focused PBM; beginning under founder Dave Bianconi (one of the best people in the business…ever). If anything that focus has grown under the current Auen-Young-Sisson triumvirate; customers are (with rare exceptions) universally pleased.

So, Helios it is.

That will be a d/b/a; due to legal, regulatory, compliance matters I would not expect to see the Helios name show up on provider contracts and other legal stuff as that may well trigger all kinds of re-filing and jumping-through-legal-hoops.  But what we’ll very likely see is a big re-branding push, with lots of PR, a new logo, and a splash in Florida next month and Vegas in the fall.

Meanwhile, Aetna’s much-discussed sale of its workers’ comp sub (I know, I owe a bunch of folks on my mis-call on this one) hasn’t been finalized – as far as I know.  In conversations with several potential financial buyers, Coventry WorkComp’s declining revenues and earnings, coupled with the problems inherent in re-contracting a provider network without mother Aetna’s market clout and concern over PBM First Script’s strong ties to network Express Scripts makes for a “sub-optimal-go-forward-scenario.”

Yup, that’s a direct quote. I think it means the potential investor doesn’t think they can pay what Aetna wants and get a decent return on that investment.

Undoubtedly, someone else will come up with a different scenario; whether it’s enough is to-be-seen.

Side note – long time First Script exec Brain Carpenter has joined Healthcare Solutions as their top clinical pharmacist.  HCS has been dramatically increasing the number and expertise of their pharmacist corps and the addition of Brian is a big plus. Brian will report toy EVP Jim Andrews; kudos to Jim (who I am fortunate to consider a good friend) for successfully building HCS’ clinical programs.

What does this mean for you?

Stability at one PBM…

 

Compound drug use is exploding – so much so that Texas has changed their employee benefits program to limit reimbursement to $300.  They didn’t have much choice, as the Texas Employees’ Retirement System’s compound drug costs have gone up 4,600% over five years.

That was not a typo.

They’re now requiring prior auth and ONLY covering FDA approved drugs.

The only thing that may potentially slow down the growth is bad news – and that was delivered in spades last week with the news that a coroner’s report found the infant died after ingesting a topical pain cream.  After sustaining injuries at work, the baby’s mother, Priscilla Lujan, applied some of the cream to her knee and back, made a baby bottle, and some of the substance got on the nipple.  The story was broken by Karen Foshay of KPCC; Foshay reported the cream contained the

“antidepressant amitriptyline, the pain reliever tramadol and the cough suppressant dextromethorphan…

Workers’ compensation records show Jarminski’s office billed $1,700 for the initial 25-day supply of the cream. That is much more than the prices of various mass-produced medications, asserted McCann.

Jarminski [the mother’s physician] was informed the cream was linked to Lujan’s son’s death but, according to McCann, that didn’t stop the doctor from sending more creams.

“Priscilla had expressed she didn’t want to see that cream anymore or use it anymore,” McCann said. “Despite that they continued to send her more creams by mail and bill workers’ comp for it.”

McCann said at least two to four more tubes of cream were sent to Lujan after her son’s death. It’s unclear how much Jarminski billed in workers’ compensation claims for those additional tubes.

As horrible as this is, this baby’s death may protect others from this deadly scam. The press is all over this, medical malpractice insurers are undoubtedly quite concerned, and law enforcement is getting more engaged.

While one would hope the mother’s doctor prescribed this medication solely for health reasons, the prescribing physician was one of those indicted in the California compound drug case.

Of course, the compounders have hired a PR firm to try to convince us with BS that which they can’t validate with science – and even started an astroturf group to “fight for patients rights”.  Like the right to have tubes of deadly cream lying around…

UPDATE From a colleague’s email –

One strategy that seems to work well in Texas is to approach every compound as Experimental and Investigational and require prior authorization for ALL. The Texas WC UR rules appear to allow for that approach since essentially none of the compounds has gone through specific FDA approval. Without high quality (or essentially any) studies to support their use compounds can only be viewed as E&I in Texas.

At least one large carrier I know of is approaching compounds this way in Texas and other jurisdictions.

For those interested in the current state of research into compounds and workers’ comp, CompPharma’s research paper can be downloaded here.

What does this mean for you?

DO NOT approve compounds without proof of medical necessity and safety.

Today’s post is authored by Jack Johnston who is spending his summer interning at Health Strategy Associates; Jack is going to be a senior at Syracuse University (my alma mater); he’s studying Health and Exercise Science.

The three largest PBMs have sent out their annual drug trend reports to tell the Workers’ Comp world what’s been going on this past year.  Instead of you having to read through each entire report and finding out what’s new, I’ve bit the bullet and gone through them for you.  Coventry-First Script, Progressive Medical-PMSI, and Express Scripts have all made much progress and developed new ways to further develop their success.  Let’s give you the skinny…

PBM Goals:

Coventry-First Script has been working with physicians to eliminate the use of narcotics  – due primarily to widely known potential for misuse.  Increasing generic brand utilization to lower costs and helping the older workforce remain healthy enough to work have also been other tasks Coventry’s been working on.

Progressive has managed to accomplish their goal to decrease opioid usage by working with physicians, prescribers, and injured workers.  Progressive Medical is working to ensure injured workers will return to work healthy, as soon as possible, while employers (payers) are getting the lowest possible costs.

Express Scripts is focused on reducing drug costs, utilization, and abuse for workers and prescribers while increasing the use of more affordable generic medication wherever possible.

Summary Findings:

With all three PBMs reporting that OxyContin is once again the most prescribed drug (in terms of dollars) on the market, they’ve been working on ways to decrease the use of opioids.  Progressive reported a 5.0% decrease in opioid usage while Express also showed a decrease of 3.0%.  Progressive also reported that the opioid cost per claim dropped by 6.0% and the workers who were prescribed opioid analgesics this past year used lower dosages compared to 2012; with MEDs diminishing by 9.6% over the year as well.  (First Script did not show any indication of an opioid usage % decrease in their report) correction – First Script indicated utilization per claimant decreased 9.1%, the biggest decline among the three PBMs.

Progressive is using a “Multiple Prescriber Service” to identify injured workers that are getting drugs from more than one prescriber.  With the main focus on multiple opioid prescribers, Progressive notifies all prescribers treating the injured worker and offers guidance to address the issue.

Express Scripts’ MED Management Program allows clients to set max levels for the amount of narcotic medication prescriptions an injured worker can fill.  Once the amount is exceeded, the program employes a review process before additional medication is dispensed. According to Express, the MED Management Program has successfully reduced drug abuse, limited addiction, and controlled costs.

Express has also continued to developed their Physician Outreach Program to encourage the use of generics, which appears to be Express’s main concern.

The First Script network pharmacies are being re-credentialed under stricter requirements including background checks and site audits to ensure legitimate dispensing practices.  The network also blocks narcotics and other controlled substances through mail service to prevent potential drug overdose, diversion, and misuse.  This reduces risk to the patient and the community.

Summary:

• Opioid use is the main focus of these PBMs.
• PBMs are having success with decreasing opioid usage through a variety of targeted programs.

What Does This Mean For You?

• Claimants have a lesser chance to become addicted to their medications (Yay!).
• Medication costs have lowered over the years.
• If you’re not using a PBM, sign up and reap the benefits!

California released their new opioid guidelines; not to put too fine a point on it but they are underwhelming.  That’s my layman’s perspective.

A good friend and colleague, who also happens to be the Medical Director of a worker’s compensation insurer, provided a professional’s perspective which is below.

I’ve taken the liberty of moving what I believe is a key takeaway to the top: “This DWC Guideline is a review of eight existing guidelines—it is not a de novo review of primary sources.

The DWC has posted for comment its guideline [link added] for the use of opioids in WRIs. It sets out to accomplish three goals:

1. To provide a set of best practices for safe and effective prescribing of opioids in the context of WRIs in the acute, subacute and chronic phases;
2. To prevent and reduce opioid-related long-term disability, morbidity, mortality and substance abuse and misuse; and
3. To recommend opioid prescribing practices that promote functional restoration.

Its intended audience is clinicians, utilization reviewers and insurers.

Below is a summary and review of this 321-page document. It is not exhaustive, but I trust it will be useful as a starting point for discussion and further evaluation.

In my opinion, the best parts of this proposed Guideline are

1. Discouraging the use of opioids in minor injuries
2. Encouraging the use of other therapies before considering opioids
3. Encouraging lowest effective dose, time limits on opioid use
4. Encouraging the prescription of opioids for use at night and when the patient is not working
5. Listing relative contraindications for the use of opioids
6. Suggesting that current substance abuse (or illicit substance use) is a[n absolute] contraindication to opioid treatment
7. Encouraging education and informed consent
8. Encouraging education about safe storage and disposal of opioids
9. Recommending that CNS depressants (including antihistamines, benzodiazepines and alcohol) should not be used concurrently with opioids
10. Requiring the use of CURES [California’s prescription drug monitoring program], treatment agreements and UDT
11. Limiting UDT to baseline plus two to four times yearly; limiting UDT to prescribed and additional opiates, alcohol, amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, fentanyl, methadone and oxycodone
12. Emphasizing the importance of documented functional improvement as a prerequisite to continued opioid use
13. Giving criteria for discontinuation (lack of pain reduction or functional improvement; intolerance or severe side effects; or non-compliance)
14. Recommending MED documentation at every patient visit
15. Recommending opioid weaning semiannually for IWs on ≥ 80 mg MED

In my opinion, problematic parts of this proposed guideline are

1. Although addressing opioids only (the MTUS addresses chronic pain separately), this Guideline includes “rest” as a treatment for pain (paradoxically, rest is considered a “physical activity” in this Guideline). Unless rest is clearly defined (for example, it may be appropriate to rest/immobilize a joint, depending on the clinical situation) and it is taken to mean bed-rest or inactivity, the “cure” may be worse than the disease.
2. Likewise, this Guideline recommends complementary and alternative modalities “such as acupuncture”. What other treatments fall in this category? They do not elaborate and they do not address the requirement for effective, evidence based treatments and that’s a concern because it may open a door that providers will take advantage of—especially in California. Are they opening the door to massage, chiropractic, TENS, magnet therapy, hyperbaric oxygen, homeopathy, Chinese herbal medicine, etc.? You would have to reference the MTUS Chronic Pain Guideline to answer this question and this Guideline should point the reader to this fact.
3. Guidelines as to when to discontinue opioids are absolute in some places, but very flexible in others. For example, the Executive Summary states that, “In order for opioids to be prescribed beyond the acute phase, there should be no contraindicated comorbidities…” In the Abbreviated Treatment Protocol and elsewhere the Guideline recommends that the prescriber “consider and document relative contraindications…If these conditions are present, written documentation must be provided to justify the use of opioids.”
4. Aberrant use of medications or substances (as evidenced in an inconsistent UDT, for example) is indicated as an absolute disqualifier for further opioid prescribing in one section; however, another section invalidates that pronouncement (see below, footnote 9).
5. The use of CNS depressants, such as sedatives, hypnotics, H₁ antihistamines, benzodiazepines and alcohol seem to be an absolute contraindication in the Recommendations. However, Section 7 (Concurrent Use of Benzodiazepines and Other Sedative Hypnotics During Chronic Opioid Treatment) only recommends counseling the patient against using these substances concurrently and states that, “If, after careful consideration, the clinical decision is made to prescribe other sedatives or muscle relaxants to patients on chronic opioid treatment, counseling should be provided to stagger dosing to avoid excess sedation and potentially disastrous complications.” It seems to me that avoiding disastrous complications, including “fatal overdose events” should be a physician’s first priority. This also flies in the face of one of the three purported goals of the Guideline: “to prevent and reduce opioid-related long-term disability, morbidity, mortality and substance abuse and misuse.”
6. Urine alcohol testing (as recommended as part of UDT by this Guideline) is not accurate and may not be clinically useful.

The proposed Guideline was completed before the publication of the new ACOEM Opioid Guidelines (March 2014) which, in my opinion, is far superior as a thorough and true evidence-based practice guideline. [emphasis added]

My colleague’s review provides necessary insight into the pros and cons with the Guidelines.  To DWC’s credit, they are looking for comments, and I’d encourage you to submit yours here; deadline is TODAY..

My layman’s suggestion would be rather simple – adopt ACOEM and be done with it.

 

Opioids, ACOEM’s new guidelines, compounds, and, alas, physician dispensing.

Here’s a quick guide to the top issues and sources for additional info.

Opioids continue to plague the industry; while many PBMs and payers are having some success in reducing the use of opioids in new claims, there’s still a huge group of legacy claimants that have been on far too many pills for far too long.  Sandy Blunt and I conducted a survey on the opioid issue last fall (thanks to CID for sponsoring and the 400 participants for their insights) – The Survey of Opioid Management in Workers’ Comp can be downloaded here.

Last reminder – make sure you are going to Operation UNITE’s Prescription Rx Summit in Atlanta April 22 – 24.  The Summit is focused on all aspects of the prescription drug abuse problem.

Perhaps the best new tool in our armamentarium comes from ACOEM – their opioid guidelines were released last month and are available to subscribers here.  (you can also get a 14-day trial subscription).  A trio of highlights that challenge conventional wisdom merit attention:

• No comparative trial shows that an opioid is superior to another medication (out of 28 trials.)
• No evidence shows the long-term efficacy of opioids – the longest placebo controlled trial lasted only 4 months
• 80-94% of opioid trials have industry conflicts (funding and/or conflicts of interest in the trials).

I’ll be posting an in-depth review of these guidelines later this week.  For now, my non-clinicians take is these are the best opioid guidelines out there; very well researched, highly credible, and desperately needed.

Express Scripts published a report on their work comp results; you can get a summary here. (hat tip to WorkCompWire)

CompPharma, the consortium of work comp pharmacy benefit managers (of which I am president), released a research paper on compounding medications in work comp; you can get a copy here (no cost, and no registration required)

I don’t see medical marijuana as a big issue; If anything it will be of occasional interest.  That said, in our upcoming Survey of Prescription Drug Management in Work Comp, we will be asking payers what their view of the issue is, and will report back on the results. Participants (previous reports can be found here).

Finally, we’d love to have you participate in the Prescription Drug Management in Work Comp survey; participants receive a MUCH more detailed copy of the report than regular people which includes a wealth of data points and statistics.  e-mail me at infoAT healthstrategyassocDOTcom (replace the caps with symbols first!) and we’ll sign you up (all responses are confidential and no company-specific data is shared).