Category: Research

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. 

 

Mar
8

Wrapping up the workers’ comp week

Posted by Joe Paduda on Friday, March 8th, 2013 | Comments

Here’s the highlights from the week after the annual WCRI meeting and Physician Dispensing Summit…

The incontrovertible proof that physician dispensing of repackaged drugs extends disability and increases claims costs has raised the stakes in Maryland, Hawai’i, and Pennsylvania, states that are all working on legislation or regulations addressing physician dispensing.  The key takeaway – dispensing extends disability and raises medical costs – over and above the cost of the drugs.

It’s no longer about controlling the cost of the repackaged drugs, it’s now about the impact of dispensing on employers and taxpayers.

I’ve heard from multiple sources – including folks in Hawai’i –  that the new new thing in the repackaging/physician dispensing world is SpeedGel...developed and sold by the wonderful folks at Gensco Labs.  SpeedGel is currently available in both OTC and prescription strengths, but word is the over-the-counter version will no longer be available (amazing what you can learn when you talk to their sales reps).  Evidently some payers have been reimbursing the prescription version at the OTC price, and we can’t have that!!

As you can see from the link, Gensco isn’t resting on their laurels.  Nope, they’ve been busy filing trademarks for new and wonderful topical medications that are sure to solve myriad problems – to date Randy M Goldberg has filed for 43! Coincidentally, there’s a gentleman with the same name who’s affiliated with Automated Healthcare Solutions…

They sure are busy down there in Miramar, Florida!

Don’t worry about the disclaimer on their site…the one that reads “The products and the claims made about specific products on or through this site have not been evaluated by the United States Food and Drug Administration (FDA) and are not approved to diagnose, treat, cure or prevent disease.”

Finally, I’m going to be on holiday all next week in Italy.  See you in ten days.

 

Mar
4

WCRI’s research wrap-up

Posted by Joe Paduda on Monday, March 4th, 2013 | Comments

Only the thoroughly nerdy (and yes that includes your intrepid reporter) stuck around for the final session, a WCRI research sampler based on their CompScope research database for lost time claims from 2008-2011.

It’s not just medical benefits that vary wildly – indemnity benefits per claim ranged from almost $10,000 per claim in IN to $28,000 in NC.  The researchers broke this down into the various components and sub-components; temporary and permanent disability benefits.

This is NOT my area of expertise – so be warned.

One study looked at the Michigan workers’ employment after a lump-sum settlement of their claim.  19% of those claimants who didn’t have a job at the time of settlement found one within a year, most took their time.

Among those claimants who were working at their “pre-injury” employer, 41% left their job and were no longer employed a year later.  For those who had found a job at a new employer after their original injury, 75% kept that job.

About a third who had a job at time of settlement quit and weren’t employed a year after that settlement.

That’s it for me – time to get back get back to work.

Mar
1

WCRI Wrap-up

Posted by Joe Paduda on Friday, March 1st, 2013 | Comments

With a day and a drive to reflect on the WCRI conference, there’s much to be taken away.

Attendance was high.  Over the last decade, WCRI has become a must-attend for many payers and regulators, and as a result the number of service entities at the conference has grown steadily.  That’s good; all stakeholders need to hear what’s happening, share ideas, and debate solutions.

WCRI’s growing use and acceptance of social media is impressive.  Andrew Kenneally was tweeting away through every session, and there were several other media folks there live blogging (including your trusty author).  They’ve gone out of their way to make our work easier, and the benefits for WCRI can be measured in the media mentions – which were likely in the gazillions.

From a content perspective, it was (with one exception) perhaps the best I’ve attended.  WCRI’s done an admirable job “freshening” their data: a past criticism was that the research was based on data that was quite dated, and therefore was not actionable.  The research we heard about this week reflected information from November 2011 – quite an improvement.

The discussion of guidelines was (generally) quite good – a solid explanation and background, a necessary albeit discouraging discussion of challenges getting docs to comply with guidelines, and a good synopsis of some key results in the non-WC world. There was also a review of some WC-specific results (I would have liked more results, but that’s a quibble). Prof. Wickizer’s summary was excellent, altho some of the citations were dated.

Some came away from that talk lamenting that they hadn’t heard much they hadn’t heard before.  I hadn’t either, but in fairness those I spoke with have very long and deep experience in this area; several could have given the talk themselves.  For many attendees, it was “new news”.

The focus on opioids on day two was absolutely on point.  I have the uneasy feeling most payers, actuaries, and rating agencies have yet to consider the financial impact of long-term opioid usage – and when they do it’s going to be really ugly.

OperationUNITE’s Karen Kelly gave a presentation on the human impact of opioid abuse that was terrifying.  In some counties in Kentucky, over half the kids are in households with NO PARENTS.  In one small elementary school, over ten percent of the kids had lost parents to opioid abuse. And there’s no question we in the workers’ comp world are contributing to this problem.

A colleague texted me during that session that IAIABC’s Executive Committee would do well to meet with Ms Kelly; they may well decide to reverse their decision and promulgate model language for opioids…

The following sessions detailed the cost, prevalence, and trends of opioid usage in WC.  Data on opioid usage was revealing, current, and actionable.

That was followed by two presentations by vendors – Paradigm (cat claims management) and Ameritox (urine drug testing).  Both were well-done, professional, and polished.  And totally inappropriate for WCRI.  The speakers discussed their company’s programs, provided details on their results, and shared their research, essentially marketing their services to the 350 attendees.  More to the point, their presence on the podium amounted to a subtle, if unintended, endorsement by WCRI. It would have been acceptable if their clients had presented; Paradigm has a long and successful relationship with the Travelers and Ameritox has many payer customers who have used their services for years.

Lest you, dear reader, think this is sour grapes, it is not.  As I’ve disclosed umpteen times, a competitor in the UDT space, Millennium Labs, is a consulting client.  If Millennium had asked me for my views on presenting at WCRI, I would have strongly discouraged their participation.  There are plenty of other venues where it is quite appropriate; the National WC and Disability conference, WCI, and RIMS are the top three.

WCRI is different.  And should remain so.

 

 

Feb
27

Medical care variation among states – what’s the status and do guidelines help?

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

It has long been known that medical care delivery can vary dramatically from state to state, and even within a state.  Jack Wennberg and his colleagues at Dartmouth have reported deep and long on the issue, with the initial revelation – and it was that – coming forty years ago.  The latest work can be found at the Dartmouth Atlas of healthcare – and it is well worth visiting.

So, here’s the deal – medicine is as much art as science, driven by local knowledge and personal beliefs as much as by best practices and evidence-based clinical guidelines.  While we like to THINK it’s about science, it often isn’t.

WCRI’s Dr Rebecca Yang delivered the initial presentation at WCRI’s annual meeting focused on interstate variation in medical care.  Their analysis looked at surgery, MRIs, pain management injections, and physical medicine; a few highlights (for those not able or willing to make it to Boston this year) include:

  • Surgical rates varied from about 18 percent in Massachusetts to 38 percent in Indiana.
  • MRIs of the lumbar region had an even larger range, from 18% in MA to 50% (FIFTY PERCENT!) in Florida; Florida’s rate was 20% (8 points) above the next highest state.
These data raise multiple questions; do the UR requirements in MA have anything to do with the lower rate of surgery?  Could that rate be affected by Mass’ very low reimbursement for workers’ comp surgery?
Florida has (relatively) tight managed care provisions, yet their MRI rate was 250% of Massachusetts.  Both states have strong UR, and in FL employers can direct. And there’s no discernable variation in the types of injury.  Which begs the question – what are payers not doing that they should be doing in FL?
And another – are there too few MRIs in Massachusetts? ( I personally doubt this, as the rate may well too high even in MA).   Much more in Dr Yang’s presentation…
Ohio State Prof. Tom Wickizer followed Dr Yang.  He gave an excellent background on small area analysis and practice pattern variation.  he mentioned one of my heroes, Dr Jack Wennberg (noted above): and highlighted seminal research indicates “spending 50% – 80% more on health care did not lead to meaningful differences..”
Wickizer quickly pivoted to matters of specific interest to WC, discussing the wide variation in back surgery rates across the nation; there’s a nine-fold difference in the lumbar fusion rate between the northeast and the west…(which says don’t bother pre-certing in New England, but pre-cert every case in the southwest).
So, how does one “fix” this?  Well, guidelines can help improve results – if they are used.  Wickizer said adherence – the usage of guidelines – is often less than 50 percent.  There are a number of reasons for this, but not many are very good (a few are valid).  And, adhering to guidelines does lead to improvement in functional outcomes and better health – although it’s not a dramatic difference (Feuerstein study, 2003).  There was a larger impact in a study of the impact of PT guidelines, with costs and pain rating much lower and better outcomes as well.
All that’s well and good, and it indicates that guidelines can and do help – but they have to be used.  And getting providers to follow guidelines is very difficult – unless you force the issue.  The state of Washington did just that, and delivered better outcomes and lower costs way back in the early nineties… and those better outcomes included lower disability payments.  One can, and probably should, infer that better medical care delivers lower medical costs.
Thereby “proving the meme”…
Feb
27

Report from the Physician Dispensing Summit

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

Yesterday’s meeting in Boston was very, very productive.  The audience included trade groups, insurers, TPAs, large employers, physicians, researchers, regulators, analysts, PBMs, and media, all focused on the single issue of physician dispensing.

Among the sessions was a report on a just-completed study of the impact of dispensing on claim outcomes – very compelling and highly revealing.

Here were some of the other highlights:

AIA CEO Leigh Ann Pusey led off with the keynote; the fact that Ms Pusey took the time to prepare for and attend the Summit is revealing indeed; her members write over a hundred billion dollars of insurance premiums and are dealing with critical, industry-altering issues including Dodd-Frank, TRIA, and the sequester.  She was very knowledgeable and detailed the work AIA is doing both internally and with other groups and associations.  Suffice it to say that this is a very high priority for AIA and their members.

Dan Reynolds, managing editor of Risk and Insurance moderated an excellent panel on the issue of patient safety.  Pharmacists, a physician, and the nation’s leading authority on prescription drug monitoring programs provided insights into the risks inherent in physician dispensing.  Notably, John Eadie of Brandeis’ PDMP Center for Excellence revealed that most states require/request dispensing physicians access the PDMP prior to dispensing scheduled drugs.   He provided a guide for finding out how different states address the issue; I’ll provide a link in a later post.

Sedgwick’s Kimberly George noted that, where appropriate, the giant TPA uses physician dispensing as a data point in assessing and rating physicians. This can affect the volume of patients directed to specific practitioners.

For me, the major takeaway was CWCI’s analysis of the impact of physician dispensing on claim costs and outcomes.  Alex Swedlow’s concise presentation noted that after reform eliminated the upcharge for repackaged drugs;

  • each physician-dispensed repackaged drug prescription added $545 to the average medical benefit costs. 
  • paid medical benefits on claims with physician-dispensed repackaged drugs averaged $7,297, or 37.3 percent more than the $5,316 average for claims without these types of prescriptions.
  • indemnity payments on claims with physician-dispensed repackaged drugs averaged $5,039, or 28.2 percent more than the $3,930 average for claims without physician-dispensed repackaged drugs.
  • claims with physician-dispensed repacked drugs averaged 50.3 paid TD days – 8.9 percent more than the average of 46.2 days for claims without repackaged drugs.

The research, conducted by Swedlow, John Ireland, and Laura Gardner, destroys physician dispensers’ claim that better outcomes and lower costs result from physician dispensing.  

Undoubtedly, dispensing advocates will now roll out their PR flacks and physician shills in an attempt to refute CWCI’s study results, methodology, impact, and applicability to other states.

Good luck with that.

Swedlow, Ireland, and Gardner are three of the most respected researchers in this industry.  Their expertise, insight, intellectual rigor, and objectivity are beyond question.

With the release of CWCI’s excellent work, we can now refute every claimed benefit offered up by physician dispensers – leaving no doubt as to the only real benefit of the practice:

taking hundreds of million of dollars from taxpayers and employers to do nothing other than line the pockets of dispensing docs, dispensing companies, their investors, and their partners.

What does this mean for you?

Read the study here.

Send it to regulators, employers, policyholders, legislators, lobbyists, attorneys – anyone and everyone.  Get the word out.  

Feb
21

WCRI’s latest research says…

Posted by Joe Paduda on Thursday, February 21st, 2013 | Comments

 

The good folk at WCRI were kind enough to send me their latest CompScope research which covers workers’ comp cost drivers, components, the impact of regulatory changes, and trends in 16 states.

Needless to say, there’s a LOT there.  And I’d be ‘less than truthful’ if I said I’d read them all.  So, here’s what I gleaned from reviewing what I could in between working on client stuff.  The reports examined data from 2005/06 to 2010/11 for lost-time claims, providing insight into trends, the impact of regulatory reform, and changes in provider practice/billing patterns

  • Inpatient hospital payments per episode – a measure of price inflation – were up 36 percent on average over that period.  Remember, price is but one component of cost – others include intensity of services (e.g. using an MRI instead of an X-Ray) and utilization (how many MRIs per episode) plus the percentage of all claims that get that service (frequency).
  • Outpatient hopsital average payments per claim were up about 31 percent – but fewer claims used outpatient services…
  • The average payment per claim for hospital outpatient treatment/OR/recovery room services increased about 62 percent.
  • The variation in the use of opioids was striking.  17% of Louisiana claimants who started using opioids were still using them 3-6 months later, compared to about 3 percent in Arizona.
  • Less than a quarter of all long-term opioid users were tested for drugs via urine drug screening.
  • Surgical claims were pretty interesting.
    • Average payment for claim for major surgery (not including hospital providers) increased 27.6 percent; however there was essentially no change in the percentage of claims that had major surgery over the study period
    • However, utilization – the volume of services delivered to each claimant who did have surgery – was up about 10 percent.
    • So, we have price and utilization up, but not frequency (the percentage of claims that had surgery)

So, what does all this mean?

Well, surgical costs were driven more by utilization and price than frequency.  Outpatient hospital costs look to be all-but out of control. Clearly, payers need to do a much better job addressing these cost areas.

There’s wide variation in drug usage, indicating one-size-fits-all approaches probably will be too much in some areas and far too little in others.  Payers and their PBMs who understand regional differences will be better able to address this critical cost driver.

A good chunk of the research period was undoubtedly affected by the Great Recession.  Teasing out the impact of the recession will help drive deeper understanding in two ways; the impact of that most powerful of external factors, and structural drivers v macro drivers.

Feb
14

Variations in medical care – it happens in PT, too.

Posted by Joe Paduda on Thursday, February 14th, 2013 | Comments

There’s yet more evidence that treatment patterns vary significantly across providers.  Today’s evidence comes courtesy of two academic institutions and Medrisk, Inc. (consulting client) which reported significant differences in the type and duration of physical therapy provided to workers’ comp claimants.

The study looked at several variables contained in billing data: location of service, duration of care, type of care, and other data points; the data was case-mix adjusted.

There are several key takeaways:

  • corporate physical therapy centers billed for more visits and more units per episode than other practice settings.
  • there was a “large difference in treatment utilization between geographic regions regardless of practice setting, diagnosis, body-part treated or surgical intervention”
  • these corporate centers billed for “a lower proportion of physical agents indicating a greater use of those interventions supported by evidence-based guidelines (exercise and manual therapy) compared to other practice settings.”

These findings were consistent across diagnoses and after controlling for surgical v non-surgical cases.

Let’s look at the second takeaway.  It should come as no surprise that the type, volume, and delivery of medical care one gets varies a lot from region to region.  While one would like to think that the care we get is based on science, in many instances the care you receive depends more on where your provider was trained, the local standard of care, and the personal opinion of the treater than what has been scientifically proven to work.

That said, the final point – that treatment in line with evidence-based medical (EBM) guidelines is more common in corporate settings is…intriguing.

Increasing the use of treatments for workers comp claimants that are in line with evidence-based medical (EBM) guidelines is a primary goal of many payers, regulators, and other stakeholders; WCRI’s just-published review of state workers’ comp regulations provides ample evidence of this trend.  While there could well be reasons the use of treatments supported by EBM were more common in corporate-based settings, the discussion in the report appears to address some of the key factors; delay in initial treatment, severity, and acute v chronic status.

Let’s be sure to recognize that these findings are general, overall, and based on statistical analysis.  Undoubtedly there are clinic-based, private, facility-based, and other PT practices that are quite focused on EBM and rigorous in their application.  And, to reiterate, there may well be sound and valid reasons for the differences noted by the stdy authors.

What does this mean for you?

1.  Good to see research focused on this key area of workers’ comp; with 15 to 20 percent of medical dollars spent on physical medicine, the more we know, the better.

2.  Payers should talk to their network partners to find out what type of care their PT providers deliver.  If they don’t know, find a network that does.

Feb
12

Variation in hospital results – how to use the data

Posted by Joe Paduda on Tuesday, February 12th, 2013 | Comments

It has long been known that there’s wide variation in the type, quantity, and outcomes of medical care across providers.  A new report – research done by Dartmouth, and funded by the Robert Wood Johnson Foundation – looks at variations in re-admission rates among and between hospitals, and provides some striking insights.

The researchers used 2010 Medicare data; the overall results indicate one of eight surgical patients were readmitted within 30 days of discharge.  Non-surgical patients were readmitted more often; one out of six was back in within 30 days.

According to the report, the “issue of patients being readmitted to the hospital is considered important because many are avoidable and, as the report notes, can occur because of differences in patient health status; the quality of inpatient care, discharge planning, and care coordination; the availability and effectiveness of local primary care; and the threshold for admission in the area.” [emphasis added]

CMS recently began reducing reimbursement to hospitals with high levels of readmissions – which will make it really important for those hospitals.

So that’s kinda interesting, but not really. Here’s what’s really interesting.

The good folks at Dartmouth have published the re-admit rates for all hospitals, and you can download the spreadsheets.  Now before we go picking the best hospitals based only on their numbers, let’s look a little deeper.

Looking at two hospitals in my home state of CT, one can see the readmit rate for St Vincent’s in Bridgeport is much higher than Middlesex Hospital’s.  One answer may lie in the population; Bridgeport is a lower-income area than Middlesex, and likely has a much higher proportion of patients without adequate primary care and/or insurance.  Dartmouth provides some insight into this – 82% of patients discharged from Middlesex after congestive heart failure treatment saw a primary care provider compared to only 60 percent at St Vincent’s.

A couple other stats looked interesting; the data for surgical re-admits for UPMC facilities indicates they do a pretty good job keeping readmits down – and therefore overall quality is likely better than most (again this is just one data point).  Similarly, patients discharged after a heart attack from Geisinger’s Wyoming Valley facility have a high incidence of primary care follow up – compared to other facilities in PA (58 percent v 48 percent.  However, they’d be just above average in Wisconsin (54.4 percent).

What does this mean for you?

While there’s a LOT to digest here, I’d suggest one use would be for network direction.  Identify the hospitals with statistically better results, assess them for confounding factors, and think about how best you can direct patients/injured workers to those better-performing facilities.

 

 

Feb
5

What we nerds love…

Posted by Joe Paduda on Tuesday, February 5th, 2013 | Comments

is research that helps us understand why things are the way they are.

And while we rarely get to make out with supermodels like the guy in the SuperBowl ad (word is it took 45 takes to get it “right” (good for him!!),

Bar Rafaeli and…

we do get pretty excited about great research.  Which makes today a pretty good day.  Two studies were released – one from Washington on back surgery outcomes and complications and the other from CWCI discussing the use and cost of compound medications in worker’s comp.

First, Gary Franklin MD and colleagues published a study in the February edition of Health Services Research on the safety of lumbar fusion, an all-too-common procedure in workers’ comp.  Here’s my non-clinical take on the key findings.

  1. Outcomes  – defined for this study as complications within 90 days of a fusion – for workers’ comp patients were not nearly as bad as I thought they’d be. Surprisingly, they were somewhat better than the average!
  2. However – and it’s a BIG “however”, that may be due in part to the Washington state fund (L&I)’s tough stance on authorizing fusions.  In turn, that was based on priori research that indicated fusions had generally poor outcomes.  So, L&I’s numbers for outcomes may have been better because they do a good job of winnowing out those claimants more likely to have poor outcomes.
Pretty cool, eh? Gotta love the power of the monopolistic carrier.
Well, here’s some not-so-cool news.
Eileen Auen, CEO of PMSI and Alex Swedlow and his colleagues at CWCI have co-authored a study examining the cost and trends associated with compound medications in California. (disclosure – both are friends and I was a reviewer of the draft report)
And the results are about as appealing as Ms Rafaeli’s ad-mate.
For the blissfully-unaware, compound medications are concoctions of various real and pseudo-medications fabricated by parties evidently more interested in sucking money out of employers and taxpayers than healing patients.  There is precious little evidence supporting the use of these medications for the kinds of conditions suffered by workers’ comp claimants; nonetheless they are inordinately popular among a subset of providers.
California instituted controls on the use of compound meds 1/1/2012, the thinking being these “controls”would reduce compounds in comp.
The good news is compounds dropped from 3.1 percent to 2 percent of scripts.
The bad news is while there were fewer compounds dispensed, the cost of each went up over 68 percent, so compounds’ share of drug costs increased from 11.6 percent to 12.6 percent.
That’s right – fewer compounds cost more money.
How’d that happen?
Well, compound prescribers and dispensers quickly figured out how to game the “controls” by adding more ingredients and more of each ingredient to each compound.  
There it is, another example of unintended consequences.
What does this mean for you?
Unscrupulous providers will quickly figure out how to game regulations/controls that are not well-developed and carefully considered. Better to do something right than to do it quickly.