CWCI released a report detailing the latest in what’s been a long line of schemes to manipulate workers’ comp regulations to suck money out of employers’ and taxpayers’ wallets.

CWCI’s Bob Young, Jackie Secia, and Steve Hayes conducted the research, which found opioid scripts dropped from three of every ten prescriptions in 2011 to one out of nine today. That’s the good news – or rather, great news.

The research also identified two drugs – fenoprofen calcium and ketoprofen as the other primary reason NSAID costs jumped from 14.2% of total drug spend to 23.5% in less than two years. Oh, and these meds aren’t wonder drugs that grow hair while curing low back pain and strengthening joints and rejuvenating shoulder cartilage…they are similar to aspirin, ibuprofen, and naproxen.

OK, here’s how the scheme works.

First, both drugs are exempt from prospective Utilization Review (also known as Prior authorization) requirements, so prescribers don’t have to get approval before prescribing, and dispensers don’t have to worry about getting paid. 

Second, neither drug is on the California workers comp drug fee schedule, so employers and taxpayers have to pay 83% of the “average wholesale price”. AWP is a number made up by the drugs’ manufacturers, and can be anything they want it to be. Over the last four years, the average cost of fenoprofen calcium (FP) sextupled (is now 6 times higher); ketoprofen’s costs jumped more than ten times.

So, some smart schemers figured out that they could make a shipload of money by a) jacking up the price of a drug that costs pennies to make, and b) convincing a few docs to prescribe it to workers’ comp patients.

FP and ketoprofen are the main reason “not listed” drugs suck up more of employers’ and taxpayers’ dollars than other drug categories.

graph courtesy CWCI

It’s not just California.

PBM audits we’ve recently completed found both drugs showing up in New York; I’d expect they’ll appear in other states soon enough.

There’s a lot more we need to know – who’s pushing these drugs, why are docs prescribing them, what does the supply chain look like, are FP and ketoprofen also gaining traction outside of workers’ comp.

That said, we know enough right now to know we’ve got a big problem on our hands.

What does this mean for you?

Every PBM program must have an early warning capability to identify emergent drugs, and an ability to adapt quickly to ensure abuse is minimized. 

Over the last few years I’ve been involved in multiple engagements with workers comp payers where their “vendors” just weren’t performing.

Responsiveness was…poor.

Problem solving was more client-blaming than taking responsibility.

“Proactive” was a word used in stewardship reports and entirely absent from actual account service.

Platitudes.

Excuses.

Sure, every service entity has problems – I’ve dropped the ball more than once myself. And there’s no question a client’s performance may be part of the problem and/or expectations may be unrealistic.

That’s not what I’m seeing, rather consistently poor performance seems to be OK with the execs at some service providers. My sense is there are two general problems. First, some service companies focus on what’s important to them, not to the customer. Increasing revenue, raising prices, selling other services, pulling back on commitments/turnaround times, adding fees for services that were previously part of the package – all are seemingly more important than just making the customer happy.

I recall a site visit to a client’s then-vendor where a senior exec proudly pointed to a wall of accolades for employees. The exec voiced delight at the many notes lauding employee performance. I looked closely…every one referenced an employee adding services, billing more, creating revenue. None referenced a delighted customer, a happy patient, an employer with a solved problem.

Is this what your customers are doing when the video feed is off?

“Success” = more vendor $.

Second, execs – and their subordinates – are not listening to customers. And if they do, all they are listening for is opportunity to sell more stuff. The execs are NOT asking how the client is doing, what they are focusing on, what problems the client is facing, where the client is heading – and what the vendor can do better and how they can improve.

Is this your client?

Many vendor execs aren’t seeking to understand what makes the individual they are working with successful, how they are measured, what is important to them.

Most recently this may be driven by COVID’s impact on claims volumes and the trickle-down reduction in medical services producing fewer visits, fewer medical services, fewer bills, less need for UR and case management and everything else.

But this was happening long before COVID hit.

What does this mean for you?

Understand and solve your customers’ biggest problems, and do it without adding to their workload.

Or fail. 

It is times like this that determine if people have souls.

To those who say stay out of politics, I say – I wish I could [see comments at link].  What happened last year, and last summer, and last week make that impossible.  We can’t just continue on as if nothing had happened.

Our country – lauded by self-described “patriots” as the greatest country in the world:

• has – by far – the worst COVID death total of any nation on Earth;
• continues to mistreat and marginalize people of color, poor folks, and other minority groups; and
• saw its Capitol ransacked and a Police Officer killed by a horde of terrorists seeking to impose their will on our nation, goaded on by a President and demagogues who know they are lying.

photo credit Daily Mail, circled object is fire extinguisher thrown by rioter that struck and killed Officer Brian Sicknick

American Carnage indeed.

I get that people are upset when their candidate loses a critical election – millions of Americans – your fellow citizens – were crushed when Trump won in 2016. I was – and still am – among them.  As much as it hurts to say it, Trump won in 2016 – and we accepted that victory. We did not riot, lie, provoke, build scaffolds on the Mall, threaten to hang the Vice President and shoot the Speaker of the House. We did not file 60 lawsuits seeking to overturn our fellow citizens’ votes.

I accept and understand that Trump supporters are distraught, angry, even terrified – as I was in 2016 (and still am of the damage Trump has done and will do). I do not accept and cannot allow the anti-American behavior of many to pass unremarked and unchallenged.

I applaud the businesses that have stopped contributing to politicians lying about election fraud. Among those organizations fed up with Trump and his enablers are AirBnB, Amazon, BestBuy, the Blue Cross Blue Shield Association, Commerce Bank, Dow, Marriott, GE, Hallmark, AT&T, MasterCard, Verizon.

I decry CVS, Berkshire Hathaway, Facebook, Goldman Sachs, JP MorganChase, Microsoft, Google, BlackRock, Charles Schwab, VISA and others who have suspended all political contributing to all politicians – this smacks of false equivalency when it is blindingly obvious that the Ted Cruzes and Josh Hawleys are guilty of fomenting insurrection – not the Sherrod Browns and Jason Crows.

My family has agreed that we must do more. So, I will contribute 10 percent of my income to organizations dedicated to righting wrongs. The Southern Poverty Law Center, BLOCbyBLOC, FairFight, and the Native American Rights Fund are the ones we’ve chosen.

This may well cost me readers, business, income, and prominence – and I am totally fine with that. What we are on the verge of losing is immeasurably more important.

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Tomorrow – back to health care and related topics.

Winter here in northern New England is long and cold, with short days too often grey. Sunday night sleet driven by  howling winds pounded the house, leaving a layer of ice on everything.

We are all facing a northern New England winter – long, cold, dark, with far too little sunlight. 

Which leaves each of us with a choice – we can rail against nature, furious that our lives are disrupted, mad at the world. We can scream at each other, curse each other, denigrate and demean, as if this is going to solve anything or be in any way remotely helpful.

Or, we can succumb to lethargy, going through the motions in survival mode, making no difference, taking no responsibility, endlessly waiting for…something.

Or, we can make that something happen.

We can do something positive, something helpful, something neighborly, something kind. Like…

Get takeout, and tip way too much.

Add a few extra things to your shopping list and drop them off at the local food pantry.

Shop for an elderly neighbor, get their mail, shovel their driveway.

Smile at everyone you see – not to worry, they’ll see it in your eyes.

Buy $5 gift cards from local merchants and give them to teachers, aides, neighbors.

Be extra patient.

We interrupt this healthcare blog to bring you a few moments of humorous relief…

Here’s for enthusiastic voters…

Gotta love Steve Schmidt et al…

Colbert is always so helpful!

Yeah, I don’t get it either…

Ouch.

And calls, and posters, and signs, and…

Oh God NOOOOOOOO!!!!!

What does this mean for you?

Everything.

President Trump has tested positive for the coronavirus; we’ll divert from our usual focus on healthcare matters to highlight what we know now, and potential implications.

It is important to understand that most people with coronavirus have no symptoms or  relatively mild cases. Statistics favor a positive outcome for the President.

Infection source

We do not know how the President become infected. We do know that one of his closest advisers, Hope Hicks, tested positive. Reports indicate Hicks has multiple daily encounters with the President, traveled with him on Air Force One, and accompanied him on his latest trips.

The President’s health

• President Trump’s public disclosure of his health indicates he is generally healthy, a positive sign.
• However, his age puts him at elevated risk.
  • Older men are five times more likely to be admitted to a hospital than young (19-29 year old) adults, and 90 times more likely to die.
• According to his personal physician, the President is obese. As an obese 74 year old, President Trump is at higher risk of severe illness. From the CDC:
  • Obesity increases the risk of severe illness from COVID-19.
  • Obesity may triple the risk of hospitalization due to a COVID-19 infection.
  • Obesity is linked to impaired immune function.
  • Obesity decreases lung capacity and reserve and can make ventilation more difficult.
• Ronny Jackson MD, at the time the President’s personal physician, reported data that indicate the President had a build-up of plaque in his coronary arteries and higher-than-safe levels of blood fats (lipids). These correlate with a diagnosis of heart disease, which would increase the risk of an adverse outcome.

Implications

CDC data indicates that one out of ten people in their 70’s with positive diagnoses of COVID19 died. The report did not separate data by sex; it is likely men are at higher risk of death. (note there are no credible reports that Trump has COVID19 – he has tested positive for the coronavirus which may lead to COVID19.)

The same study indicated almost one out of three COVID19 patients 70-79 with an underlying medical condition died; note that obesity was not specifically identified as a medical condition.

Near-term implications

First, the President will suspend his campaign schedule during a two-week quarantine period. Events will be canceled for the time being as his campaign awaits developments.

If his health is severely impaired, his powers as President can be delegated to the Vice President under the 25th Amendment to the Constitution until such time as he is able to resume those duties.

Worst-case implications

If a sitting President dies at any time during his/her term, the Vice President assumes the Presidency.

If a major political party’s candidate dies after being nominated by her/his party, and during the election campaign, that candidate’s political party would nominate a replacement candidate. The process differs by party; for the GOP, the Republican National Committee would oversee the process which gives each state the same number of votes it has at the party convention.

[Note the Democratic Party’s process is generally similar]

It is unclear what happens if the Party’s candidate is medically incapacitated at the time of the election.

There is no Constitutional provision to delay a Presidential election in the event of a candidate’s illness, incapacity, or death after nomination and before the election.

For more information on the latest details on COVID19 treatment, click here.

What to watch for

There will be a lot of political maneuvering and posturing , most of it just noise.

Rely on credible news sources – the major broadcast networks, NPR, and major newspapers – and ignore nonsense from YouTube, twitter, and the like.

And there are already lots of ridiculous conspiracy theories – ignore them too.