Insight, analysis & opinion from Joe Paduda
Health Affairs hosts this fortnight’s edition of Health Wonk Review, and does it with their usual thorough style. Host Chris Fleming’s put together the best o’ the blogs on health care costs and drivers thereof; presents an alternative view of the nursing “shortage” (hint: there won’t be one); and digs into Louise’ discussion of the merits of charging smokers more for health insurance.
All the best of the blogging world, brought to you each bi-week by your buds at HWR!
I was chatting with Jennifer Wolf-Horesjh, Executive Director of IAIABC, this morning when the conversation turned to medical marijuana in workers comp. I have no idea how we ended up there, but Jennifer is a great conversationalist and very well informed about everything work comp-related, so she’s on top of the issue (and pretty much everything else).
As luck would have it, IAIABC just completed a survey of states’ positions on work comp and medical marijuana. A couple states have specifically banned the use of medical marijuana in worker’s comp treatment (Montana and Vermont), while others have administrative restrictions/requirements in place. Others allow it. (Jennifer also told me about a recent court case wherein an insurer was required to pay for the marijuana growing equipment used by a claimant; if anyone has a record of that send it over and I’ll update the post. )
So, here’s the deal. What logic would one use to approve the use of medical marijuana in workers’ comp? There’s very little evidence that it is beneficial for most conditions for most people, although some anecdotal evidence that it works for a few. But just because a (very) few find relief from cannabis does not make it a viable medication – and one employers should be paying for – without careful scrutiny and ample evidence that it works for a specific claimant.
Alas, logic and workers’ comp aren’t often used in the same paragraph, so perhaps this is just another indication of how screwed up WC is. As if we needed one.
There’s an excellent white paper on the topic from PBM myMatrixx as well as a webinar for your edification. PMSI’s Jay Krueger has also authored a paper on the subject, and WorkCompInsider was an early reporter on the subject as well. Oh, and in case you think you’ve heard it all, read Jon Coppelman’s piece on an idiot who a) got stoned and b) then went to feed bears in an animal park.
It’s full-on panic mode; flu season is upon us, the media’s in a frenzy, and the world is coming to an end. If you didn’t get your shot, you’re going to be in serious trouble, laid up for weeks with a nasty case of the horribles if not stuck in a hospital ER with tubes dangling from your appendages.
To listen/watch the media, you’d think the Mayans were right about the end of the world, if not precise with the timing or cause of earth’s demise. Then again, this is what (much of) the media does – generate eyeballs/ears by getting us all excited about something or other. Now that the most recent fiscal crisis is a distant memory, there’s got to be something to get us riled up – so flu it is.
Unfortunately the sensationalism isn’t limited to the illness itself; the enthusiasm for Tamiflu, the equivalent of the mining-after pill for flu sufferers, is similarly hyped.
Through a combination of carefully-orchestrated clinical trials, precisely-written journal articles, and professionally-managed media placement, the makers of Tamiflu have been able to convince many of the drug’s powerful ability to moderate the effects and shorten the duration of the illness. Sounds like a no-brainer, except…
Except the reality is nowhere near as encouraging. Turns out Tamiflu actually only shortens duration by a day or so, and while it can moderate the worst of the symptoms, isn’t going to get you up and going in no time. Here’s what the Cochrane Collaboration, perhaps the world’s leading analysts of medical research and intervention concluded after reviewing the research behind Tamiflu:
1. The manufacturer of the drug sponsored all the trials and the reviewers found evidence of publication and reporting biases.
2. The studies did not show that Tamiflu (oseltamivir) reduced the risk of hospitalization.
3. The studies were inadequate to determine the effect of Tamiflu (oseltamivir) on complications.
4. The studies were inadequate to determine if Tamiflu (oseltamivir) reduced transmission of the virus.
5. The use of Tamiflu (oseltamivir) did reduce the duration of symptoms by about a day.
I bring this to your attention, dear reader, not to scare you even more, but rather to encourage you to learn more about medical miracles/drugs/treatments before signing up. If you don’t, you may well find yourself poorer, just as sick, and perhaps with a few side effects you hadn’t counted on.
Thanks to Gary Schwitzer at Health News Review for the tip; his blog is a must-read for those seeking the real story behind the mass media’s health hype of the moment.
There’s going to be more change in health care this year than in any year in memory. Here’s what I see coming.
1. Most states will expand Medicaid.
Despite their protestations to the contrary, governors – even those in redder-than-red states – will accept the federal dollars and expand Medicaid. The pressure from hospitals and providers will be overwhelming. Expect all but a relative handful to bow to that pressure and take the money.
2. There will be a lot more M&A at the highest levels – among providers, health care systems, and payers.
Expect the big to get much, much bigger. They have to – the need for cash to fund innovation and change demands it, and smaller organizations just don’t have enough resources to meet the needs. Anthem, Aetna, UnitedHealthcare, Express Scripts, Yale-New Haven Hospital, St Luke’s in Boise, CIGNA, Wellpoint; all are actively and aggressively looking to grow through acquisition.
3. Many more docs will be employed by hospitals by 1/1/2014.
About a third of all physicians are currently working for hospitals/health systems today. Many more will be in 12 months. The pace of consolidation is accelerating, driven by the new focus on Accountable Care Organizations, a desperate need to strip out cost, and increasing expenses associated with independent practice. I’d expect another 5% of docs will be employed by health systems by the end of 2013.
4. Congress will not fix Medicare physician reimbursement
It will add too much to the deficit, plus they are stuck between the rock (really mad physicians) and the hard place (need to cut entitlements) so Congress will do what they do Oh so well; punt.
5. The feds and CMS will get even more aggressive on Medicare and Medicaid fraud.
CMS, the FBI, and various other governmental entities have greatly expanded efforts to combat fraud related to Medicare, Medicaid, and other federal health programs over the last few years – ranging from relatively small cases to medium-sized actions to mega-busts. Total in 2012 was about $3 billion; expect a substantial increase in 2013.
We’ll revisit at the end of the year to see how I did.
Warning, this post contains adult language.
Not content with reaching into employers’ pockets and taxpayers’ bank accounts, the physician dispensing industry’s slimy tentacles are oozing into the world of what passes for journalism at the Sunshine State News, and, based on SSN’s own writing, may well be spreading their noxious slime into the Florida Medical Association as well.
Nancy Smith, ostensibly an “editor” at the Sunshine State “News” said this: “A new report from the state Division of Workers’ Compensation (DWC) points to continued interference by insurance carriers into the doctor-patient relationship.”, citing payers’ efforts to control the cost of physician dispensed repackaged drugs. I’ve read the report – I doubt Smith has – and that is NOT WHAT THE REPORT SAYS. It doesn’t infer that, imply that, implicitly or explicitly state that or anything close to that. There are a number of other completely false assertions in Smith’s pathetic piece, but my head will explode if I go into them individually…
Here is the report – and I’d encourage you to send it to Smith on the off-chance she actually decides to read it and correct her gross mischaracterization. Her email is nsmith@sunshinestatenews.com.
It appears Smith is just parroting a blatantly misleading hatchet job put out by the Florida Medical Association. If the FMA wrote it, shame on them. If it was written by a physician dispensing company and just distributed by FMA, even worse
BTW, I emailed the FMA and asked for a copy of the FMA’s statement about the DWC report. No response.
The DWC report indicates the number of reimbursement disputes is up some 872% over the prior year, driven primarily by “increases involving physician dispensed medication.” That’s a good thing; employers and governmental entities, fed up with paying outrageous upcharges for repackaged drugs, are disputing physician dispensers’ bills. As it is indeed their fiduciary obligation to do, and as they were encouraged to do by the previous CFO of the State of Florida. In reality, in many of the disputes payers are paying a nominal amount, and end up agreeing to pay what they’d normally pay a retail pharmacy.
So that’s what the DWC report said. And somehow this shill who masquerades as a journalist – and/or the FMA, masquerading as a patient advocate – interprets this as insurers interfering in the doctor-patient relationship.
This is absolute, complete, total, utter bullshit.
Here’s how a colleague put it when asked if insurers are “interfering” :
“…we’re interfering all right.
We’re interfering with their clear abuse of the workers’ compensation system, of employers who foot the bills; we’re interfering with their profit-seeking brethren who hide behind a curtain of their arrogant claim to be a sole protector of their patients, when they can’t know in dispensing repackaged drugs what all other medications their patient might be taking and thereby potentially jeopardizing their patient’s health. And, we’re interfering with their unethical practices that even their own professional organization has frowned upon. The AMA has an ethical rule against physician dispensing for profit. So, yes we’re interfering – and we’re imploring Florida’s policymakers to interfere, to protect the public from the cost abuse, to protect patient safety, and enforce their own medical ethics. Since the FMA is unable to do this themselves. That’s what I’d say.”
Here’s what the AMA says in Opinion 8.06
(2) Physicians may not accept any kind of payment or compensation from a drug company [emphasis added] or device manufacturer for prescribing its products. Furthermore, physicians should not be influenced in the prescribing of drugs, devices, or appliances by a direct or indirect financial interest in a firm or other supplier, regardless of whether the firm is a manufacturer, distributor, wholesaler, or repackager of the products involved.
(3) Physicians may own or operate a pharmacy, but generally may not refer their patients to the pharmacy…
Hello, FMA! Can you spell “conflict of interest”?
Sorry for the adult language – this is the first, and hopefully only – time.
Now that the easy ones are out of the way, let’s get into the final four predictions.
7. We’ll learn that physician dispensing of repackaged drugs has harmed patients
When physicians dispense drugs, they don’t have access to the huge databases used by pharmacists to track patients’ meds and alert them to potentially dangerous drug-to-drug interactions. Moreover, the work comp doc often is seeing the patient for the first time, doesn’t know what drugs they are taking, and the patient often misremembers as well. This is a recipe for disaster.
This year we will learn of one (or likely more) patients harmed or killed as a result.
8. The good folk at NCCI will finally schedule a credible liberal speaker for their annual meeting.
After a steady diet of Charles Krauthammers, Arthur Laffers, Peggy Noonans, and Scott Harringtons, it’s time for a little balance – and not a token a la Alan Colmes. No, we need a real liberal to shake things up. How about Barney Frank? Jon Stewart? Rachel Maddow? Bill Moyers? James Carville? Donna Brazile?
Ok, I know it isn’t going to happen, but still, wouldn’t that be great? Alas, I’m afraid we’re going to hear yet another polemic about the evils of socialized medicine, wealth redistribution, and over-regulation…
9. The level of interest and activity around opting out of workers’ comp will increase – significantly
Driven by growing frustration with the moribund, hide-bound, usually-dysfunctional “system” that is workers comp in most states, employers and legislators will push harder in more states for the ability to opt out of workers’ comp. See Peter Rousmaniere’s excellent review of Texas’ approach for more on this, and kudos to Sedgwick for funding the project.
10. Predictive modeling for claims management will come of age.
If there’s one over-hyped yet misunderstood topic in workers comp it’s predictive modeling. I’m hoping 2013 sees a lot more precision and clarity in articles about, discussions of, and reports on predictive modeling. Less marketing blahblah and more specifics; way less hype generation and a lot more “this is what we did and this is what the results were and this is what we learned”. There’s no question that effective and targeted statistical analysis can drive much better results; there’s also no question much of what we’ve seen to date shows the talk has not delivered the sought-after results.
However, as studies such as the one published by Dr Ed Bernacki and Jeffrey Austin White of Accident Fund show, there is good work – very good work – being done. We just need more results; I expect we’ll see more this year…
We shall see what happens, what doesn’t, and what surprises the New Year brings. As it undoubtedly will.
Following yesterday’s post on predictions for workers’ comp in 2013, here are three more.
4. Aetna will keep – and grow – their workers’ comp services business
With the acquisition of Coventry, Aetna consolidated its position as one of the largest health plans in the nation. They also jumped into a leadership slot in the comp services industry, a business that is attractive to mother Aetna for several reasons. Despite opinions to the contrary, it is all but certain that Aetna will keep and seek to grow the Coventry workers comp business. That will be welcome news for CEO David Young, who’s long been tasked with generating cash while being starved of resources.
5. Physician dispensing of repackaged drugs – we’ll see higher prices in some states and much more physician dispensing in many.
With their gravy train in Illinois and Michigan brought to a screeching halt by new regulations, the physician dispensing industry will drive up prices in those states where the practice is still allowed. North Carolina, Florida and Maryland are among those states where payers should keep a VERY close watch on dispensing and billing patterns. When and where possible, use direction to steer away from those bad actors…
There are also some distressing reports that the big dispensing firms are looking to hire lobbyists in states that currently prohibit or significantly restrict the practice. Be on the lookout for this in NY and TX.
6. Several more states will adopt clinical guidelines to help determine appropriate/medically necessary care.
While this may seem like a no-brainer, the reality – as demonstrated by recent events – suggests it is anything but. The adoption and effective use of evidence-based clinical guidelines is often subject to political grandstanding, parochial attitudes, and ignorant complaints about “cookbook medicine”. That said, I’m hopeful we’ll see significant progress in New York, Illinois, California and other states. The more that evidence-based medicine is the basis for assessing workers comp treatment, the better.
We’ll finish up tomorrow.
Here’s what I see happening in the world of workers’ comp and WC services in 2013… three today, three tomorrow and the last four Wednesday – unless other news intrudes.
1. Vendor consolidation
There are two main drivers – the dramatic increase in private equity involvement in workers’ comp services and large payers seeking to internalize services to increase their top lines and bolster profits. And we ain’t seen nothing yet. Expect several of the larger players to join forces/be acquired/become “platform” companies that PE firms use to build large, diverse service providers.
2. Higher medical costs driven by facilities
We have seen harbingers of the future in WCRI’s report on cost drivers in Indiana and other research. Facilities – hospitals, health care systems, vertically-integrated delivery systems – whatever version or name you want to give them – are becoming an increasingly large, and increasingly expensive provider of medical services to work comp claimants. According to the latest data, about a third of all physicians are employed by hospitals – and that data is a couple years old. And, provider consolidation is accelerating – driven by PPACA and market forces as well as much higher Medicare reimbursement (procedures billed by hospitals get paid at higher rates than those billed by docs).
Most WC fee schedules are based on Medicare – or on some mechanism that is even more lucrative. Thus, as health care systems acquire occ med practices, work comp payers are going to see the same procedure cost more – just because it is billed by a facility rather than a doc. Providers will figure out work comp is a really profitable line of business. When they do, they’re going to be upgrading their occ med departments and tying them much more closely to orthopedics, home care, PT, and related services.
3. Continued ignorance of opioids’ impact on long-term costs and outcomes, coupled with inaction by most payers.
When insurers finally figure out how bad this problem is, they’re going to either go catatonic or their heads will explode. We will know that top execs really understand how bad this is when they get very focused on this issue internally and externally and very demanding of their staff, vendors, and regulators. This will manifest itself through aggressive efforts to identify and address existing claimants – and not just attempt to prevent extended use of opioids by new claimants. To those who would argue this is already happening, I would respond “perhaps in some small ways at a relatively few payers and in a handful of states, but the response to date is all out of proportion given the size of the problem.”
Three more tomorrow…
Brad Wright is the first HWR host of the year, and he rings in 2013 with the January edition. Great stuff, including the best use of Saturday Evening Post covers ever witnessed!
In a deal just done, workers comp managed care firm MCMC will be/has acquired California-based CompPartners. The deal gives MCMC a greater footprint in the nation’s largest workers’ comp market, and adds significant strength in physician peer review along with CompPartners’ MPN network.
CompPartners’ clients include the state fund of California (SCIF). Bunch and Associates, Liberty, AIG, TriStar, and Harbor America. As MCMC does not have much business with most of these, there’s every indication that CP staff will remain in place to serve existing customers and find cross-selling opportunities to deliver MCMC services to Comppartners’ present customer base.
Word from an informed source close to the deal is the two companies will continue to operate separately although cross-selling will be key to leveraging the deal. The transaction, which closed before the end of the year, was a stock deal which makes a great deal of sense for all parties.
Finally, adding significant strength in California has long been a need for MCMC. Acquiring CompPartners gives them a staff with long experience and a solid track record in the Golden State, along with a robust client list, certified/licensed product/service offerings, and all the benefits of taking over a going concern.
The net – Smart deal for both parties, and good news for their clients and owners.
