The Sun Is Shining

Many of you have written me the past few weeks to comment on, or commiserate with me regarding, the plight of my parents - which I have used as metaphors for workers' compensation.

The compassion, concern and caring that you have expressed is likewise indicative of the heart and soul of workers' compensation - people genuinely care about other people, which is why workers' compensation for the most part works as well as it does (regardless of the various criticisms I have, or anyone else has).

When visiting my dad the other day, he kept asking, in his faltered and struggling voice, for his "chart."

I didn't know what he was talking about.

Eventually I figured it out - it was a grid that hospice publishes to help patients and families understand the process of dying and where one is in that process.

Early to mid stages of dying

Late stages of dying

From what I can gather with reference to the stages of dying in these charts is that Dad is somewhere in the early "late" stage.

He doesn't have much interest in eating or drinking, he is confused and is hallucinating, sleeps most of the time and when he is awake he's not entirely aware, and has a very tough time talking.

But there can still be some enjoyment - he was able to sing with me a couple lines of "his" song and give me a smile.

Some of his symptoms are because body systems are shutting down, and other symptoms are because of his morphine regimen.

It's A Beautiful Morning

Dad can't walk, can hardly move his arms now, and certainly can't move around in his bed. I can't imagine this state of being, and yet it is graphically right in front of me in all of reality two or three days a week.

THIS is where the use of opiates is appropriate - easing the pain of the terminally ill.

How would Dad be if he didn't have morphine to cloud the stark reality of dying? What kind of pain would he be experiencing (and for which I would have untold guilt) if opiates were not available for this condition?

Thank goodness morphine is available to my father - this is an appropriate use of the drug.

But I can't think of much appropriate use of these class of drugs in workers' compensation cases - not that many are terminal...

The medical and insurance communities continue to research the effect of opiates in workers' compensation. These studies invariably focus on the costs of opiate dispensation, in terms of medical treatment, indemnity, and social costs.

One of the bigger factors in the opiate debate seems to be physician dispensing - when most of the variables are accounted for or controlled, it appears that higher costs and higher rates of prescription and dispensation are associated with physician dispensing.

A recent study to be published in the Journal of Occupation and Environmental Medicine found that in cases where opioids were dispensed by physicians rather the pharmacies, medical costs were 78% higher, indemnity costs were 57% higher and lost-time days were 85% higher.

These are generally run of the mill workers' compensation cases, not cases of the terminally ill like my dad.

The latest study implicates physician dispensing with significantly greater use of opiates and time off work.

The number of prescriptions in the physician-dispensing claims was 2.99 times higher than in claims without dispensing by a physician according to this study.

The average amount of time lost by claimants who didn’t receive medications dispensed by a physician was 64 days compared to 85 when dispensed by the doctor.

When it came to opioids time off was 66 days when dispensed by a pharmacy but 122 days when by a physician.

When I was growing up I had a huge respect for physicians - they were commanding, authoritative, educated, and knowledgable. Dad was a dentist - the same personality qualities applied. Ask anyone who knew my dad, even as a retiree, and they will tell you that these characteristics described him.

Dad was also hugely forthright. I will never forget when I was a very young workers' compensation defense lawyer and cases were coming out of questionable medical/dental shops of Temporal Mandibular Joint Disease. I asked Dad about this condition as I prepared for my first expert deposition on the topic. Dad was blunt: "it's bullshit."

I don't hear much about TMJ any longer. Dad was right.

Dad would probably say the same thing now about physician dispensing and its ties with opioids.

The hospice physician prescribed the morphine. It is dispensed by Dad's residential community for which they charge $350 per month.

What would this cost if this were workers' compensation? And what would be the outcome?

I know most of you out there have heart and soul, and strive to do the right thing. When we get word of the bad things in comp, like the study mentioned in this post, we tend to lose sight of the fact that these represent the outliers. 

There is a time and place for everything - "today's another day."

Dad is still breathing regularly so I know there's still some time. When I visit I remember to touch him softly, hold his hand, kiss him on the forehead and talk to him reassuringly. His mind might be cloudy, he might not hear or see very well, and his sense of taste is completely gone.

But Dad can still smile.

"It's a beautiful morning," he'll sing with me. The sun is shining and everything's okay.