Comp Should Sue Purdue

Over the past weekend the Los Angeles Times published a startling investigative story on Purdue Pharma, the maker of Oxycontin, and everything they knew about illegal distribution of the drug, their investigations, their suspicions ... and the company's complete lack of communication with anyone that could put a stop to the company's $31 billion revenue stream from the nation's best selling opioid.

How much did Purdue know?

And how much did they keep to themselves ... until pressured by law enforcement and the government?

According to the story, since 1999 more than 194,000 people have died from opioid overdoses, and more than 4,000 per day become addicted.

Four thousand a day...

Yet, even after three of Purdue's executives pleaded guilty to federal charges of misbranding Oxycontin and the company paid $635 million in fines and fees, the company turned a blind eye to clinics they knew were overprescribing, and even fronting criminal enterprises, all after touting increased security and controls over their drugs.

One year after the settlement, a Los Angeles pain clinic, Lake Medical, opened its doors on the license of Dr. Eleanor Santiago, a physician who had fallen on hard times and whom the operators of Lake Medical recruited to write prescriptions.

Santiago wrote 1,500 prescriptions for the pills in a single week - more than most pharmacies sell in an entire month; and according to the story, in October of 2008 she prescribed more than 11,000 pills.

Purdue investigated and concluded Lake Medical was part of a criminal enterprise working with a pharmacy in Huntington Park.

“Shouldn’t the DEA be contacted about this?” the sales manager, Michele Ringler, told company officials in a 2009 email, according to the story. She opined certainty it was an organized drug ring.

Still, Purdue didn't take any action against Lake Medical, and didn't tell anyone about what they knew until the clinic went out of business and its leaders indicted.

According to the LA Times, Purdue had collected exhaustive evidence suggesting criminal distribution of the drug, and not only did not share that information with law enforcement, but kept selling the drug to those being investigated.

"Purdue knew about many suspicious doctors and pharmacies from prescribing records, pharmacy orders, field reports from sales representatives and, in some instances, its own surveillance operations, according to court and law enforcement records, which include internal Purdue documents, and interviews with current and former employees," the Times says.

Since 2002 Purdue had been keeping a list of suspicious doctors, and the Times investigation revealed there were 1,800 names on that list.

Only 8% of them were reported to law enforcement.

Rather than risk its interfering with the obscene profits Oxycontin was delivering by releasing its information, Purdue instead came out with a tamper-resistant formulation. It was only after many arrests had been made that Purdue supplied its "suspicious" list to the DEA - by that time it was old news; many on the list had already been arrested.

The Times investigation and the resulting story are hugely incriminating. Big business making big money off of ... big business, when put into the context of the workers' compensation system.

The issues with opioids in workers' compensation are well known, the accounts well documented.

The harm to lives, families, business is huge.

The financial damage to workers' compensation payers is monumental, especially when tallying up the costs of unnecessary disability indemnity, drug rehab, lost production, medical bills, etc.

Suffice to say, the industry has probably supported, to its detriment, Purdue to the tune of billions of dollars, directly and indirectly.

Many states have sued and settled with Purdue, but those suits were based on the company's labeling misrepresentation.

Actively concealing damaging information for the sake of profits against the workers' compensation industry is another matter, however. (To be clear, there isn't evidence that workers' compensation was targeted, but certainly work comp was a huge victim.)

It seems to me, that the workers' compensation insurance industry (and self-insured employers along with them) have some leverage in the form of a class action lawsuit to recoup much of the damage Purdue caused by its fraudulent activity.

And it IS fraud! Knowingly concealing information that causes harm and damage to others is just as bad as misrepresentation.

Jack Crowley, who held the title of executive director of Controlled Substances Act compliance at Purdue and had spent decades at the DEA, told the Times, “Well, once we start to learn about it, we’ve got to report it. That’s for sure.”

Purdue didn't.

Pretty much a slam dunk to my jaundiced work comp "no fault" legal mind.

If any carrier wants a referral for a class action law firm, contact me...

Capitate It

Workers' compensation medicine is often critiqued against general health medicine, the implication that general health does things better.

And to an extent that is correct. General health medicine coverage, in general, seems to turn out better patient satisfaction, greater physician participation, and overall less acrimony.

But a huge difference between work comp and general health is that work comp is "first dollar" for the most part - meaning that work comp pays right off the bat. There is no co-pay, no deductible, etc.

Also, whether it is because of tradition, technology, culture, politics, or whatever, but work comp is for the most part a fee for service system. A provider performs a certain function, denotes its billing code, and gets paid whatever the system says that code is worth.

General health is moving away from that model towards a "capitation" model. Basically that model makes a one time payment per "population" that is assumed to require a certain level of service. Incentives for quality and outcomes are built in, and measurements are required to adjust the cap level.

Brent James, MD and Gregory Poulsen in the July-August issue of the Harvard Business Review make a Case for Capitation, outlining how such incentives can be built, monitored and deployed to the benefit of everyone: patients, providers and payers.

There are some elements that could be applied to workers' compensation.

The University of California, Los Angeles and R&Q Healthcare have partnered on a limited capitated plan for a select service: outpatient treatment for pain and addiction.

UCLA provides the service, R&Q does the selling.

The benefits are that uncertainties regarding treatment cost are reduced, and longer term, payers should see reduced claim costs as the injured worker’s drug use decreases.

I might add, that if an injured worker's addiction to opiates is the product of workers' compensation treatment the system has a moral obligation to reverse that...

William Lape, chief executive officer of R&Q Healthcare Interests. He told WorkCompCentral the capitation model turns the tables on the traditional workers’ comp system in which a provider outlines a course of treatment and then faces challenges from the payer for anything that seems inappropriate.

“What we’ve done is reverse that,” Lape said. “It’s not the way workers’ comp is used to doing it.”

Indeed, physicians interviewed by WorkCompCentral for the story were pleasantly surprised, saying they would welcome a system where each treatment request wasn't second guessed or challenged by the payer.

Before a payer commits to the program, the injured worker is sent to a free, in-person evaluation to assess various factors, including whether the claimant wants to reduce her dependence on painkillers.

If the claimant seems to be a good fit for the program, the payer can enter an agreement for up to six months of outpatient treatment. The maximum price is capped, Lape said, but if the cap is not reached, the payer will pay for only the services used.

The program can also be customized to a degree. For example, if the injured worker needs detoxification before entering the outpatient program, that service can be added, Lape said. And if an injured worker drops out midway through the program, she'll have one opportunity to re-enter.

There are other capitated or bundled payment programs around the country, though not many.

It seems like nirvana, and that's because capitated programs are, for now, of limited application, ergo value. The models have to be refined for various injury treatment scenarios to ensure that incentives are properly placed and deployed.

But I think capitated plans are the future of medical care, and in particular workers' compensation. We'll see more of this as experience is gained.

People Don't Change

Psychological issues are more prevalent in workers' compensation claims than in the general health population studies show.

Yet workers' compensation claims management traditionally does the least to address them, typically for fear of opening the proverbial Pandora's Box.

A 2002 study published in the Journal of Occupational and Environmental Medicine found 37.7% of injured workers had a pre-existing psych condition categorized as “Axis I,” (on the three Axis scale as published in the Diagnostics and Statistics Manual IV by the American Psychiatric Association) which includes conditions such as anxiety, depression and substance abuse, but not personality disorders. In comparison, 15.4% of the general population had one of those conditions.

For injured workers with psychological conditions before their injury, 10.2% had pre-existing major depression, 9.2% had an anxiety disorder and 24.9% had any substance disorder, including 15.9% with alcohol dependence and 13.5% with drug dependence, according to the study.

After the injury, the rate of major depression found in the study increased to 48.5%. The rate of alcohol dependence dropped to 1.3%, but the rate of opioid dependence grew to 13.8%, compared to 1.6% pre-injury (which makes sense now as we understand the path to opiates within the treatment context of pain complaints).

The JOEM study looked at 1,595 injured workers with chronic musculoskeletal pain who had been out of work for at least four months, and had begun a rehab program in Dallas.

Stalled in the Colorado state legislature is House Bill 1399, by Rep. Jonathan Singer, D-Longmont, that would prohibit denying a claim for mental impairment benefits based solely on the occupation of the worker.

The bill would have also required injured workers who file a psychological stress claim to undergo an examination by an accredited physician BEFORE the claim could be denied.

Daniel Bruns, a psychologist in Greeley, CO, told WorkCompCentral in a phone interview that the state's treatment guidelines recommendation of a psych evaluation for all patients with chronic pain or delayed recovery, before more radical treatments such as surgery, has reduced costs in those claims categories.

“In workers’ comp there’s been this fear that it would drive up costs,” Bruns told WorkCompCentral. “In Colorado, it lowered costs.”

There's a movement afoot in work comp claims to treat "the whole body" and this trend is facilitated by billing codes that permit such treatment without implicating wholesale acceptance of a person's entire psychological dysfunction.

Psych issues are more pronounced in workers' compensation than the general health population because of the disruptive nature of a work injury and the way the system responds. It makes sense to provide services intended to mitigate psych impact.

Certainly, work comp as currently configured, can not address all of a person's psychology. The system isn't designed for such intervention, and I suspect doing so would meet quite a bit of resistance not only from payers, but from the injured workers themselves who may be adverse to opening up their lives to possible exposure to others.

Still, I'm guided by the old saying, "people don't change; their personalities just become more acute."

Studies and anecdotes show that claims payers and their subject who recognize that maxim, in general, have more positive results.

But it takes both, the willing payer and the willing subject, to make addressing psych issues in the work comp context ... work.

The Customer

A lot of effort and expense goes into controlling medical costs in workers' compensation, but savvy vendors seem to always find a way around those controls.

The Workers' Compensation Research Institute's latest study on physician dispensed medication reflects this "whack a mole" phenomenon.

The conclusion: vendors steer around fee schedule limits with odd-sized dosages that aren't scheduled ... yet.

“When prices are reduced by regulation, the regulated parties — in this case physician dispensers — sometimes find new ways to retain the higher revenues they had prior to the reforms,” Dr. John Ruser, president and chief executive officer of WCRI, said in a press release. “The results raise questions about the effectiveness and sustainability of the price-focused reforms.”

In California, for example, the average price paid to physicians for 5- or 10-milligram pills of muscle relaxant cyclobenzaprine was about 39 cents per pill in early 2014. But a new 7.5-milligram product, introduced in 2012, cost $3.01 per pill.

As of early 2014, the 7.5-milligram cyclobenzaprine pills accounted for 55% of drugs dispensed by physicians in California, compared to only 2% of drugs dispensed by pharmacies in workers’ compensation claims.

In Tennessee, as of August 2012, reimbursement of physician-dispensed repackaged drugs is based on the average wholesale price of the original drug product, with no added dispensing fee. The intent is to curtail repackagers’ practice of giving drugs their own national drug codes and often-inflated AWPs.

So instead, vendors changed the dosage. Before the reform, 91% of physician-dispensed cyclobenzaprine was in 10-milligram pills; by early 2014, that had dropped to 76% and prescribing of 7.5-milligram pills grew to 19%. The 7.5 milligram pills cost $3.97 each at that time, while the 10-milligram pills were $1.08.

There's many different opinions on the topic, and frankly I don't see any reason for physician dispensing on a regular basis for lengthy periods a valid practice whatsoever. Most people have a pharmacy reasonably close, and for those that don't there are mail order pharmacies.

But that's not the point of this rant.

In work comp we tend to focus on the "problem" to look for a solution - hence proposed formularies, or banning of physician dispensing - rather than perhaps more simple, and likely effective, strategies.

This is tied to the way we perceive and treat the person at the receiving end of benefits: the injured worker.

If you are a consumer of nearly anything you have an interest in what you are consuming: what it is, how it is delivered, how much it costs, and whether there are better (however you define "better") alternatives.

Not in workers' compensation. The consumer of the goods and services is left out of the equation. There is no decision power with the injured worker, and even less information and education.

It's cultural - for so long, because the injured worker has no financial stake in the goods and services provided, since work comp is a zero dollar system, it's assumed that there's no need for consumer engagement.

That's wrong.

We need to change our thinking. The injured worker is our CUSTOMER. And the CUSTOMER needs to be informed, and engaged, at all stages, and not with legal mumbo jumbo as required by various state laws (and which causes confusion and a call to the attorney), but with clear, concise explanations of what is being paid to whom, for what and when ... and with comparison to less expensive, potentially better alternatives.

Medicare does this. When I got a doctor's bill for services for Mom, it would be followed up with a Medicare statement of all of the benefits reviewed, paid for, and whether there is any further obligation on behalf of Mom.

We don't do that in work comp. The Explanation of Benefits is rarely, if ever, copied to the CUSTOMER, and if it is, it's confusing and not self-explanatory.

There are many other examples. The injured worker is treated as a non-participating beneficiary and kept in an information void; when in reality the injured worker is the industry's first line of defense against unethical vendor behavior.

Treat the injured worker like a CUSTOMER, like a GOOD CUSTOMER, like a CUSTOMER you want to return for future business (I know, in reality you don't want that customer back because that means another injury...). Good customers return the favor. They look out for their favorite merchants and will return favor if asked.

Tweak all the fee schedules and implement all the formularies you want - but if this industry wants to combat the "whack a mole" phenomenon then engage the CUSTOMER.

Pain in Mental Health

In just a couple of weeks Boston will host the annual Workers' Compensation Research Institute's conference. Lots of interesting research presentations on things that workers' compensation wonks love to cavort about.

A lot of the conference this year is medical in nature: fee schedules, outcomes, utilization review, jurisdictional issues on medical control and treatment...

We'll find out, predictably I think, that states with fee schedules cost less than those without. We'll probably learn that rewarding system vendors based on measurable outcomes, rather than on the services provided, generates better results and system savings. We'll learn that there are differences between jurisdictions that some may, or may not, exploit to their benefit or detriment.

Missing in the grand scheme, though, is this industry's unwillingness to accept that mental health is just as important to controlling costs, to achieving good outcomes, to minimizing disability, as any external, artificial controls dictated by law or regulation.

A lot of jurisdictions have laws that minimize employer liability for psychological or psychiatric issues, whether or not caused by work. Treatment is segregated - body parts are treated as though independent of the rest of the body, or the mind.

There is one commonality among all injuries, whether industrial or not: pain.

The reason someone seeks medical care is because something is causing pain. It might be the flu making one's head hurt with coughing, sneezing, running sinuses, achy back... It might be some trauma, a wound or fractured bone.

It might be that the boss yelled or was mean-spirited.

That's all pain. Pain isn't felt by the appendage, or the organ. Pain is an interpretation of signals from nerves that is processed by the brain. The purpose of pain is to send a message - stop doing what it is that causes the pain.

It's really pretty simple. Pain is in the head. It is real because our minds say it is.

Some of the most interesting breakthrough research is about how the mind can challenge pain, alter its character, change the outcome.

Becky Curtis, our 2015 Comp Laude Injured Worker award winner, can tell you all about how the mind can change the perception of pain.

Michael Coupland, a vociferous proponent of cognitive behavioral therapy, has the data and statistics on pain perception and altering outcomes to demonstrate the power of the mind over pain.

Senator Patrick Kennedy, talking about his battle with addictions, notes that the social stigma against mental health has stymied medicine's ability to take care of the whole person. We take statins to forego the possibility of a heart attack or stroke. We support biennial dental care to stem tooth decay. We promote exercise to stave off obesity and stimulate our muscles.

Yet, we eschew mental health services ... until it's too late. It's easier to dispense a pill than it is to dispense good psychology.

We know the path to wellness, to productivity, to return to society, is through the mind.

The Journal of Occupational and Environmental Medicine, in this month's issue, looks at wellness programs and why one company's program is a success, and another's a failure. The conclusion - it's about the whole person, an integrated approach.

What happens in workers' compensation treatment (and, frankly, in much of general health medicine) is a focus on the symptom, but not the problem. We treat the broken bone, the laceration, the low back pain, with physical modalities and drugs.

Throw a psych ICD code into the mix, though, and all hell breaks loose. We are conditioned to treat mental health as a negative, as that person's problem and not part of the claim.

But it's irrefutable that the mind controls the body, and controls one's perception of pain.

I have a high tolerance for pain. My threshold is miles higher than my wife's. Maybe it's because I've been a daredevil all of my life, jumping off roofs, skying a table top on my motorcycle, leaping off cliffs on a bicycle - all those crashes, all those broken bones and organs... I heal and move on to the next adventure.

Others don't have the same tolerance. They may become slaves to their injuries - instead of having an injury, they ARE the injury...
We can't help everybody. There are some that can not be redeemed, their issues too deep; complications interfere with desired outcome.

But most can be helped. Most can be brought back into productivity and well being; if mental health services are implemented earlier in the claim. Much earlier in the claim - like right at the very beginning of the very first treatment implementation.

The trite phrase, "prevention is the best medicine," applies. Identify early-on mental obstacles to return to health, deal with them head on. Don't worry about assuming someone's psychological disability - the fact is that's already happened by virtue of the workers' compensation claim!

When workers' compensation's culture changes to recognize the realities of mental health on successful outcomes, then the conversations at WCRI's annual conference will be less about controlling medical costs, and more about what to do with all the money that's saved on claims...

Suits And Ties

I'm not a very good businessman.

Sure, I have a Masters in Business Administration, but that just means I could read books and pass tests. That doesn't mean I know anything about business.

About all I really know about business could be summed up in a single sentence in my first finance class by Professor Daneise: "Cash is King."

That's it. Assets, liabilities, balance sheets, project management, financing, mergers, acquisitions - all foreign to me.

I'm a simple guy really. Have a dollar, spend ninety cents, and I get to keep the dime - that's my profit for intervening in some process or product that someone else wants.

Big business is mystifying. Scale - it's all about scale. A small transaction, that dime, turns into billions of dollars if there are enough units generating that dime.

Which is why, I believe, the workers' compensation space is attracting outside investment.

The trend started a few years ago and doesn't appear to be waning yet - health care consolidating and moving into workers' compensation.

The medical care world is talking about the purchase of Helios pharmacy benefit management company by UnitedHealth Group subsidiary OptumRx.

The transaction has been estimated to be valued in the one and a half billion dollar range.

That's quite a few dimes.

Rumors of talks between the companies had been reported by Bloomberg Business news service as early as last October. The deal was confirmed earlier this month.

Optum purportedly did about $67 billion in business last year, and Helios, formed just a couple of years ago through the merger of Progressive Medical and PMSI Group, had been owned by private equity owners, Kelso & Co. and Stone Point Capital. Obviously those equity groups made a wise investment.

I'd often thought that the logical step for group health was movement into workers' compensation, and that it would be this progression that would foster, ultimately, the consolidation of institutions: general health and workers' compensation.

I've heard all the arguments about why workers' compensation can not be a part of the overall health system in this country: health knows nothing of how to deal with disability (and I'd argue that work comp isn't much better, but that's another blog post...), there's not enough money in comp, the market sector is too small, group health has deductibles and other tools to regulate access while work comp is "first dollar," etc.

To me, none of the excuses or reasons why a universal health system for employed people present much of an obstacle.

Really, the only thing that is in the way of a "get hurt or sick and get treatment regardless of cause" type of system is just the law.

Workers' compensation was the first health care system, getting traction after the United States Supreme Court blessed it in 1917. There wasn't any medical insurance around until the Blues were taken to task for price fixing between hospitals, so they decided to become insurance instead in the 1950s. Medicare was right around the corner then too.

The two systems grew up independently because they were created, by law, independently at different times due to different facts and circumstances - certainly nothing that was logical. No one could have predicted when these institutions were created that they would become as big or as pervasive as they are now.

All of the major health companies now have occupational divisions: e.g. Anthem Blue Cross, Kaiser On the Job, etc.

If the law (i.e. our legislators) doesn't eliminate the medical silos that developed, business will. Consolidations, mergers, acquisitions - all of these will continue as the blend of work comp into the health sector moves towards a universal care system.

Henry Loubet, a former CEO of UnitedHealthcare’s Western operations and chief strategy officer at Keenan, told WorkCompCentral the Helios acquisition fits in with UnitedHealth’s strategy of diversifying outside of health insurance plans.

“They’ve been looking for a much broader reach,” said Loubet.

All health carriers are looking for a broader reach. The Affordable Care Act is pushing the growth in scale. Lots of observers think that there's bleed and shifting in services between group health and workers' compensation, though no one has yet to actually back up any claims one way or the other.

And those concerns may be irrelevant anyhow. I think that's what is really happening as the health market moves into work comp.

It really just comes down to a simple fact: sick or injured person needs care - who's going to pay?

Take the patient out of that question and everything else is a back room argument between suits and ties.

The Nonsense of Pot in Comp

Marijuana for medicinal purposes is like prescribing alcohol for treatment.

It's just bullshit.

The real bottom line is that there are absolutely no scientifically controlled, peer reviewed, high quality studies that confirm pot is good at treating anything.

There just isn't.

There's anecdotal evidence of course.

Sure, it might make the "patient" feel better in the short term, but so does alcohol. Both have limitations on efficacy, both were illegal at some point, both gave rise to significant underground economies, both are highly susceptible to abuse, neither are controlled as to dosage, and both come in a wide variety of strengths.

New Mexico's experimentation with marijuana in the workers' compensation setting is providing a valuable lesson for the other states - write the laws now declaring pot un-reimbursable.

I'm all in favor of just legalizing pot for recreational purposes. The same scientific void as to efficacy for treatment also fails to show there is any risk to health greater than alcohol or tobacco, and the tax revenue potential could be enormous.

While New Mexico is going so far as to set up a reimbursement schedule, the fact is that none of the treatment guidelines that are widely followed in state work comp systems recognize weed as a valid treatment option.

New Mexico law is decades behind other states in describing what is "reasonable and necessary" medical treatment, which is how the courts surmised that if the patient says pot works then it must be paid for.

Which of course is ludicrous.

The same courts would not condone abusive dosages of opioids under that same theory.

New Mexico regulators figured they had better nip the issue at the bud (all pun intended) by coming up with a reimbursement schedule, which also includes an ad hominy dosage schedule (an allocation which, by the way, is unbelievably liberal - that much pot means someone's stoned 24/7/365...).

General health doesn't have this problem because there is no law out there that says a health insurance company has to pay for pot. The relationship is nearly completely contractually controlled, and in most cases those contracts provide for treatment per recognized guidelines.

Workers' compensation does not have that luxury. Workers' compensation is statutorily controlled, and there is no room for contractual restriction or modification on a personal basis with the consumer.

Consequently, when the law is interpreted by the courts, particularly New Mexico courts, the conclusion is that if the injured worker says it works, and nothing else does, then it must be paid for.

New Mexico will have to statutorily define the role of pot in workers' compensation if the state wishes to put some boundaries around the issue.

All of the other states should do so now before they end up in the same vortex of insanity that New Mexico is going through.

Declaring pot unwelcome in workers' compensation will probably draw the ire of pot advocates, and they are a growing and vocal segment of society with some votes (and a lot of money) behind them.

But work comp, for better or worse, is a political football used to make deals in unrelated matters. The deal should be centered around the legalization of pot for recreational purposes, but also declaring that it is not a part of the workers' compensation system.

There's no place for pot in work comp and states need to declare that policy now before the issue finds a slippery slope in court rooms.

Accepting the New Paradigm

This is guest post by Becky Curtis.

Becky was severely injured in an industrial, single person, motor vehicle accident. Her injuries resulted in signifiant disabilities and chronic pain. She attempted all of the usual pain management modalities for a few years. Nothing seemed to work.

Eventually she learned how to channel the pain away, and she learned how to teach those techniques to others, founding the Take Courage Coaching clinic.

This is a success story:

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Mike* is a former construction worker who was injured doing search and rescue work.  Despite several corrective surgeries, he has suffered with chronic pain for 8 years, limited mobility, anxiety and depression, diabetes and high blood pressure. 

Pain the entire length of his body—the severest involving his leg—made it difficult to walk, climb, and carry things.  He could no longer work.  Furthermore, he had abandoned a healthy social life in order to hide his depression from friends.  He was no longer doing woodworking or fishing and camping—activities he had been passionate about.  He was referred to TCC by his disability insurance case worker for pain-management coaching.

During Mike’s initial assessment, he rated his pain at 7 out of 10.  His total POQ was 122 (out of 190), reflecting impairments to Activities of Daily Living (70%), Fear and Avoidance (45%), Mobility (65%), and Vitality (67%).

With help from his coach Mike dug deep to envision his life not dominated by pain.  He imagined being able to do the things he enjoyed—fishing, camping, woodworking, family outings, and getting restful sleep.  In the end, he wanted to know his life contributed to his family and community.

Once a week Mike met with his coach and participated in a group call with others living with pain—a facilitated session that combines education and pain-management strategies with community support. 

Mike had never had someone to lean on. His fear of talking about the pain and depression was gradually replaced by a small glimmer of hope.   

Within two months he was exercising, sleeping better, and reconnecting with friends.  Conversations with his coach were less about pain and more about what he wanted to accomplish.  

By six months, Mike had cleaned up his shop, become a city councilman, and taken his wife camping.  He reported feeling much less pain and depression.  His POQ came in at 68 (compared to 122 at intake).

Mike continued to increase his activity levels—traveling, camping and fishing, getting a part-time summer job, and volunteering.  Instead of dead ends, he was seeing possibilities, even with his physical limitations.  

Upon completion of the program, Mike no longer needed pain medication, he was working a part-time job and fulfilling his duties as Councilman, and his POQ was down to 46 from a starting score of 122.  With his self-management program, Mike continues to live with reduced pain and increased vitality as he explores the possibility of starting a home-based business.  

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What is important in the Mike's story is not only about beating the burden of daily pain, but his realization that life is going to move on, but now his role is changed.

It's not just the pain associated with an industrial accident (or any life altering injury and disability) but it's the adjustment to a new order in life - THAT's a critical part of the "outcomes" equation that we all too often miss and/or ignore.

People like Becky Curtis, Dwight Johnson, and of course Mike above, all came to the realization after dealing with chronic pain and disability that life has changed for them. The same routines don't apply any longer. There's a new life paradigm.

The key is accepting the new paradigm, and having the courage to move on to that new path and direction.

It's not easy.

If you know someone who has mustered the courage to face their new life's paradigm, or someone who has been instrumental in helping an injured worker find their place, please nominate them for a Comp Laude award (https://www.workcompcentral.com/gala-voting). Nominations close August 31.

Drugs, Formularies, Concepts

Will California become the fifth state in the nation to adopt a prescription drug formulary for workers’ compensation?

By all accounts, it certainly seems so.

There is hardly ever a proposed legal change to California's workers' compensation system that doesn't draw out divisive, contentious battle ground lines between various interest groups, but the adoption of a drug formulary has parties that are normally fighting each other embracing the concept.

Assembly Bill 1124 (Perea, D-Fresno) drew support from representatives of employers, insurers and the medical cost containment industry during an Assembly Insurance Committee hearing yesterday. Representatives of health care providers, labor and applicants’ attorneys all expressed conceptual support but called for amendments.

Texas, Washington, Oklahoma and Ohio have already adopted formularies. The purposes are two-fold: reduce the cost of prescriptions, and expedite drug access.

Ken Eichler, a spokesman for Work Loss Data Institute, told the committee according to WorkCompCentral's account this morning, “It basically creates two buckets: a bucket of drugs which could be pre-approved for expedited authorization and a second bucket, not a bucket that denies the care but requires further investigation and specific authorization rather than pre-authorization based upon documentation of medical necessity for that specific individual.”

Besides reducing costs and increasing access, a formulary should, theoretically, also reduce the need for utilization review, independent medical review and opioid addiction. Drugs are the single largest review component in UR and IMR according to studies by the California Workers' Compensation Institute, and opioids, which would be outside the formulary, should decrease significantly.

Denying a person his opioids, though, likely will just send him to the street for substitutes. As Michael Gavin, president of Prium, recently noted in his blog, when Purdue Pharma changed the formula for OxyContin so that it could not be so easily altered for "recreational use" the incidence of heroin use rose dramatically.

Gavin says that while overall opioid prescriptions appeared to have declined 19% from projected volume, heroin overdoses increased by 23%!

The parent company to Prium, Ameritox, recently released a study, Gavin noted, that concludes:

• 4 out of 5 heroin users abused prescription drugs first
• 56% of the time, in heroin positive samples, the opioid prescribed to the patient was not found
• 66% of heroin users abused both heroin and prescription painkillers in the last month

Mark Pew, Prium's senior vice president, said that the "true success from a drug formulary would be a decrease in disability, a decrease in addiction and dependence, an increase in return to work and in increase in the use of less dangerous drugs.”

Agreed - but these goals are in terms that what the workers' compensation industry can measure against it's own information. We may fix OUR problem, but not THE problem.

Don't get me wrong. I think a drug formulary is a positive supply control method that should make it easier for injured workers to get the drugs that are included in the formulary, and that likewise should reduce both direct and indirect costs.

Thinking that the health of those who are pre-disposed towards abuse will improve overall, however, is wishful thinking - that burden and cost just gets shifted onto the public sector in some other manner.

Give And Take

California is considering the adoption of a prescription drug formulary and a bill has been introduced into the Assembly directing the Division of Workers' Compensation to do so.

Assemblyman Henry Perea, D-Fresno, on Feb. 27 introduced AB 1124, on his own, rather than carrying the measure for a sponsor, according to his press secretary, Alicia Isaacs, in order to "start the conversation."

A formulary is essentially a list of approved drugs for which carriers would have to pay without much debate or review, if any.

The conversation had been started a couple of years ago, frankly, when the California Workers' Compensation Institute, among other research agencies, started noting the increasing burden that drugs have on the workers' compensation system in terms of costs, and the detriment to injured workers that were being given drugs for "off label" use - primarily opioid variants to control pain.

Bernardo de la Torre, president of the California Applicants' Attorneys Association, indicated to WorkCompCentral Monday that the organization isn't necessarily against a formulary, but that there must be alternative provisions in case a person can not tolerate a particular drug or if what is in the formulary is not effective.

He said a formulary should include all medications and drug therapies that are available for a covered medical condition. Additionally, CAAA believes a formulary that includes only generic drugs "constitutes an unreasonable restriction" on the treatment of injured workers, he said.

Finally, he said prescriptions for a formulary drug from a network provider should not be subject to utilization review and IMR, de la Torre said.

Inclusion of "all" medications and drug therapies for a given medical condition does not seem workable to me, but the other requests seem reasonable.

Abraham Verghese on the failed human component of medicine.

There are two extreme examples of drug formularies in existence now: Washington and Texas.

Washington is seen as a more conservative formulary and much more restrictive than the one adopted by Texas a few years ago.

Both have been instrumental in controlling pharmaceutical expenses and have resulted in fewer opioid consequences - largely because those drugs aren't authorized for much.

In the WorkCompCentral article, president of Voters Injured at Work, Jesse Ceniceros, was critical of the talk of a formulary adoption, characterizing the plan as another attempt at cutting benefits under the guise of controlling costs.

"Who's saving what? All they're doing is taking away," he said. "It continues year in and year out."

And frankly Ceniceros makes a good point - study after study has affirmed that different treatments, such as physical therapy and cognitive pain management adaptations, are as good if not better than a fistful of drugs.

But by and large workers' compensation does not pay for these alternatives, or does not pay adequately so physicians are loath to engage them.

Reimbursement rates for office visits, where bed side listening can occur and is often very effective (sometimes folks just need someone to "listen") are generally too low, if there's any reimbursement at all, so physicians don't practice this important part of the care delivery equation.

In California, chiropractic therapy is limited to 24 visits - an artificial number that was a compromise arrived at when there was huge abuse by a few bad apples in the chiropractic community. But certainly there are instances when paying for an adjustment is cheaper than paying for the aftermath of prescription drugs gone bad.

In other words, what has happened over time is that treatment alternatives have been constricted so that handing an injured worker a bottle of pills is the only reasonable option.

We certainly can't discount the financial incentives that drug manufacturers and their distributors wave in front of physicians either - these conflicts of interest exacerbate an already volatile situation.

But, as Abraham Verghese pointed out in his excellent TED talk that I blogged about some time ago, there is a medical ritual that is transformative to patient healing: listening and then examining. The message this conveys to the patient is, "I will always, always, always be there. I will see you through this. I will never abandon you. I will be with you through the end."

Workers' compensation on the other hand seems all about abandonment.

Imagine if workers' compensation actually communicated "I will always be there."

So here's the bottom line:

The debate over a drug formulary needs to include as discussion points exclusion of formulary prescriptions from utilization and independent medical reviews, and a review of alternative therapies that can take the place of drugs in the first instance with adequate reimbursement schedules to promote those alternatives.

Give and take. Don't just take.

Pharmaceutical Conundrum

Drugs and workers' compensation seem to go together.

And it seems, generally not for the purpose of ensuring the injured worker gets better.

2 stories in WorkCompCentral this morning highlight the creep of prescriptions into work comp and demonstrate how these become issues later down the road.

First, the Federal Drug Administration has been studying whether to reclassify marijuana out of the current Schedule 1 classification. The FDA has been looking at this since 2013.

Doing so would essentially be an admission by that administration that there are some legitimate medical and therapeutical value to pot.

Though New Mexico courts have ruled, twice now, that workers' compensation insurance companies must pay for medicinal marijuana as part of their medical liability, other states have not gone that far, and most payers are not authorizing payment for pot because it is still a Schedule 1 drug.

And the state trend to legalize marijuana, both for medicinal and recreational use, continues, exacerbating the friction between the federal law, state law, and medical research (which, for the most part sanctifies marijuana for very limited medical purposes, and generally no conditions that are typically the provence of workers' compensation cases).

States are also encouraged by the probability of increased tax revenue from pot, looking at pioneer Colorado's tax income as evidence. That state saw $45 million in pot tax revenue as of the third quarter in 2014 according to the Washington Post - revenue that otherwise would not be realized at all when the drug was solely under ground.

Some observers say that the introduction of marijuana into the work comp system as a recognized treatment option may affect the employment of injured workers because employers are going to be reticent to have pot users return to work to, for instance, operate machinery, until they can demonstrate lack of THC in their system.

Bowzer confronts the Conundrum

Of course, the likelihood is that the folks that are using pot now are probably working with it in their systems now - employers just don't know it for sure even though they may suspect it.

Combine the marijuana issue with physician dispensing compound medications, and we have a new, powerful trend to deal with.

The practice of medicine is, after stripping away the Hippocratic Oath, after all a business, which means there's a profit motive.

There are a few in the medical field for whom "In God We Trust" is more compelling than "Do No Harm." But these few disgrace the rest of the profession, and provoke undue burden on doctors who take The Oath seriously.

The Workers Compensation Research Institute issued a report the past week that physician dispensers had found a way around price controls adopted by both Illinois and California: The doctors dispense drugs in unusual dosages, such as 7.5 mg, which allows repackagers to adopt a unique National Drug Code number instead of using the NDC assigned by the drugs' original manufacturers.

WCRI found that physicians were dispensing a 7.5 mg strength formulation of the muscle relaxant cyclobenzaprine, a 150 mg extended release version of the painkiller tramadol, and a generic formulation of Vicodin containing 2.5 mg of hydrocodone and 325 mg of acetaminophen. Because there had been no corresponding increase in those novel dosages dispensed by pharmacies, WCRI concluded, "it is likely that financial incentives drove some physicians to choose the strength for their patients."

What WorkCompCentral reporters found was that the FDA database shows just 19 suppliers of the drug formulations highlighted in the WCRI report. Seven of them provided all three of the formulations, three that supply hydrocodone and cyclobenzaprine, five that only provide cyclobenzaprine and one that only provides hydrocodone.

Several of the companies had been fined or warned by the federal government for engaging in unsafe practices, while another paid $12 million to resolve allegations that it paid kickbacks to doctors to prescribe its products.

One company highlighted in the story markets itself an industry leader in "prepackaged pharmaceuticals." It offers physicians drug-dispensing software that will fill clinics with "healthy patients and healthy profits."

So while states are going to tackle with physician dispensed compound drugs, and just may eliminate all physician dispensing (which in my opinion is the only way to deal with removing the inherent conflict of interest, except in emergency or special circumstances), the new "mole" will arise: legitimization of marijuana and a whole new revenue stream.

Formulary Coming To You

A panel presentation at the the upcoming Workers' Compensation Research Institute's 31st Annual Issues & Research Conference (March 5–6, 2015) to be held in Boston, MA will review physician dispensing of pharmaceuticals and the impact on costs (of course) and health outcomes for patients.

This is a timely topic as the trend of prescription drug formularies is spreading across the nation, and part of the debate is whether or not doctors should be fulfilling prescriptions from their offices.

Regulators in Tennessee, Arkansas and Oklahoma are writing proposals to establish a formulary based on the Official Disability Guidelines. The Maine Workers’ Compensation Board is forming a task force to consider creating a formulary, while California regulators have wrestled with the idea for years.

Formularies are already in place in Texas, Washington and Ohio. Oklahoma is operating a formulary under emergency rules that expire in September.

Formularies' primary purpose is to restrict the prescription of opioids and compounded drugs and that should lead to reductions in the number of injured workers receiving those drugs. Texas' experience seems to support that goal.

Texas adopted a closed formulary in 2011. Since then, the number of opioid prescriptions for injured workers in the state has dropped 10%, according to the Workers’ Compensation Research Institute. Prescriptions for opioids not on the formulary list have dropped 60%, while scripts for all drugs not in the formulary have fallen 70%. Overall prescription drug costs for injured workers have declined 15%.

A study by WCRI published last year postulated that a Texas-like formulary would likely result in savings for other states. The institute’s researchers found that if physicians in other states behaved the same as Texas doctors, a Texas-like formulary would cut prescription drug costs 29% in New York, 25% in New Jersey, 18% in Florida, 16% in Illinois and 14% in California.

The California Workers’ Compensation Institute in its own study last year found that a Texas-like formulary would cut prescription drug costs by $102 million to $541 million annually in California.

Alex Swedlow, president of the California Workers' Compensation Institute, will be part of a panel on physician dispensing at the conference.

Certainly the insurance community likes the idea of "closed formularies."

This chart has nothing to do with formularies - I just thought it was a neat infographic...

The American Insurance Association supports formularies, and is lobbying legislatures to adopt Texas' process, which is based on The Official Disability Guidelines published by the Work Loss Data Institute.

Still, the handful of states that are considering formularies doesn't mean that this is a sweeping trend.

As Maine Workers’ Compensation Board Executive Director Paul Sighinolfi told WorkCompCentral, “The real focus is to minimize pain as much as possible and ... bring [injured workers] back to a functioning level, and I think that's what our focus is really going to be,” citing concerns that insurance companies and other claims payers will use formularies solely as a means to cut expenses.

The WCRI study found that claimants in Texas increased the use of alternative options such as non-steroidal anti-inflammatory drugs and physical therapy since the state’s formulary went into effect in 2011, effectively shifting medical spending away from opioids and toward those treatments.

Regulators in California have the same concern.

California Department of Industrial Relations Director Christine Baker told state legislators in 2013 that the department was considering a formulary as part of a package meant to fight the over-prescription of opioids. The department is still looking at the issue.

"We are doing due diligence in terms of researching the benefits both from an appropriate medical care standpoint, because that's really important that injured workers get appropriate medical care and there are formularies that can do that, (and) we are also looking at it from a (cost-benefit analysis) standpoint," she told WorkCompCentral Wednesday.

States in general like to watch what happens with an innovator for a couple of years before considering adoption of something new. Then there seems to be a tidal wave that sweeps across jurisdictions in an exponential way.

My best guess is that formularies are more likely than not to be a part of your workers' compensation system within 10 years - particularly if California adopts one because state legislators and regulators like to see how a very large system adapts so anticipated issues can be planned.

The WCRI conference will also include presentations on the Affordable Care Act, fee schedules, and lessons from a couple of decades of "reforms" reflecting the last couple of trends across the nation.

Get On Your Bike and Ride

Yesterday, after posting about mental health and its importance to the overall workers' compensation claims process I went for my morning bicycle ride.

Those of you who know me, or who have followed me for a while, know that I'm obsessed with cycling. I don't "follow" the sport like most sports aficionados because I can't sit long enough to "watch" anything, but I like to ride.

I have always been that way - I'm one of those "doers" - and I've been "doing" pretty much anything related to 2 wheels since I could ride without training wheels.

That also means that I have had more experience with the downside of two wheels than most people - aka crashing, or at least falling.

That's just a part of life on two wheels; eventually you WILL go down. Hopefully it is not that traumatic of an event, but it is a fall, and it does hurt.

I'm also fortunate (or maybe not) to have a very high tolerance for pain. Pain doesn't affect me as much as most people. Yep, things still hurt when I'm stupid and fall off my bicycle, but for the most part I just pick myself up, utter a few curse words, try to wipe up the blood as well as possible, and carry on.

Sometimes, like when I ended up in intensive care for a week due to a host of serious internal injuries after a particularly bad get-off, I endure a bit more pain than normal. In those situations it's just my body telling me that, yep, it really IS bad this time! I was thankful for the Demerol drip that time...

But for the  most part injuries are just part of my life. Which means pain is also just a part of my life.

Bowzer crashed into a wall, but dealt with the pain.

My wife can't tolerate any pain. She is a s frail a flower as I know. She complains of the slightest discomfort. Any minor bruise, burn or laceration causes her great irritation and misery.

The sight of blood terrifies my wife and she goes into shock - like the time I was riding "trials" on the rock jetty in front of my house on my mountain bike a few years back. I missed a step and got gored in the leg by a piece of rebar. Blood was spurting everywhere and of course I knew I needed stitches (and a tetanus shot), but my wife was so overwhelmed by the sight of blood that she couldn't drive me to the emergency room - she had to sit shot gun while I operated the throttle and brake with my left foot.

What is it that makes some people so resilient and able to deal with adversity, pain and suffering only to come back better, stronger and ready to take on more?

And others who can't tolerate nearly any pain or get set back by seemingly minor issues?

I was reminded of this yesterday after, serendipitously, posting about mental health. Took a little spill on my bicycle after only about seven or eight miles of what I had planned to be about a fifty mile ride.

The worst part is that I wasn't even going fast, which made me mad - there's nothing worse than an active person sustaining injuries in a relatively non-active way...

After picking myself up off the pavement I assessed my injuries: blood gushing from my right hand, blood all over my left calf and thigh, left shoulder abraded but thankfully no damage to the new cycling jersey I was wearing.

I hosed myself off with the water bottle, cursed a whole bunch for being stupid, saw that blood was spurting out everywhere ... and got on and rode to complete that fifty miles.

The injuries sort of hurt - I mean, lacerations, abrasions and contusions eventually induce some pain. But what I noticed most is that the cut on my right thumb wouldn't stop ejecting blood and that damned red stuff was getting all over everything.

To my compulsive way of thinking this was a huge inconvenience. I had a mission - complete my ride! But blood was getting in the way of that mission.

I was reminded of the time I went windsurfing in some big surf before work one day, ended up "biting" the sail boom on my first tack out through the waves and spit out my broken front tooth. Most rational people would call it a day, head back to shore and get an emergency dental appointment.

Not me! No sirree ... give up premium wave sailing just because of a broken tooth, cut lip, and enough blood to attract an entire school of sharks?!

And so it was with my thumb ... what do I have on me that I could tourniquet that thumb so I can complete my ride? Sunglass bag in my pocket! Wrapped it up, tied it up, thumb throbbed and wasn't much good for griping the handlebars, but I could still ride.

In the good old days when I was less tolerant of others I could not understand why some injured workers couldn't just wrap it up and still ride. I didn't have any compassion for those people who were unable to overcome a little pain and discomfort.

I've matured now, and understand that a lot of people can't tolerate pain like I can. And that's just part of the mental profile of being human - the variance in which we perceive and deal with pain is huge.

This is what makes the issue of "pain" in workers' compensation so controversial. Some people, like me, have something going on either psychiatrically, or psychologically, or both, that minimizes the perception of pain. To those of us, pain is an inconvenience but we adapt.

There are others, like my wife, who perceive pain in a much different way and for whom pain is a major concern, interferes with nearly all daily living activity, and which has no place in life.

In workers' compensation schemes we try to account for pain. There are pain scales. Some doctors specialize in treating pain. Impairment tries to adjust for pain.

For some people accounting for pain is over-compensation. For many others there isn't any adequate compensation.

In the civil world a jury awards money based on "pain and suffering." It's up to a dozen people of the community, with their collective experience, judgement and knowledge, to determine if someone is really experiencing pain and what that pain is "worth."

In workers' compensation we have disability guidelines and statutory schedules that tell us what an impairment is worth, and sometimes there is a factor to adjust for pain perception.

We know now that prescribing certain medications, e.g. opioids, is more risky and has worse effects on the pain patient than the pain itself.

And there will always be injured workers for whom the remedy is inadequate. There is no adequate answer for them, unfortunately, other than perhaps providing as much emotional and psychological support as possible to assist those persons in dealing with pain.

Mental health treatment is as much a part of workers' compensation as physical health treatment.

As for me, I'm going on my bike ride now.

Drug Testing En Masse Risky

A federal appellate court gave a pyric victory to an employer in Tennessee, remanding a case back to the trial level because the reasons for mass drug testing of its workforce might have a reasonable basis and not be violative of the Americans with Disabilities Act; that it was an issue for the jury and not the judge.

Dura Automotive Systems is a manufacturer of glass windows for cars, trucks, and busses. Its facility contains a variety of heavy equipment and active machinery, including high-temperature injection molds, presses, air powered tools, cutting machines, die casts, fork lifts, tow motors, hi-lo lifters, and portable cranes.

Between the end of 2006 and early 2007, the company claimed, workers at its Lawrenceburg, Tennessee plant experienced substantially more work-related accidents than Dura's other facilities. Several employees allegedly also tested positive for controlled substances after their accidents.

Dura said that Lawrenceburg police had alerted its local management of illicit drug activity taking place at the plant.

The company decided to implement a new substance-abuse policy, which appeared in the March 2007 revision of the employee handbook and a July 2007 document issued by the company’s human resources department.

Pursuant to this policy, Dura reserved the right to conduct drug tests on its employees, and employees were expressly prohibited from “being impaired by or under the influence” of alcohol, illegal drugs, prescription medications, or over-the-counter drugs, if the use of such drugs endangered others or affected their job performance.

In May 2007, Dura ordered a plant-wide drug screening of the Lawrenceburg facility’s more than 400 employees. Dura hired Freedom From Self to administer the drug tests to its workforce.

Dura instructed FFS to test for 12 substances—amphetamines, barbiturates, benzodiazepines, cocaine, ecstasy, marijuana, methadone, methamphetamine, opiates,oxycodone, phencyclidine, and propoxyphene—some of which appear in prescription medications.

Velma Bates, Claudia Birdyshaw, Mark Long, John Toungett, Carolyn Wade, Richard White and Willarene Fisher had all worked for Dura at its Lawrenceburg plant.

Between them, Bates, Birdyshaw, Wade, White, Long, Toungett and Fisher, had prescriptions for oxycodone, Cymbalta, Didrex, Lortrab, Soma, and Xanax. They claimed that their use of these medications was what yielded positive results on the FFS drug test.

Dura placed all workers who tested positive on a 30-day leave of absence and instructed them to inform FFS if they were taking any prescription medications that contained the prohibited drug compounds.

An FFS employee then identified which of the medications carried a warning from the manufacturer for users not to operate dangerous machinery while taking the drug. FFS relayed this information to Dura, which informed the employees taking the medications that they would be terminated if they continued to use the drugs. However, if the employee tested negative after a second drug test, Dura said the worker would be allowed to return to work.

Wade and Fisher complied with the requirement and Dura reinstated them to their positions. But the remaining plaintiffs continued to take their medications and Dura fired them after they again tested positive.

After the drug testing, Dura claimed, the accident rate and amount of property damage at the Lawrenceburg facility decreased.

Bates, Birdyshaw, Wade, White, Long, Toungett and Fisher filed a complaint against Dura in May 2008 alleging the company had violated the ADA by subjecting them to an unlawful drug screening and then terminating them on the basis of their disabilities, or perceived disabilities.

There is some procedural history where the case goes back and forth between the trial court and the appellate court to resolve issues such as standing to sue, reclassification under different portions of the ADA and other issues.

Ultimately the trial judge found that Dura's drug testing of its workforce qualified as a medical examination or disability inquiry, in violation of Section 12112(d)(4), as a matter of law. The jury then returned a verdict collectively awarding the plaintiffs over $870,000 in damages.

On appeal, Dura argued that its drug testing had screened for substances that were "either illegal or, even if legally prescribed and used, may impair an individual’s mental alertness or motor skills" thus constituting an unreasonable business risk given the busy factory and heavy machinery, thus the drug testing was "job-related and consistent with business necessity."

The plaintiffs said that Dura's "plea for safety inside the front door of the plant," was a merely a pretense for conducting a drug test protocol that "was designed to seek information on possible weaknesses in employees." Thus, they said, the "substance screen as practiced by Dura Automotive Systems was a medical exam."

The 6th Circuit said the issue was not so clear-cut and that the issue of whether Dura violated the ADA should have gone to the jury and could not be found as a matter of law.

"Much depends on Dura’s credibility," the court said, stating it was possible a jury could see Dura’s explanation as a pretext, or find that the drug test had targeted information about employees' physical or mental health, regardless of Dura’s stated intent.

But it was not a matter of law that Dura violated the ADA.

The case is Bates et al. v. Dura Automotive Systems, No. 11-6088.

A Drug Testing Rebuttal

Last Friday I blogged a title, "Urine Is Big Money."

What I opined was that the very public lawsuits and jury verdicts in the cases between Ameritox, Ltd. and Millennium Laboratories, Inc. revealed unsavory marketing tactics that incentivized physicians to do drug testing and that there was a lot of money involved.

I called this "nonsense" because you and I pay for this surreptitiously through higher fees and greater utilization.

Specifically I said, "Drug testing may have its place in certain situations, but the incentives these companies throw at providers of care to initiate services is offensive to me, and should be to you."

Michael Gavin is president of Prium, a medical intervention firm that has particular expertise in providing tools for drug management.

He called me the other day to tell me that he a) enjoyed WorkCompCentral's new adaptive newsletter format (I know, shameless self-promotion) and that b) he had written a blog post rebuttal to Urine is Big Money but decided to run it past me rather than publish it publicly to deter the wrath of a potential counter-point.

Heck - I think dialogue is good! So with Michael's permission, I took the easy way out today and am posting his opinion with just a little editing for format and readability:

_________________________________________

When Ameritox purchased PRIUM, I did my own due diligence on the Ameritox management team.  I believe I'm working for the good guys and we're genuinely trying to do the right thing.

I like David DePaolo.  A lot.  He is a voice of reason in our industry and I've enjoyed his musings, both personal and professional, for years.  

But on the issue of urine drug monitoring, I think he's off the mark.  On the one hand, I'm coming at this from an admittedly self-interested perspective (PRIUM is a wholly owned subsidiary of Ameritox), but on the other hand, the context and conclusions of David's recent post on drug monitoring beg for someone to clear up the confusion.  

What did he miss?  Nowhere in his piece did he mention several key facts.  David knows all of these things, but critical context is missing from his view on Urine Drug Monitoring.  Namely, he didn't mention that: 

• People are dying.  Overdose deaths from prescription opioids now outpace deaths from traffic accidents and have tripled since 1990; 
• The CDC has identified the opioid crisis as an epidemic, a term the CDC does not use lightly; 
• More than 12 million people reported using prescription painkillers nonmedically in 2010; 
• Urine drug monitoring technology is relatively new.  David's quote from the CWCI data that suggests 192X growth in spend on urine drug monitoring in CA doesn't recognize the point at which the health care community sat on the adoption curve for this technology in 2004.  Nor does it recognize that we still didn't realize the enormity of the opioid crisis in 2004.  And don't tell me we knew in 2004 how bad this was going to get.  I came into this industry in 2010 and spent my first two years here at PRIUM trying to convince payers there was an opioid problem in the first place.   
• There's a distinction between point-of-care testing in a doctor's office and reference lab testing. Failing to make this distinction leads the reader to conclude that all inappropriate behavior rests with reference labs and fails to recognize that some physician practices are by themselves driving inappropriate utilization.  Physicians who partner with experienced and capable reference labs that understand payers' perspectives and expectations can help align stakeholders (injured worker, physician, lab, and payer).   
• There are guidelines for the appropriate use of urine drug monitoring and these guidelines are based on risk stratification of the patient.  We follow these guidelines.  We help payers follow these guidelines. Testing beyond the guidelines is as inappropriate as not testing patients that should be tested.  
• Even in light of these guidelines, WCRI data tells us that less than 25% of injured workers on long term opioid therapy are being tested at all.   David states "we know [the guidelines] are specific case recommendations particular to a certain set of medical facts, not to be applied universally."  Agreed.  Perhaps David doesn't realize how many injured workers fit that "certain set of medical facts."  A lot more than he apparently realizes.  
• Not all companies offer direct financial incentives to physicians.  He lumps an entire industry together and does so just a couple of paragraphs after he details that Millennium's practices were found by a jury to be illegal and that all counterclaims against Ameritox were dismissed.  Perhaps David missed the most important take-away: there's at least one company trying to do it right. 

Bottom line: what David blithely dismisses as "nonsense" is, in fact, a critical patient safety tool, a mechanism for effective claims management, and a necessary application of clinical technology that isn't going anywhere. To suggest otherwise in light of the largest man-made epidemic in the history of the world is simply irresponsible.  

Michael

_________________________________________

So I agree that drugs are a public health concern. I agree that drug testing can be an important part of patient care. And that Ameritox was found clean of engaging in questionable marketing tactics is comforting to me.

But Michael misses the theme of my post.

The point I was making was that the Millennium/Ameritox case simply provided insight into how medical supply businesses work, and how much money is involved. 

This occurs inside, and outside, workers' compensation. And not just drug testing companies, but nearly all medical supply businesses have some marketing systems that provide physicians incentives to use and/or promote their products.

Marketing practices that improperly cause physicians to prescribe specific products or services should not be tolerated without full disclosure to the patient and the payer as to the nature of the incentives to the doctor. 

That's the bottom line.

That Gavin's company, Prium, and it's parent Ameritox, don't engage in "direct financial incentives to physicians" is a good start. Next would be disclosure as to what incentives are placed in front of physicians so the people can make informed choices about whether prices and utilization are appropriate for any given case.

Thank you Michael for taking the time to write a rebuttal.