Archive for June, 2015

Peter Rousmaniere Takes On The Opioid Controversy And Offers A Prescription For The Future

Monday, June 29th, 2015

Work Comp Central has published We’re Beating Back Opioids – Now What? written by columnist Peter Rousmaniere in cooperation with CompPharma, a consortium of workers’ compensation Pharmacy Benefit Managers.

To say the Mr. Rousmaniere is a “workers’ compensation thought leader” is a little like saying Ted Williams was a pretty good baseball player. In this provocative analysis he expertly  chronicles the increasingly alarming rise in opioid usage to treat work injuries from the early 1990s through the first decade of this century, what he calls “the twenty year crisis.” He describes how Purdue Pharma’s introduction and heavy-handed marketing of Oxycontin in 1996 lit the fuse of the opioid rocket ride to the moon, setting off a series of  cataclysmically destructive personal odysseys on a grand scale. Lives ruined, families torn apart. And he documents the myriad counterattacks mounted by responsible parties around the country, most notably Dr. Gary Franklin, the neurologist and medical director for the Washington State Department of Labor & Industries, who, by anyone’s standard has been a torchbearer in the battle.

Rousmaniere describes how the responsible physician community, recognizing that things were getting more than a little out of control, began to question the effectiveness of opioids in treating pain:

In 2013, the American Medical Association published a review of pain medications, in which it concluded that “Narcotics provide little to no benefit in acute back pain, they have no proven efficacy in chronic back pain, and 43% of patients have concurrent substance abuse disorders, with aberrant medication-taking disorders [in] as high as 24% of cases of chronic back pain.” The “no evidence” concept has been stretched to raise more questions, as in this conclusion published in early 2015: “There is no evidence that opioids improve return to work or reduce the use of other treatments. They may even limit the effectiveness of other treatments.”

Finally, he tells the story of how the federal government as well as almost all the states, the insurance industry, the American Medical Association and workers’ comp pharmacy benefit managers took definitive action to bend the opioid curve to the point where all of the leading indicators have been significantly slowed or reversed.

But Peter Rousmaniere’s report up to this point, the halfway mark, is merely preamble to the real thrust of We’re Beating Back Opioids – Now What? It’s the “Now What?” that concerns Mr. Rousmaniere. The “baby and the bathwater” question. He writes:

The workers’ comp industry was victimized by opioids and their well-resourced purveyors and ardent advocates. But it also made a costly, unforced strategic error. It paid more attention to wrestling with this flawed solution than to the underlying problem: chronic pain.

In short, Rousmaniere says, “We have equated pain management with drug use.” He isn’t shy about making his point:

Too much attention was diverted to fighting the opioid threat. For example, when states introduce hard hitting formularies, such as Texas did and others are doing, hardly any thought is given to making sure patients and physicians have access to a balanced array of non-opioid treatment. This needs to change – now.

Well, chronic pain is real. So, if not with opioids, how should the medical community be treating it?

Rousmaniere’s prescription is an elastic version of conservative care. He describes the approach of California’s second largest private employer, Albertsons / Safeway / Vons, who “learned through experience” that every injured person is a unique individual and that new ideas need to be brought to the recovery process.

For example, it’s almost a cliche  to say that chronic pain sufferers tend to depression as well as other mental and behavioral health issues. Consequently, Cognitive Behavioral Therapy, an underused treatment because of its perceived fuzziness, is gaining traction within the world of claims management.  As is the idea of treating injured workers in a biopsychosocial way. And, because opioid treatment is still an option, many in the medical community are saying that before any injured workers receive opioid prescriptions they should be screened for depression.

Rousmaniere argues persuasively that “one size fits all” treatment just doesn’t work for many people and that the solution to this thorniest of workers’ comp problems will take a heretofore unheard of level of cooperation and coordination among and between the industry’s disparate factions. He even goes so far as to compare the effort required to the largest single public infrastructure project in the nation’s history, Boston’s Big Dig. Although, having lived through the Big Dig and its daily remapping of Boston’s streets, that’s a bit of a long pull for me. But I get his point:

The goal of the Big Dig was to improve the livelihood of the Boston metropolis – more than reworking traffic flow. The goal of a chronic pain initiative is to keep workers productive – more than managing drugs.

Peter Rousmaniere’s  We’re Beating Back Opioids – Now What? is a compelling, stimulating and thought provoking work by a person with 30 years in the workers’ comp trenches and the scars to prove it. It should be required reading for anyone whose job it is to help injured workers return to the productive future each deserves.



News Roundup: ACA, WC & Profitability, Pain, Opioids & More

Friday, June 26th, 2015

The big news that’s dominated the week is the Supreme Court decision on the Affordable Care Act subsidies. NAIC’s statement on the ACA ruling sums things up well:

“Uncertainty in insurance is not a good thing. The decision allows regulators, consumers and the industry a level of certainty that supports stability for insurance markets in our states. The NAIC will continue to support state insurance departments – as we have done since the passage of the ACA – and ensure consumers are protected, regardless of the type of exchange in any given state. There are still a number of challenging issues facing health insurance consumers across the country, and U.S. insurance regulators are working together through the NAIC to promote stable and competitive markets.”

Here are some related news stories / opinions we found noteworthy

Is Workers Comp Profitable?
If you haven’t yet checked it out, don’t miss Joe Paduda’s three part posting on the profitability (or lack thereof) of workers comp. Part 1: If workers’ comp is so profitable, why is Liberty Mutual de-emphasizing the business? Part 2: Workers’ comp profitability, Part 3: Workers’ comp profitability.
Related: Boston Globe, Liberty Mutual shedding its workers’ comp roots

New Blog
We’d like to welcome a new work comp related blog to our blogroll – Work Comp Psych Net – an eponymous blog from an organization of the same name. Work Comp Psych Net is a New Jersey-based network of behavioral health practitioners who facilitate return to work. They specialize in addressing psychological and mental health obstacles delaying return to work. such as PTSD, traumatic brain injury, chronic pain, adjustment and mood disorders, and the like.

Worker Misclassification – What Employers Need to Know in Light of New Enforcement Efforts
D. Earl Baggett, Amanda Weaver | Williams Mullen, JDSupra Business Advisor: “The Virginia Department of Labor and Industry (“DOLI”) has recently announced the implementation of a new Virginia Occupational Safety and Health (“VOSH”) policy directed at preventing the misclassification of workers in VOSH cases. VOSH will be seeking to identify workers who have been misclassified as independent contractors during the course of VOSH inspections and investigations. Misclassification occurs when an employer improperly classifies a worker as an independent contractor when the worker should be classified as an employee. The new policy, which takes effect July 1, 2015, comes on the heels of Governor Terry McAuliffe’s 2014 executive order establishing an inter-agency task force on worker misclassification and payroll fraud in Virginia.”

Nancy’s super-simple guide to pain, Jennifer Christian: “Nancy Grover’s June 15 column on Work Comp Central is a super simple guide to pain for anyone who isn’t really interested in the latest science of neurophysiology — but who wants a basic understanding of how the science of pain is changing our view about how to treat it.Nancy interviewed me and wrote her column after reading a white paper entitled Red Herrings and Medical Over-Diagnosis Drive Large Loss Workers’ Compensation Claims released by Lockton Companies. I am one of the co-authors, along with Keith Rosenblum, senior risk consultant at Lockton Companies and Dr. David Ross, a Florida neurologist who is CEO of NeuroPAS Global…”

Massachusetts: Task Force Says Opioid Abuse an EpidemicClaims J0urnal: “Massachusetts is in the midst of an epidemic of deadly opioid abuse, according to a task force created by Gov. Charlie Baker that said Monday that drug addiction must be considered a medical disease.
The 18-member group released a total of 65 recommendations in the areas of prevention, education, intervention, and treatment and recovery, after holding a series of meetings around the state in recent months.
“Over the past decade, more than 6,600 members of our community have died because of opioids, and behind those deaths are thousands of hospital stays, emergency department visits, and unquantifiable human suffering inflicted upon individuals, families and our communities,” the task force said in an overview of its report.”

Don Blankenship / Massey Energy
New York Times: ‘The People v. the Coal Baron’ – At Coal Tattoo, Ken Ward Jr. dissects the recent NYT story on Don Blakenship, correcting the record on several counts. Ken Ward offers a sterling example of why local journalism is so vital. As the October 1 criminal trial of former Massey Energy CEO Don Blankenship approaches, we expect more national media coverage, but for the definitive source, you can’t do better than Ken Ward and his coverage at the Charleston Gazette.

More Noteworthy News

Exclusive Remedy wins: Safe in Florida … for now. Also upheld in DBA suit

Thursday, June 25th, 2015

The big workers comp news of the week: A three-judge panel of the 3rd District Court of Appeal overturned a ruling that challenged the concept exclusive remedy: Appeals court tosses out key workers-comp ruling. Refresher: In the 2014 Florida case often referred to as the Padgett ruling, Miami-Dade Circuit Judge Jorge Cueto ruled ruled workers compensation unconstitutional, commenting that state legislative reforms had weakened the law to a point where the remedy for employees was no longer sufficient to warrant the loss of their right to sue employers.

But before exclusive remedy proponents break out the champagne to celebrate the victory, in Padgett Out, Now What? Dave DePaolo dissects the ruling, explaining why any celebrations may be premature.

“But the 3rd DCA set aside Judge Cueto’s ruling on procedural grounds, not addressing any of the merits. This leaves the question open.

The organizations pushing the constitutional challenge have vowed to continue the fight.

And those defending the system realize that the attacks will continue, particularly since there are still two cases pending in the Florida Supreme Court attacking smaller provisions of the law on similar grounds (Westphal v. City of St. Petersburg is about the statutory limits on the payment of temporary total disability benefits, and Castellanos v. Next Door Co. involves a challenge to the cap on claimant attorney fees).”

For the legal nerds in the crowd, a must-see analysis on the case can be found at Judge David Langham’s post It is Padgett Time, Third DCA Reverses. As Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims and Division of Administrative Hearings, Langham wields some expertise on the matter — his post is worth reading.

Exclusive remedy upheld in Defense Base Act ruling

In other recent exclusive remedy legal news, the U.S. Court of Appeals for the District of Columbia Circuit (D.C. Circuit) reaffirmed that the Defense Base Act (DBA) is the exclusive remedy for contract workers. See: The D.C. Circuit’s Message to Injured Government Contractor Employees: ‘There’s an Exclusive Remedy For That’ in National Law Review.

“Despite the Act’s broad exclusivity provision, in Brink v. Continental Insur. Co., an estimated class of 10,000 contractor employees who were injured in Iraq and Afghanistan brought a purported class-action lawsuit for $2 billion against dozens of government contractors, alleging that the contractors conspired with their respective insurance carriers to deny the workers DBA benefits. But a three-judge panel of the D.C. Circuit unanimously rejected plaintiffs-appellants’ claims and, in a 17-page opinion, made five key findings that will help government contractors defend similar lawsuits in the future.”


3rd DCA Reverses Summary Judgment in FWA Constitutional Challenge to Exclusive Remedy

Brink v. Continental Insurance Company, Court of Appeals

Appeals Court Tosses Out Key Workers Comp Ruling

D.C. Circuit tosses suit brought by injured military contractors

Counting down to the Supremes with a fresh Health Wonk Review

Thursday, June 18th, 2015

If you have facial tics waiting for the Supreme Court to issue a ruling in King v. Burwell, we have just the antidote to get your health wonk fix. Journalist and blogger Tinker Ready has posted Kings, dogs and Burwells: The latest policy posts from the Health Wonk Review #HWR at Boston Health News.

It’s a roundup from prominent health policy bloggers who submit their “best of” posts for the prior two weeks so it’s always an eclectic array of topics and issues. Check it out – there won’t be another issue until mid-July!

By the way – are you following us on Twitter? Twitter is a great source for workers comp news…you can also follow our Health Wonk Review Twitter list/feed.

News Roundup: New must-read blog, opiate epidemic, nurses impact on claim costs & more more

Friday, June 12th, 2015

We’re catching up on the news with a Friday roundup — but first and foremost, we issue a warm welcome to Dr. Jennifer Christian, who has a new blog. Here at Workers Comp Insider, we’re unabashed fans of Dr.C – we have no doubt that her blog will be one to follow. See her recent post: Why aren’t we saying and doing THESE THINGS about the ADA?

Quest Data Shows Rise in Positive Test Rates for Workplace Illicit Drugs – Caroline McDonald, Risk Management Monitor: “Organizations in the United States that tested employees for drugs saw a 9.3% jump in the number of positive drug tests for illicit drugs in the general workforce, to 4.7% in 2014 from 4.3% in 2013, according to data from Quest Diagnostics. These results may mark a rising trend, as 2013 was the first year since 2003 in which the overall positivity rate for about 1.1 million tests increased in the general U.S. workforce. The analysis shows a potential reversal of a decades-long decline in the abuse of illicit drugs in the U.S. workforce, Quest said.”
NPR – Emergency Rooms Crack Down On Abusers Of Pain Pills
MCN: A Changing Landscape: America’s Opiate Epidemic
Boston Health News: Much Massachusetts news on the #heroin #overdose epidemic and #opioid abuse
Paradigm: Two New Approaches to Curbing the Opioid Epidemic

Health care cost drivers, or, Here’s where you’re getting screwed – Joe Paduda of Managed Care Matters covers two recent studies in Health Affairs and their likely effect on workers comp costs: one indicating that orthopedic fees paid by private insurers are measurably higher in those markets with higher concentration and the second on hospital markups, the 50 hospitals with the highest charge to cost ratios.

Proving Value – Roberto Ceniceros, Risk & Insurance: “Sellers of workers’ compensation products that fail to grasp shifting marketplace dynamics or help buyers with the pressure they are under will increasingly lose to competitors.
You can see evidence of these changing dynamics in the challenges workers’ comp underwriters face. Their inability to earn adequate investment income is reshaping their view of the vendors they buy from.
Other buyers, including third party administrators and self-insured employers, are also re-evaluating their purchasing arrangements.”

How do nurses impact workers’ comp claim costs? – Melissa Hillebrand, “Medical and total loss dollars are reduced by double digit percentages when nurses become involved on a workers’ compensation claim, according to a report from Liberty Mutual Insurance and its wholly owned third-party administrator, Helmsman Management Services.
Based on the findings from an internal study of 42,000 claims, a nurse’s participation in the workers’ comp process decreases a claimant’s future medical costs by 18% and overall costs by 26%. The study, “The N Factor: How Nurses Add Value to Workers’ Compensation Claims,” pulled data points across four categories.”

South Dakota Supremes Declare Horseplay Compensable: Bob Wilson, Bob’s Cluttered Desk: “Workers’ compensation is no stranger to stupid stories. Lord knows we have seen our fair share of inane dumbassery. This story – make that this court decision – would be one of them.”

Overview of California Workers’ Compensation SystemConference Chronicles presents a recap of Dave Bellusci’s overview of California’s workers’ compensation system from the Workers’ Compensation Insurance Rating Bureau of California’s (WCIRB) perspective. Dave is the WCIRB Chief Actuary.
Related: Dave DePaolo offers his perspective on the WCRIB goings-on on two posts: The Whole Person and The Value Image.

Cognitive Therapy, Cognitive Dissonance – Michael Gavin, Evidence Based: “”One of the most frequent recommendations I see resulting from our peer-to-peer discussions on chronic pain claims is Cognitive Behavioral Therapy (CBT). CBT is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving. Its goal is to change patterns of thinking or behavior that are behind people’s challenges and, thus, change the way they feel about and deal with those challenges.
Despite the growing body of evidence regarding the effectiveness of Cognitive Behavioral Therapy, it still seems to cause a great deal of cognitive dissonance in our industry. We want to mitigate chronic pain symptoms for injured workers so they can take fewer medications, have a higher quality of life, and perhaps even return to work. But we’re resistant to the idea that 6-12 CBT sessions can actually help with those goals, despite what the evidence suggests.”

Heat Hazard – Claire Wilkinson, Terms + Conditions – offers a variety of links to the growing risk posed by excessive heat and drought in various parts of the globe and in various industries.
Related: California Employers Take the Heat . . . of new Revised Heat Illness Standards

Other noteworthy news

Hospital Medicare Charges: You Don’t Always Get What You Want

Monday, June 8th, 2015

In early June of this year, the Centers for Medicare and Medicaid Services (CMS) let loose a treasure trove of data. One data set lists inpatient charges of 3,000 hospitals for the 100 most frequently billed diagnoses of 2013. The differences between what the hospitals billed and what Medicare paid are eye-popping, as are the differences between what hospitals within just a few miles of each other charged.

The inpatient data shows Medicare paid about $62 billion to cover more than 7 million discharges. Our good friends at Modern Healthcare have analyzed the data. This, from Modern Healthcare’s Bob Herman:

Hospitals have been under intense scrutiny for their billing practices, often triggered by extremely high charges—or sticker prices—for common procedures. Consumer groups and patient advocates argue hospital pricing is shrouded in secrecy, which has put patients on the hook for costly bills. But hospitals have said the listed charges are irrelevant because they only serve as a starting point for negotiations with insurers and that patients rarely, if ever, pay those prices.

The CMS data is shining a light on the process. The agency has now released data from 2011, 2012 and 2013. Charges for various inpatient and outpatient procedures differed significantly again in 2013 as they did in prior years. In many instances, charges fluctuated greatly among hospitals in the same region.

A Modern Healthcare analysis of the inpatient payment data shows Philadelphia, Los Angeles and Newark, N.J., had the largest gulfs in charges between the top and bottom hospitals. For example, in Philadelphia, the average difference in average hospital charges across all procedures was $123,847. In Los Angeles—an area rife with academic medical centers such as Cedars-Sinai Medical Center—the average difference between the highest-charging hospital and the lowest-charging hospital was about $112,000.

Did you catch the part about the listed charges being irrelevant, because they’re only starting points for negotiations? Reminds me of the last time I bought a car.

You might be tempted to say, “That’s crazy! Why do hospitals do that?” Let me answer with a little story.

A few years ago, I was a Trustee at a major teaching hospital in Massachusetts, a tertiary care facility, one of the biggies. At one Board meeting early on in my trusteeship I asked the CEO how the hospital was compensated for uninsured people who were indigent. His answer? “We charge them the moon.” Note to reader: he’s talking about the indigent patient, here. “Then, when the state’s uncompensated care pool gets around to paying us, we’ll get a lot more than if we just charged them what the procedure cost, in which case we’d get a lot less than what the procedure cost.” I never forgot that lesson in hospital economics.

So, you see, when hospitals say their charges are “starting points,” they’re telling the truth. And that is one spooky scary example of what a first-class horrendoma the American healthcare system (if you can call it that) has become.

What to read right now: Summertime! Health Wonk Review

Thursday, June 4th, 2015

For an eclectic collection of health care posts, check out Summertime! Health Wonk Review curated and hosted by Louise and Jay Norris at Colorado Health Insurance Insider. This bi-weekly roundup features some of the best thinking in the health policy blogosphere. This week’s edition: King v. Burwell, conflict of interest in health care, health care costs, emergency services & more. All this — and some charming photos. Check it out!

Work Comp Fraud Control, Barn Door Style

Wednesday, June 3rd, 2015

A recent edition of 20/20 – Who’s Freeloading – deals with insurance. The first 12 or 13 minutes focuses on flagrant workers comp fraudsters caught in the act. The episode shows a worker with an alleged injured foot strutting the beauty pageant walkways; a worker incapacitated with a shoulder injury break dancing in a commercial; a “disabled” worker competing in extreme wrestling. While one might think someone deceiving their employer would have the street smarts to keep a low profile, this is often not the case. Many clueless fraudsters are caught in very public activities: See Caught on The Price is Right.

These cases are egregious and infuriating, particularly because the claimants are so brazen.
It’s worth noting that workers comp fraud comes in many flavors, and individual claimant fraud may be the tip of the iceberg: doctor mills, employer premium fraud and attorney fraud add up to much more in terms of sheer costs to the system.

Still, that can be cold comfort to an employer who deals with a fraudulent claim. It can feel very personal to to be duped and swindled by an employee.

We encourage employers who suspect fraud to work with their insurers to ferret it out – it should be a zero tolerance approach. But chasing down fraud after it occurs is still a case of “closing the barn door” style of management — the horse has already escaped.  In the Coalition Against Insurance Fraud’s Emerging Issues, Professor Malcolm Sparrow, a pre-eminent fraud expert from the JFK School of Government at Harvard University says it better:

There is widespread misplaced emphasis on detecting and investigating committed crimes, rather than on controlling, neutralizing, and deterring future crime. Despite some progress, the probability of detection and of criminal prosecution is still extremely small. The risk/reward ratio is still very attractive in insurance fraud — small risk with high reward. There is great potential in shifting the investment balance from heavily weighted identification of already committed crime — the “pay and chase” model — to more investment in detecting attempted fraud and defeating it.

We believe that vigilant employers can nip most fraud in the bud with a tight workers comp management program that focuses on preventing injury, treating employers fairly and compassionately when injuries do occur and closely monitoring the recovery process until return-to-work on full or transitional duty. By actively demonstrating vigilance repeatedly, opportunistic fraudsters may think twice and sophisticated fraudsters may choose an easier target. Here are some best practices:

  • Zero tolerance message. Educate employees about their rights and responsibilities under workers comp, and be clear that your intention is to care for anyone who is injured on the job, but that you aggressively prosecute fraud as a crime.
  • Publicize your return-to-work program. Establish and reinforce a goal of recovery and return-to-work for any work-related injuries.
  • Train supervisors. Your supervisors should understand workers comp and their role in the process. They should understand the employer/employee rights and responsibilities and what to do if an injury occurs. They should be alert for red flags.
  • Aim for same-day injury reporting. Train employees to report injuries immediately when they occur.
  • Conduct accident analyses. As soon as possible after a work injury or near miss, gather facts and witnesses while things are fresh. This will also set the stage for getting to the root cause and taking any remedial actions to prevent future occurrences.
  • Set the tone at point of injury. Escort an injured worker to the treating physician in your network. Remind them of rights / responsibilities and that you will be monitoring their recovery.
  • Keep in close touch with out-of-work injured employees. Let the employee know how important they are to the team. Have transitional work available that conforms with any restrictions and establish a return to work date.
  • Work with your insurer. Be familiar with “red flags” and report any suspicious activity immediately.

Fraud resources

10 “Red Flag” Warning Signs of Workers’ Compensation Fraud

10 ways for employers to fight workers’ comp fraud

Seven Steps You Can Take to Stop Workers’ Compensation Fraud

National Insurance Crime Bureau

Coalition Against Insurance Fraud

III – Insurance Fraud