Archive for February, 2017

Fresh Health Wonkery and other news of note

Friday, February 24th, 2017

Check out the newest Health Wonk Review: Presidents’ Day edition, hosted by David Williams at the excellent Health Business Blog. This week’s issue has a plethora of posts about the Affordable Care Act, aka Obamacare – quelle surprise! The wonks offer diverse and informed opinions. Don’t miss David’s post on the Cadillac Tax – that one was news to us. There are other topics discussed, too. We always Like Roy Poses posts – he is always holding someone’s feet to the fire for conflicts of interest, and we like that about him!

Other noteworthy news

I can tell you from my own experience that injured workers entering our system are confused and befuddled, guided by complete misperceptions about who we are and what we do. The general lack of thorough communication in the form of understandable explanations and dialogue often creates a vortex of negative opinion with damaging results. Living Abled & Healthy is designed and intended to cure that particular ill. It provides explanations that will empower the willing injured, not in a confrontational mode, but rather one that can help them determine a better outcome for themselves

 

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What Is The Meaning Of “Life?”

Wednesday, February 22nd, 2017

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men…” – The Declaration of Independence of the United States of America

“People with type 1 diabetes need to take insulin every day to stay alive.” – The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

““I must pay my mortgage.” If it’s a choice between the mortgage and the insulin, “It’s going to be the mortgage.” – 74-year-old Kathleen Washington. Some months, her insulin runs over $300 a month – more than she can afford.” – CBS This Morning, Anna Werner, 22 February 2017

As politicians and high-paid lobbyists dance around the Washington DC Tower of Babel debating the future of health care in America, here are three questions that, as far as I can tell, have yet to be asked:

  1. In the phrase, “Life, Liberty and the pursuit of Happiness,” what did the Founders mean by the word “Life?”
  2. Is good health care an “unalienable” right?
  3. Should Ms. Washington have to choose between paying her mortgage and buying her insulin?

Let’s begin by considering the phrase, “To secure these Rights, Governments are instituted.” Then, consider, “Pursuit of Happiness.” Those two phrases suggest that one of the prime responsibilities of Government is to insure nothing prohibits citizens from being able to seek Happiness. Everyone must have the opportunity to find Happiness for themselves, the key word being “opportunity.” Government doesn’t guarantee Happiness, just that we have the chance to land on it. It’s up to us, but Government must do all in its power to see that unreasonable impediments are not placed in our way.

But what about Life and Liberty? The Founders did not choose to put the word “pursuit” in front of Life and Liberty. What does that mean? If Life and Liberty are unalienable rights that Governments are instituted to secure, what must Governments do to accomplish the mission?

Consider Liberty. Government has created a national defense system to defend our country and, by extension, our Liberty. The Founders recognized taxation as the most equitable means of paying for this, and so every year each of us kicks in our share (although this might be debatable) to guarantee our unalienable right of Liberty.

Now, think about Life.  Some may say Life is what national defense is all about, but, as I have shown, Liberty is more closely aligned with national defense. If the Founders wanted to make Life and Liberty go together, they would have written, Life and Liberty, not Life comma Liberty.

Then what does “Life” mean? For the answer to that center of the bull’s eye question, I turn to those great English philosophers, the Bee Gees: Life means Stayin’ alive. What should Government be doing to secure this first of the three unalienable rights for us? If Type 1 diabetics require insulin every day to stay alive, to continue Life, should Government guarantee they are only able to pursue it, as in the “pursuit of insulin?” Or, to secure the unalienable right of Life, must Government provide the insulin, paid for by taxation of all citizens, as it provides a national defense system?

It is unfortunate that these most basic of questions are not front and center in our nation’s capital. But to truly “secure” our “unalienable Right” to “Life” requires the goring of too many oxen (or, an unlucky Matador), as Joe Paduda writes in his blog today.

Pity the Republicans. They’ve caught Obamacare, like that dog that caught the bus, a trite phrase, but, in this situation, apt. They need to do something, but whatever they do, a large swath of America is going to pour fire and brimstone on their heads. Damned if they do, damned if they don’t.

Too bad. It didn’t have to be like this.

 

 

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Barack Obama, I Have A Bone To Pick With You

Monday, February 13th, 2017

Dear Mr. Former President,

I’m writing about the Patient Protection and Affordable Care Act, which you signed into law six years, ten months and twenty-one days ago. That’s 2,519 days. Nearly seven years. Didn’t take but about two hours to become ObamaCare.

The law has saved lives and money, a lot of both. It’s allowed nearly 20 million people to become insured, most of them poor. Those people were able to get that insurance because the law helped them pay for it. The Medicare Hospital Insurance Trust Fund, which in the year before the law’s passage was projected to run out of money right about NOW, is good for another 12 years as of today, according to Medicare’s actuaries as reported by the Kaiser Family Foundation.

No lifetime caps, no pre-existing condition denials, kids on the plan until age 26, free preventive care, donut hole gone, I could go on.

But you, sir, and your administration made a mess of what came after. Consider:

  • You did such a wonderful job of selling the ACA to the American public, that you got waxed in the 2010 mid-term elections. You lost the House big time, 63 seats, and also the super-majority in the Senate, six seats;
  • You had three and a half years to get Healthcare.gov ready, and what happened on 1 October 2013? A system crash that took months to fix. You were warned 18 times prior to scheduled launch that the project was mismanaged and in deep doo-doo, but your team did nothing;
  • You let a clever-as-a-fox, but dumb-as-a-doorpost former Governor of Alaska, of all places, get away with introducing Death Panels into the conversation, and to this day 29% of Americans still believe that lie;
  • You sat by and watched the House of Representatives vote 54 times to defund, delay or outright repeal the law you signed;
  • I could go on.

But it’s your failure to educate the American people and your failure to get down and fight for your signature legislation that bothers me the most. Maybe you should have demanded to get your cell phone back and taken to Twitter like the two-year-old who now sleeps in your used-to-be bedroom. Anything would have been better than the cerebral, thoughtful argument you brought to the battle. Right up there with the old knife to a gunfight thing.

And that is such a shame, because, sure, the law has flaws, but you could have fixed them if you’d been willing to approach the job like Lyndon Johnson, or even Harry Truman. But perhaps that kind of street fighting was beyond the Constitutional Lawyer, the Editor of the Harvard Law Review.

Obamacare had the potential, with a few tweaks here and there, to be a monumental achievement. Instead, it has had a tortured existence and may yet prove to be the only death panel victim.

But, wait. Hold on. Here’s a thought: It is looking more and more as if the Republicans, who now control all three branches of government (well, maybe not the Executive, after all) have become the dog that caught the bus. They do not appear to have a clue. For example, last Thursday the highly-respected Bob Laszewski wrote in his blog, “the repeal part is still on track to occur this spring, … likely in March.” But just the day before, the two-year-old with the Twitter account, who thrasonically said he’d repeal Obamacare on Day 1, told Bill O’Reilly we may not see any changes until sometime in 2018 (but they’ll be beautiful when they happen, really beautiful).

Here’s another thought: Maybe when the public actually begins to realize what it’s about to lose things will begin to change. Maybe when the 35% of Americans who still think Obamacare and the Affordable Care Act are different laws realize they are in danger of losing the Obamacare they hate as well as the Affordable Care Act they love, things will begin to change.

One can only “hope.”

Sincerely,

Tom

P.S. We miss you.

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Fresh Health Wonk Review at medicareresources.org blog – check it out!

Friday, February 10th, 2017

Steve Anderson has posted the latest and greatest Health Wonk Review – the #alternative_facts Edition at medicareresources.org blog.

The Affordable Care Act (aka Obamacare) is not all that’s on our wonks’ minds of late, but it certainly takes up a huge portion of the mind share as evidenced by the plethora of related posts. We are a diverse crew, though, so there are also posts about a variety of other topics: the reaction to/impact of the immigration ban on healthcare industry, best cancer treatments, the process of healthcare M&As, legal liability in the form of class action suits for a data breach. and workers comp. One thing we find: the contributors are all very knowledgeable people – even if a topic is not on your radar, it’s a good way to learn something new.

Two posts we think are particularly worth calling out:

If ACA is repealed, how many will max out on restored lifetime coverage caps?

If ACA is repealed, how many are at risk of losing coverage by U.S. Congressional District? (Data covers 35 states)

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Reader Reactions To Our Psychosocial Issues Series

Tuesday, February 7th, 2017

A number of readers wrote to us about last week’s two-part series on psychosocial issues and how they confound claim adjusters and increase costs. A few readers pointed out that we paid scant attention to the “social” in psychosocial. These adjusters and nurses wrote that too often they’d seen and handled claims where life and “societal issues” seemed to get in the way of recovery. Sue Separa, who has overseen workers’ compensation claims for more than 30 years in 40 states and jurisdictions, put it this way:

Employee loses car, loses license, loses driving privileges and can’t get to work, but still needs a source of income;

Employee is having daycare issues and needs to be home, but also needs a source of income;

Employee has a sick relative or child they need to stay with/watch, but still needs a source of income;

Employee is attending school to better themselves, has a heavy school schedule, but still needs a source of income;

Employee has a comorbid or health situation that requires medical care and possibly surgery or absence from work, and has not secured short term disability, or it is not available with the employer; 

Employee has asked for vacation time and it is denied due to no time left, or not eligible, or because someone else is off work at the same time.

And she’s right. Of course these real life situations occur. However, they’re present and happen all the time without injuries, too. They are non-physical, “social” comorbidities; things that can easily impede and delay return to work. Unless, that is, claim adjusters are trained and experienced enough, as Ms. Separa is, to dig a little deeper, find them and address them appropriately.

We also heard from our friend Robert Aurbach who wrote from Down Under to say, while he “applauds” our efforts and thinks “they are valuable,” he suggests “perhaps they don’t go far enough.” Rob believes the “problem is partly the system itself;” we create the harm I cited. As that great American philosopher, Pogo, opined on Earth Day, 1971, “We have met the enemy and he is us.” The system is iatrogenic (system caused).

Rob Aurbach also sent me a paper he authored in late 2015 for the Injury Schemes Seminar, put on bi-annually by the Australian Actuaries Institute. In the Paper (opens in pdf), titled “Better Recovery Through Neuroscience: Addressing Legislative and Regulatory Design, Injury Management and Resilience,” (bit of a mouthful that, but it won the Taylor Fry Award for the Seminar’s best paper) Rob explores Neuroplasticity, a theory dating from the 1800s and recently confirmed by functional Magnetic Resonance Imaging. Neuroplasticity is the process by which our brains continually rewire themselves throughout life due to environment, behavior, thinking and emotions. In short, it’s true; our brains are malleable. Rob writes that when work is disrupted through injury (or, through anything, really) for a long enough period, Neuroplasticity begins rewiring the brain to adapt to the new situation – being out of work. In other words, our brain creates a new “facilitated neural network.” This can happen in as little as 12 weeks, as Rob points out:

Timing is everything. There is a substantial research literature demonstrating that if a worker does not return to work within 12 -16 weeks, the probability of eventual return is reduced to 50% or less.

Rob Aurbach’s paper is a valuable contribution to understanding how easily a claim can deteriorate to the point where an injured person’s life is forever changed, and not for the better. I urge you to read it. It’s well-researched, well-written and profoundly thoughtful. Twenty-seven pages long, the last seven of which are endnotes and references. I found the first half of the text compelling and enlightening. His common sense recommendations that follow are pretty simple, but wickedly difficult to implement: Claim managers and adjusters should intervene early, demonstrate respect for the injured worker, promote early return to work, align incentives that encourage recovery, restrain negativity, listen attentively to the worker’s story, etc. In short, all the things managers, nurses and adjusters like Sue Separa know they should be doing, anyway. Trouble is, for these often overworked professionals, each managing a steamer trunkful of claims, there isn’t a lot of time to devote to Rob’s prescription. The iatrogenic system isn’t built to allow it.

And that’s where behavioral health clinicians and therapists, for the most part underused and undertrained, should be called on to help. Work Comp Psych Net, the New Jersey company I described last week, would be a good place to start.

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Workers’ Compensation’s Costly Psychosocial Issues (2)

Wednesday, February 1st, 2017

First, a review.

Yesterday, we described the challenges confronting claims adjusters and injured workers when psychosocial issues are present in a workers’ compensation claim. These issues impede recovery and exacerbate costs. We confidently picked up our saw and walked out on the proverbial limb to suggest this thesis:

Our nation’s current system for treating injured workers with mental health issues is uncoordinated, overly fragmented, highly wasteful and does not focus enough on speedy return to work. There is a critical need for a more systemic approach as well as an integrated coterie of clinicians and practitioners, trained in workers’ compensation, whose goals are to provide compassionate treatment with a steady return to work trajectory. 

Finally, we listed the serious factors that make finding a solution to this looming crisis tremendously difficult.

But early in 2015 in New Jersey two Neuropsychologists, Mary Ann Kezmarsky and Richard Filippone, had an idea. Over a couple of decades, they’d treated a number of workers’ compensation claimants and had been appalled by what appeared to be the lack of a coherent system to deal with the issues they saw in their patients. They weren’t exactly sure what to do about it – they didn’t know much about workers’ compensation – but they saw it as a business opportunity.

They contacted me, and over the next year we created a company, Work Comp Psych Net (WCPN), and built a systemically organized and integrated specialty network of workers’ compensation clinicians and therapists to treat injured workers in New Jersey who might have behavioral health issues delaying recovery. Here’s how we did it:

  1. Over the last half of 2015, we recruited, credentialled and vetted 44 mental health professionals covering 55 offices throughout New Jersey’s 21 counties. Providers within WCPN’s network include psychologists and neuropsychologists, as well as cognitive rehabilitation and biofeedback specialists. All of the clinicians and therapists gave up a weekend to attend Lynch Ryan training in workers’ compensation. They learned about the New Jersey law, as well as the way workers’ compensation works – how a premium is constructed and  what indemnity and medical benefits are. They now understand experience modification, maximum medical improvement and the law regarding injuries “arising out of and in the course of employment.” Further, they have been educated regarding early return to work and have agreed to work with employers, adjusters and nurses to effectuate modified duty wherever possible.
  2. We built (with difficulty, because it wasn’t easy) the nation’s first electronic Claimant Intake & Referral Portal that allows claims adjusters, nurse case managers and attorneys to refer a claimant instantly. The paperless portal’s referral system is geographically and specialty based, meaning that referrers are assured that claimants will not have to travel far to reach their assigned clinician. In the past, referrals and appointments took weeks, even months, to arrange, but they can now be finalized within minutes. In Beta Testing from May through October, 2016, the longest time from referral to Provider scheduled appointment was 27 minutes.
  3. We built (with even more difficulty) the nation’s first mental health Electronic Health Record system for workers’ compensation. The EHR is set up as a roadmap for all WCPN clinicians to follow, meaning reports have a consistently structured form. The EHR is paperless, HIPPA-compliant and cloud-based. Initial Psychological Evaluations and subsequent treatment reports reach claims adjusters in pdf form within five business days.
  4. Our clinicians are all highly qualified and experienced; they know how to treat workers with mental health issues delaying recovery. But to make the system work we needed to understand the needs of adjusters and defense attorneys who would be referring the injured workers the clinicians would treat. Consequently, we conferred with experienced adjusters and defense attorneys. After doing so we decided that every referral would begin with a thorough Initial Psychological Evaluation (IPE), which, although not technically an IME, would be done at the IME level (we priced the IPE at $450, and, since nobody’s complained, we now think that’s too low, but we’re sticking with it). If the Initial Psychological Evaluation determines the presence of one or more mental health issues which are deemed to be work-related and requiring treatment, the treatment prescribed is initially authorized for up to 12 sessions unless medically justified, extraordinary circumstances are present. Additional treatment requires the approval of the referring party.

We officially launched in November, 2016. Over the intervening three months  we’ve learned two things (among a lot of others): First, our solution works extremely well; referrers have been highly receptive and pleased. They appreciate the ease of referral and the EHR reports.  They appreciate even more the fact that our clinicians and therapists have been trained in workers’ compensation. We’ve signed contracts with insurers and TPAs. Second, this could be a national solution.

So, our solution is working in New Jersey, but every state workers’ compensation system is grappling with how to deal with psychosocial issues that frequently hobble recovery. This may be work comp’s final frontier. Time will tell whether our template and software could help others. Regardless, we will continue to improve our solution at Work Comp Psych Net, as well as report on our outcomes.

It’s taken us nearly two years to get to this point, so if any reader wants to take this issue on in another state, we’d be happy to offer the wisdom (and sometimes folly) of our experience.

 

 

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