Author Archive

Allstate – How Could You? Worcester?

Wednesday, August 27th, 2014

A stake through the heart.
That’s what it felt like yesterday when Allstate published its 10th annual America’s Best Drivers Report and awarded Worcester and Boston, two Massachusetts cities 38 miles apart, with the gold and silver medals, respectively, for most car crashes per capita in the nation.
Upon learning of this dubious distinction, local television stations instantly knew that such a story cried out for “man in the street interviews,” and we got plenty of those. Maybe there were people interviewed who were horrified, but most interviewees who made the cut for broadcast seemed to treat it as if it were a badge of honor.
Frankly, I felt a bit like Claude Rains in the film Casablanca who, just prior to collecting his winnings, exclaimed “I’m shocked, shocked to find that gambling is going on here.”
Boston drivers are legendary in their demolition derby attitudes. The driving Zeitgeist has forever treated traffic rules as purely advisory. A green light means “go,” and a yellow light means “go like hell.” Pedestrian crosswalks might as well not be there. If you’re riding a bike, you’d better have good radar. So, one learns early on that driving in Boston is not for the faint of heart.
And right now it’s at its worst as 152,000 college students return to 35 colleges for the next school year. Thirty-seven thousand live on campus in the heart of the city. Another 50,000 live in apartments around the city. The rest are commuters. The majority of the commuters ride the oldest-in-the-nation transit system. Boston University, alone, has more than 31,000 students.
So, I can absolutely understand Boston, a city I love, winning the trophy for 2nd place. But, geez, Worcester? Really? The most dangerous city in the America for car crashes? Worcester’s like a home town to me (so is Boston, by the way, so I’m doubly hurt).
Worcester has 181,000 people spread out over about 38 square miles. There are ten colleges in the city, not 35. Students total less than 35,000. Worcester never seems to have the driving hyperactivity one finds in Boston. Although the two cities are connected by the Massachusetts Turnpike umbilical cord, they are like yin and yang. They don’t even have the same water supply. It’s true that Worcester has a lot of traffic lights, so the yellow light “go like hell” possibility exists, but the traffic density is so much less than Boston’s that one rarely sees the Boston mania. Friends from Boston visit Worcester and think they’ve gone to the land of Zen.
Right now, you may be asking, “So, where’s the safest place to drive in America?” That, according to the driving gods at Allstate, would be Fort Collins, Colorado, a city of more than 56 square miles with a population nearly 30,000 less than Worcester’s. A city of two, count ’em, two colleges, one a community college, the other Colorado State University. A city with 30,000 college students, and I’m assuming that most of them always wear a smile and speak kindly of everyone.
Actually, Fort Collins looks like a beautiful place where everyone rides bikes without a worry and where the average blood pressure is so low that nobody has to worry about getting life insurance. Congratulations, Fort Collins.
The question I’m left with is this: How did Worcester, the city of the seven hills, home to the Hanover Insurance Group (and everyone knows that insurance employees are good drivers) earn Allstate’s first place, bottom of the bird cage award? Beats me. I’m stumped and, yes, shocked. My Great Mandala has been poleaxed.
I’m going out for a drive.

Undocumented Immigrants In The Workers Comp Bullseye?

Monday, June 16th, 2014

This morning, Work Comp Central’s Mike Whiteley published a well-researched 2,500+ word article focusing on the plight of undocumented immigrant workers who get hurt on the job. His article, Immigration Reform Expected to Impact Comp Systems, highlights the attempt of the National Employment Law Project to push for passage of immigration reform legislation adopted by the U. S. Senate last year. The legislation would make it much easier for undocumented workers to collect workers comp benefits following injury on the job. It is unfortunate that, given recent political machinations (see Eric Cantor, John Boehner, et al), the Senate’s legislation has as much chance of being passed anytime soon as a thrown strawberry has of putting a hole in a battleship.

As of 2013, twenty-eight U. S. state Supreme Courts have ruled that undocumented immigrants are entitled to workers comp benefits. Only one, Wyoming, has ruled otherwise.
We’ve been writing about this since 2004 – ten years. In 2005 we wrote:

It’s one of our nation’s dirty little secrets: immigrant workers are doing some of the nation’s most dangerous jobs, are being injured and dying disproportionately in those jobs, and denied benefits when injuries and deaths occur. In a political climate where the rhetoric and emotions are high and seemingly getting higher by the day, a “blame the victim” mentality is pervasive.

Unfortunately, the only thing that seems to have changed in ten years are those court rulings. But just because a worker is entitled to benefits doesn’t mean the worker is going to get them. And that, I think, is the primary thrust of Mr. Whiteley’s article.

In addition to the quite understandable fear of undocumented workers that if they report an injury they’ll likely face aggressive retaliation, there is the little problem of a social security number (SSN), which, by definition, undocumented workers don’t have. At least, not legal ones. In any event, an SSN seems to be required on the First Report of Injury (FROI). And that’s where the trouble begins, because as soon as an injured undocumented worker gives a fraudulently obtained SSN, ICE, Immigration and Custom Enforcement, comes calling.

I say, “seems to be required,” because, although the FROI does have a block for the SSN, more and more states are allowing workers to choose to have a random number assigned to them, rather than the SSN. Trouble is, many workers don’t know this. It will take time for this to catch on.

Meanwhile, as Mr. Whiteley reports, many workers get caught in the Catch 22 of the “seemingly required” SSN. Moreover, it is not unusual for ethically compromised employers to do everything in their power to prevent benefits being awarded to undocumented workers they have hired. I call these employers American Predators, because they hire workers they know to be in the country illegally and then kick them smartly to the curb when they get hurt on the job. This is probably why experts think that only a small percentage of undocumented worker injuries ever get reported into the workers comp system.

There’s an interesting twist to this story. In addition to Mike Whiteley’s article, Peter Rousmaniere, working independently, published his own column in Work Comp Central this morning on the same subject. Peter has long advocated for better treatment of undocumented workers, even going so far as to create a blog in 2006 on the subject – Working Immigrants.

Immigration reform seems to be a bridge too far right now. I fear that undocumented workers will continue to be workers compensation’s bastard stepchildren. And that is shameful.

Jennifer Christian, MD: A Big Idea Person If There Ever Was One

Tuesday, June 3rd, 2014

The workers comp buzzword of the era seems to be “Opioids.” Whether it’s big Pharma creating ever stronger varieties and then using money and muscle to co-opt doctors, or physicians dispensing from a kind of pharmacy in their offices and over-prescribing on a grand scale, Opiates rule the day. Everyone talks about them and many try to do something to counter what is turning, or, in some areas has turned, into a bona fide epidemic.

The Opioid problem is relatively easy to understand. Greed throws a Fancy Dress Ball, and everyone shows up. And there are villains. Joe Paduda has been shining an arc light on many at his highly influential Managed Care Matters blog. He deserves great credit for making it just about impossible for people to ignore this issue. Joe does outrage well.
We’ve also written about it often, for example, recently focusing on my home state of Massachusetts and the Zohydro ER wars.

Which brings me to Dr. Jennifer Christian, a heroine of mine of considerable distinction.

Jennifer, or Dr. J, as she’s sometimes known to friends, does not go after the easy answers. Smart and articulate, she never settles for a quick fix when something more profound is needed. Unfortunately, quick fixes seem to be what everyone clamors for these days. In any event, before I get to the main point of this screed, I want to take just a moment of your time to sing Dr. Christian’s praises.

I’ve known Jennifer since Managed Comp, which many readers (I hope) recall as the nation’s largest managing general underwriter and which I co-founded with Tufts Associated Health Plan in 1987. Jennifer became Managed Comp’s Chief Medical Officer in the mid 1990s and thus began to have an impact on how injured workers were treated on a large scale. Earlier in her career she had tremendous success reducing frequency and severity (by 68%) at Maine’s Bath Iron Works, where 8,000 iron workers were breaking records in their workers comp race to the bottom.
After Managed Comp, she founded Webility, her consulting company, and, in 2001, the Work Fitness & Disability Roundtable, still going strong with more than 1,300 worldwide members from all areas of workers comp and disability management. The Roundtable just published issue number 3,206.
In 2006, Jennifer, a woman of big ideas, created the 60 Summit Project, whose mission was to “Propagate the work disability prevention paradigm across North America.” From 2006 to 2012, she fashioned 60 Summit groups in all 50 states and 10 Canadian Provinces.

As Chair of the Work Fitness & Disability Section of the American College of Occupational & Environmental Medicine (ACOEM), Jennifer was instrumental in creating the ACOEM Guidelines, which emphasize a systems and evidence-based treatment of the whole person.

So, why am I heralding this remarkable physician? Here’s why: Over time, Jennifer came to realize more and more that, as we say at Commonwealth Care Alliance, “Healthy is harder for some.” And the ACE Study proved that. Haven’t heard of the ACE Study? It’s a 17,000 person study and collaboration between the Centers for Disease Control and Kaiser Permanente. ACE stands for Adverse Childhood Experiences, and the the study produced a 10-question tool that can predict injuries that will more than likely have difficult outcomes unless systemic and personal intervention is applied. I say “personal,” because Jennifer believes that what’s required in those kinds of cases is not the traditional approach to working with injured and disabled people. She realizes that returning those unfortunates to good health requires the assistance of a guide or coach, trained, experienced and good at helping people see what is in their best interest, who will lead them to find the tools and resources they need to make themselves better.

Sounds touchy-feely, doesn’t it? A little soft? So what? Jennifer is proving that it works.

She’s created a program she calls Maze-Masters, and is piloting it with a couple of insurers (confidential, at the moment). She’s hoping that as she builds success after success, insurers will see the benefits to this one-on-one, personal approach. I think insurers and employers will always do what is in their economic best interests, so I’m hoping she trumpets the cost savings above all else, because that’s the way the world works.
I’m also hoping that at least one insurer, a super-regional perhaps, dives into Maze-Masters with both feet. Better yet, SSDI, Social Security’s Disability Insurance program, is fertile ground for this kind of effort.

Lately, I’ve been writing about people, Quixotes all, charging great big windmills. Some will say this is another windmill charge. Not me, though. That is small mind thinking. Disability in all its forms with all its problems (think about those opioids) requires great big minds thinking great big ideas. That’s Jennifer Christian in a nutshell.
Oh, one last thing, just in case you’re wondering: I have absolutely no connection or involvement, economic or otherwise, in anything Jennifer is doing. I just admire the woman.

What Are They Breeding In Snohomish, Washington?

Wednesday, May 28th, 2014

Yesterday was a dank, dour, dreary, drizzling day, so, rather than diving deep into work, I spent a good part of the day devouring dumb and dumber insurance stories from the internet.
I came away asking, “What are they breeding in Snohomish, Washington?”
But before I tell you about Danny Calhon, a 19 year old from Snohomish who has achieved his 15 minutes of fame in a way you could never in your entire lifetime conceive, permit me a small digression and a bit of a rant.
I grew up in Massachusetts in the idyllic Leave It To Beaver and Dobie Gillis era. Maynard G. Krebs was the closest thing to a weird kid as one could encounter, and he was tame fiction. True, we had our share of “Whoops, Billy and Betsy have to get married” moments, but that was about as far as anyone my friends and I knew strayed from the beaten path, and that wasn’t often. Just often enough to make you sincerely grateful you weren’t Billy.
In those days, the closest one came to technology was the party line rotary dial phone sitting on the bench near the kitchen and the black and white, 15-inch television resting in the living room, gathered around which, every night at 6:30, the entire family would take in NBC’s Huntley-Brinkley Report. Fifteen minutes of all the news in the world. “Good night, David. Good night, Chet.” There was no internet. There weren’t even area codes. Calculators were “adding machines,” and they were hand-cranked. People hand-wrote letters. The postal service was a marvel of efficiency. Mail a letter then and within three days it would be delivered by hand through a mail slot in your front door by your own, personal, smiling, friendly (except when there were dogs around – no leash laws then) mailman. Sorry, no women. Feminism and women’s rights hadn’t hit the post office yet, or anywhere else for that matter, which is a real pity. Gloria Steinem had yet to go undercover for 11 days as a Playboy Bunny in Hugh Heffner’s New York Playboy Club. That wouldn’t happen until 1963.
That world blew up, and this may surprise you, in 1967 with the appearance of Texas Instrument’s hand-held calculator, which added, subtracted, multiplied and divided. That was it. In the early 1970s, I bought one for our office. It cost $479. After that, there was no stopping the communications bullet train (which didn’t exist back then, either). Pretty soon, Al Gore invented the internet and Steve Jobs and Bill Gates and, eventually, Mark Zuckerberg dragged everyone kicking and screaming into the galaxy we now inhabit. Facebook, Twitter, Instagram, you name it. Everyone’s a reporter and everything gets reported. If a Bumble Bee farts in Pasadena, we know it in Boston within five minutes.
One of the fun games my friends and I used to play when we were 11 or 12 was to take a deep breath and hold it while blowing really hard on our thumb, which we had stuck in our mouth. We’d then pass out for a second or two, and a friend would catch us before we hit the ground. Seems a little childish now, but, well, we were children.
Which brings me back to Danny Calhon. Remember him? Danny – he’s going to put Snohomish on the map – Calhon made it into the local newspaper, and now all over the country, maybe the world, for – get ready now – causing a three-car crash after fainting due to intentionally holding his breath while driving through the 772 foot long Dennis L. Edwards Sunset Tunnel near Manning, Oregon.
You can be forgiven right about now for asking yourself if you read that last bit correctly. Trust me. You did.
There’s good news and bad news here. The bad news (my wife always wants the bad news first – seems counterintuitive, but there you are) is that after he fainted, Danny’s 1990 Toyota Camry, which was carrying him and his friend, 19-year-old Bradley Meyring, drifted across the center line and crashed, head-on, into a Ford Explorer being driven without a care in the world just before the roof caved in – literally – by 67-year-old Thomas Hatch. His wife Candace, 61, was in the front passenger seat. The good news is that there are no life-threatening injuries.
Young Mister Calhon faces a laundry list of charges. At this time, we don’t know why in the world he was holding his breath enough to faint while driving through the tunnel. Neither does Lt. Gregg Hastings, with the Oregon State Police, who drew the short straw to investigate. Maybe Danny doesn’t even know, himself.
Back in Leave It To Beaver country, we would never have known about this. Think of all we were missing.

Another Day, Another Battle in the War on Over-Prescribing Opiates

Friday, May 23rd, 2014

Fresh off Massachusetts Governor Deval Patrick’s donnybrook with Zogenix, maker of Zohydro ER, District Attorneys from Orange and Santa Clara Counties in California have filed a consumer protection lawsuit against five opioid manufacturers, charging they conducted a more than decade-long massive and deceptive marketing campaign to mislead doctors about the risks of long-term use of the drugs and to encourage their use for minor aches and pain.
The suit, filed in Superior Court by Orange County DA Tony Rackauckas and Santa Clara Counsel Orry P. Korb, names as defendants:

  • Purdue Pharma;
  • Teva Pharmaceutical Industries’ Cephalon, Inc. (Teva purchased Cephalon in a hostile takeover in 2011);
  • Janssen Pharmaceuticals (owned by Johnson & Johnson since 1961);
  • Endo Health Solutions; and,
  • Actavis
  • The 100-page suit paints an ugly picture of a huge conspiracy to co-opt “chronic pain advocacy and research groups” and charges that the five firms “directly and through their front organizations made and caused their misrepresentations to be made and broadly disseminated.” It names the American Pain Foundation, the American Academy of Pain Medicine and the American Geriatric Society as co-opt targets.
    The suit also names Key Opinion Leaders, KOLs, who the Defendants “rely on … to promote the use of opioids for the treatment of chronic pain.” These are doctors who are considered thought leaders in the management of pain and hold lofty positions at important medical institutions. The suit alleges that some of them have been promoting widespread use of opioids since the mid-1990s,
    I found fascinating one particular footnote, located on page 37 of the lawsuit. It reads:

    “Opioid makers were not the first to mask their deceptive marketing efforts in purported science. The tobacco industry also used key opinion leaders in its effort to persuade the public and regulators that tobacco use was not addictive or dangerous. For example, the tobacco companies funded a research program at Harvard and chose as its chief researcher a doctor who had expressed views in line with industry views. He was dropped when he criticized low-tar cigarettes as potentially more dangerous, and later described himself as a pawn in the industry’s campaign.”

    Hmmmm. Linking what the Counties allege is a more than decade-long opioid over-prescribing conspiracy to a proven decades long tobacco conspiracy. Now that’s brilliant.
    This could get very interesting.
    Note: Thanks to WorkCompCentral for alerting us to the lawsuit.

New York Workers Comp: Once More Unto The Breach

Thursday, May 22nd, 2014

Public Citizen, a national non-profit representing consumer interests on a broad range of issues, has just published a report entitled, Aim Higher: New York Should Reform Its Workers’ Compensation Laws To Reduce Injuries. The report focuses on New York’s Service Industry Sector, which, according to the U.S. Bureau of Labor Statistics (BLS), represents 91% of New York’s non-farm working jobs and 83% of all occupational injuries and illnesses.
Public Citizen suggests that OSHA is woefully under-serving New York’s Service Industry, given that sector’s over-representation in both population and occupational injuries and illnesses.
Public Citizen looked at New York for a number of reasons, one of which was its 2012 position in the Oregon Department of Business Insurance’s bi-annual rankings of the states – New York came in as the fifth most costly, even after all of the Spitzer reforms had settled in. We’ve written often about New York’s myriad problems and the efforts of the Workers’ Compensation Board to address them. And we’d be remiss if we didn’t mention that the recent revamping of New York’s Trust Fund Assessments, by far the largest in the country, will lower costs. However, it will take some time to make a significant dent there.
But the Public Citizen Report’s primary recommendation is that New York modify Labor Code Part 59: Workplace Safety Loss Prevention Program.
Part 59 requires that an employer with payroll greater than $800,000 and an Experience Modification Factor greater than 1.2 institute a formal safety program, the requirements of which are listed in Part 59. Public Citizen’s recommendation is that:

“New York state’s legislature should remove the threshold(s) for requiring a workplace safety plan to capture all employers in New York state.”

In otherwords, New York should mandate that all of its employers comply with the requirements of Part 59, which, in case it has slipped under your professional radar, is a safety inspection and remediation program. Its 19 pages of bureaucrat mumbo jumbo require that state-approved consultants inspect employers who exceed the threshold. Part 59 lists the requirements for employers, the duties of the consultants, their required qualifications and the costs the state imposes on them for certification ($1,000 per consultant if you’re a one or two person shop).
There. Now you don’t have to read it. You can thank me later.
Public Citizen’s Report is well-intentioned, but it misses the mark and is rather impractical. For example, in 2012 there were 592,148 workplaces in New York. Using OSHA inspection rates as a model, inspecting all of them in one year would require more than 12,000 consultant inspectors. Moreover, Public Citizen’s recommendation lacks any loss cost or injury reduction performance requirements.
Nonetheless, right about now you may be asking about New York employer compliance with Part 59 as it currently exists. Me, too. However, a call to the New York Department of Labor was not returned.
In November, 2012, we wrote about Part 59’s sister regulation, Part 60:, the New York Workplace Safety and Loss Prevention Incentive Program. If Part 59 is mumbo-jumbo, Part 60 is mumbo-jumbo written in Pig Latin. Like Part 59, it is totally process-driven. No performance requirements; no performance measurement. Just build a certified program, and good things will happen. As we wrote then, “The New York DOL doesn’t seem to care if the program reduces loss costs. All the DOL wants to know is: Have employers built their programs the way we told them to build them?”
Well, we said it then, and we’ll say it now: the most successful workers comp incentive program in history is the Massachusetts Qualified Loss Management Program (QLMP), instituted at the height of the worst workers compensation crisis ever – 1990 to 1993.
To describe how it works, here’s what we wrote in 2012:

Premium credits accrue to Loss Management Consulting Firms whose Massachusetts customers the WCRIB certifies have reduced their loss costs in the year following engaging a firm. The greater the loss cost reduction, the greater the credit, up to 15%, which is then passed on to the Loss Management Consulting Firm’s customers in the succeeding year. Lower loss costs mean lower premiums for employers. The Loss Management Consulting Firms have to requalify every year. So, if a Firm’s results slip, it will see its credit, and probably customer portfolio, reduced. In the QLMP, all of the incentives are lined up so that everyone is motivated towards reducing costs, while providing safe workplaces and high quality care for injured workers.

In the first year following QLMP approval, loss costs dropped more than 20% throughout the entire Massachusetts Residual Market. Our Lynch Ryan clients saw reductions of 49.6%.
After Massachusetts, we tested the QLMP in Missouri’s $145 million Assigned Risk Pool. Fifteen percent of the pool entered what we called the Missouri Injury Management Program (MIMP), while the remaining 85% of the Pool received normal Pool service.
After one year, the MIMP accounts had incurred loss ratios of 48% and paid loss ratios of 15%, while the non-Mimp group had incurred loss ratios of 90% and paid loss ratios of 25%.
Employer premiums go down, insurer residual market loads decline and consultants flourish – but only if the loss cost results of their employer clients remain stellar.
One would think that Chambers of Commerce and Business Councils everywhere would be clamoring for this type of program for their members, but such has not been the case. Perhaps we happy few who were present at the creation never publicized results well enough. You live and learn.
Regardless, if New York, or any other state, wants to really incentivize employers to reduce injuries and loss costs, it should consider adopting a version of the Massachusetts QLMP. The good people at the Massachusetts Workers Compensation Rating & Inspection Bureau would be happy to help, and so would I.
Note: Thanks to friend and colleague Peter Rousmaniere for sharing the Public Citizen report with us.

An Opioid Call To Arms

Wednesday, April 30th, 2014

In October, 2013, the Food and Drug Administration (FDA) allowed the opiate Zohydro ER to come on the market despite its own Advisory Panel voting 11-2 against it because it was not tamper resistant. Twenty-nine state Attorneys General petitioned the FDA to reverse its decision, but the FDA declined to do so, saying that the drug is safe and effective if used as directed.
We chronicled Massachusetts Governor Deval Patrick’s Quixote to the Windmill charge as he attempted to ban the sale of the drug in the state. The windmill won when US District Judge Rya W. Zobel overturned the state’s ban. Shortly thereafter, just days before his ban was due to expire, Governor Patrick remounted Rocinante and made a less Quixotic charge: he followed the lead of governors in other states by imposing sweeping restrictions on how Massachusetts doctors prescribe the powerful pain killer, the first pure opiate.
The restrictions, which Zohydro ER’s maker, Zogenix, calls “draconian” and “unjstified,” require that doctors:

  • Evaluate a patient’s substance abuse history and other current medications;
  • Provide a “letter of medical necessity” to the pharmacy;
  • Enter a “pain management treatment agreement” with the patient; and,
  • Use the state’s online Prescription Monitoring Program, which tracks prescriptions of controlled substances, before prescribing drugs like Zohydro that are extended-release medications containing only hydrocodone and do not come in an “abuse-deterrent form.”

Zogenix is fighting back. On Monday, the San Diego-based company filed a federal lawsuit arguing that the Massachusetts new restrictions impose “draconian” mandates on doctors and “amount to an effective ban of the drug” that is unconstitutional.
The Suit asks that the Court vacate any restrictions imposed on the sale of Zohydro ER.
Governor Patrick says that his problem with Zohydro ER is that it does not come with “abuse deterrent” packaging. Zogenix responds with three assertions:

  • The active ingredient in Zohydro ER, hydrocodone bitartrate, is no more potent than most other opioids;
  • There are more than 30 extended-release opioids on the market, and only one has an FDA-approved label indicating it has abuse deterrent properties; and,
  • No product on the market today addresses the most prevalent form of abuse, taking an excessive number of tablets or capsules.

Yesterday, things got even hotter in the Bay State when drug abuse prevention groups, state lawmakers and organized labor leaders rallied outside the statehouse on Beacon Hill demanding even more restrictions.
The rally drew more than 150 demonstrators who, in addition to the call for greater restrictions, urged Congress and federal officials to reverse the FDA’s approval of Zohydro ER.
Those who attended the WCRI’s annual conference in Boston in April will recall the stemwinding luncheon speech of Steve Tolman, former Massachusetts state Senator and now President of the Massachusetts AFL-CIO. Tolman, who ardently and passionately does all he can to combat drug abuse in the Commonwealth, was in rare form at yesterday’s rally.
“We don’t need any more opiates! We don’t need any more addiction,” he shouted to the crowd. “Yes, we know that people need pain medication, but they need the right type of medication. And it needs to be monitored.”
Massachusetts Senate President Therese Murray promised the demonstrators that the legislature will take action and is now working on a comprehensive bill dealing with all aspects of addiction, from education to prevention to treatment.
But, with the exception of theft, the only way people get opioids is by doctors prescribing them, and, right now, doctors are cautious and, in some ways, befuddled. They know there’s a big opioid problem, which has prompted Governor Patrick to declare a state of emergency, but they don’t want government invading their patient examination rooms. Nonetheless, shortly after the Governor announced his restrictions, the Massachusetts Board of Registration passed emergency regulations adopting them.
Moreover, in this week’s New England Journal of Medicine, Doctors Yngvild Olsen and Joshua M. Sharfstein present a thoughtful op-ed focused on Zohydro ER and the greater issue of the intersection of chronic pain and pain management medication. They write:

Chronic pain, which affects tens of millions of people in the United States, is associated with functional loss and disability, reduced quality of life, high health care costs, and premature death. U.S. physicians are now more likely to recognize and treat chronic pain than they have been historically, with the number of prescriptions written for opioids having increased 10-fold since 1990.

Over the same period, however, the rate of overdose deaths in the United States has more than tripled. This is not a coincidence. Many doctors have prescribed opioids for chronic pain without following best practices, understanding the risk for the development of substance-use disorders, or recognizing the red flags that can emerge in clinical practice. There is now evidence from states including our own, Maryland, that some individuals whose path to addiction may have started with a prescription for pain are progressing to heroin.

It is becoming crystal clear that re-educating doctors regarding opioid usage is central to any attempt to fix this problem.
It is also clear that this crisis is not about Zohydro ER, although the drug may prove a catalyst for change. Rather, we are witnessing a growing countrywide realization that we are slipping into a public health crisis unlike anything we have ever seen.
In the workers comp field, there is a glimmer of hope. Progressive Medical and PMSI yesterday reported a slight drop in the number of opioid prescriptions written, as well as the costs of those prescriptions in 2013. Other PBMs are reporting similar moderate declines. But that is workers comp, the tiny caboose on the great big health-care train.
This issue demands more than the piecemeal approach it now is getting. Lives, careers and families are being destroyed, while too many constituencies operate alone, unable to achieve any kind of a cohesive and comprehensive solution. It is time for the FDA, the AMA, the US Congress and Big Phama to come together in serious purpose to address this public health emergency, which is rapidly spiraling out of control.
If not, more of America’s humanity will just continue to wither and die. We are better than that.

Coingate: The Gift That Keeps On Giving

Tuesday, April 29th, 2014

Imagine, for a moment, that you hold the lofty position of Inspector General for a major midwest US state. Imagine further that down the road and around the corner, before you time, way back in 2005 gross malfeasance and criminal activity happened in your state’s Bureau of Workers’ Compensation (BWC). And people went to jail. All told, there were nineteen criminal convictions, including several prominent Republican politicians. Your governor at the time, a member of the state’s most distinguished political family of the 20th century, a family that includes one member who became both President and Chief Justice of the US Supreme Court, pleaded “no-contest” to criminal charges of misdemeanor ethics violations.
Your name is Randall Meyer, and you inherit this mess in Ohio. You inherit it, because nine years ago, a political lifetime in the past, your office was charged with investigating the whole thing and producing a report that would explain what happened, along with how and why, as well as what the state and Bureau have done to prevent such a sorry affair from ever happening again.
The whole thing came about, because even farther back, in 1998, the BWC gave Thomas Noe, a major Republican fundraiser and professional coin dealer, $50 million to invest in rare coins, an investment with, essentially, no liquidity. And that is probably why no other state in the nation pursued such an investment with its workers comp surplus.
The concept wasn’t complicated: Noe and his partners took the state’s $50 million and, applying their professional experience, bought rare coins, which they then tried to sell at a profit. Sound risky?
In 1999, Keith Elliot, the BWC’s manager of internal audits, picked up the corner of the rare coin rug and tried to see what was growing underneath, because of “the unique nature of the investment.” He asked uncomfortable questions, was able to put a few minor controls in place and was essentially stonewalled by the Bureau’s leaders.
Time passed. Six years, actually. Finally, the whole thing blew up in April, 2005, when Mike Wilkinson and James Drew, of the Toledo Blade, published a long piece on Noe, his business and the, till then, history of what came to be known as “Coingate.”
The scandal was mothers milk to investigative journalists. As so often happens in these situations, the Blade grabbed hold and would not let go. It infuriated comfortable politicians and, in the process, performed huge public service for Ohio. For that service the Blade and its investigative journalism team won more than a dozen national, state and local awards, including being a Pulitzer Finalist for Public Service.
We at the Insider also drank deeply of Coingate’s milk, writing about it numerous times. How could we not?
But, back to you, Randall Meyer, Ohio Inspector General. Last week, you issued your office’s final report on Coingate – and, really, the only reason you released the redacted cat from the bag was because the Toledo Blade sued you to do it.
One would think that a report coming nine years after the investigation began and six years after the last prosecution would be juicy, indeed. But such is not the case. Your report was a mere chronology of events, not much of an investigation. You report that, “As the task force investigation was completed prior to the current inspector general assuming this office, there were no resources utilized to reinvestigate an already completed matter.” So, the Report did not include any investigative records, such as witness interviews. You didn’t even interview Mr. Coingate, himself, Tom Noe.
You did cause a bit of trouble for yourself, however, when you wrote in the Report that Noe’s ex-wife, Bernadette Restivo, was one of those against whom the BWC won civil judgements. The lady reacted strongly to that, and the day after you released the report, you had to change it to take her out of it.
We used to sing a song in my college folk group called The Cat Came Back, a cute little ditty about a cat that would find its way back to the back porch regardless of where you sent it, even outer space. I’m reminded of that song every time I hear something new about Ohio and Coingate. Even now, despite its experience with investing in rare coins, the BWC has decided that safe stocks and bonds still aren’t enough. Nope. On Sunday, the Toledo Blade’s Jim Provance, picking up on a story originally reported by WorkCompCentral’s Peter Mantius, reported that the BWC has invested another $50 million (that’s its limit on investments) “in a Wisconsin health-care real estate fund headed by a major national Republican donor and money-raiser, Jon Hammes.”
I can hardly wait.

Where’s Aristotle When ABC Needs Him?

Friday, April 18th, 2014

This morning, ABC’s Good Morning America shone its media arclight on Cathy Caswell as she spun the great big wheel on The Price is Right, not once, but twice. But while doing so Ms. Caswell was drawing $3000 per month in workers comp indemnity payments, according to ABC. And she was collecting those payments because of a shoulder injury, which prevented her from standing, running, reaching or grasping, as reported by ABC’s eagle-eyed Cecilia Vega. Vega “reported” that Caswell was one of “the countless people accused of faking an injury” to the tune of “hundreds of millions of dollars.”
The report then cut to some fraud words of wisdom from private eye, “master of disguise” (not my words; they’re Vega’s), Bob Keane who fancies himself cut from the James Bond cloth. Keane claimed that if you’re committing fraud the only way to avoid being caught by him is “by completely staying in your house for three to five years,” because if you venture outside he’s going to “get you.”
By using phrases like “countless people” and “hundreds of millions of dollars” ABC implies that Ms. Caswell is merely the tip of a very big iceberg. Frankly, I think Ms. Vega skipped Philosophy 101 – Aristotelian Logic. You know, the part about faulty inductive arguments going from the particular to the general? But I digress.
We all know that there are people who commit workers comp fraud. In fact, some of them are workers who fake injuries or malinger trying to milk the system. But the fraud committed by workers is dwarfed by that of many others in the system.
Consider Devon Lynn Kile and her husband Michael Petronella. In 2010, while Ms. Kile sought to appear on the Bravo TV series “The Real Housewives of Orange County,” the couple gained a different kind of notoriety when federal authorities, after raided their three roofing businesses as part of a two year probe, charged them with 31 felony counts involving tens of millions of dollars of underreported workers comp premiums. Petronella went to jail for 10 years, and Kile was sentenced to 10 years probation and ordered to make $2.8 million in restitution.
There are many dimensions to fraud in the workers comp system. While many people think of fraud primarily as a problem involving employees, in dollar terms most fraud is committed by other players in the system. There are opportunities for wrong-doing in virtually every financial transaction within a system that generates multiple billions of dollars every year.
Just to be clear, fraud can be committed by, yes, employees, but also by employers (see Devon Kile), attorneys, medical providers, claim adjusters, insurance agents and even investment firms (see the “Coingate” scandal in Ohio).
Despite the many opportunities for fraud in the comp system, outright fraud is relatively rare. The vast majority of transactions within the comp system, involving all of the above players, are carried out with integrity and good faith. Nonetheless, vigilance is always necessary to ensure that comp dollars are spent prudently and wisely.
ABC has scheduled an expanded report on Ms. Caswell, et al, this evening on its World News Tonight program. It should make for some interesting, if infuriating, entertainment, faulty logic and all.

Zohydro ER Vs. Deval Patrick: The Latest Gunfight at the OK Corral

Wednesday, April 9th, 2014

The U.S. Food and Drug Administration (FDA) has acknowledged that prescription drug overdoses are now the leading cause of injury-related death in America, surpassing auto accidents. Couple that with the Agency’s approval last October of Zohydro ER, the first pure opiate painkiller, and you begin to understand why many lawmakers are left scratching their heads. More than half the states’ attorneys general have asked the FDA to withdraw approval of the drug. But the Agency is unrepentant. FDA Commissioner Margaret Hamburg told the Senate that the drug is a safe and effective option for patients with excruciating pain.
In late March, a stymied Governor Deval Patrick took the highly unusual step of banning the sale in Massachusetts of the controversial opioid made by California-based Zogenix, Inc. Many in the Massachusetts legislature as well as a number of workers compensation claims professionals thought it was the best thing any governor had ever done, a bold step to protect the citizenry.
Only it’s not as simple as that. It’s turning out that, however well-intentioned Governor Patrick may be, he probably can’t ban the sale of the drug, after all. Yesterday, US District Court Judge Rya W. Zobel told state lawyers that by Monday she wanted to see a lot more research that would buttress the Governor’s ban. Nonetheless, she said that she would more than likely grant a preliminary injunction on behalf of Zogenix that would allow Zohydro ER’s sale in Massachusetts. Said Zobel, “I think, frankly, the governor is out of line on this.”
According to Patrick, his issue with Zohydro ER is that it is not in “an abuse-resistant form,” meaning that it is not crush-resistant. Consequently, addicts (or anyone else who has the drug, for that matter,) can crush it and snort it or inject it.
Why would anyone want to do that instead of simply washing it down with a sip of water? Because in its pill form Zohydro ER is an “extended release” medication. That’s what the ER stands for. In fact, Zohydro’s full legal name is Zohydro ER (hydrocodone bitartrate) Extended Release Capsules. Crushing and snorting or injecting simply bazookas the whole dose at one time, which can be a deadly proposition.
Zogenix’s President, Steven J. Farr, attended yesterday’s hearing and, afterwards, took pains to let everyone know that Zohydro ER is safer than other hydrocodone drugs because it does not contain Acetaminophen, which can cause liver damage and failure with prolonged, high-dose usage. Farr did not mention that Zohydro ER contains up to five times the hydrocodone found in Vicodin. He did say that the company is in early stage development of abuse-deterrent formulations of the drug. That gave cold comfort to the Governor.
Whatever happens, it is hard to believe that Governor Patrick, a very smart lawyer, actually thinks he’s on firm legal footing here, although outside the courthouse that’s exactly what he said. As Judge Zobel pointed out (and she was decidedly irate that Patrick banned the drug without ever talking with Zogenix), Patrick cannot blame the Massachusetts opioid epidemic on Zohydro ER because the drug has yet to be dispensed in the state. She urged lawyers for the state and Zogenix to meet before the hearing scheduled for Monday, but she told everyone that Zogenix “probably will prevail.”
I have a few thoughts about this little mess:
First, it is not the fault of Zogenix that we have an opioid epidemic in Massachusetts or anywhere else. Yes, there’s an epidemic, but drug makers didn’t cause it. Irresponsible physicians, doctors who consider the Hippocratic Oath to be a mere suggestion, have placed their patients on the slippery slope to hell by prescribing over and over again strong and addictive narcotics for conditions for which those narcotics were never intended.
Second, the vast majority of physicians would never knowingly over-prescribe any medication. They have not forgotten that Oath and why they went to medical school. The ones I know resent and cannot understand the over-prescribers.
Third, although I wish it had built crush-resistance into Zohydro ER from the beginning, Zogenix did nothing wrong here. In fact, the Zogenix complaint notes: “When FDA approved Zohydro, it considered but rejected the idea of requiring the drug to utilize abuse-deterrent technology.” The company did everything it was supposed to do in gaining FDA approval. And that isn’t easy. One of the more difficult tasks in the universe is to get FDA approval for a new drug. The camel through the eye of the needle doesn’t even begin to describe the process. It takes many years and boatloads of money. So, you can understand that after all those years and money devoted to bringing this drug to market, to have it summarily banned is a bit hard to take.
Fourth, there are many people who suffer with agonizing pain. Think end-stage cancer. Those human beings need and deserve the best pain amelioration they can get, and the goal of the pharmaceutical industry, in addition to making money, is to give them that relief.
Finally, ending the opioid epidemic will require political courage and a much more highly-regulated process to oversee and assure that the relatively few ethically-challenged, weak-kneed and overly greedy physicians who now abuse their privilege are forced to change their bad behavior and follow that “do no harm” rule. If it weren’t for them, there would be no epidemic.