Archive for the ‘health care’ Category

Health Wonk Review: 2015 Holiday Edition

Thursday, December 17th, 2015

We’re happy to host this year’s holiday edition of Health Wonk Review. But before we get to the meat and potatoes, we like to check in on The Santa Index to see how the Big Guy is faring. We’re happy to report that he got a raise of 3.8% or $3,130, bringing his annual wage to $143,054, which seems pretty paltry when you consider that “he’s a manufacturing executive, professional shopper, sleigh driver, delivery person, list checker, and heads a customer service department for nearly 2 billion children.” calculates his life insurance needs but we learn nothing about whether he’s getting health coverage through the ACA or not. He engages in some very hazardous work, has adopted some bad health habits — too many cookies, driving too fast and lack of seat belts, to name a few — and has a quite a few risk factors, so he’d likely benefit from the lack of restrictions on pre-existing conditions.




Affordable Care Act

All is calm, all is bright? Let’s get to the controversies right out of the gate:

At Health Affairs Blog, opponents of the Affordable Care Act propose an alternative plan and to enact major reforms to the tax treatment of employer-sponsored health care, Medicaid, Medicare, Health Savings Accounts, and other areas. In their post Improving Health And Health Care: An Agenda For Reform, authors Joseph Antos, James Capretta, Lanhee Chen, Scott Gottlieb, Yuval Levin, Thomas Miller, Ramesh Ponnuru, Avik Roy, Gail R. Wilensky, and David Wilson say that their plan would “reorient health care policy away from bureaucratic regulation and toward the preferences of patients and consumers.”

However, at least one of our wonks has a bone to pick with one of the study authors. At, Charles Gaba calls out Avik Roy in a recent post for data “disingenuousness” in his critiques of the Affordable Care Act, and again in a follow-on post for lack of acknowledgment of the problems.

In another matter that many use to signify the death knell of the ACA, United Health has made headlines with its rumblings of pulling out of the exchanges. Would such an exit mean that the that the ACA isn’t viable or is United just not up to the challenge of fierce competition? At Health Business Blog, David Williams offers his perspective in his post United pulls out of ACA exchanges: Should we care?

At Colorado Health Insurance Insider, Louise Norris looks at whether or not open enrollment for health insurance plans should end by December 31 and finds she’s recently changed her mind. Previously, she supported consumers having a chance to review and change auto-renewed plans if they learn that changes resulted in a plan that isn’t quite what they expected. While she still supports as much leeway as possible in plan selection during open enrollment, she explains how the system can be gamed and what the long-term implications for adverse selection and rate volatility would be if open enrollment continues after the coming year’s plans have already started to take effect.

In another hotly contested ACA issue, the Supreme Court has agreed to hear Little Sisters of the Poor Home for the Aged v. Burwell, the latest legal challenge to Obamacare’s birth control mandate. Amy Lynn Smith explains what a win for the plaintiffs could mean for millions of Americans in her post at Blog, How millions could lose birth control coverage.

At InsureBlog, Hank Stern is thinking about men’s issues. He reports that the new “healthcare freebies” list is out but notes that “once again men’s health is omitted. But they still get to pay.” Check out his post Still sexist after all these years.

via Ryan Todd at

via Ryan Todd at

How Docs Get Paid

At Managed Care Matters, Joe Paduda says that changes in the way that providers are reimbursed are painful, but they are necessary. He offers a brief explainer of different methodolologies and tells us the three things we should know about what’s happening with provider reimbursement

How will Medicare reform provider payment going forward? Will they tie payment to quality? If so, how will benchmarks be defined? What about providers who participate in multiple quality incentive programs? In Reforming Medicare Provider Payment, Jason Shafrin of The Healthcare Economist investigates these questions and more.

At The Population Health Blog, Jaan Sidorov looks at the Limits of Financial Incentives for Docs. He examines a recently published study showing that financial incentives did not have as big an impact on physicians as commonly imagined. Jaan argues that’s because physicians live by more than bread alone.



Compliance, Data and Legal Matters

David Harlow takes his role in “preventive law” seriously in reminding all members of the “regulated community” to get their affairs in order. At HealthBlawg, he posts about recent enforcement activity by “the federales,” which shows that they mean business when it comes to HIPAA compliance and enforcement: Third Time’s a Charm: Triple-S and its Data Breaches. David says this should serve as yet another reminder that when they eventually kick off the long-promised audit program, covered entities and business associates are likely to feel the sting.

Remember the good old days, when times were simpler, and health technology was all about electronic patient records? Not today. Peggy Salvatore points out that world of health technology is about telemedicine, wearables, data collection and privacy. In her post at Health System Ed Blog, she looks at the challenge of how the health system sould harness all this unstructured patient data: Challenge: Consumer Healthware and the Glut of Unstructured Patient Data. 

Calling medical malpractice “bloggers crack” or the gift that keeps on giving, Bradley Flansbaum dedicates his post at The Hospital Leader to examining the results of the recently released Medscape 2015 Malpractice Report, and he his colorful interpretation: More Med Mal Sustenance

Brain Neong San

Brain Neong San

Faulty Ethics at Play

Roy Poses is a health care rabble rouser and we mean that in the most positive way.  At Health Care Renewal, he’s shining a light on “highly unethical” medical trials that involved multiple academic medical centers, including some of the most prestigious in the US – yet which received scant media attention. The studies involved sleep deprivation on physician-trainees. Trainees previously worked up to 36 consecutive hours, which new rules now limit to 16 hours. This increased the number of patient hand-offs, so the study goals were ostensibly to assess a method to reduce the hand-off problem. But Roy makes the case that the trials may have violated several major components of the Nuremberg Code, the set of principles for ethical research that were developed in response to Nazi medical-trial atrocities. Learn more at Drinking the Managerialists’ Kool-Aid? – Why Did Medical Educators Launch Trials of Increased Sleep Deprivation of Physician Trainees Apparently in Violation of the Nuremberg Code?

Finally, we have our own submission, a post by Tom Lynch in which he extends kudos to Work Comp Central’s Greg Jones for his ongoing reportage of the Michael Drobot case. If you are unfamiliar with this half billion dollar fraud case in which docs were given kickbacks for referring patients to surgery and legislators were bribed, you can catch up at this post and an earlier one, Workers’ Comp Fraud: The Drobot Case Grinds On.

James Curran

James Curran


See you in the New Year

This is the final edition of HWR for 2015 so we extend our best wishes for t holiday season. Our wonkers will be back bright and early in the new year: Look for a Jan. 14 edition by Hank Stern at InsureBlog.



Kudos And Thanks To Work Comp Central’s Greg Jones

Wednesday, December 9th, 2015

Work Comp Central’s Greg Jones has relentlessly followed and reported on the Michael Drobot case in Southern California, a case that fairly oozes greed and sleaze.

For the uninitiated, Michael Drobot’s Pacific Health Corporation owned two hospitals, Pacific Hospital of Long Beach and Tri-City Regional Medical Center in Hawaiian Gardens. For around 10 years, he paid kickbacks to a number of doctors for referring spinal fusion patients to Pacific Hospital of Long Beach for surgery. In February, 2014, Drobot pleaded guilty to making the kickbacks, which are illegal, and for charging California’s workers’ compensation system, the U.S. Department of Labor and about 150 workers’ compensation insurers somewhere in the vicinity of $500 million dollars for the surgeries over the ten year period. At that time, we wrote about this with Honor Sold, Trust Betrayed: Unbridled Greed in California.

Drobot is also charged with bribing state senator Ron Calderon for his help in easing one of the SB 863 requirements, which we don’t need to go into here. Calderon has pleaded not guilty, and that case is moving through the system.

Throughout this sordid business, Greg Jones has been there, providing a valuable service with his spot-on reporting, most recently last week with his story (subscription required) that a number of the doctors who took the kickbacks, at $15,000 a pop, also had filed “more than 15,000 liens with a total claimed value of $93.8 million.” To get that story, Jones had to wade through what must have been a steamer trunk full of documents.

Personally, I owe a debt of gratitude to Mr. Jones. He found two errors in my post of 30 November, Workers’ Comp Fraud: The Michael Drobot Case Grinds On. I had written that the kickback scheme involved both of the Drobot hospitals. That was wrong. They only happened at Pacific Hospital at Long Beach. Also, I had written that Drobot had pleaded guilty to bribing Calderon. He did not. He is charged with doing it, and both he and Calderon have pleaded not guilty. Before Work Comp Central ran my post, Greg found the errors and made edits to correct them, for which I am grateful.

The Drobot case is complicated and it represents the bottom of the workers’ compensation bird cage. However, the solid reporting of Greg Jones shines an arc light on the sorry mess and will help to improve the system so that in the future the Drobots of the world will think twice about this kind of criminality.



Workers’ Comp Fraud: The Drobot Case Grinds On

Monday, November 30th, 2015

In late February, 2014, we wrote about the sordid tale of corruption perpetrated in southern California by Michael Drobot and his gang of thieves. Honor Sold, Trust Betrayed: Unbridled Greed In California describes the astonishing criminality of a large group of highly placed people whose job it was to care for others.

This from our original post:

Suppose you’re a doctor in California with a patient who complains that his back hurts a lot. Suppose further that Michael Drobot, the owner of California’s Pacific Health Corporation, will give you $15,000 if you refer your patient to his Pacific Hospital of Long Beach for lumbar fusion surgery, which may or may not be warranted. And what if Drobot’s Pacific Hospital were hundreds of miles away and that other qualified hospitals that wouldn’t pay you a kickback were much closer. What would you do?

The answer? Many doctors took the money and delivered up their patients to the Drobot surgical mill. Drobot paid the doctors in this scheme somewhere between $25 and $50 million.

Drobot’s two hospitals, Pacific Hospital of Long Beach and Tri-City Regional Medical Center in Hawaiian Gardens, billed thousands of mostly spinal fusion surgeries to California’s workers’ compensation system, the U.S. Department of Labor and workers’ compensation insurers. Over an eight year period, the hospitals were paid more than $500 million.

Drobot pleaded guilty in early 2014 to paying the kickbacks. He also pleaded guilty to bribing state Senator Ron Calderon to the tune of $100,000 for massaging the SB 863 legislation so that the fraud could continue for all of 2013. After his indictment in February, 2014, Calderon pleaded not guilty.

The wheels if justice have ground slowly but exceedingly fine in the nearly two years since. Former U. S. Attorney Andre Birotte, Jr., now a U. S. District Judge in California’s Central District, passed the baton to his replacement U.S. Attorney Eileen M. Decker. Last week Decker announced that Drobot’s CFO, James L. Canedo, and Paul Richard Randall, a “health care marketing recruiter” (he recruited doctors to refer patients in return for the illegal kickbacks) pleaded guilty to fraud, money laundering, conspiracy and other crimes. Also, two orthopedic surgeons, Philip Sobol of Studio City and Mitchell Cohen of Irvine, and Alan Ivar, a Las Vegas chiropractor who used to live in Southern California, have agreed to plead guilty to conspiracy and other charges.

There will certainly be more to come in this tale of sleaze.

There’s No Fairy Godmother For This Cinderella

Monday, July 13th, 2015

I’d like to make a bet with you. Here it is. I bet you will answer “Yes” to at least one of the following three questions:

  1. Do you know anyone who works as a Personal Care Aide or a Home Health Aide?
  2. Has anyone in your immediate family, now or in the last 10 years, been taken care of by a Personal Care Aide or a Home Health Aide?
  3. Do you personally know anyone who  now or in the last year employed the services of a Personal Care Aide or a Home Health Aide?

I like my odds. According to the Bureau of Labor Statistics, six of the ten fastest growing occupations from 2012 to 2022 will be in the health care industry and numbers two and three on the list are – you guessed it – Personal Care Aides and Home Health Aides, growing by 49% and 48%, respectively, closely following Industrial-Organizational Psychologists, a profession that is expected to grow by 53% during the ten year period.

While Psychologists are projected to have the greatest rate of growth, they’ll only be adding about 900 jobs to the economy. This is dwarfed by the numbers of new jobs for the Aides, 581 thousand and 424 thousand, respectively. Taken together, they’ll be adding more than a million workers to the economy. A hefty number, indeed.

The rate of injury for both of the Aide groups is 2.5 times the rate for all public and private sector workers.¹ You would think that would get somebody’s attention, maybe somebody at OSHA, for example. And, you know what? It did. This from OSHA:

The Occupational Safety and Health Administration (OSHA) announced a new National Emphasis Program (NEP) to focus outreach efforts and inspections on specific hazards in nursing and personal care facilities with high injury and illness rates.

“Nursing and personal care facilities are a growing industry where hazards are known and effective controls are available,” said OSHA Administrator John Henshaw. “The industry also ranks among the highest in terms of injuries and illnesses, with rates about two and a half times (emphasis added) that of all other general industries. By focusing on specific hazards associated with nursing and personal care facilities, we can help bring those rates down.”

Only one problem with that: It was written exactly 13 years ago this month!

Now read this:

Non-fatal injuries to health care workers requiring days away from work are on the rise, according to new data from the Bureau of Labor Statistics released Nov. 9, and OSHA Administrator Dr. David Michaels has vowed to launch a National Emphasis Program on Nursing Home and Residential Care Facilities.

“It is unacceptable that the workers who have dedicated their lives to caring for our loved ones when they are sick are the very same workers who face the highest risk of work-related injury and illness,” said Michaels.

According to BLS, the incidence rate for health care support workers increased 6 percent to 283 cases per 10,000 full-time workers, almost 2.5 times the rate for all private and public sector workers (emphasis added) at 118 cases per 10,000 full-time workers. The rate among nursing aides, orderlies and attendants rose 7 percent, to 489 per 10,000 workers. Additionally, the rate of musculoskeletal disorder cases with days away from work for nursing aides, orderlies and attendants increased 10 percent to a rate of 249 cases per 10,000 workers.

“The rates of injuries and illnesses among hospital and health care workers underscore OSHA’s concern about the safety and health of these workers,” said Michaels.

That was written by OSHA in November, 2011.

A National Emphasis Program is becoming kind of predictable for OSHA. Maybe we’ll see another one around 2020. Until then, or until ever, Personal and Home Health Aides will be the Cinderellas of the health care universe. Except their story won’t have a “happy ever after” ending, and they’ll never get to meet a Prince.²


¹ And this rate of injury does not include the thousands of Aides who are hired to take care of Grandpa and Grandma in the home and who are paid minimum wage.

² Paying lip service to this issue goes back at least as far as 1997 when the BLS, using 1994 data, published an Issues Paper, and said this:

Overall, the 1994 injury rate in home
health care services (474 lost workday
cases per 10,000 workers) is about 50
percent higher than the injury rate in
hospitals, the institutional setting from
which many home-care patients are
released, and 70 percent greater than the
national rate.


Related: A Living Wage For Caregivers, New York Times, 10 July 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.



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.

Health Wonk Review: September 11, 2014; plus, a 9-11 remembrance

Thursday, September 11th, 2014

David Williams posts the first issue of the fall season at Health Business Blog – Health Wonk Review: September 11, 2014. Topics include Obamacare, Medicare, performance measurement, power plants and more…

And speaking of 9/11…
Our condolences to all who lost loved ones on 9-11 — our thoughts particularly go to the many heroic 9-11 first responders – both those who lost their lives, and those who continue to suffer today with the mental and physical after-effects.

Our thoughts also gravitate to the many in our industry who lost their lives while doing their jobs. Marsh lost 293 colleagues and 63 consultants and Aon lost 176 colleagues. Astounding still today. Hug a colleague in their memory. Be kind to those around you.

Robert Hartwig and Claire Wilkinson of the Insurance Information Institute have produced some reports on the impact of 9/11 on the insurance industry – as well as the documented need for renewal of a terrorism insurance backstop.

Terrorism and Insurance: 13 Years After 9/11 The Threat of Terrorist Attack Remains Real
The 20 most costly terrorist acts by insured property losses
Terrorism Risk: A Constant Threat – 2014 – download the report here

Health Wonk Review: The “Undeterred by World Cup Fever” Issue

Thursday, June 19th, 2014

While people all over the globe are gripped by World Cup fever, here in health-wonk-istan, our bloggers take a more philosophical approach to football. They are not distracted from their important mission of bringing you the best in the health policy arena. Without further hooplah, we give you our bloggers’ best posts from the prior two weeks. Because our entries are all winners, we dish them up in the order in which they were received.
We begin with a steamy post from Henry Stern at InsureBlog, who reports on a (now former) anesthesiologist’s – say THAT 10 times fast – unique (and disturbing) multi-tasking abilities in his submission More Red Hot Lover/Physician Tricks.
David Harlow of HealthBlawg interviews Roy Schoenberg, CEO of American Well about the model policy recently adopted by the Federation of State Medical Boards to get state medical boards up to speed quickly and to access standards of care that are both protective of patients’ interests and offer baselines against which physician behavior may be judged by an individual board. (After this post went up, the AMA issued a halfhearted endorsement of the whole enterprise.)
David Williams has launched a Health Business TV YouTube channel as an adjunct to his respected Health Business Blog. You can see his debut edition, in which he discusses Castlight Health, the Affordable Care Act, and more.
At Health Care Renewal, Roy Poses continues watchdogging bad behavior by corporate health entities. He reports on two recent health settlements involving companies that are no strangers to legal misadventures in his post Fool Me Twice? – Boehringer Ingelheim, Medtronic Settle Lawsuits Alleging Deceptive Marketing. One settlement involved allegations that the company hid data about the adverse effects of a popular and heavily promoted drug; the other involved allegations of paying off doctors to promote use of expensive medical devices. The settlements provide a cloak of deniability so kudos to Dr. Poses for shedding light on perverse incentives.
Jason Shafrin says that numbers do not lie: health insurers with the largest market share have the largest increases in health insurance premiums. Check out his post on Healthcare Economist to find out why the numbers may not tell the whole story: Are market leaders raising health insurance premiums?
For Father’s Day, Maggie Mahar dished up the scoop on the great cholesterol con at her Health Beat Blog. Despite a lack of medical evidence that statins helps anyone who hasn’t already had a heart attack, the perpetuation of the idea that “bad cholesterol” causes heart attacks successfully demonized eggs – a perfectly good source of nutrients = while bolstering the bottom line for statin manufacturers.
Brad Wright talks about the Geographic Divide: How Federalism Has Formalized Health Disparities at Wright on Health. He looks at the Medicaid expansion (and non-expansion) and how this affects border communities that straddle sate lines. The issue of whether or not people have health insurance and access to care is a sometimes matter of which part of town they live in.
At the NCPA’s Health Policy Blog, NCPA Senior Fellow Devon Herrick talks about how so-called specialty drugs are displacing traditional drugs as the primary component of drug spending, noting that there are a number of regulation challenges that will impact how patients will get access to these drugs and how much they will pay. See his post, At a Pharmacy Near You: The Specialty Drug Turf War
While mountains of commentary appeared about the problems with the so-called “roll out” of the computer system for the federal Affordable Care Act, there were also similar problems in several states that had decided to run their own public exchanges. At Healthcare Talent Transformation, Patrick Pine looks at some of the reasons why the feds and several states had so many problems setting up computer programs for the public exchanges.
At Health Affairs Blog, Joel Kupersmith, former head of research at the Veterans Health Administration, CEO of Kupersmith Associates, and an adjunct professor at Georgetown offers his thoughts on the VA scandal and the future. He outlines the VA’s scope and assets, its problems, and strategies for moving forward in both the short and long terms.
On the front lines of the Affordable Care Act roll out, Louise Norris of Colorado Health Insurance Insider reports that health insurance enrollment continues to climb, even in this “off-season.” She reports hard numbers on on enrollment growth and offers predictions for how tie enrollment period will likely look when it wraps up in the next five months, and the prospects for 2015.
At Managed Care Matters Joe Paduda looks at the “collateral damage” that occurred in layoffs related to a recent spate of workers compensation mergers & acquisition activity. He notes that strong non-compete agreements executed under duress needlessly and unfairly tie the hands of experienced professionals in his post The Good, the Bad, and the Ugly.
Here at Workers’ Comp Insider we point you to Tom Lynch’s excellent tribute to industry thought leader Dr. Jennifer Christian. He chronicles her past achievements as well as some of her current initiatives in occupational health.
That concludes this issue off Health Wonk Review – we’re kicking the ball to Jennifer Salopek at Wing of Zock, who will host the July 17 edition.

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.

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.