When looking for cutting edge activities in workers comp abuse, it’s a good idea to start in California, where key stakeholders occasionally function like pirates in the Gulf of Aden. We have frequently focused on the burgeoning costs of opioids in the workers comp system. As we learned at the Workers Comp Research Institute conference last November, too many doctors who prescribe opioids have no idea what they are doing, no idea how to manage opioid-based treatment and no clue about the potential for harm.
In the entrepreneurial free-for-all that is California, we see the latest trend in opioid abuse: turning the “best practice” of drug testing into an opportunity to milk the system. (The details are available in Greg Jones’s article at WorkComp Central – subscription required.)
Here’s how it works: doctors who tend to over-prescribe opioids are jumping on the drug testing bandwagon: either through their own testing, or through contracted services, they are able to parlay a simple $200 drug test into a bill for $1,700 or even $3,000. The labs are playing with billing codes, performing the less expensive qualitative tests but charging for the more expensive quantitative tests. It’s a clever scam: first over-prescribe, then drug test and over-bill.
The WorkCompCentral article quotes Howard Appel, president of Millennium Laboratories of San Diego: “I’m offended when workers’ comp is paying $3,000 for a drug test that cost $200.” Appel’s company operates under a “responsibility pledge” where explicit ethical standards are used for drug testing and billing.
Genuine Best Practices
We remind Insider readers of the best practices that should accompany virtually any prescription for opioids:
1. Above all, use opioids sparingly; most prescriptions for opioids in the comp system are unnecessary, ill-advised and poorly managed.
2. Virtually all injured workers prescribed opioids should be evaluated for dependency issues prior to beginning an opioid regimen, drug tested prior to receiving opioids and throughout the course of treatment. Without these pre-conditions, opioid use is full of uncertainty and fraught with danger.
3. Ideally, opioids should come with a written contract and a User’s Manual. Workers should be tested on their knowledge of the benefits and the risks.
Note that drug testing is a necessary component of the treatment protocol. The problem in California – and probably elsewhere – is that drug testing is of little value where opioids have been mis-prescribed in the first place. Under best practices, opioids are a last resort, rarely used and carefully managed. Under California scheming, they are over-prescribed, over-monitored and over-billed. All of which goes to show that you don’t need a fishing boat and a few automatic rifles to become a pirate. A nice white coat and a plastic cup can work just as well.
Posts Tagged ‘opioids’
Cost Containment Piracy
Monday, April 23rd, 2012Health Wonk Review and assorted news of note
Thursday, April 12th, 2012Brad Wright of Wright on Health tees up all the health wonkery this week as he hosts Health Wonk Review: A Masterful Edition.
Texas – Texas does things differently and their work comp program is true to course. Employers are not mandated to have workers comp insurance – they can opt out. According to a 2010 survey, 15% of businesses with 500+ employees choose to opt out. And now Walmart is opting out of work comp in Texas. See more on this at PropertyCasualyt360, including a graph of market share for the top 10 insurers comparing 2010 to 2011: Concerns Arise over Texas Workers’ Comp. State System After Walmart Drops Out
Mississippi reform – Mississippi is working on workers comp reform and we note that one provision about “medical proof” establishes a pretty high bar to hurdle for some injuries; for example, a back injury: “It also would require a worker to provide the employer with medical proof that an injury or illness is a direct result of the job if the worker’s claim is contested.”
Dirty Business – Is workers’ comp dirty? Some people seem to think so and Dave DePaolo considers whether there’s more to the frequent use of the term than coincidence. See Work Comp and Dirt – Do They Have to be Synonymous?
Florida drug wars – Tampa Bay Times says that drugstores are the new focus of painkiller investigations. From the article: “The U.S. Drug Enforcement Administration says that in 2009 no Walgreens retail pharmacies were listed among the DEA’s top 100 Florida purchasers of oxycodone — a key ingredient in OxyContin, Percocet and Percodan. / By 2011, 38 Walgreens made the list. By February, the total reached 53 of the top 100. So says a warrant filed last week in U.S. District Court for the Middle District of Florida. / In Fort Myers, the DEA says one Walgreens pharmacy sold more than 2.1 million oxycodone pills in 2011. That’s more than 22 times the oxycodone sales at the same pharmacy two years earlier.”
Healthcare’s 1% – Who are the chronically costly? The costliest 1% of patients consume one-fifth of all health care spending in the U.S., according to federal data. Doug Trapp of amednews digs into the data to profile the most costly patients and where so much of the medical spend goes.
From the courts – Fred Hosier of SafetyNewsAlert has an interesting post about whether workers comp will be on the hook for prescribed drug’s side effects. He cites a case related to a West Palm Beach police officer who has filed for additional workers’ comp benefits for the treatment of his gynecomastia, an excess growth of breast tissue, a side effect of medication he was prescribed to treat a work-related injury. Initially denied, an appeals court has reopened his claim for review by an expert medical advisor.
Occupational Medicine – It’s been a bit since we visited the American College of Occupational and Environmental Medicine (ACOEM) site. ACOEM offers up a few new guides, and a revision of an older guide – Fatigue Risk Management in the Workplace (PDF), Guidance to Prevent Occupational Noise-Induced Hearing Loss and Guidance for the Chronic Use of Opioids.
Affordable Care Act – At Health Care Policy and Marketplace Review, Bob Laszewski looks at what individual health insurance might cost if the court strikes the mandate down and still requires insurers to cover everyone. Hint: a lot.
Briefly….
- US Labor Department’s OSHA announces new National Emphasis Program for Nursing and Residential Care Facilities
- Light-duty work 387 miles from home not ‘suitable’
- Big Mistake for Employers to Demand Employees’ Facebook Passwords
- There’s no such thing as lawsuit avoidance in 2012
- Mike Wallace’s battle with depression leading to a suicide attempt
- Seven Key Slicer Errors to Avoid
- Oil and gas operations safety
Risk roundup, pill wars, odd lot, obesity & more
Thursday, March 8th, 2012Risk Roundup – Emily Holbrook hosts Cavalcade of Risk #152 at Risk Management Monitor
Florida’s pill war – Timothy Martin and Arian-Campo Flores of the Wall St Journal take in the Florida landscape after the pill mill crackdown in New Front Opens in the Florida Pill War. They note that, “One former hot spot in Broward’s Oakland Park now has just two pain clinics, compared with 26 a few years ago, said Lt. Pisanti. “It changed almost overnight,” he said.”
However, the addicts haven’t gone away. The authors note that, ” … drug users and dealers adapt to the changing landscape and pill demand shifts to retail pharmacies and other establishments that appear to have been set up to skirt the new restrictions.” The article talks about the pressure pharmacists are facing and an increase in forged prescriptions.
Pill pushing docs, take note – My colleague recently posted about the prosecution of Ohio’s Dr. Paul Volkman, the single most prolific prescriber of Oxycodone and related opioids in the entire country. (Four life sentences) Individual states and the feds are starting to get tough about cracking down on this stuff. Joe Paduda talks about the prosecution of drug-dealing docs in CA, FL, CO and other states. Also see Roberto Ceniceros’ blog post on the race to stop opioid abuse.
“Odd Lot” Doctrine – Dave DePaolo talks about the psychology of disability and the inter-relatedness of disability and mental health as illustrated by a case of a injured Wyoming worker. After his claim wended its way through the courts, the worker was granted permanent total disability benefits under the “odd lot” doctrine.
Is obesity getting a bum rap? – Maggie Mahar challenges assumptions about obesity in her post Obesity: Fact vs. Fiction at Reforming Health blog. As with everything Maggie writes, it’s worth a read!
ADA and Veterans – The Equal Employment Opportunity Commission recently released a new Guide for Employers on Veterans and the Americans with Disabilities Act (ADA). EEOC says that, “The revised guides … make it easier for veterans with a wide range of impairments – including those that are often not well understood — such as traumatic brain injuries (TBI) and post-traumatic stress disorder (PTSD), to get needed reasonable accommodations that will enable them to work successfully.” Related:
Guide for Wounded Veterans, which answers questions disabled vets may have about the protections and rights when returning to their former job or looking for civilian jobs.
Market Pulse – Clair Wilkinson of Terms + Conditions posts about more evidence of a slowly turning market citing new reports and studies.
Quick takes
- Cameras at company sponsored events
- Cash-Based Performance Bonuses May Be Hazardous To Your Company’s Health
- Hair, Formaldehyde, and Industrial Hygiene
- The ergonomics of dual computer monitors
- Supervisors and Employees Identify Major Obstacles to Workplace Safety
- Wellness Focus for March: National Workplace Blindness Prevention
- Retaliation: Most Common Charge And Still the Stupidest
Dr. Paul Volkman: The People’s Pusher
Tuesday, February 21st, 2012Dr. Paul Volkman specialized in mitigation of pain. Did he ever. From 2003 to 2005 he was the most prolific prescriber of Oxycodone and related opioids in the entire country. He was recently sentenced to four life terms in prison for the deaths of four patients. There were eight additional overdose deaths associated with his practice, but these lacked enough evidence to prosecute. Patients came from hundreds of miles away and were charged $125 to $200 in cash for visits to see a doctor. Volkman’s distribution system had a devastating effect on southern Ohio, where he based his practice.
Prosecutors said Volkman rarely, if ever, counseled patients on alternate treatments for pain, such as physical therapy, surgery or addiction counseling. Volkman denied the allegations and said he always acted in good faith. A month before his conviction, he dismissed his attorneys and defended himself. His skills as an attorney appear to be totally in sync with his skills as a physician.
Street Creds and Credentials
Volkman went to work at the Tri-State Health Care and Pain Management clinic in southern Ohio in 2003. The clinic was operated by Denise Huffman and her daughter Alice Huffman Ball, who have pled guilty to one count of operating Tri-State as a business whose primary goal was the illegal distribution of prescription drugs. Denise has been sentenced to 12 plus years in prison; her daughter is serving five years. Both testified against Volkman, as did a horde of witnesses including pharmacists, police investigators, clinic employees and patients who received pills from Volkman.
What is striking about this case is the harsh sentencing. Four life terms is the kind of sentence you rarely see applied to white collar criminals; Volkman was sentenced as if he were a run-of-the-mill (pun intended) drug kingpin, which, minor differences aside, he was.
Through the wonders of the internet, we learn that Volkman had a three star rating from his patients and earned his medical degree at the University of Chicago Pritzger School of Medicine in 1974, followed by a residency at Duke Medical Center. After that, well, something went terribly wrong. Nonetheless, with his impressive creds, he’s sure to be a very popular man for the rest of his highly circumscribed life.
Opioid Abuse in Florida: Who Controls Controlled Substances?
Monday, December 5th, 2011Florida is famous for at least three things: citrus fruit, sunshine and pain pills. The citrus and sunshine are pretty much permanent, but it appears that the easy dispensing of opioids may be coming to an end. HB 7095, the state’s new law regulating opioid distribution, bans doctor dispensing of drugs and subjects pharmacies to inspection of prescription records. The state is determined to put an end to its reputation as the pill mall of America.
Now CVS, the giant pharmacy concern with over 700 stores in Florida, has stepped into the breach. They have notified a small number of doctors that they will no longer honor their prescriptions for opioids. CVS has analyzed prescription data and determined that these doctors are over-prescribing. As with so many issues involving insurance coverage, the data goes into a black box and a determination comes out the far end. What happens in the box remains a mystery. Our esteemed colleague, Joe Paduda, has strongly endorsed the CVS effort at his Managed Care Matters blog.
Feeling the Pain
It should come as no surprise that a key stakeholder in the use of opioids, the Florida Academy of Pain Medicine, is crying foul. The academy points out that the criteria for blackballing doctors is unknown and that doctors – and only doctors – should be allowed to determine who needs pain killers and for how long. As Jeffrey Zipper, chair of the Academy’s Medical Affairs committee puts it, “I don’t want to be subject to the scrutiny of CVS.”
Given the immense dimensions of the prescription drug problem in Florida, it’s clear that some doctors have long been abusing their power to prescribe medications. They need scrutiny and they need to be sanctioned. While CVS and other pharmacies are a key part of the distribution network, their leverage in this area is somewhat limited. To begin with, other pharmacies may choose to pick up the rejected business: we’re talking big bucks. In addition, CVS at some point will have to disclose the criteria used for rejecting the prescriptions written by certain doctors. Once this happens, doctors may attempt to manipulate their prescription practices to avoid detection and sanction.
In attempting to get its arms around this formidable problem, the State of Florida has reframed the question about who controls controlled substances. While it’s apparent that doctors no longer have sole discretion in the area, it remains to be seen how effective and how equitable the control exerted by pharmacies can be. The Insider will monitor with great interest this important experiment in substance abuse control.
Health Wonk Review & other news notes
Thursday, September 29th, 2011Best of the healthcare blogosphere – Looking for your biweekly fix of health wonkery? Check out Health Wonk Review: Muppets Edition! – posted by Joe Colucci at The New Health Dialogue blog.
Health Care Costs – The Kaiser Family Foundation’s 2011 Employer Health Benefits Survey revealed that average annual premiums for family health benefits are up 9%, topping $15,000. According to the report, “Premiums increased significantly faster than workers’ wages (2.1 percent) and general inflation (3.2 percent). Since 2001, family premiums have increased 113 percent, compared with 34 percent for workers’ wages and 27 percent for inflation.” It’s pretty jolting, and even more so when you check the graphic depiction of rising costs. You can find additional report documents here.
Drug deaths – Los Angeles Times reports that drug deaths now outnumber traffic fatalities in U.S.. Apparently, we’ve been so busy fighting “the drug war” that we’ve overlooked the creeping and insidious threat of the prescription pain and anxiety drug problem. Deaths related to these drugs now outpace deaths from heroin and cocaine combined.
Mark Walls pointed this article out and he has a discussion going on the LinkedIn Work Comp Analysis Group. He also links to several related resources – here’s a sampling: ACOEM – Comments to State WC Officials on Prescription Opioid Abuse in the U.S.; Joe Paduda – Understanding Opioid Abuse; and Mark Walls – It Starts with the Regulators
Safety tools – The Federal Highway Administration has a portal for Work Zone Safety. It includes some good highway safety tools and resources for you safety program.
Time Capsule – What was work life like in 1943? Check out The Ropes at Disney’s, an employee handbook from 1943. Pop quiz: How many current labor law violations can you spot?
And in another look back at days of yore, Oregon’s Willamette River Bridge Project posts an historic construction photo of the Willamette Bridge, inviting readers to spot the safety hazards. The answers are already posted, so if you want to play along, don’t peek at the comments.
Florida is getting tough on the pill mills
Thursday, September 8th, 2011Florida doctors bought 89% of all the Oxycodone sold to practitioners nationwide last year and thousands of outside visitors flocked to the state to buy drugs at the 1,000+ pain clinics. But armed with new legislation, the state is cracking down hard by shutting down pill mills and suspending the licenses of about 80 physicians who were high-volume prescribers. And physicians are now generally barred from dispensing narcotics from their offices. In October, things will get even tougher as a new prescription drug monitoring system will be implemented.
Lizette Alvarez reports on on the Florida pill mill crackdown in The New York Times, stating that “As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.” This article has some eye-opening observations about the scope of the prescription drug problem: “Last year, seven people died in Florida each day from prescription drug overdoses, a nearly 8 percent increase from 2009. This is far more than the number who died from illegal drugs, and the figure is not expected to drop much this year.”
You can read more about how authorities are going after medical licenses of over-prescribers in a Miami Herald article by Audra Burch. This article discusses some egregious abuses, including a physician who dispenses from the back of a car and an office with long lines waiting outside and many cars with out-of-state license plates in the parking lot.
Related Resources
The issue of physician dispensing is one that our colleague Joe Paduda has covered extensively. See:
Physician dispensing – Exactly how much more does it cost?
Why Florida’s work comp costs are heading up
Florida’s dispensing legislation clarified
The issue of transparency related to a physician’s relationship with pharmaceutical companies is one that ProPublica has been taking on in their Dollars for Doctors campaign. See:
Patients Deserve to Know What Drug Companies Pay Their Doctor
Piercing the Veil, More Drug Companies Reveal Payments to Doctors
For more about Prescription Monitoring Programs, see:
Alliance of States with Prescription Monitoring Programs – The Alliance was formed in 1990 to provide a forum for the exchange of information and ideas among state and federal agencies on prescription monitoring programs. Since then, it has grown to be a valuable resource to all those concerned with combating the increase in prescription drug abuse, misuse and diversion. Currently, 48 states and one territory either have operating Prescription Monitoring Programs, or have passed legislation to implement them.
Health Wonk Review, Valentine’s week edition, and other news of note
Thursday, February 17th, 2011When is healthcare like a box of chocolates? Find out over at Colorado Long Term Care Insider, where Louise & Jay Norris host an excellent Valentine’s Week Edition of Health Wonk Review.
Other news of note:
Tasers & cop claims – Roberto Ceniceros of Comp Time has an interesting post on how taser use by police is reducing injury rates and comp claims because it provides a low-impact way to subdue suspects. But tasers are also used on cops-in-training, sometimes resulting in serious injuries.
The straight dope – Joe Paduda has a do-not-miss post on narcotic opioids in workers comp and Cephalon’s role, in which he discusses how drugs like Fentora & Actiq, which are FDA approved only for cancer patients, are being promoted to workers comp patients. (One court ruling stated, “data suggested that more than 80% of patients using Actiq did not have cancer,” and “oncologists accounted for only 1% of Actiq prescriptions filled at retail pharmacies in the U.S.”) Cost is a huge issue, but Joe points out that it is not all about the money: Actiq has been linked to dozens of deaths from overdose.
Medical marijuana – Last week, Michigan court rulings dealt a double blow to medical marijuana. One of the Michigan rulings upheld the firing of a Walmart employee who had been proscribed the drug to control symptoms of his brain cancer, a case we posted about last year: Walmart: Shopping for Souls in Aisle Three. (Also see our recent post: Medical Marijuana in the Workplace: Dude, Lock Me Out!.)
Insurer market share – Cyril Tuohy of Risk & Insurance offers a short journey through the latest insurance industry statistics, including some great stats about market share: This Just in: Known and Lesser Known Facts About the Industry
Not something you see every day – CompNewsNetwork informs us that the Ohio Bureau of Workers’ Compensation has recently snagged a record $830,000 in restitution from a prior fraud conviction. The case was truly egregious – an anesthesiologist who bilked the system for $60 million in fraudulent claims – while contributing to at least two deaths in the process. Dr. Jorge Martinez was sentenced to life in prison for “the first known conviction involving a criminal charge of health care fraud resulting in death after the overdose of two patients seeking treatment for work related injuries.”
Illegal immigrant update – Peter Rousmaniere’s Working Immigrants blog is your in-the-know source for tracking the latest issues and stats on the topic. Via the Pew Hispanic Center, he informs us that the 2010 illegal population in 2010 remains about the same as in 2009: about 11.2 million, of which 8 million are in the workforce, and 58% of which are Mexicans. See more detail: Estimate of illegal immigrant population in 2010.
Good WC bookmark – We are adding WorkCompWire as a bookmark in our sidebar and you should keep it handy too. It’s a good source of news and opinion – check it out!
Savings on complex care – Yvonne Guilbert points out that overlooking simple facts can add significant costs to a claim very quickly. She asks carriers what they are missing on complex claims that might be costing them money.
Market pulse – At PropertyCasualty360, Caroline McDonald talks about why buyers shouldn’t get too comfortable with low workers comp rates. One of the primary sources for the article is our friend Mark Walls of Safety National – who is also well know as the founder of LinkedIn’s Work Comp Analysis Group.
Diversity – Jared wade posts that 18 insurance firms are among the best companies for LGBT employees to work for – “scoring a perfect 100% as a Best Place to Work for their ‘support equality for lesbian, gay, bisexual and transgender employees,’ according to HRC.”
Distracted driving in NY – A sign of things to come? In New York, drivers will get two points for talking on hand-held cell phones. A two-point penalty has already been in place for texting while driving. At that rate, auto insurance sure could get expensive quickly for compulsive phone-o-philes.
Mental health – CCOHS, the Canadian counterpart of OSHA, makes the case for why employers should care about mental health at work.
Chronic pain management in workers’ comp
Friday, February 26th, 2010Recently, I attended the 2010 Health and Productivity Forum jointly sponsored by the Integrated Benefits Institute (IBI) and the National Business Coalition on Health (NBCH) in San Antonio. I had been invited to participate in a panel discussion by Gary Anderberg, of Broadspire, who, as I have written previously, is one of the smartest people I’m fortunate to know.
With me on the panel were Dan Shaughnessy, Director of Disability Programs, Textron, Inc., and Mike Machanich, Chief Executive Officer, Workers’ Comp Solutions. Gary’s charge to us was to discuss the effect of national health care reform on workers’ compensation. Thanks a bunch, Gary. But we had a stimulating discussion as we opened that colossal can of worms. I’ll write more about this in another post. One of the issues our panel tossed around was chronic pain. We’ve written about chronic pain many times over the last few years. Here are links to a couple of the relevant posts:Workers Comp Drugs: Paying too much…For the Wrong Medicines!; The Pain Conundrum.
Our concern is that the treatment of chronic pain often involves what is to us a highly problematic overutilization of narcotics. So, I was a bit surprised to learn of Broadspire’s well thought out and relatively holistic approach to treating this debilitating and often times life-changing medical condition. With that in mind, I invited Broadspire’s medical team to submit a guest blog post for the Insider. Our one requirement was that it be informative to our readers, but not a self-serving advertisement for Broadspire. The company accepted our invitation, and what follows is Broadspire’s approach to the treatment of chronic pain. I’d be remiss if I didn’t add that Broadspire is not a client of Lynch Ryan’s and our publication of this guest blog post does not constitute an endorsement of the company’s products or services.
Chronic Pain Management Matters
Candy Raphan RN, BSN, ARNP, MAOM and Dr Jacob Lazarovic, MD, FAAFP, Broadspire
In 2006, The Center for Disease Control and Prevention (CDC) released its 30th annual report on the health status of America, “Health, United States, 2006” which found that the overall health of the nation seemed to be improving or holding steady, but highlighted one particular condition as needing further attention: pain.
Pain is a common and troubling condition around the world. In a 2005 European study, it was estimated that 20% of the world’s population deals with some form of chronic pain. In Europe, chronic pain accounts for over 30 billion euros in lost productivity. In 2002, an American study found common pain conditions caused 13% of workers to experience a loss of productivity over a two-week period. The estimated cost to corporate America was $61.2 billion dollars that year. In fact, pain has been such a prominent health care issue that the 106th U.S. Congress passed Title VI, Sec. 1603, of H.R. 3244, declaring the period between January 1, 2001 and December 31, 2010 the “Decade of Pain Control and Research.”
Solutions
Conventional treatment of chronic pain is time-consuming and often very expensive, particularly for those claims that continue without resolution over the course of several years. For this reason, it is important that employers and payers understand the dynamics and drivers of the costs associated with chronic pain. By employing a focused, multi-disciplinary clinical approach very costly segments can be targeted. It is then possible to effectively manage chronic pain from the overall costs associated with medical care and treatment as well as loss of a productive workforce.
Using evidence-based medicine to create a plan of action for those individuals with inadequately managed chronic pain promotes optimum results. Medical management programs can provide information and resources to the claimant’s current treating doctors, clinics and hospitals. These types of consultations with providers help achieve the following objectives:
- Safe, rational and effective management of the chronic pain population
- Maximized functionality and return to work
- Management of medical costs
- Focused and designated processes/people to reduce internal duplication of effort
- Documented and measurable results and ROI metrics
How It Works
Broadspire’s Chronic Pain Program, for example, uses a defined and rigorous process. After an initial eligibility assessment, a team of specialty physicians and nurses reviews the medical and psychosocial aspects of each case. The team establishes a list set of customized strategies in the form of recommendations to ultimately achieve the goals and objectives for each case. The team then monitors the impact of interventions during subsequent meetings and follows the case through to timely resolution.
The key to the program is the expertise clinical and claim professionals bring to each claim. A highly experienced staff performs the data analysis, oversight and management of the process. An expert panel of specialized pain physicians (anesthesiologists, physiatrists, orthopedists, and psychologists or psychiatrists) provides guidance. Other contracted resources such as selected, accredited pain management facilities and urine drug monitoring labs help ensure that patients are compliant with prescribed regimens.
A Chronic Pain Program has the power to make a sizable difference. With proven methods, resources, and expertise it can provide the support and control to help employees beat pain back and return to productivity.