Quick takeaways from CWCI’s annual meeting

One of the best conferences of the year is CWCI’s annual get together in Oakland California.

More information is packed into a morning than you’ll find in most multi-day events – and in a more entertaining format – and no one is more informative and entertaining than CWCI’s Alex Swedlow (I’m fortunate indeed to count Alex as a good friend and colleague).

First question – As Alex noted, way back in the pre-Triangle Shirtwaist fire days (no, I wasn’t around then), business claimed 95% of injuries were considered to be the fault of the workers – what is the actual number?

And why do many claims organizations/processes seem to operate as if that statistic is true today?

Okay, back to key takaeaways…

  • Average drug spend dropped 34% from 2012 to 2015 – Rx and DME combined amount to 8 percent of total spend of med payments at 24 months after inception
  • Opioid spend dropped dramatically, while NSAIDs went up.
  • Compared to all claims reported, Cumulative Trauma injuries have increased – a lot – since 2009. CWCI thoroughly debunked the contention by others that CT cases have decreased.
  • IMR decisions continue to uphold UR determinations more than nine times out of ten, a rate that’s held steady since 2014.
  • UR decisions on compounds are upheld in 99.2 percent of all cases.
  • Work comp administrative expenses are higher in California than any other state – by a lot. Part of the answer is the outright abuse of the IMR process by a handful of scummy providers in SoCal…and a couple up north too.

Gary Franklin MD gave a compelling, passionate, and pointed argument that opioid manufacturers are at fault for the disaster that’s killed more than 200,000 of us. Gary never hesitates, never waivers, and is the individual who has done more than anyone else to confront the opioid issue.

More to come next week.


Opioids – bad news and good

Patients taking opioids over the long term don’t go back to work, yet many long-term opioid patients can be weaned off opioids within two years.

Those are the quick takeaways from two studies that came out last week.

First, a study from WCRI validates earlier research, finding:

  • patients with multiple opioid scripts are out of work three times longer than patients with no opioid scripts, and
  • patients who lived in places where providers prescribe a lot of long term opioids…are more likely to get opioids for longer periods than individuals who lived elsewhere.

This is the first study that looked at ALL lost-time claims with a diagnosis of low back pain in a very large area – 28 states that represent 80% of claims – over a five-year period. This is important because it shows  cause-and-effect independent of so-called “severity” measures, which often use cost, treatment, or prescriptions to indicate medical severity, instead of actual clinical indicators. By looking at ALL low back claims with lost time, claims, it is clear that the driver of disability is long-term prescribing of opioids.

The takeaway is this – chronic use of opioids extends disability, and you can figure out where you need to focus your efforts by looking at publicly-available prescribing data.

California is one state with way too much experience in dealing with opioids in work comp; the graph below shows both the overuse, and the progress made in the Golden State since it got serious about reducing opioid usage.

source – WCIRB

Which brings us to the good news: weaning works, as research from California’s Workers’ Compensation Insurance Rating Bureau shows: 

47% of the injured workers demonstrating chronic opioid usage weaned off of opioids completely within the 24-month Study period. Injured workers who did not wean off completely over the Study period still reduced opioid dosage by an average of 52%.

The research included all patients with more than 50 morphine equivalents over at least 3 months within 24 months of the date of injury.

Yes, it is difficult, expensive, requires a lot of assistance from trained professionals, and does not always work. All that said, given the finding that patients taking opioids for longer periods are out of work a lot longer, it is well worth the time and effort to help these patients reduce or end their use of opioids.

Why isn’t anyone talking about health insurance costs?

A couple years ago, we heard endless stories about how “Obamacare” premiums were shooting up, individual health insurance was unaffordable, and families were going bare because the morons that came up with the ACA screwed it up.

Now, with average premiums up 30 percent, we hear…crickets.

The reason premiums have gone up by about a third is simple; President Trump stopped the payments that subsidized low-income folks and insurers are scared he’ll stop enforcing the individual mandate. Unsurprisingly, many people dropped coverage, and insurers had to raise premiums because their risk pools worsened.  

Chart credit Charles Gaba, ACASignups.net

If CSR payments were still in place, and insurers assured the mandate would be enforced, premium increases would be less than half they are today.

What’s scary about this is how easily the media’s focus is influenced by outside efforts. Instead of informing us of this very real, and very important issue, the media is all wrapped up in arming teachers, death penalties for drug dealers, and Stormy Daniels.

What does this mean for you?

A reminder that all of us have to stay focused on the important stuff, not the shiny objects.



Stuff that affects work comp

Here are a few of the events/transactions/deals that may affect the workers’ comp industry, along with my take on that impact.

First – Trump’s steel and aluminum tariffs

Leaving aside the fact that China – Trump’s primary target – supplies just one-twentieth of all foreign imported metals, there are way more American jobs in other industries  that would be lost if the European Union and/or other trading partners impose retaliatory tariffs.  

Agriculture, autos, bourbon, bluejeans, and bikes are on the list of possible targets. Total exports amount to $1.4 trillion

Our cultural exports – fashion, film, music, sports – may fall out of favor as Asians and Europeans angered with Trump stop buying American.

My take – the Trump Tariff is going to cost jobs, unless it is quickly hollowed out by exemptions.

(an excellent discussion is here)

The Trump tax plan

First, if wages and hiring increase, as promised by the President, premiums will rise.

So far, that isn’t happening. The vast majority of the windfall is being spent on stock buybacks.  While this is inflating stock prices it isn’t going to have any material effect on the

With the added focus on deporting undocumented workers, industries that demand low-skilled workers for high-stress jobs such as meatpacking are often struggling to find enough workers. Jobs are usually filled with first-generation immigrants – as those jobs always have been.

Third, Employment changes.

The automation of both low-skilled and white-collar jobs is accelerating…over time many low-skill jobs are going to disappear – including burger-flipping, while white collar work including healthcare administrative jobs is being automated as well.

credit Daily Mail

The unemployment rate has improved  from 4.7% to 4.1% over the last year, while labor-force participation has remained flat (working-age people who’ve not looked for work).

Wages are up about 2.5% over the last 15 months, slightly more than inflation.

My take – hiring is strong, and wage growth may accelerate somewhat. This would generate more premium dollars over the near term. As Flippy and it’s relatives take over from Mary and Mike, we may well see average wages increase as there are fewer low-paid jobs available.

And Last-but-not-Least, changes in healthcare, specifically how and where healthcare is delivered.

Compare the revolution in retail – moving buying and delivery from stores to the home. That hasn’t happened at all in healthcare – but it will.

Enjoy the weekend.

Your baby isn’t that pretty. Really.

OK, got my cranky pants on today, so here goes.  I get about a dozen press releases a day, most of which breathlessly tell me about something I NEED to know about – like right now!

This is your baby in a PR release.

And of course, I NEED to tell you, dear reader, all about the new product/executive hire/office location/logo/study that is so damn important it makes North Korea’s nuclear threat totally inconsequential.

Like these…

  • Formaspace just unveiled a new virtual furniture designing tool that is going to shake up the world of office furniture procurement
  • I’m writing to suggest a story idea for Managed Care Matters on the top three “fake it till you make it” hacks for entrepreneurial millennials.

  • Below is VisualVault’s latest press release sharing the exciting news of their new Director of Healthcare Solutions, Kathy Biggers.

And those are just from today. Many are so far out of my (and probably your) area of interest it’s hard to imagine how they found MCM. I wish I knew, then perhaps I could hide from them.

I get it – the executive at company X thinks their news is really, really important. Ground-breaking. Game-changing. A Black Swan, Unicorn, or some other super-cool mythical beast. What they don’t get is the more they send, the less anyone pays attention.

A few suggestions…

  • Press releases should be about important stuff. Think of it this way; if you got your announcement from some random organization, would you care? Really?
  • STOP with the hyperbole and adjectives. The more hysterical you are, the less anyone cares.
  • Target your stuff precisely. DO YOU CARE ABOUT OFFICE FURNITURE?
  • Be brief, to the point, use short sentences and bullet points.
  • Personalize the release – use the addressee’s name and tell her/him why s/he should care.





Big changes in work comp pharmacy spend

Sometimes data is so compelling you have to get it out there immediately.

CompPharma’s annual survey of prescription drug management is underway; here are quick takes from the first ten surveys.

  • 2017 drug spend dropped 13.4 percent from 2016 – the biggest decrease in the 15 years we’ve been doing the survey
  • Opioid spend decreased twice as much – over 26 percent.

Note that the huge drop in opioid spend occurred BEFORE adoption of formularies and other controls in big states like Pennsylvania, New York and California.

Note also that this is the sixth drop in drug spend since 2010.

Graph from last year’s Survey, Public version available for download here.

There are a few other newsworthy findings;

  • compound spend is down dramatically in most areas – but has spiked in a couple of states.
  • the decrease in spend is attributed primarily to lower opioid utilization
  • despite the big drops in spend, respondents (typically the executive at a work comp payer with overall responsibility for medical management) see pharmacy as MORE important than other medical service types…because pharmacy drives disability and return to work

This is very preliminary; we expect another 15 or so respondents and I’d expect things to change with more data. (if you want to participate and receive a detailed copy of the 2018 Survey Report, email Helen Patterson at HKnightATcomppharmaDOTcom)

What does this mean for you?

The work comp industry’s decade-long focus on pharmacy is delivering far better care and lower costs.

What you don’t know WILL hurt you

Insular, self-absorbed, and unaware are three traits far too common in the workers’ comp world.credit Rational Faiths

When combined with lousy marketing and poor brand identity, the outcome is akin to life in the Dark Ages – nasty, brutish, and short.

Here’s a few things I’ve learned after decades in the healthcare and workers’ comp worlds.

  • Brand Is Everything.
  • Few executives in the work comp world understand this, some healthcare people do.
  • Marketing is NOT proposal writing, powerpoint production, or event planning…yet most “marketing departments” spend most of their time and too-small budgets doing just that.
  • There’s waaaaay too much “presenting” in sales – and waaaaay too little listening.
  • No one cares about your company, your products, your results, your story. Until they believe you understand their problem and have a potential solution.
  • There are several companies that charge high prices and deliver crappy results – yet they consistently win business because their brand images are strong.
  • Companies don’t buy anything. People do.  Just because your “solution” seems to meet a “business need” does NOT mean the person who has to say Yes will say yes.

So, a few suggestions.

  1. Figure out what your brand is.
  2. Invest in it.
  3. Do marketing – real marketing.
  4. Be brutally objective. Don’t blow smoke up your boss’s shirt – or your’s.

You’re going to have a spend a lot more dollars on marketing than you ever have, get your “marketing” people involved much earlier in strategic, product development, and sales, listen to what they say and likely change a lot of what you do.

This is going to make a lot of people really uncomfortable – and that’s good. Business people who are comfortable get complacent, and complacent people lose.

What does this mean for you?

It’s really hard, and most won’t be willing or able to do this.

But the ones that do will win.

What the %$#(*& is going on with opioid policy?

I’m somewhat encouraged, but mostly confused.

Briefly, this is the problem with national opioid policy.

There’s a major disconnect in DC on what to do about opioids – criminalize addicts, incarcerate them, kill drug dealersor expand treatment, go after opioid manufacturers and distributors, increase funding for solutions, change Medicaid policy to allow more treatment options.

While these aren’t mutually exclusive, the messaging coming from the White House is wildly inconsistent.

[HHS Secretary] Azar’s emphasis on medication-assisted treatment for opioid abuse also stands in stark contrast to Trump, his boss, who typically focuses heavily on law enforcement whenever he’s addressing the epidemic. That’s the approach Trump took yesterday, telling summit attendees that cracking down on drug dealers is a key to solving the problem — and even suggesting that imposing the death penalty on them would be helpful.

“Some countries have a very, very tough penalty — the ultimate penalty,” the president said. “And, by the way, they have much less of a drug problem than we do. So, we’re going to have to be very strong on penalties.”

While there’s lots of press out about the recent White House confab on opioids, what’s really happened behind the scenes is a lot less exciting. It sure looks like the policy experts are being sidelined from the real work, which is being handled by, you guessed it, political types…

from Politico

[Senior White House Advisor Kelly Anne] Conway’s role [as chair of the WH “opioid cabinet] has also caused confusion on the Hill. For instance, the Senate HELP Committee’s staff has been in touch with both Conway and the White House domestic policy officials, according to chairman Lamar Alexander’s office. But lawmakers who have been leaders on opioid policy and who are accustomed to working with the drug czar office, haven’t seen outreach from Conway or her cabinet.

“I haven’t talked to Kellyanne at all and I’m from the worst state for this,” said Sen. Shelley Moore Capito, a Republican from West Virginia, which has the country’s highest overdose death rate. “I’m uncertain of her role.” The office of Sen. Rob Portman (R-Ohio), another leader on opioid policy, echoed…

Of course, there’s still no Director for the Office of National Drug Control Policy, but at least it isn’t being run by a 24 year old.

I’ve talked to professionals deeply involved in national drug control initiatives and policy; some are convinced Trump et al are serious about the opioid disaster and are focused on it; others say it’s all a sham, the Administration is either unable or uncaring about this, and just bounces from policy statement to policy statement without getting anything done.

My takeaway is this.

Good people in the Administration know the opioid disaster is a disaster, and want to help address it. But they can’t.

The complete and total managerial incompetence, institutional attention deficit disorder syndrome, and lack of understanding of how to govern on the part of the White House’s current occupant and his staff hamstrings any and all efforts to develop and implement solutions.

What does this mean for you?

Big problems require thoughtful and diligent approaches.

Who says gubmint can’t do anything right?

Not me.

One state fund has reduced the number of patients dependent on opioids by 60 percent over five years.

That’s 4,714 moms, dads, brothers, sisters, grandparents, sons, and daughters who can get back to living a real life, one free of opioid dependency.

BWC Ohio’s remarkable reduction in opioid usage was the result of a thoughtfully planned and well-executed approach to addressing the opioid scourge that has ravaged the state.

WIth leadership from the state’s Republican governor and a lot of work by the good folks at BWC, thousands of work comp patients have stopped taking opioids or greatly reduced their dosages. And BWC didn’t do this by cutting these patients off; the insurer paid for treatment, weaning, a wide array of programs and services to address chronic pain.

BWC’s pharmacy and therapeutics committee developed a comprehensive approach to opioids, one vetted by practicing physicians and embedded in the state’s Administrative Code. The approach requires prescribers follow a carefully crafted process, mandating compliance with the prescribing rules for all workers’ com patients.

Moreover, BWC did NOT start the opioid reduction effort until there were enough treatment facilities, programs, and trained providers to handle a big influx of patients.

I was peripherally involved in the early days of this; the State worked with a number of experts including Gary Franklin, MD, the Medical Director of the Washington State Fund (L&I). Dr Franklin was among the first to sound the warning about opioids, and as the leader of the State’s Agency Medical Directors, he was instrumental in developing and implementing the first comprehensive opioid guidelines. When Ohio started their planning process, Dr Franklin was heavily involved in helping the state develop it’s program.

Washington’s Guidelines were first implemented in 2007 – over a decade ago – and updated three years later. Dr Franklin et al were years ahead of most of us in identifying and developing comprehensive approaches to the opioid prescribing disaster.

Similar to Ohio, the impact on patients in Washington has been a major reduction in opioid prescribing and big drop in opioid-dependent patients. What’s not “reportable” is the thousands of families that haven’t been devastated and hundreds of lives ruined by opioids.

What does this mean for you?

Washington and Ohio have shown what government can do.