Tag Archives: long term

What Physicians Say on Workers’ Comp

At the 2015 Harbor Health MPN Medical Directors Meeting, a panel discussed current issues affecting workers’ compensation. The panel consisted of:

  • Dr. Tedd Blatt (moderator)
  • Dr. Craig Uejo
  • Dr. Don Dinwoodie
  • Dr. Minh Nguyen
  • Dr. Kayvon Yadidi

Question: What are the things physicians can do or should do to improve workers comp?

  • Physicians need to assist in training their peers. There is inadequate training of occupational medicine physicians on the nuances of the workers’ compensation system. This is something other stakeholders in the system could also assist with.
  • Physicians need to be considering psycho-social issues in the treatment of patients. These can have a significant impact on claim outcomes.
  • There is not enough training for physicians on how to properly write medical reports, especially in the workers’ compensation arena.
  • It is imperative that physicians are responsive to questions from the payers. Failure to respond in a timely way to questions causes delays in reimbursement and creates animosity.

Question: How should physicians be approaching the issues of opioids, and are payers willing to consider alternatives?

  • This is something that needs to be considered from the initial visit forward. These drugs can lead to long-term issues, and prescribing them cannot be taken lightly. Too many physicians just prescribe these to make the patient happy.
  • There are inadequate detox programs to wean people off these drugs. Patients tend to bounce from one pain clinic to the next, which just continues the cycle of using these drugs.
  • Payers are often hesitant to authorize detox programs or non-pharmaceutical pain management alternatives because they view these things as experimental.
  • Physicians will soon be required to utilize CURES, the California prescription drug monitoring program, prior to prescribing opioids. This is intended to identify people who are doctor-shopping to abuse the opioids.
  • If you don’t prescribe the opioids, the patient will find someone else who does. Until there is a consistent approach to how these drugs are prescribed, this will continue to be a problem.
  • This is the greatest physician-created public health crisis in the history of the U.S. These drugs are massively overprescribed and should only be used for a very short term for post-operative care. They should never be used for long-term treatment.

Question: What do you think about utilization review? Are there things that you feel should always be subject to utilization review?

  • All surgeries should be subject to mandatory utilization review. Too many physicians are conducting unnecessary surgeries, which cause harm to their patients.
  • Compound medications and medications not usually prescribed in workers’ comp should be subject to utilization review.
  • There needs to be a level of common sense in UR. It should not be used if the recommended treatment is part of the normal course of care for an injury. Payers also are sometimes paying more for the UR review than the actual service requested costs.
  • If you have quantified that a physician is producing better outcomes for injured workers, these physicians should be subject to less utilization review.
  • The UR process needs to be more selective and focus on the outliers, not routine care. The perception from providers is that UR is being grossly overused. Physicians view this as punitive.

Question: More physicians are becoming part of larger health systems. Is this a positive change?

  • This is a positive change because the physicians have a better support structure to assist in writing reports and navigating the nuances of the workers’ compensation system.

Question: Is the Affordable Care Act going to affect workers’ compensation?

  • We will see an increased focus on outcomes, and, if a physician does not deliver superior outcomes, then payers will not refer patients to them for treatment.
  • Many of the policies under the exchanges have high deductibles and, because of this, it is likely we will continue to see pressure to push treatment into the workers’ compensation space.

Question: What changes would you recommend on the claims administrator side?

  • There needs to be more focus on better internal communication within claims organizations. Physicians end up sending reports and responding to requests multiple times because the claims organization does not have good internal communication.
  • The fee structure is affecting the number of physicians willing to treat workers’ compensation patients. Many specialists have stopped treating workers’ compensation patients because they do not feel adequately compensated for the amount of work required.

‘Surviving Workplace Wellness’: an Excerpt

Our series of excerpts from Surviving Workplace Wellness starts with the epilogue, because Aetna managed to incorporate everything that is wrong with workplace wellness, as described in the book, into one press release. It is the book’s epilogue because Aetna’s announcement followed the completion of the text. We actually held up publication of the print version to squeeze this epilogue in.

The caveat for brokers: Be careful what you sell. Your commission checks may come from the seller, but your business value comes from retaining your clients.  As your clients grow more skeptical of wellness vendor claims, you need to be a step ahead, anticipating their skepticism rather than being blindsided by it.

Dr. Aetna Is In

Imagine how you’d feel if you got a letter saying basically:

Dear Fat Person,

We aren’t doctors, and you’re not sick, and you never asked for our help and probably never would, but we’ve got the solution for you anyway: Arena’s Belviq and Vivus’s Qsymia, obesity drugs made by companies we’re partnering with. True, these drugs are expensive, have side effects that you may not tolerate (the nasty outcomes in clinical trials included a 20% incidence rate of paresthesia, a 5% incidence of high blood pressure and a 12% incidence of back pain) and lack a generally accepted treatment protocol, but nonetheless we’d like you to give them a try.


Dr. Aetna

This is basically what Aetna has in mind. They essentially made a list of all the things wrong with wellness programs — unwanted interference in people’s lives, playing doctor, unproven therapies, opaque relationships with “recommended” suppliers, high expense and “diagnosing” people who aren’t sick — and packaged them all into one press release (1/14/14).

This release came out after our e-book, and we considered holding our two cents for Surviving Workplace Wellness: The Sequel. Yet naïve optimists that we are, we decided that by the time any sequel would be published, wellness will have gone the way of the Edsel, pet rocks, Netscape, colon cleanses (we hope) and Sarah Palin (see “colon cleanses”), thus rendering us obsolete along with the rest of the industry. Hence we are squeezing them into an epilogue now.

To summarize, Aetna is pitching specific name-brand drugs — not just any name-brand drugs but name-brand prescription drugs that consumers have rejected (Arena’s Belviq and Vivus’s Qysmia) to the point where one Wall Street analyst described them as ”flailing” — to “selected Aetna members” who aren’t even sick, just obese. So this is a wellness first two different ways. No health plan has ever pitched name-brand drugs to its members before, let alone to members who aren’t sick.

But wait…there’s more.  Because it’s likely that not a lot of obese people would ever call Aetna to ask: “What specific flailing drugs from manufacturers you’ve made side deals with would you recommend for me even though I’m not sick?” Aetna isn’t taking any chances by just sitting by the phone. Instead, it is providing “outreach” to those members (maybe not using that exact letter above but not far from it) — combined with an incentive that is really hard to come by, a totally free app — to convince people to take these drugs.

In your eagerness to get this free app and lots of drugs that don’t work, you’re probably asking: “How do I get to be a ‘selected Aetna member’? I bought a policy from them.” Haha, good one. You didn’t seriously think Aetna would actually spend its own money covering its own insured members for its own program covering its own partners’ drugs endorsed in its own press release, did you? Hello? Have you actually read this book? Obviously, Aetna executives don’t believe this program can save money any more than you and I do, so participation is a privilege they reserve for their self-insured employer customers who want to follow Harvard Professor Katherine Baicker’s advice in Chapter 3 to ”experiment” on their employees, taking the advice a step farther by using flailing drugs.

After you’re done wondering how something could be good enough to sell to Aetna’s customers but not for Aetna’s insured members themselves, you may also be excused for then wondering whether Aetna knows anything about weight control in the first place, as the release demonstrates a failure to understand the difference between short-term weight loss and long-term weight loss maintenance, an overreliance on anecdotal outcomes and an insufficient disclosure of product side effects.

However, the misunderstanding of the basics of study design and weight control — along with the ignoring of any consequences of Aetna’s actions such as any potential liability if these drugs turn out to be another fen-phen (phentermine of fen-phen fame is one of the two active ingredients in Qsymia) — is not the lead here. The lead here is that Aetna is playing doctor with a license it doesn’t have, pushing drugs that no one seems to want on people who aren’t actually sick, without even taking the financial consequences of its own actions but rather foisting those consequences on the very same employer customers whose financial risks and whose employees’ health it is supposed to be protecting.

Now you see why we couldn’t wait for the sequel even if there is one, and why there’s likely to be one.

Long Term Care Insurance: Group plan vs Individual

As long term care insurance gains more traction as a critical component of everyone’s retirement planning, more and more employers and associations are offering group long term care insurance to their employees and members. Unfortunately, most people just assume a group plan is better than an individual plan. This is rooted in the concept that the more people who subscribe to a benefit, the lower the premium should be for the group. Also, we tend to have somewhat of a blind allegiance that our employer is looking out for our best interests when they shop the market for an insurance product to offer their employees. So let’s look at the differences in benefits and premiums between a group and individual plan.

The People Who Benefit From Group Plans Are People In Bad Health
First off, the idea that long term care insurance should be lower in premiums for a group is a fallacy. As Kiplinger’s Finance states: “group plans have very limited underwriting, which means that healthy people end up paying the same price as less-healthy people. If you have medical conditions, this could be a wonderful deal. But, if you’re healthy, you can do better with an individual policy that’s tougher on medical issues.” Most group plans have what is referred to as “Modified Underwriting” which means that anyone within the group is guaranteed coverage if they can answer a few “knock-out” questions. The “knock-out” questions are questions designed to identify the worst of the worst in terms of medical conditions such as: have you been diagnosed or treated for Alzheimer’s, Parkinson’s, or are you HIV Positive. The group policies typically do not check medical records nor conduct personal telephone interviews. As the Kiplinger’s Article also states: “most group plans do not offer special rates for people in particularly good health nor discounts for couples.” With individual plans, there is always an additional 10% to 15% discount for people who would qualify for the “Preferred” rate and between a 20% to 30% discount for any couples who sign up together.

Group Plans Do NOT Offer an Asset Guarantee
Lastly, you will almost never see a “Partnership” plan in the group market. This has become the latest and greatest industry benefit that is available to most people who qualify for a plan on the individual marketplace. The Partnership is a partnership between the State of California and 5 Insurance companies. The State of California has decided to become very aggressive in encouraging people to take out Long Term Care Insurance plans. The idea of a Partnership plan is that you get a smaller policy which means a smaller premium and the State of California will provide you with an asset guarantee. It amounts to an entitlement the State of California provides to you whereby for every dollar of benefits paid by the insurance company, you are able to protect an equal amount of money from the spend-down requirements of Medicaid (MediCal in California). So in other words, if the long term care policy paid out $500,000 in benefits, then if the policy were to be exhausted, you would then be guaranteed to protect $500,000 from having to be spent down to qualify for MediCal. So if your estate is valued at a half million dollars, you would essentially be protecting your entire estate from having to be spent down to the typical $2,000 that MediCal requires one to spend down to in order to qualify for MediCal benefits. This program has been so successful in California that the Federal Government has created the National Partnership through the passage of the Deficit Reduction Act. So all states will now be offering Partnership plans. It is a clear message that both federal and state governments want to encourage people to take out Long Term Care Insurance plans. Keep in mind this asset guarantee is not available in over 99% of all group plans ever sold.

In Conclusion
So in conclusion, unless you are not healthy enough to qualify for an individual plan, group plans are never a better deal. With an individual plan you will receive more benefits at a lower cost, and you would be able to obtain a Partnership plan which would guarantee that a large portion of your assets will never have to be spent down due to long term care. And isn’t that the whole point of taking out this kind of protection? But, beware, group plans give you the illusion that they’re cheaper. They do this by taking out inflation protection or giving you a very watered down version of it. Keep in mind that historically, over the last 30 years, the costs of nursing homes have increased an average of 5% per year compounded. Most group plans and certainly all Partnership plans have a built-in 5% compounded inflation protection. This means that your benefit will increase 5% every year you own the plan, but the premiums do not increase with the increase in benefits. So with an individual Partnership plan you will receive: Inflation protection, the Asset Guarantee, and a lower premium for the same benefits you would receive with a group plan.