Tag Archives: medication

5 Reasons Doctors Are ‘Non-Standard’

Non-standard physicians and surgeons are practicing doctors who have had claims frequency or severity issues or board actions or have been previously or are currently on probation. It can often be difficult for non-standard physicians to find affordable malpractice insurance coverage because they are considered a higher risk by insurance companies. Typically, a doctor remains in the non-standard market for about five years, provided once they enter the non-standard market they have kept themselves clean. In this post, we examine the top five reasons doctors become non-standard physicians.

#1 Claims – The common reasons for claims filed against physicians include: poor communication, poor bedside manner, erroneous documentation and failure, delay or change in diagnosis. To reduce the likelihood of lawsuits and claims, physicians might take just a few minutes of extra time to answer all questions and address all concerns. Patients and their families will walk away feeling as though they had all the information, even if a bad outcome occurred. They will be much less likely to seek the counsel of an attorney. Click here to read our blog post Top 5 Reasons Doctors Get Sued.

#2 Lack of informed consent – Informed consent should occur with every patient encounter. Patients must be informed on the details of their options, especially when care involves an invasive or new, cutting-edge procedure. Top breaches in informed consent that lead a doctor to the non-standard market include the use of non-FDA approved medications, and new or innovative procedures. Physicians should engage with a risk management consultant to learn best practices and get risk management advice specific to a particular practice specialty, especially those that are considered high-risk.

#3 Substance abuse issues – While physicians are about as likely to abuse alcohol or illegal drugs as any member of the general public, they are more likely to misuse prescription drugs. The motivation for this often initially includes the relief of stress or pain or to stay alert when suffering from sleep deprivation. Physicians often work strange hours and long shifts, especially in the ER. The cycle often begins by using medication to stay awake and alert to manage the stress and the hours. These stresses combined with easy access to medications can lead to substance abuse issues.

#4 High-risk practice profile – Physicians in a practice with higher claim ratios automatically fall into the category of “high risk.” Examples of high-risk specialties include: bariatric surgery, OB/GYN, neurosurgery, plastic surgery and pain management. These specialties are either composed of high-risk and invasive procedures such as in the case of surgeons or they are prescribing medications that are new or dangerous, such as with weight-loss or pain-management clinics. Physicians in these practices will most likely have to remain in the non-standard market throughout their entire careers.

#5 Poor record keeping – Following a bad outcome or an adverse event, the first thing that the patient’s attorney will request is a copy of medical records. These will be scrutinized. Any incorrect or conflicting information contained within the medical record will prove problematic for the physician’s case. Accurate and thorough record keeping proves especially challenging for older physicians, who may have been away from practice for some time and re-enter wanting to pick up where they left off. Or perhaps they are just resistant to change. Medical clinics are now using electronic medical records (EMR), which provides a more streamlined and accurate system of record keeping; they even have informed consent forms built right in. From a risk management perspective, EMR is highly encouraged.

Bottom Line – Physicians should consult a clinical risk management expert for help in developing strategies to decrease the risk of becoming a non-standard physician. Thorough protocols covering documentation, informed consent and communication will all prove invaluable in risk reduction. It’s also important that doctors are honest about their personal bandwidth when it comes to patient load capacity, stamina for extended work hours, overall physical and emotional health and stresses that may be coming from personal circumstances. These factors are important to consider and if not tended to can lead to events that have a long and lasting impact on a doctor’s ability to practice medicine.

5 Limitations to CMS 5-STAR Ratings

When it comes to general liability insurance for long-term care facilities, ratings are often based on the CMS 5 STAR rating system. This is data that consumers view as the holy grail of quality metrics for skilled nursing facilities. It essentially says a facility rated 5 STAR is well above average, and a facility rated 1 STAR is much below average. This provides a good overview for nursing home quality, but there are flaws inherent to this system, whether it is inaccurately reported data, variation in quality standards between states and survey districts or facilities that specialize in higher acuity and have sicker patients in-house.

Here are some of the variables that I have noticed not only as an insurance underwriter but also as a licensed nursing home administrator for more than 20 years.

1. Health Inspections STARS – This is a three-year average of annual surveys and complaints surveys and is calculated based on the number of citations and their severity compared with the state averages. The average is not as important as knowing the facility is improving with survey compliance or getting worse.

2. Staffing STARS – This is based not only on the number of hours of care provided to each patient per day by nurses and nursing assistants but is also heavily weighted to the number of RN hours. What you need to know is that the staffing data used is only for a two-week period that is self-reported by the facility during the annual survey. This is a limited snapshot and may not be indicative of normal staffing patterns or could be inaccurately reported.

3. Quality Measures STARS – This is based on 18 quality measures (QMs) for short-stay and long-stay residents. Some of the more scrutinized are for the prevalence of pressure ulcers, falls and antipsychotic medication. What you need to know is, if the facility has a focus in caring for these types of high-acuity patients, the star ratings may be lower in comparison with state averages, and this is not necessarily an indication that the facility is deficient.

4. Overall Rating STARS – A rating of 1 to 5 stars is based on health inspections, staffing and quality measures ratings combined into one. The more stars the better. What you need to know about this is that the facility is being compared in relationship to other facilities in a geographic area. Why this is relevant is, if all the facilities around you are excellent operators, a low star rating may not be a good indication of that facility’s overall operation.

5. Trends – A facility that is improving or declining cannot be detected with just an overall 5 STAR score. The CMS 5 STAR system has many good points and provides a consistent rating for all 16,000 nursing home in the U.S. but should not be used without interpretation for insurance purposes. We need to first validate that the self-reported data used for each facility is accurate and also consider the types of residents the facility has chosen to admit and care for. Higher-acuity residents will have an effect on the three categories that drive the overall rating and could make the facility appear as an underperformer. Lastly, both the quality performance and performance improvement of a facility are becoming a heightened area of focus for centers. Effective quality improvement programs play a role in assessing risk that is easily overlooked.

Here’s a link the CMS website: CMS 5 STAR Ratings

uncompensated

Time to Focus on Injured Workers

When WorkCompCentral released a report, The Uncompensated Worker, I wrote about how a work injury affects family finances. I applied several realistic work injury scenarios to each state. In 31 states, workers receive a reduction in take-home pay of 15% or more when they’re injured on the job. In half the states, households with two median wage earners—one on work disability and the other working full time—cannot afford to sustain their basic budget.

These findings confirmed what workers’ comp claims adjusters, attorneys and case managers already know: Many injured workers live on the edge of financial collapse.

But the findings are by no means conclusive.  The research done for “The Uncompensated Worker” was too limited. I know, because I did it. To really understand the financial experience of being on workers’ comp benefits, one should run not a handful but thousands of scenarios through a statistical analyzer and then compare the data results with actual cases researched through interviews.

The research agendas of the workers’ comp industry rarely involve looking at the worker her or himself.

Instead, the industry has funded research mainly to understand the drivers of claims costs, specifically medical care. This focus can be explained. Over the past 25 or so years, the workers’ comp industry has absorbed a huge rise in medical costs, more and more layers of regulation relating to medical treatment and even more specialties needed to deliver or oversee medical care.

To illustrate the extent of this industrial-medical complex: Nationwide spending on “loss adjustment expense,” a proxy for specialist oversight of claims, has grown annually on average by 9.4%  since 1990, while total claims costs have risen on average by 2.5%.

The quality of industry-funded research has improved, because of better data and strong talent pools in places like the Workers’ Compensation Research Institute (WCRI), the California Workers’ Compensation Institute and the National Council for Compensation Insurance. Their research focuses on cost containment and service delivery. These two themes often intertwine in studies about medications, surgeries or medical provider selection.

It’s time to pay more attention to the worker. Close to a million workers a year lost at least one day from work because of injury.  We hardly know them. Bob Wilson of Workerscompensation.com predicts that, in 2016, “The injured worker will be removed from the system entirely. … Culminating a move started some 20 years ago, this final step will bring true efficiency and cost savings to the workers’ comp industry.” Industry research, one might say, has left the worker out the system.

An example of how the worker is removed can be seen in how the WCRI did an analysis of weekly benefit indemnity caps. These caps set a maximum benefit typically related to the state’s average weekly wage. (The methodology has probably not been critiqued by states for generations, despite better wage data and analytical methods.) The WCRI modeled different caps to estimate the number of workers affected. But it did not report on what this meant to workers and their families; for example, by how much their take-home benefits would change.

As it happens, Indiana is one of the worst states for being injured at work; it has close to the stingiest benefits for a brief disability. You are not paid for the first seven calendar days of disability. Benefits for that waiting period are restored only if you remain on disability for 22 calendar days. Take-home pay for someone who is out for two weeks or less will likely be 83% less than what it would have been without injury. An Indianapolis couple, both at the state’s median wage, cannot afford a basic month’s budget for a family of three when one is on extended work disability. These poor results are partly because of Indiana’s benefit cap, which is one of the lowest in the country. The weekly benefit cap used in the report, a 2014 figure, was $650.

Les Boden, a professor at Boston University’s School of Public Health, read a draft of “The Uncompensated Worker.” For years, he has studied the income of injured workers and the adequacy of workers’ compensation benefits. He told me, “Studies have shown that many people with work-related injuries and illnesses don’t receive any workers’ comp benefits. I don’t think that the problem is too little research. It’s political. Unfortunately, workers are invisible in the political process, and businesses threatening to leave the state are not.”

I am not sure how the politics of this issue can change until the strongest research centers in the industry begin to pay attention to the worker.

This article first appeared at workcompcentral.com.

Legislative Preview for Work Comp in 2016

Common wisdom suggests that major workers’ compensation legislative activity won’t take place during an election year. For 2016, that would seem to hold true.

That is not to say, however, that various interested parties will be sitting idly by, waiting for the clock to turn to 2017.

CENTERS FOR DISEASE CONTROL ADD TO THE LIST OF CHRONIC PAIN GUIDELINES

On Jan. 13, the Centers for Disease Control and Prevention (CDC) closed the public comment period for its proposed Guideline for Prescribing Opioids for Chronic Pain. According to the CDC, the guideline is being proposed to offer “… clarity on recommendations based on the most recent scientific evidence, informed by expert opinion, with stakeholder and constituent input considered.”

The guideline goes to great lengths to address two important issues. The first is that current guidelines in many states – both public and private – are based on dated information. The second, which is critical, adds to the growing number of voices to say that best practices for providers include accessing physician drug monitoring programs (PDMP) to reduce the risk of doctor shopping and toxic – and sometimes fatal – mixtures of prescription drugs when the patient provides incomplete histories or none at all of their drug use (both prescription and illicit).

This need to access a PDMP before, and during, treatment with opioids is echoed by the Medical Board of California (MBC) and the DWC. Their comments also underscore a considerable problem facing California policymakers when trying to create incentives for providers to use the Controlled Substance Utilization Review and Evaluation System (CURES) without directly mandating access.

This dilemma is best summed up by the analysis of Senate Bill 482 by Sen. Ricardo Lara (D – Bell Gardens) that is at the Assembly Desk pending referral to committee. The bill, which would mandate participation in the CURES system as well as other measures to curb the abuse of opioids, has garnered opposition from medical associations and one medical malpractice insurer. The opposition, according to analyses by legislative staff, is based on two issues – the first being whether the CURES system is capable of handling the volume of inquiries a mandate would engender, and the second being concern that requiring CURES access will become a standard of care that could subject providers to malpractice liability.

As to the former, this issue arose during the campaign waged against the 2014 ballot measure Proposition 46. According to the non-partisan Legislative Analyst’s Office (LAO), “Currently, CURES does not have sufficient capacity to handle the higher level of use that is expected to occur when providers are required to register beginning in 2016.” This raises an important question – does the CURES system now have the capability to meet the demand that a mandate would create? If it doesn’t, then the legislature needs to understand why.

As to the second issue, it is difficult to comprehend the level of distrust that is subsumed in the position that opposing a mandatory review of possible prescription drug abuse by a patient would establish more potential malpractice liability than knowing that the CURES database exists and not checking it. In time, perhaps, it will be the appellate courts that resolve that issue.

There is no shortage of guidelines that address the appropriate use and cessation of use of opioids for non-cancer chronic pain. The DWC is finalizing its latest iteration on this issue as part of the MTUS. It will differ from both the CDC and the MBC guidelines to some degree, but the overall treatment of this issue is very similar. In addition, the division will be implementing a prescription drug formulary as required by Assembly Bill 1124 by former Assembly member Henry Perea (D – Fresno). That, too, will likely provide opportunities to address the proper use of opioids in the workers’ compensation context, preferably after the chronic pain guidelines are completed.

As noted by the CDC and the MBC, and implicit in the DWC’s guidelines, this is not just a question of UR. If all the work by the division is simply viewed as a more effective way of saying “no” regardless of the circumstances, then the public health issues associated with the abuses of opioids will continue.

Workers’ Compensation Insights is a bi-monthly publication of Prop 23 Advisors. Subscribers will receive in-depth analyses of pending California legislation and regulations, review of important WCAB and appellate court decisions and commentary on trends within the system in California and nationally. To read the rest of this newsletter, click here.

Radical Thought on End-of-Life Care

Pull up your drink and relax – you’re in for a deeper read. Thanks in advance for your eyes and time. Read on …

Here, I subscribe to the Elon Musk school of applying “first principles” to problem solving. I like to call this one my “Big W.” It has the potential to save tens to hundreds of billions of dollars annually, as well as provide solutions for other challenges we have outside of healthcare.

[Note: “Big W” comes from one of my favorite movies – if you know it, feel free to let me know. Chime back. Let’s just say a “Big W” is something so obvious many people simply pass right by. Often, value comes from finding and digging deeper.]

https://www.youtube.com/watch?v=r97Nv8N7-mI

OK, let’s get the scary numbers out of the way and frame the situation.

Numbers: According to the latest government statistics, private health insurers, Medicaid and Medicare collectively pay nearly $2.7 trillion annually to doctors, hospitals and other healthcare services. There is $53 trillion in Medicare and Medicaid unfunded liabilities. Mind you, expectations call for these numbers to rise considerably.

Players: On one side, we have services and products, including health insurers, doctors, medical services, hospitals and big pharma. On the other side, we have consumers, which are self- and fully insured companies, private pay citizens and individuals who receive state or government benefits.

Problems: Our healthcare system is for-profit, with publicly owned companies in different sectors, with shareholders, with funds held by current and future retirees and with massive numbers of employed individuals.

So, which companies willingly lower their charges to let customers keep more money to afford growing healthcare costs? Aetna, Merck, HCA? If they do lower their revenues, what happens to their stocks? Do people continue to hold? If not, how does that affect employment in the respective healthcare sectors?

The latest stats show that nearly 35% (78.6 million) of U.S. adults are obese. Obesity leads to heart disease, stroke, type 2 diabetes and certain types of cancer, which together are some of the leading causes of preventable death. About half of all adults – 117 million people – had one or more chronic health conditions. One in four adults had two or more chronic health conditions. Just think about the magnitude of this.

Do you honestly believe Americans are going to change their poor eating and exercise habits en masse and in a reasonably short term? Do you really expect the majority of obese individuals to take action to lose their excessive weight?

The reality is that we have a connected group of self-serving and self-centered individuals, businesses and political leaders, none of whom are willing to make sizable efforts to fix our healthcare system. Add in the massive marketing from food and beverage companies (sodas and alcohol), as well as fast-food restaurants that appeal to a majority of Americans who have little in the way of savings. That all spells a continuing downward spiral for our country’s healthcare costs and future affordability.

Enter the Big W

The Big W is the creation of what I call the “transition plan.” This starts with the revelation that a mere 6% of Medicare patients who die each year make up an astounding 27% to 30% of all Medicare costs. This accounts for nearly $200 billion in outgoing payments. According to statistics ​provided ​from the Center for American Progress fellow Ezekiel Emanuel and the latest CMS report on ​our 2014 ​national health expenditures (NHE), ​we add in another $250 billion for end-of-life care ​on those ​covered under Medicaid and private insur​ers. ​In all, that is nearly a half-trillion dollars per year, which plays, I believe, a very important role in our healthcare crisis.

The “transition plan” starts with an understanding that those insured individuals who will die in the next 12 months are, in a sad way, a monetary commodity for medical professionals, hospitals, big pharma and medical services/products companies.

Many of these individuals will die with little to no net worth. Since 1989, the proportion of those older than 75 with mortgage debt has quadrupled. Many seniors have large amounts of debt because of high medical bills, long-term care and dwindling retirement savings. In addition, credit card debt for seniors is larger and is rising faster than for the younger generations.

Let’s also not forget that many “last year” patients are people who are not senior citizens. Some come from the nearly 47 million Americans living in poverty or from the working, lower- to middle-income earners. While a portion of this population has life insurance, the industry reports that, of all U.S. adults, only 60% carry any level of coverage at all, and that our country is underinsured for life insurance by nearly $15 trillion.

We’ve extended life, and that is a noble task, but ask a chronically ill person or even an elderly person what they think about being kept alive for as long as possible. Those who are suffering recognize the importance of dying with dignity, instead of slowly wasting away through a myriad of medical appointments, drugs, therapies, surgeries and lab tests.

Here’s where the transition plan begins. It’s a system where health payers identify terminal patients or those who are highly likely to become terminal patients and willingly choose to forego payment for most related medical services. In return, they receive a guaranteed tax-free, single-windfall payment. The payment constitutes a large portion of what would have been paid out to the medical community.  

Take Charles Smith, a 68-year-old man who has been diagnosed with Stage 3B lung cancer. The average case has a 95% chance of death. Let’s estimate that between chemotherapy, radiation, lab tests, doctor visits, home health, costly medications, pulmonary therapy and several possible surgeries, a typical health payer can expect to reimburse between $345,000 and $375,000.

The health payer, ABC Insurance Co., receives the patient’s initial diagnosis on a medical claim. It’s flagged – the case is passed to the company’s medical management department. Once substantiated with medical records, the health payers’ actuaries set an estimated value of $350,000 on the case.

Now, the health payer gets in contact with the patient and presents the offer for the transition plan. The letter would state the following:

  • That, with the current diagnosis, the payer is offering the opportunity for the beneficiary to participate in the offer.
  • That the program is voluntary. If the beneficiary does not choose it, nothing will change with his current health coverage.
  • That, if the offer is accepted, the payer will send a one-time, tax-free, non-refundable payment to Mr. Charles Smith for $150,000.

Once the insurer makes the payment, the following would occur:

  • The health payer would no longer be responsible for payment for any treatment or services, directly or indirectly related to the chronic condition. All such conditions would be clearly identified in the Transition Plan Agreement.
  • The insured could continue to see medical providers and have them bill services to the health payer, so long as such conditions are separate from the main diagnosis and other listed conditions. However, payments for any future medical services billed, in keeping with company policy, must be determined to be medically necessary.
  • The insurer would continue to pay, on an as-needed and medically necessary basis, any palliative or “pain management” care associated with the main condition. This would not include hospitalization, therapy, home health or premium-brand medications.

What has just happened is a unique meeting of the minds between poor to middle-class dying Americans and the health insurance industry. In giving insureds the option to be financially compensated, health payers shift payments from the medical establishment back to individuals who are taking clear control of their lives.

In this specific case, corporate or private insureds receive back a large portion of the $200,000 cost savings in the form of reduced premiums, perhaps mandated by government to certain levels based on certain savings points. Naturally, for self-insured entities, the savings would flow back to the company or organization.

Imagine Mr. Smith having less than $5,000 of total savings and no insurance.  He is divorced, yet he has two children who are also in the lower income class.  While $150,000 of tax-free money is not millions, it could make a difference to that family and perhaps their ability to afford healthcare, a home or even college.

Without the transition plan, Mr. Smith might struggle to pay his remaining debts and have no money left over for funeral expenses. With the transition plan, he might take, or at least send, his two kids and their families on a trip around the world. Perhaps he would choose to contribute to several 529 plans for the education of his grandchildren.  He could also choose to give to charities, political groups or churches or even share with his most beloved friends.

The transition plan is the patient’s choice. If the patient is mentally unable to make a choice, she may default to the normal relationship with the health insurer, or the decision could shift to her immediate family or appointed surrogate. 

Public payers, private health insurers and corporations that pay for their own health benefits will now have the ability to help others make the transition and perhaps leave better legacies. Nothing puts a smile on someone’s face, especially in times of stress and depression, quite like when they give and get to see others enjoy their gifts.  Contrast this transaction with the same money going into medical and drug house pockets, leading to a continual raise of everyone’s plan premiums and a decrease in savings.

Who are the financial losers here? End-of-life medical services including chemotherapy, radiation, imaging, testing, surgeries, therapies, medical equipment sales and home health services.

The transition plan may not be the entire answer for our growing healthcare crisis and spiraling costs. Certainly, it is not going to be the choice for those who are dying and have plenty of savings to pass on to their loved ones or charity; nor will it be the choice for those who want to fight their diseases to the very end.

However, for a large majority of Americans who don’t have the assets to leave but recognize their value per historical healthcare payments to providers, the transition plan could be a useful measure. It would effectively allow them to stake a claim toward money normally ending up in the pockets of medical service professional  for cases not often resolving positively.