Tag Archives: michael gavin

How to Find Jobs in the Insurance Industry

When Elizabeth and Ryan graduated from college, they didn’t have jobs and, frankly, didn’t know what jobs would fit their skills and abilities. Elizabeth was a psychology and history double major who didn’t want to pursue graduate school; Ryan was a biology major, with a minor in chemistry but had no interest working in a laboratory. 

When they applied for jobs, they were like a lot of new grads. Both were bright and motivated, but they lacked an understanding of what value they brought to the workforce and which employers would have an interest in their backgrounds. Further, they had a lot of questions about how to conduct a job search. As CEO of a national firm that hires over a thousand new grads every year, I see stories like this every day.

According to our research, they are not alone. Only about 20% of graduating seniors actively use career services during their senior years. Further, 60-70% of new grads don’t know where their education and skills fit in the workforce. Combine these stats with the fact that over 75% of new jobs are created by employers with 500 or less employees, companies that typically don’t interview at campuses, and it’s easy to see that the entry-level job market is highly inefficient.

Other trends are also having an impact. For example, the larger companies that typically dominate college recruiting significantly reduced on-campus recruiting after the recession. Now, college recruiting is much more targeted, with advances in technology making direct interaction with college students much easier. Initial contacts are often made through social media, and interviews are often completed using video interviewing techniques.

See also: The First Step in Recruiting Millennials

Further, corporate college recruiters are also focused on high-demand majors in computer science, math and engineering or high performers in other majors with high GPAs. They know the majority of college grads can be easily hired through less expensive conventional recruiting methods after they graduate. The net result of all these factors is that fewer than 30% of graduating seniors have a professional job at graduation.

This has led innovators to develop a variety of ways to make the entry-level job market more efficient. From job posting sites targeted on the entry-level to online skills assessment and career counseling to third-party recruiting and placement firms, this market is seeing a high level of activity.

Since new grads typically don’t have direct experience in the positions they are seeking, one way to solve this problem is to match the transferrable (or soft) skills possessed by the candidate with positions that require those same skills. Important transferrable skills include critical thinking, time management, effective communication, leadership and initiative.

Since the beginning of 2012, Prium Inc., a provider of managed care and medical intervention services located in Duluth, Georgia, has used a third-party career matchmaking firm to recruit, interview and select qualified candidates on behalf of Prium for their entry-level positions.

Michael Gavin, Prium’s president, says, “Outsourcing helps take the college recruiting burden off our shoulders. More importantly, it’s incredibly effective for finding the skills and talents we need.”

Prium’s experience underscores the value employers see in the outsourced college-recruiting model. Most small and medium employers like Prium don’t hire in the volume to justify building their own college recruiting programs. Using this approach, positions are filled quickly with highly qualified candidates.

See also: How Colleges Can Work With Insurers  

Since January 1, 2014, candidates from many of Georgia’s great colleges and universities, as well as candidates from other regional and national colleges, have started careers at Prium. For colleges and universities throughout the country, the “matchmaking” model helps them offer their students a proven job search option.

Both Elizabeth and Ryan are thriving in their roles at Prium. Reflecting on being placed at Prium, Elizabeth said, “I never thought I would be working in the healthcare industry, and I hadn’t heard of Prium prior to interviewing. I never would have found this job on my own.”

The labor market is changing rapidly at every stage of the process. Colleges, job-seeking grads and prospective employers all need a more efficient way to evaluate and select the right entry-level hires. Hearing success stories from young grads such as Elizabeth and Ryan show how effective an outsourced college-recruiting model can be in matching great candidates with rewarding careers in industries like insurance and healthcare — careers that most new grads would never consider.

Laying the Foundation for Drug Formularies

When Texas announced an 80% drop in the cost of “N” drugs prescribed for new injuries, workers’ compensation stakeholders took notice. (Medications designated as “N” in the Official Disability Guidelines are not appropriate for first-line therapy.)

Since that announcement, the implementation of a closed formulary has placed near the top of the list on several state legislative agendas. While the results being reported out of Texas are still fairly recent, the concept of a closed formulary is not a new idea in that state. Although changes in Texas’ work comp medical cost trends appear sudden, the process for achieving these was anything but.

When HB 7 was passed in 2005, it created the Division of Workers’ Compensation (DWC) within the Texas Department of Insurance and, among other things, authorized “evidence-based, scientifically valid and outcome-focused” medical treatment guidelines and a closed formulary for prescription medications. These steps, along with the existing preauthorization and dispute-resolution processes, provided the solid regulatory infrastructure needed to implement a successful closed formulary.

The Texas Closed Formulary (TCF) requires preauthorization for medications identified as “N” drugs in the current edition of the Work Loss Data Institute’s Official Disability Guidelines (ODG). These guidelines are updated on a monthly basis to encompass new medications and new research surrounding current medications. The TCF excludes not only “N” drugs but also any compound medication that contains an “N” drug, as well as experimental drugs that are not yet broadly accepted as the prevailing standard of care.

Naturally, implementing these requirements would mean a substantial change in prescribing habits. (That was the point.) The problem was that immediate and strict implementation could mean that injured workers were suddenly denied previously prescribed medications without allowing proper time for weaning. To counter this problem, the DWC created a “legacy period” during which older claims would not yet be subject to the closed formulary, even while providers had to comply with formulary requirements when treating newly injured patients. This approach allowed providers to adapt to the new preauthorization requirements and adjust their treating habits over time in existing claims. At the same time, it ensured formulary compliance from the outset in new claims.

After the conclusion of the two-year legacy period, all claims became subject to the TCF. In effect, this legacy period was a compromise that allowed Texas to begin implementing the TCF in all of its claims without hurting patients already on long-term prescription therapy.

The first (and, to date, only) state to attempt to replicate the Texas model was Oklahoma. Oklahoma followed the Texas model closely and, in some places, added improvements. For example, while the TCF excludes all compound medications containing an “N” drug, Oklahoma’s closed formulary excludes all compound drugs, regardless of ingredients.

Unfortunately, there are also some drawbacks – the main one being limited application. Because the Oklahoma Closed Formulary is contained within the rules for Oklahoma’s new Workers’ Compensation Commission, it applies only to those cases within the commission’s jurisdiction. The commission has jurisdiction over all claims with a date of injury from Feb. 1, 2014, on. Older claims are handled by the Workers’ Compensation Court of Existing Claims, which has no closed formulary provision. This means that a doctor treating a worker who was injured on Jan. 31, 2014, and another who was injured on Feb. 1, 2014, will only have to abide by evidence-based treatment guidelines for the second worker.

While Oklahoma has adopted medical treatment guidelines and taken steps to require preauthorization, these requirements are relatively new within the Oklahoma workers’ compensation system. As a result, providers, patients and payers are still adjusting to the new system, and there has been a fair amount of confusion.

Implementing a successful closed formulary does not happen overnight. Texas started the process 10 years ago and has been consistently working to ensure that its reforms were successful. After taking the time to establish the necessary regulatory infrastructure, adopt treatment guidelines and create a logical solution to ensure a unified standard of care issue across all claims, the state is finally seeing clinical and economic benefits.

As Arkansas, California, North Carolina, Tennessee and other states start thinking about replicating the results of Texas by implementing their own closed drug formularies, they would do well to have conversations about these principles first.

This article was originally posted at: WorkCompWire.

Marijuana Case Gets Even Weirder

Of all the states, who would have guessed that New Mexico would be the hotbed of medical marijuana court decisions?  Between the Vialpando v. Ben’s Automotive in May and the Maez v. Riley Industrial case, handed down earlier this month, New Mexico’s court of appeals appears to be one of the most pro-marijuana courts in the nation.

Back in May, when I first wrote about this issue, I wondered why the reasonableness of the marijuana treatment was not questioned, and our corporate counsel told me that surely there be additional case law. Sure enough, the court in Maez decided to take on the issue.

Maez suffered from an industrial accident and was treated by Dr. Reeve.  Dr. Reeve prescribed a variety of medications, including several opioids. As required for patients on long-term opioid therapy, he performed regular urine drug tests. Maez tested positive for marijuana.

Typically, recreational marijuana use, or the use of any illicit substance, raises red flags with the prescriber. But not with Dr. Reeve!

Dr. Reeve informed Maez that, if he was going to use marijuana, he needed to have a medical marijuana license. Luckily for Maez, Dr. Reeve was happy to provide him with one. According to Dr. Reeve, “Patients are going to use cannabis either one way or the other. . . . If a patient requests that I sign [a license], I will sign it . . . but I’m not recommending . . . or in any way advocating for the use of medical cannabis.” Dr. Reeve also considers the use of medical marijuana to be the patient’s decision, “as it’s private and voluntary, and it’s not overseen by a physician.”

So the guy ended up on a medical marijuana regimen because of a failed drug test. That should be sufficient for the court to find in favor of the payer, right?

Nope.  And it gets worse.

The court went on to rationalize Dr. Reeve’s actions as reasonable, stating that “[Dr. Reeve] adopted a treatment plan based on medical marijuana. He would not have done so if it were an unreasonable treatment.”

Imagine if that logic was applied to all workers’ comp medical treatment. The doc says it’s reasonable. . . so it is. State statutes and regulations have been evolving for more than a decade to specifically counter this argument. But not in New Mexico.

And it gets even worse.

To take this determination one step further, because the physician said it is Maez’s choice whether to use medical marijuana, the court, by default, has determined that the self-directed use of marijuana by this injured worker is reasonable because the physician signed off on it.

This is patient-directed care at its absolute worst.

To recap what led to this decision: illicit drug use, perpetrated by the injured worker, condoned by the doctor and supported by a court of law.

I wish I could tell you that marijuana should be the least of your concerns, but if this is the specious logic to which we’re beholden. . . we’ll need better guidelines, better tools and better lawyers.

An Argument for Physician Dispensing

A January 2015 Workers’ Compensation Research Institute (WCRI) study that focused on three new medication strengths has again questioned the practice of physicians dispensing medications.  Some analysts argue that the new strengths are designed to skirt price controls and generate exorbitant profits for doctors and drug manufacturers and repackagers. But another explanation is possible: that doctors and drug companies have identified new strengths that patients want. In any case, competition will, over time, drive down prices on the new medications just as it did on ones that have been in the market for a long time.

The study titled, “”Are Physician Dispensing Reforms Sustainable?” prompted Michael Gavin, president of PRIUM, a subsidiary of Ameritox, to write an article titled “Physician Dispensing: I’ve Changed My Mind” on this website. He said: (1) ”that drug repackagers in California created novel dosages of certain medication to evade the constraints of the physician dispensing regulations”; (2) “allowing repackagers to create new NDC codes and charging exorbitant amounts of money for drugs that would have been substantially cheaper had they been secured through a retail pharmacy”; and (3) “Worse, utilization of these medications skyrocketed as a result of the revenue incentives for physicians (my conclusion, not WCRI’s)”.

This article analyzes the Cyclobenzaprine HCL medication, with emphasis on the new generic 7.5mg strength that was reviewed in the WCRI study and cited in the article, “Loophole for Doctors on Drug Dispensing,” that Ramona Tanabe from WCRI wrote for this website.

The 7.5mg Cyclobenzaprine HCL was first made available as a generic by the pharmaceutical company “KLE 2 Pharmaceuticals” ((www.kle2.com). The company’s mission statement reads: “It is our goal to provide new therapies via unique strengths, delivery methods and/or new formulations.” KLE 2 identified a marketing opportunity to meet the needs of those who found that the 5mg strength was not effective enough and that the 10mg was too strong. There is evidence on the Internet of people attempting to split a Cyclobenzaprine HCL tablet to reduce its strength, with limited success.

From late 2011 through early 2013, KLE 2 was the only manufacturer of the generic Cyclobenzaprine HCL 7.5mg strength, which was included in the Medi-Cal formulary and used for California workers’ compensation claims. In April 2013, the manufacturer Mylan released a generic 7.5mg strength, and it was also included in the Medi-Cal formulary. KLE 2 has a Medi-Cal price of $3.2153 per tablet; Mylan, $3.99. The brand name “Fexmid,” by Sciele Pharma, owned by Shionogi, has a Medi-Cal price of $4.4383 per tablet.

Pharmaceutical pricing in the U.S. is unregulated; the more manufacturers there are, the lower the price to the consumer. In the case of the 7.5mg strength Cyclobenzaprine HCL, there are currently only two manufacturers, so the price will remain high until more manufacturers produce this strength or there is less demand for it. The 10mg strength, in comparison, has currently around 17 manufacturers. The average Medi-Cal price for 10mg is $0.1035. The lowest Medi-Cal price is $0.0468, from the manufacturer KVK Tech. (Refer to page 7 of “Understanding Pricing of Pharmaceuticals,” available here under the Dialogue tab, for a Medi-Cal price comparison of 10mg Cyclobenzaprine HCL).

The 5mg strength is manufactured by about 11 pharmaceutical companies. The average Medi-Cal price is $0.1586 — that is down from Mylan’s price of $1.3616 in 2006. The current lowest Medi-Cal price for a 5mg strength tablet is $0.0468, again from KVK Tech.

I mentioned earlier that attempts to split either a 5mg or 10mg tablet in half have not been successful. It has been well documented that the coating applied to the 5mg and 10 mg Cyclobenzaprine HCL tablets does not allow them to be easily cut, regardless of the device used. The opportunity therefore for cutting a 5mg in half to take 1½ tablets of 5mg of Cyclobenzaprine HCL and accurately administer a strength of 7.5mg is not possible. The release of the 7.5mg strength addresses this need.

Although the 5mg, 10mg and now 7.5mg strengths are the most commonly dispensed Cyclobenzaprine HCL medications, there are also other strengths, such as the 15mg and 30mg extended-release capsules manufactured by Mylan, which have a Medi-Cal price of $8.7899 per capsule. There are also the brand name “Amrix” extended-release 15mg and 30mg capsules manufactured by Cephalon, a subsidiary of Teva Pharmaceuticals, which have a Medi-Cal price of $25.0163 per capsule for both strengths. These 15mg and 30mg strengths further illustrate how a lack of competition for a specific medication leads to higher prices.

Medi-Cal prices apply to all dispensers of California workers’ compensation medications, including pharmacies and physicians, and the same Medi-Cal maximum price has applied since 2007, as explained in my article, “The Paradox on Drugs in Worker’s Comp.” But the average prices paid, according to the WCRI study, are significantly higher than the Medi-Cal prices. The WCRI said prices paid for the 5mg and 10mg strengths were 35 to 70 cents a tablet, yet we find that the average Medi-Cal price was 10 cents for 10mg and 16 cents for 5mg. This discrepancy requires further clarification, because it appears that claims administrators have been paying significantly more than Medi-Cal’s maximum price.

The WCRI reported a range of between $2.90 and $3.45 for the 7.5mg strength. The $2.90 price is lower than Medi-Cal’s prices and indicates that a competitive price was paid by claims administrators.

If, as some have suggested, new strengths such as the 7.5mg are medically inappropriate, have claims administrators moved to remove the doctors who prescribe those strengths from their medical provider networks (MPNs)? Have claims administrators reported those doctors to the California Fraud Assessment Commission?

Gavin said in the second point I pulled from his article that medications dispensed by physicians cost more than those in retail pharmacies, but obtaining prices of Cyclobenzaprine HCL from a number of retail pharmacies on the website goodrx.com are higher than the average Medi-Cal price paid for the same medications to dispensing physicians. (Prices on the website can change at any time and cited here for illustration purposes only. The Medi-Cal formulary can also change at any time in both its suppliers of medications and prices paid.)

This analysis of the Cyclobenzaprine HCL medication further reinforces the need for claims administrators to be vigilant when dealing with pharmaceuticals. Let the buyer beware, too, when interpreting studies produced by organizations such as the WCRI.

Physician Dispensing: I’ve Changed My Mind

In the past, I’ve argued that there are legitimate reasons a doctor might dispense medications to a patient and that legislative and regulatory efforts to curb abuses of physician dispensing should be focused on the elimination of the financial incentive to do so while preserving the practice for the limited circumstances in which it might be necessary.

I’ve changed my mind.

The WCRI report published recently makes it crystal clear that the creativity of physician dispensers will always lead to maximization of revenue (and clearly inappropriate utilization of medications) unless the practice itself is eliminated.

The report shows that, essentially, drug re-packagers in California created novel dosages of certain medications to evade the constraints of the physician dispensing regulations. This allowed them to return to the typical physician-dispensing practice of creating new NDC codes and charging exorbitant amounts of money for drugs that would be have been substantially cheaper had they been secured through a retail pharmacy. Worse, utilization of these medications skyrocketed as a result of the revenue incentive for physicians (my conclusion, not WCRI’s).

Physician dispensing doesn’t make sense. Not in any circumstances. I could see a potential allowance for a one-time, short-term fill, but the routine dispensing of medications by physicians to patients should be banned. Immediately.

(Disclosure: PRIUM, and our parent company, Ameritox, provide financial support to WCRI).