Tag Archives: mpn

settlement

A Better Reality for Injured Workers

When is the last time you haggled with your doctor over pricing?

It’s certainly not a negotiation most Americans are prepared for or even one they know how to approach. However, when it comes to workers’ compensation settlements, the system anticipates that, after settlement, injured workers can persuade their doctors to bill them fairly, according to the state’s fee schedule. In reality, the system is naïve, and injured workers are instead being unfairly stripped of their settlement funds because they are routinely overpaying for treatment.

Injured workers deserve better, and engaging a professional administration service like CareGuard provides them just that. CareGuard offers injured workers a sophisticated advocate and group-buying power to make sure they can navigate the healthcare system and get the lifetime of treatment they were promised in their settlement, with money to spare.

Each year, tens of thousands of injured workers decide to settle their cases. The vast majority (more than 95%) of these workers have no help when it comes to properly spending their funds on healthcare. After settlement, most injured workers pay out-of-pocket for treatments related to their injury, relying on their often limited knowledge of healthcare to figure out what treatments they should pay for with their funds. When they do decide to use their funds to pay, they must navigate a complex maze of fee schedule guidelines that have been provided by the state to find the correct prices. In reality, it’s nearly impossible to comply with the guidelines without a computer application deciphering the numerous pages of schedules, CPT codes, rates, modifiers and rules.

The result is that, in most instances, when injured workers are left on their own after settlement, they fail to manage their care appropriately. They overpay for treatments and drugs, depleting their funds more rapidly than expected. They lose track of bills and fail to comply with regulations, putting their Medicare and other benefits at risk. And even when they are aware they can negotiate, injured workers are left to haggle out pricing on their own, pitted against a complex and apathetic medical system. Keep in mind that most of these individuals have far more healthcare needs than the average person.

Professional administration services provide access to discounted drug, provider and medical equipment pricing, as well as access to technology that provides a hassle-free experience with medical care. Those services also provide support from a dedicated team of representatives and advocates to answer questions and help the injured worker navigate their medical care. With professional administration, there is no utilization review or any requirement to use a medical provider network (MPN). Instead, injured workers can see any provider they would like, giving them the freedom to get the care they need with the added support to help minimize administrative red tape.

The culmination of all these benefits is that professional administration helps alleviate injured workers’ concerns about settling their cases. It is a tool that can help everyone at the settlement table prepare the claimant for post-settlement success and minimize any backlash or misunderstandings after settlement.

Professional administration is often overlooked because of a common misconception that it is very expensive, costing tens of thousands of dollars. At CareGuard, our pricing is typically below $5,000, and it can be even less for smaller cases. As a result of the low pricing and high discounts we offer our members, we also find that, on average, we save the injured worker over five times the cost of our services each year.

The workers’ compensation system was built to protect injured workers. Significant work and resources are dedicated to ensuring the system runs well. However, the system was poorly designed to care for injured workers who have settled their case and have exited the system. Professional administrators pick up where the system left off and ensure the injured worker has a smooth transition to life post-settlement.

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.

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.

Are MPNs Hindering Quality Care?

Have medical provider networks (MPNs) lived up to expectations of improving access to quality of care while reducing medical costs? Recent accusations raised against Janak K. Mehtani, M.D. (“Mehtani”) before the Medical Board of California, Department of Consumer Affairs, would suggest not. (Specific details relating to case # 02 2012224474, effective Jan. 13, 2015, are available on the Medical Board of California website, under the option “Verify a License.” At time of writing, a hearing had not been held, and the case status description states, “The physician has not had a hearing or been found guilty of any charges.”

Following the investigation of a lodged complaint relating to this case, the executive director of the Medical Board of California raised the following accusations (1) gross negligence, (2) repeated negligent acts, (3) prescribing dangerous drugs without appropriate examination or medical indication, (4) failure to maintain adequate and accurate medical records and (5) general unprofessional conduct.

These accusations relate to three workers’ compensation claims for services provided between 2008 and 2013. Two claims were identified as belonging to State Compensation Insurance Fund (“SCIF”) (patients JC and RW) while the insurer for the third claim, involving a non-English-speaking 47-year-old female with a history of hypertension and chronic pain (patient GC), was not identified.

This article reviews the claims administrators’ implementation of MPNs with reference to patient GC in the Mehtani case.

Insurers promote their MPNs as being quality medical providers who have undergone extensive credentialing before selection, with continuing quality assurance control of their services. Yet a random sample of insurers’ MPN lookup facilities showed Mehtani — a psychiatrist with a practice Sacramento — being currently available to provide treatment, even though there are very serious accusations currently lodged against him. There is no warning, link or reference to the medical board website to alert an injured employee or the employer.

Information shown on claims administrators’ MPN websites to assist an employee in selecting a provider or medical specialty, such as a psychiatrist, is limited to basic contact details, such as address, phone number, distance from a specified location (such as city or Zip code), gender and language. In the case of Mehtani, there is inconsistency in the list of languages spoken; some MPNs list Hindi and Punjabi, while others include Spanish. Does providing only minimal information limit the opportunity for correctly “matching” the patient (i.e., injured employee) to the medical provider, potentially compromising the physician-patient relationship?

Additional information in psychiatry would provide better opportunities for matching patient with psychiatrist. Sub-specialties such as psychosomatic medicine, addiction medicine or administrative psychiatry play key roles in the selection process. So do special interests such as psychopharmacology and pain management and additional training in psychoanalysis at institutes such as the American Psychoanalytic Association (APsaA). Rapport between the psychiatrist and patient is of paramount importance and is assisted further when matching is based on race, ethnicity and cultural groups.

While a review identified 120 psychiatrists located within two miles of the central business district of Sacramento (CBD), a random selection of insurers’ MPNs identified only one psychiatrist, in this case Mehtani, as being within 200 miles of the CBD. Can this list be considered adequate for the employee to choose a psychiatrist, let alone attempt to “best match” a patient to a psychiatrist?

Some researchers suggest that, in patients with chronic pain, a psychiatrist may be the person best qualified to distinguish between medical comorbidity and concomitant somatic complaints and that the patients require careful multidisciplinary treatment, in which psychiatry can play an important role. Patient GC experienced a number of work-related injuries commencing in 2003 and was first seen by Mehtani in 2008, after experiencing depression and anxiety for two to three years. In line with a multidisciplinary treatment plan, Mehtani referred patient GC out for pain management and to a therapist for cognitive behavior management. Mehtani was to manage medications and provide supportive psychotherapy once a month for 12 months.

But who was responsible for approving and selecting the providers’ Pain management providers are generally listed on MPN lists, but a random selection of MPNs found that cognitive behavior therapists and others providing cognitive behavior therapy, such as psychologists, mental health nurses and psychiatrists, were either not listed or not identified as providing cognitive behavior therapy. This lack further demonstrates the limitations of MPNs in selecting medical providers.

In the multidisciplinary or multidimensional approach to addressing chronic pain, an interdisciplinary approach is also required to maximize a psychiatrist’s role in the treatment plan, where all parties involved work in a coordinated fashion. The overall responsibility of ensuring the multidisciplinary team adheres to a common objective rests with the claims administrator. In the case of patient GC, the claims administrator should have been responsible for all the activities performed by the psychiatrist (Mehtani), the pain management provider, the therapist providing cognitive behavior therapy, the primary treating physician and the pharmacist in cases where medications were being dispensed by an insurer’s pharmacy network or a pharmacy was linked to an insurer’s pharmacy benefit manager (PBM). Pharmacists and pharmacies can be held accountable for failing to identify and verify red flags that may appear when a prescription is presented. In the Mehtani case, the issue of prescribed medications is being raised in the accusations.

Documentation required by psychiatrists has been an issue of contention for some time, with many psychiatrists believing that they do not need to perform the same level of documentation generally required for “physiology-based medicine.” Lack of documentation has also been raised in the Mehtani case.

Quality assurance controls for providers can be accomplished in many ways, including automation. Technology is available to monitor diagnoses (DSM-5, ICD-9 and ICD-10), treatments rendered (CPT codes) and pharmaceuticals dispensed through the National Drug Code (NDC) to track treatment and recovery progress, as well as monitor each provider’s contribution to the objectives set by the claims administrator.

Patient GC had 40 visits for “medical psychoanalysis” with Mehtani between 2010 and 2013. All visits would have been invoiced by Mehtani and would have required documentation before payment was made. As lack of documentation was mentioned in the accusation document for all three patients, how was the claims administrator monitoring treatment progress and determining payment for services rendered over the period that Mehtani treated patient GC and the others?

The current health status of all three patients and whether they have returned to normality has not been stated in the accusation document. Patient GC was first injured in 2003, patient JC was injured in 1989, and no injury date was recorded for patient RW. Regardless of the outcome of the Mehtani hearing, could the injured employees file a tort claim against the insurer as to lack of quality care provided by their MPNs? Could a tort claim be filed by the employer against the insurer with regard to lack of controls to vet and verify costs associated with providing medical treatments by their MPNs? Although tort claims by the employee against the employer are not permitted under the workers’ compensation agreement, the insurer and claims administrator are not direct parties to this agreement.

The question remains unanswered, of whether current workers’ compensation medical treatment practices based on group health managed care programs, such as MPNs, are diametrically opposed to the workers’ compensation ethos of “return to work” where “utmost good faith” between interested parties is the aspiration. This article however, suggests that they most probably are diametrically opposed.

For a more detailed outline of the processes and procedures claims administrators can utilize to manage and monitor their medical providers, refer to the article titled, “Treating Pain Pharmacologically,” available from the website managingdisability.com under the Dialogue tab.

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.