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Regulatory Issues

Tightening the Lid on Pain Prescriptions

An article that ends with “I think we are dealing with a lost generation of patients”  sounds maybe just too depressing to read. But this article in Sunday’s New York Times, “Tightening the Lid on Pain Prescriptions,” which focuses on the effects of a Washington State law passed last year, provides a good summary of the opioid crisis nationwide and is well worth the read.

Opioid over-prescription is a subject MCNtalk has written about multiple times in the past year, and with good reason: High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States, and data suggests that hundreds of thousands of patients nationwide may be on potentially dangerous dosages.  Washington State has imposed new requirements on doctors to refer patients taking high dosages for evaluation by a pain specialist if their underlying condition is not improving. 

The clues were buried in the dullest of places: thousands of workers’ compensation claims.

A pain expert here in Seattle, Dr. Jane C. Ballantyne, said she now finds herself in the role of former believer turned crusading reformer.

“We started on this whole thing because we were on a mission to help people in pain,” she said of the medical profession’s embrace of opioids. “But the long-term outcomes for many of these patients are appalling, and it is ending up destroying their lives.”

The system is now examining how those changes have affected patients. Studies elsewhere suggest the benefits of lower opioid use may be significant for many patients. For example, Danish researchers have published a study indicating that chronic pain patients getting non-drug treatments recover at a rate four times as high as those on opioids.

So where does the “lost generation” fit into all this? Sadly, if the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years. Even avid believers in the new direction, like Dr. Ballantyne, suggest that it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle. Read more…

The End of the Oxy Express

Several months ago we posted on the in “The Oxycontin Express”  and pill mills in South Florida. It appears, per this New York Times front page article, that at long last Florida is addressing the matter with significant legislation, legal charges and other actions.

Just how extreme was the situation?

  • Florida doctors bought 89 percent of all the Oxycodone sold in the country last year
  • Nearly 80 doctors have seen their licenses suspended for prescribing mass quantities of pills without clear medical need
  • Doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year

Read more…

Our Absurd Payment System Personified – A personal anecdote

In early 2011 my mother passed away. She was 94 and developed evidence of a metastatic cancer in her abdomen. She wisely elected to receive palliative care in her final months. She had marvelous care via a hospice team in Portland Oregon but did need a few procedures. Various billings have drifted in over the months. This posting is about the most recent one.

Those of us who are insured are likely aware that there are billed charges – retail, and the actual paid charges – wholesale and that providers who participant in various public and private insurance plans are accustomed to writing off the difference between the two. These differences are often impressive, but this most recent case was to me rather startling.

A bill came in from the non-profit Providence St. Vincent in Portland. It was for a non specified ‘outpatient procedure’. Total charges were $1,519.50. Insurance paid $320.08. Adjustments totaled $1,119.40, leaving a patient balance due of $80.02, which I paid.

Noteworthy in this matter includes the fact that the bill did not name the procedure, or indicate the insurance payer. My mother had both Medicare and a Blue Cross supplement from her prior employment as a teacher. Most noteworthy was the 74% reduction in allowed charges in this bill through the insurance carrier. It is reasonable to assume that an uninsured person would be expected to pay the entire amount of $1,510.50, or a person with another carrier would have a different percentage reduction.

What to make of the original amount? Is it reasonable or is it an amount that has built-in excess to allow for cost shifting due to the reductions in the bill my mother and others paid? Or does what was paid for my mothers procedure, a total of $400.01 more accurately reflect the work and value received? What should the cost of this unnamed procedure be assuming that every patient paid the realistic cost of their care in a given facility? What would this procedure pay in Canada, Australia, Germany or any number of industrialized countries with a private provider system and a nationally enforced payment scheme?

What about the startling lack of detail in this substantial bill? Would we tolerate a bill from the grocer for $100.00 that says ‘food’? Yet we routinely receive bills for far more that are equally uninformative from health care facilities and providers. As individuals and employers, how does this sort of scheme impact us and what is likely to  occur assuming threatened Medicare cuts in the near future?

Assuming considerable cost shifting took place and is the norm, is this a rational and sustainable system and what direction is it heading? The other day, an appeals court overturned the mandated coverage component of Obamacare. Does this mean that many will continue to gamble with no insurance, and shift the cost to the rest of us?

What happens when an uninsured person comes into a facility like Providence needing care? They get the care and are not turned away. Then they get a bill for the retail cost. They either pay it, often at significant financial hardship, negotiate a reduced rate if they are savvy, or default on all or some of the payment. If the latter, it may be due to medical bankruptcy, indifference, or poverty. The cycle continues and the institution justifies further cost shifting to the private payers and commercially insured populations. This is a form of hidden tax on responsible companies individuals who buy coverage and on businesses who choose to insure their employees.

A system that routinely writes off 75% of the price of treatment for certain individuals is a sick system that is not being straight with us. Providence is a mission driven non-profit, which is not to suggest that they don’t generate serious cash flow and surplus, and pay significantly to their executives like the for-profit sectors. But alone, they are not capable of changing this situation even if they wanted to. How many of us would wish to work for or create a business where customers pay vastly different bills for the same service and what would our responses be. Airline costs come to mind here, but the difference is that in most cases we can decide not to take a given flight, and at least prices are posted for every flight option, leading to some real competition and relative price transparency. Health care costs are opaque and rarely considered or known in advance of treatment.

Those who think that our current health care payment system is working and should be left alone need only look at their next personal treatment episode to see the truth.

And one other lesson here: I have often made the point to the young healthy uninsured person who thinks that they can go bare on health insurance – that they can’t afford to; that one episode of hospital care would easily cost them in the 5 figures and that they would be expected to pay 100% of charges. I have suggested that they buy a high deductible lower cost policy, which nonetheless imposes a PPO discount on the first dollar of care, resulting in a marked discount on the ultimate bill they receive.

Panel urges crackdown on excessive MRIs

As noted in this Seattle Times article, an influential independent congressional advisory group is urging lawmakers to crack down on doctors who order too many MRIs for seniors, setting off a battle with physicians and patient groups that argue that Medicare beneficiaries might suffer significant delays in treatment.

The recommendation by the Medicare Payment Advisory Commission, or MedPAC, would require some physicians who order a lot of MRIs, CT scans, nuclear-medicine studies and other imaging tests to obtain pre-approval from Medicare.

In its latest report, sent to Congress this week, MedPAC takes aim at doctors who order these tests inappropriately and concludes that Medicare costs for such tests are surging partly because physicians are buying their own high-tech equipment. When they can perform diagnostic tests in their offices, they pocket the profits.

How much do imaging costs impact Medicare? Imaging is one of the fastest-growing Medicare costs, rising from $6.5 billion to $11.7 billion from 2000 to 2009, according to federal figures. Industry groups say the use of imaging services declined from 2008 to 2009, but MedPAC disputes that data and counters that usage is on the rise. While a 1989 law prohibited physicians from referring patients to testing centers in which they had financial interests, it didn’t stop them from performing tests in their offices.

As a side note to this article, MCN does not own any X-ray or imaging facilities and must approve such studies when performed by consultants. Imaging and X-rays are needed in fewer than 5% of orthopedic and related IMEs performed by MCN. If you find that a particular IME physician or provider orders studies at a higher rate, questions are warranted. Does the provider have a financial interest in testing facilities or equipment and is the study truly necessary to render a credible report?

Read more…

Disability-Claim Judge Has Trouble Saying “No”

Americans seeking Social Security disability benefits will often appeal to one of 1,500 judges who help administer the program, where the odds of winning are slightly better than even. This article in the Wall Street Journal* explores the decisions of one particular judge in the system, David B. Daugherty, who maintains a slightly different record: In the fiscal year that ended in September, the administrative law judge, who sits in the impoverished intersection of West Virginia, Kentucky and Ohio, decided 1,284 cases and awarded benefits in all but four. For the first six months of fiscal 2011, Mr. Daugherty approved payments in every one of his 729 decisions, according to the Social Security Administration.

Mr. Daugherty has said every decision he makes “is fully supported by relevant medical reports and physical and/or mental residual functionary capacity assessments from treating or examining doctors or other medical professionals.”

For some, applying for benefits can be an agonizing process that takes more than two years. Benefits are modest—they can run around $1,000 a month—but come with access to government-run health plans Medicare and Medicaid. Analysts estimate the total package costs $300,000 over a beneficiary’s lifetime.

In a brief telephone interview in April, Mr. Daugherty blamed high poverty rates especially in Eastern Kentucky for his large case load and high approval rate.

“People would really be surprised at how little education those people have,” he said. “If they have a fourth-grade education, they couldn’t get a job if their lives depended on it.” Read more…*

*this link to the Wall Street Journal article will be good through 5/26/11.

Revisiting IME Ethics and standards

Revisiting IME Ethics and standards

As founder of MCN and a practicing physician, I am proud of what we do as a company and hold high expectations for ourselves, our consultants and indeed our clients. I write this note with a bit of trepidation, but I have never been known as one to shrink from issues.

What I am addressing is by no means the norm in many or most cases, but there are ethical situations that should not be part of our industry, even at the smallest level. Please review this post in the spirit that it is meant – to improve what we do. Please don’t shoot the messenger. But by all means, feel free to comment on this posting, or privately to me.

It has been almost two years since a major expose in the New York Times regarding certain practices in that region.  For those who wish to read this series, please visit:

http://topics.nytimes.com/top/reference/timestopics/subjects/w/workers_compensation_insurance/index.html this page has all the links. Here are links to the individual articles over 3 days:

http://www.nytimes.com/2009/03/31/nyregion/31comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/01/nyregion/01comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/02/nyregion/02comp.html?ref=workerscompensationinsurance

To my knowledge the matter to a large degree “blew over” in that I am not aware of any significant regulatory or other outcomes on this issue or sanctions against the company featured, though I have heard that they have changed names.

I believe that it may be time to revisit standards in performance of IMEs, especially in regions of the country where we have observed that certain practices that we regard as improper and indefensible may indeed continue to be practiced by certain consultants and IME companies. Not asking, for example, how it can be that they receive and accept examination reports at price points, length and quality that would not be possible elsewhere in the country.  All clients deserve the highest quality standards from those they rely upon for important services, which in the case of IME’s means unbiased, thorough, evidenced-based assessments performed by engaged and dedicated consultants.

With recent disruption in the industry, including a very large consolidation of a number of smaller companies, it is our hope that those who oversee large numbers of IMEs will endorse some or all of the points we are raising, and take appropriate actions in their own companies to insure integrity in all exams. Likewise all doctors who examinations must perform at the highest medical standards and not allow a lower standard for IME’s.

The basic principle is to do right by clients, claimants and society. And since we facilitate medical examinations, let doctors do their jobs properly and insist that high standards be followed and maintained.

Clients who order exams generally receive quality exams, but they should still ask questions if they see possible issues, and use common sense. Doctors who do exams, whocan’t or won’t practice in a way that treats each claim and claimant as individuals, with respect and dignity, give the process enough time, write original reports where critical thinking is employed, and remember why they entered (or should have entered) the profession, should not do exams. There are certain acts that MCN finds unacceptable. We believe all involved in the business should feel likewise and take appropriate measures to ensure that substandard performance does not occur. In no particular order they include:

Exams that are too brief: We believe that a reasonable rule of thumb is that an IME should take no less than 30 minutes— and often much longer—to perform. We generally schedule an hour in our own facilities, sometimes a bit less, but never more than two an hour, and we question at times whether this is optimal. The time must allow for review of appropriate records, a history from the claimant, a focused and appropriate physical or mental status examination, and an original report. We have observed with our own eyes the extreme of the company cited in one of the articles I liked cited above scheduling 12 exams in an hour, with an expectation of perhaps 4 no shows and therefore approximately 8 exams to be done. This timeframe is simply impossible. Further, I think that it is also impossible to do 4 proper exams in an hour. Attempting to cut corners on time does not work; it leads to claimants who feel rushed and not heard, reports that are shoddy, and conclusions that are inarticulate if not inaccurate.

Use of Boilerplate in substantive content areas: The history, examination and conclusions must be original. Templates can provide a framework to follow or serve as an introduction or disclaimer. But the words used in an exam should be original. Measurements should be real and reflect human variation. Normal findings if quantified should reflect a range of normal. While a 90 degree flexion for example, might be normal, normal flexion will be vary from 90 degrees, while still in a normal range. So the number would be expected to not be 90. Yet I have observed reports where normal variation appears absent. No two exams should ever look the same in language when it comes to the history, examination or conclusions.

Reports that are too brief: I am not prepared to state how long an exam should be, but can state with a high level of comfort that an assessment of a complex injury with records to review, a history to cite and an examination and assessment to record generally ought to be more than 2-3 pages.

Ghost-writing of reports or examination performance: It is the physician’s job, and his/her’s alone, to take the history, review records, perform a substantive examination and issue the final report. And it should be the physician contacted for the exam who completes this work. It may not be delegated. While rare, we have seen instances where this is not followed, despite clear guidelines on the matter. The physician must not sign their name on the work of others. While it may be the practice of a particular physician to delegate certain practice tasks, that is not the standard in IMEs, and certainly not something to be imposed upon an unaware client or IME company.

Ordering unnecessary tests, especially when personal or corporate gain may be involved: It is no secret that society has been looking very carefully at real or perceived conflict of interests in medical services. Fortunately our clients call us and ask for exams and we don’t drive the demand. But we do expect that consultants make a determination as to whether a particular study is needed. Interestingly, when it comes to typical orthopedic type examinations, we find that the common frequency of ordering of studies in situations where testing is not on site is less than 5%. However we have learned that in situations where physician practices or certain IME companies have X-ray equipment on site, the incidence of use increases to approximately 35%. This is a massive variable and suggests that something may be amiss. The only indication for a study should be if it is necessary for a quality report. Often it is not, or prior studies are more than adequate. If a consultant is ordering common films uncritically, or clients see this taking place, questions should be asked. We believe that clients should consider exercising the option of requiring approval for studies, to insert a bit of friction in the process, especially if X-rays appear to be a norm with a particular setting, consultant or company.

Think about the New York Times test: The homily that one should never do something that they would not mind seeing on the front page of the New York Times holds true. And as you can see above, aberrant behavior in our field made the front page two years ago. Or to frame this in another manner, don’t do anything in our businesses or tolerate practices that we would not subject our immediate family members and best friends to. Some of what I have observed over the years would suggest that if this were the case, some people really dislike their friends and families, to allow certain practices to not only take place, but persist.

Some of these practices have been defended on the basis that questionable claims and claimants may justify them. To this I only can shake my head. Yes there are questionable claims and claimants but this in no way justifies lowering our standards of dignity and respect for what we do as physicians and companies.

Other justifications have included the belief that this is what the client wants and that they are price sensitive and therefore a hurried approach, done cheaply and below standard is therefore acceptable. I don’t believe that clients want claimants to be mistreated, and while price may be an issue, clients realistically understand that quality does carry a price and one can’t cut corners in key areas and achieve a defensible and acceptable product. I believe there may be business risk in the long-term if questionable practices are tolerated. Also, the practice of medicine is the province of physicians, and just as a client would not tell a doctor how to provide treatment, the client hopefully should rely upon ethical and trained physicians to be the final arbiter on examination performance and quality.

The consequences of inattention to ethical medical examination practices creates an uneven playing field in the provision of IME’s; those who do quality work and those who don’t. Some IME provider will take a pass on work at a price that could only be provided sub-optimally. Fortunately we at MCN and many of our ethical competitors are blessed with great consultants and clients who value integrity in the work they do and the examinations they expect. We as a company will continue to strive for the highest standards of integrity. We invite all consultants, clients and competing companies to set similar bars of expectation.

In closing, I invite a dialogue, comments, even respectful challenges to these ideas. We also may have missed some additional issue and areas bearing attention. Please raise them.

Brian L. Grant, MD

Chair and Medical Director, MCN

Oxycontin Express

We were told about this documentary video about the proliferation of pain clinics that basically prescribe narcotics in South Florida, attracting addicts from many other states. Very powerful and worth watching. This is available on several sites, including YouTube by searching the key words “oxycontin express.”  We previously addressed the regulatory issues contributing to this problem.

Fight Over a Fix for Florida “Pill Mills”

Per this Wall Street Journal article, Florida Gov. Rick Scott’s call to cancel a state drug-monitoring program has sparked an uproar in Appalachian states that say they are deluged with illegally bought pills from South Florida pain clinics.

Supporters of the program, which has yet to start operating, say it would help combat Florida’s “pill mills”—shady storefront operations that provide a bounty of prescription drugs, such as oxycodone and hydrodone, for addicts and traffickers. The tracking system would include a centralized database to help identify buyers who are accumulating large numbers of pills and the doctors who are over-prescribing them.

Florida, like most states, is facing a large budget deficit—in their case, to the tune of $3.6 billion. When the bill which established the drug-monitoring program was passed in 2009, the state envisioned that the program would be funded through federal monies. This hasn’t been the case, but given the size of the problem and its effect on neighboring states, the “pill mill” situation in Florida is of pressing concern to many throughout the region.

Pill mills have flourished in Florida, especially in Broward County, in recent years. Weak standards governing who can set them up, a lack of oversight by state agencies and the absence of a prescription-monitoring program have contributed to the problem, said Sherry Green, chief executive of the nonprofit National Alliance for Model State Drug Laws.

According to the Florida attorney general’s office, clinics are often cash-only enterprises employing doctors who write prescriptions for painkillers without examining patients.

They have proved to be a magnet for buyers in the Southeast. According to Frank Rapier, director of the Appalachia High Intensity Drug Trafficking Area, highway patrol officers in hot spots like eastern Tennessee routinely stop vanloads of people returning from Florida with fresh stockpiles of prescription drugs.

In West Virginia, state Sen. Evan Jenkins said flights on discount airlines between Huntington, W. Va., and Fort Lauderdale, Fla., have been dubbed the “Oxycontin Express.”

States in the region have been cracking down. Kentucky created one of the first prescription-monitoring programs in the country in 1999. The system has helped stamp out the sort of storefront businesses seen in Broward County, according to Keith Humphreys, a Stanford University researcher who has studied the programs. In all, 34 states have implemented them. Read more…

As Doctors Age, Worries About Their Abilities Grow

Per this article in the New York Times, an aging population has many implications. It’s important to note that one-third of the nation’s physicians are over 65, and that proportion is expected to rise. Many doctors, of course, retain their skills and sharpness of mind into their 70s and beyond. And the type of work a physician performs makes a difference: A 2006 study found that in complicated operations, patients’ mortality rates were higher when the surgeon was 60 or older, though there was no difference between younger and older doctors in routine operations.

Patient advocates note that commercial pilots, who are also responsible for the safety of others, must retire at age 65 and must undergo physical and mental exams every six months starting at 40. Yet “the profession of medicine has never really had an organized way to measure physician competency,” said Diane Pinakiewicz, president of the nonprofit National Patient Safety Foundation. “We need to be systematically and comprehensively evaluating physicians on some sort of periodic basis.”

Some experts are calling for regular cognitive and physical screening once doctors reach 65 or 70, and a small cadre of hospitals have instituted screening for older physicians. Some specialty boards already require physicians to renew their certification every 7 to 10 years and have toughened recertification requirements.

What would screening entail? The answer to that question is unclear. Some doubt that a single type of exam can be used to assess the performance of doctors from a variety of specialties. “More research is needed for us to define what combination of cognitive and motor issues are important,” said Dr. Stuart Green, a member of the ethics committee of the American Academy of Orthopaedic Surgeons. Read more…