Why we’re not solving opioid addiction

The reason opioid abuse disorder (OAD) is such a huge problem is because no one’s figured out how to a) fix it while b) making a shipload of money.

Sure, there are “solutions” that address bits and pieces including:

  • urine drug testing identifies patients who aren’t taking prescribed drugs and/or are taking other licit or illicit medications;
  • Medication Assisted Therapy (MAT) can and does help many wean off opioids without going thru withdrawal;
  • inpatient or outpatient detox is essential for some OAD patients;
  • physical therapy and exercise is helpful for many; and
  • cognitive behavioral therapy (CBT) is essential for many patients.

But many patients require many of these services, while some do fine with one or two.

There is no single silver bullet.

What we aren’t doing is funding community-based treatment facilities and providers. This is essential because OAD is a long-term chronic disease, and patients need follow up and support for years.

The real issue is three-fold – treating OAD usually requires dealing with the patient’s chronic pain as well; OAD is a lifetime disorder; and every patient is different.

The terror of withdrawal coupled with the dread of chronic pain is hugely difficult to overcome. Patients are justifiably terrified of both, and this fear must be addressed throughout the treatment process. This is a long-term process likely involving different treatment modalities delivered by diverse providers.

Some patients respond to MAT, others do not. Some have family support systems, others are pretty much on their own. Some respond to PT and exercise, others are too afraid the effort will trigger a resurgence of pain. And the only way to find out what works for Patient X is to keep trying different approaches, providers, modalities until you find something that works.

No one has cracked the code, come up with a set process, solution or approach that works for most patients. Until someone figures out how to make gazillions fixing people with substance abuse disorder, I don’t expect the nation will make real progress.

That does NOT mean there aren’t real successes happening every day.

California’s State Fund is one of the leaders, delivering remarkable results through a careful, methodical approach.

Here’s the key – OAD can be a lifetime issue. Do not fear this, rather accept it as reality. It’s far easier to throw one’s hands up at the difficulty of it all rather than dig in and get going, but it’s also what led to hundreds of thousands of workers comp patients with OAD.

What does this mean for you?

Those who are in it for the long haul are going to be the difference makers.

Article source:Managed Care Matters


Roads to stability

After eight days with family in Tuscany, it’s back to work.

Before we dive into the mundane, an observation from my travels.

This is a road built by the Romans about 2000 years ago. It’s still pretty functional, as were most of the ones we rode on in the hills and valleys of Tuscany. Sure, it could be smoother and a bit less steep (or a LOT less steep) in places, but it’s still there.

The Romans built these by hand, with nothing but human and animal power, with no electronics or computers or drones or satellite or engineering apps, no internal combustion or hydraulics or steam- or coal- powered machines. And they’re still here.

The Romans built these roads to speed communications, trade, and security. The labor that built these roads was drawn from the poor in the cities, local farms and landowners.

Somehow, that bumpy, narrow road of stones buried in the dirt eons ago felt a lot more…reliable.

All those opioid bills in Congress

Now we know why Congress can’t get anything done – At last count there were about 30 opioid-related bills in various stages in the House or Senate – over 20 have actually been passed by the House. One of the bills that addresses the Institutions for Mental Diseases is pretty contentious.

According to the Washington Post, the “IMD exclusion”  prohibits federal Medicaid reimbursements for inpatient treatment centers with more than 16 beds whose patients are mainly suffering from severe mental illness. The House bill would lift the exclusion for treatment of opioid addiction- but ONLY opioid addiction.

This ignores the very real and pervasive nature of other-substance addiction that has long plagued poor rural, minority and inner-city populations – crystal meth is just one example.

Why we’d pass a bill that doesn’t address crystal meth, which is a disaster in many rural communities from Maine to Arizona, is beyond me.

But there’s another issue here that’s even more troubling; this bill ignores the real problem; community-based treatment has always been starved for funds, unable to help millions of people who endlessly wait their turn for treatment.

Experts believe we need north of $10 billion per year to make a real impact on substance abuse disorder

Fact is, many with substance abuse disorder want to get treatment – there just isn’t any available. And allowing Medicaid to spend billions on care delivered in large institutions sounds a lot like a hand-out of taxpayer dollars to big business-owned “treatment” centers.

The IMD exclusion repeal is just window-dressing, a way for politicians to claim they’re doing something while handing billions to an industry with really good lobbying.

What does this mean for you?

The Romans built very expensive and very solid, stable, and durable roads that led to the long-term survival and success of the Empire.

We give truckloads of taxpayer dollars to big business while ignoring the devastation of the rural and inner-city poor.

Where will our decision lead us?


Article source:Managed Care Matters

What do these acquisitions mean?

Two just-announced acquisitions are an indicator of where things are in today’s work comp services world.

Tech firm Mitchell (recently bought by KKR) will acquire IME and peer review firm MCN.  Based in Seattle, privately-held MCN is one of the larger independent firms in that space, has a national network of 13,000 physician reviewers and a solid customer list. Brian Grant MD founded the company 30+ years ago and built it into a firm serving the auto, comp, and disability insurance industries.

This deal adds depth to Mitchell’s already-extensive utilization review/peer review offering, and adds cross-selling opportunities that should help the company compete with Examworks.

Strategically, the acquisition both broadens Mitchell’s non-bill review business and strengthens its offerings outside the auto casualty space, changes that lessen Mitchell’s reliance on auto and work comp review.  Given the long-term uncertainty about those businesses, the transaction makes sense – especially if the company focuses on disability, a space not subject to the impact of autonomous vehicles and the structural decline in work comp claim frequency.

One source indicates the price was in the 12x earnings range; that could not be independently verified.

In an unrelated transaction, TPA SUNZ bought case management firm Ascential Care in a deal announced on WorkCompWire this morning.  SUNZ sells high-deductible work comp plans to professional employer organizations (PEOs), staffing companies and larger employers.

I’d expect Ascential’s case management to be more tightly integrated with SUNZ’ claims management processes. Employers with loss-sensitive plans almost always buy into proactive, rapid use of clinical staff when claims arise. Getting case managers involved – when appropriate – can avoid problems and help patients feel like their employer is working to help them recover.

Ascential CEO Rich Leonardo is staying on and will continue to lead the business and SUNZ is investing in more staff to meet client needs.


For the umpteenth time time, workers’ comp is a very mature industry (as is auto).  Service companies looking to grow have to either:

  • take share from competitors;
  • buy other, similar businesses;
  • buy related businesses; or
  • expand into other markets.

Mitchell is growing by acquisition, adding more depth to its current medical management operation.  SUNZ is capturing more of the services delivered to current customers, thereby keeping those dollars inhouse.

What does this mean for you?

If you want to grow, see above. If that’s going to be hard to do, think about who may want to buy you.

Article source:Managed Care Matters

BWC Ohio picks a new Pharmacy Benefit Manager

Several weeks ago Ohio’s state work comp fund – the Bureau of Workers’ Compensation – selected a new PBM to replace OptumRx.

This has me thinking more broadly about the vendor-customer relationship and how that’s evolving.

First, buyers are getting smarter. BWC’s former and current pharmacy directors (John Hanna and Nicholas Trego respectively) are not just pharmacists, they have become expert in pricing, auditing PBM transactions, understanding contracting language, and negotiations.

According to WorkCompCentral’s William Rabb, BWC learned it was paying OptumRx millions more than it should have after conducting an audit earlier this year.  Quoting Rabb:

an audit showed that the current PBM, OptumRx, failed to keep drug prices below the maximum allowable cost as required.

The audit is here.

Without getting too deep in the weeds here, allegedly OptumRx was supposed to keep generic drug prices at or below a Maximum Allowable Cost, or MAC. However, the audit indicated OptumRx failed to do that, resulting in BWC paying about $5.7 million more for generics than it should have.

Seems straightforward, but this can be hard to figure out as the list of drugs subject to MAC list pricing is often not disclosed.  That is, the PBM has a “proprietary” MAC list which it does NOT have to share with its customer.

Obviously this makes it hard for the customer to figure out if it is paying what it should.

Second, major issues don’t just pop up out of thin air; its unlikely BWC first expressed concerns a few months ago.

Moving an $84 million pharmacy program – or any big service – is no easy task; there’s a ton of systems programming to be done and tested; patients to be switched from one PBM to the new one; adjusters and case managers to train; financial arrangements to be agreed upon; pharmacies and employers to educate; and myriad other tasks.

Payers do NOT make changes unless they have no other choice due to the switching cost, potential business and patient care disruption, and internal stress involved in moving to a new PBM (or any other service type).

Service providers need to ensure that their senior managers and front-line staff understand their customer’s situation, concerns, needs, and plans.  Equally important, senior management must empower their client-facing staff, giving those staff the ability to fix problems, highlight issues, and marshal resources needed to meet clients’ needs.

Third, vendors need to own up to and deliver on their commitments to all involved.  Quibbling over contractual terms, arguing over this clause or that, or word-stretching to avoid doing what the customer or the customer’s advocates need done reflects short-term, myopic thinking.

Sure, you may be “right”, but you’ll win that battle and lose the war.

What does this mean for you?

These days customers are harder and harder to come by, so when you get one, make darn sure you keep them. Listen, anticipate, deliver, and be flexible.

And most of all, meet their needs.



Article source:Managed Care Matters

Drug rebates, technology, and what’s next

Two years ago, brand drug manufacturers paid out $127 billion in rebates and other discounts and fees.

That, dear reader, is a ship-load of dollars, and shows just how distorted brand-drug pricing has become.  Huge increases jack up list prices and in many instances consumers’ costs, while those fees flow to payers, PBMs, and other entities in the pharma distribution.

Most consumers’ costs are based on the total price of the drugs they buy, not the net price after rebates etc. As a result, consumers may be paying an inflated price while their insurer gets the rebate dollars. I’d note that in some benefit plans consumers do receive a share of the rebates in the form of discounted drugs or lower up-front costs. Two big PBMs indicate they give about 90% of rebate dollars to their clients. 

Who hopefully pass those dollars along to their members.

Evidently, rebate contractual terms can be opaque, confusing, and subject to misinterpretation, a rather scary possibility given the billions at stake.

I recently spoke with the CEO of a company that’s deep into the rebate management process. Quantivus uses technology to help payers and pharma track all those clauses, heretofores, and whereas-es in rebate contracts to be sure the right dollars are paid for the right drugs to the right entities.

Quantivus’ solution helps stakeholders standardize terms and definitions, allowing them to ensure that they are comparing apples to apples when considering rival drugs – or rival payers. It does other stuff as well, and the company is working on a related service that will tie the negotiated contract to operational systems, helping to standardize reporting of rebate financials for manufacturers and payers.

It’s interesting in a couple of geeky ways; evidently these contracts are so complex and convoluted that they can be mis-interpreted or misunderstood, potentially costing the pharma company or its customer millions. Which there are plenty of.

It’s also interesting in that CEO Lisa Bair and her team have figured out a software solution to a problem that seems to get more complicated and more financially important by the minute.

If I was an attorney focused on rebate contracts, I’d be just a bit concerned that I could be replaced by Bair’s technology.




Article source:Managed Care Matters