Author: WorkCompAcademy

Most of the events that led to sustained prescription opioid use were not hospital events and associated procedures, but diagnoses that were either nonspecific or associated with spinal or other conditions for which opioid administration is not considered standard of care, according to a study published by JAMA Surgery.

The initial event associated with exposure to prescription opioids has not been widely explored, but is often maintained to stem from an injury or surgical procedure.

Andrew J. Schoenfeld, M.D., M.Sc., of Brigham and Women’s Hospital, Harvard Medical School, Boston, and colleagues evaluated the medical diagnoses linked with an opioid prescription that resulted in sustained opioid use in Americans insured through TRICARE, the insurance plan of the U.S. Department of Defense that provides health care coverage for over 9 million beneficiaries. This population may be comparable to the proportion of the general public at greatest risk of sustained opioid use.

The researchers identified 117,118 patients (opioid naïve, i.e., no use of prescription opioids for six months before receipt of a new prescription) who met the criteria for sustained prescription opioid use. Only 800 individuals (0.7 percent) received their initial opioid prescription following an inpatient encounter, with 0.4 percent having undergone an inpatient procedure.

The most common diagnosis associated with the initial opioid prescription for the entire group was other ill-defined conditions (30.6 percent). The most frequent diagnosis among patients treated in military facilities was lumbago. Spinal conditions were among the most frequent diagnoses in both civilian and military settings.

Among specific categories of conditions associated with the initial opioid prescription, spine and orthopedic disorders were the most prominent.

Limitations of the study include its retrospective design and reliance on insurance claims.

“Improved adherence to best practices in opioid prescribing and requirements for better documentation of the rationale for such prescriptions may reduce the risk of sustained use,” the authors write.

This suggestion seems like good advice for claims administrators as they review any Request for Authorization for an opioid medication.

Keenan HealthCare and actuarial consultant Milliman released the 2017 results of their California Hospital Workers’ Compensation and Payroll Benchmarking Survey.

The survey from 18 hospital systems and more than 44 individual facilities within California shows average losses paid per indemnity claim rose 2.9 percent annually over the past 10 years. Data for the survey was collected in the 2nd half of 2016 and early part of 2017 from past participants and entities that expressed an interest in participating.

The survey provides data on more than 4,300 annual claims. The survey analysis also relied on payroll and medical utilization information obtained from the California Office of Statewide Health Planning and Development website.

While the landscape of providing healthcare in the United States is seemingly in flux, “the workers’ compensation environment in California has been surprisingly stable over the last several years.” Despite this stability, workers’ compensation remains one of the most complex exposures for employers who must continue to look for ways to protect employees from injury and improve loss prevention programs.

The survey identified the following workers’ comp trends in the hospital sector:

– Projected loss cost for accidents occurring during 2016 and 2017 were at $2.10 per $100 of payroll. The decrease as compared to prior projections is largely driven by less than expected development in claim severity, while overall claim frequency has largely remained stable.
– Average losses paid per indemnity claim rose 2.9 percent annually over the past 10 years.
– Medical loss trends abated in recent years. Indemnity loss trends are less than long-term averages. Combined, these have resulted in a lower annual rate of severity increase as compared to prior versions of this study.
– However, annual allocated loss adjustment expenses increased significantly during this time period, representing an increasing share of the total cost of claims.

“Looking forward, we expect longer term trend rates closer to 5 percent or 6 percent to prevail, with stronger medical and indemnity loss trends than the recent past, and ALAE trends remaining high,” Bill Poland, marketing director of property/casualty for Keenan, said in a statement. “We believe these key indicators will be valuable in developing plans to modify or adjust programs where necessary with the goal of improving results.”

Ravinderjit Singh was employed as a physician with the California Department of Corrections and Rehabilitation (CDCR) at North Kern State Prison in Delano, California, when she claimed to have suffered a January 8, 2013, industrial injury to her psyche following a fire marshal order to close examination room doors while examining inmates.

Qualified Medical Evaluator (QME) John M. Stalberg, M.D., issued five medical reports regarding Dr. Sing. Following a workers’ compensation hearing a WCJ found, that the injury did not cause permanent disability and that based on Dr. Stalberg’s reporting, Singh “failed to meet the burden of showing entitlement to any period of temporary total disability.

Singh petitioned the WCAB for reconsideration, contending primarily that she was entitled to temporary disability. The WCAB issued its own decision finding Dr. Stalberg’s medical reporting lacking and that Singh “failed to follow-up with Dr. Stalberg and provide the requisite information for him to determine the period she was temporarily totally disabled.” The WCAB accordingly agreed with the WCJ and denied reconsideration.

Singh petitioned the court of appeal for a writ of review, and presented her case for entitlement to temporary disability payments. Singh notes that Dr. Stalberg opined she could return to work inside the prison with the reasonable accommodation of either leaving the examination room open or having a chaperone during examinations, but that the prison refused to accommodate her work restriction.

The WCAB filed a letter brief with the court of appeal stating that it “would admit error in this case and request that the Opinion and Order Denying Petition for Reconsideration issued on March 6, 2017, be annulled and that this matter be returned to the Board for further proceedings.”

The WCAB explains that while it focused its analysis on whether Singh proved temporary disability, she correctly pointed out in her petition for writ of review that “where an employer fails to provide modified work to an injured employee, temporary partial disability is deemed total. (Huston v. Workers’ Comp. Appeals Bd. (1979) 95 Cal.App.3d 856, 868.)” The WCAB explained that the record appeared incomplete, that it may have improperly analyzed Singh’s claim of temporary total disability, and expressed its desire to return the matter to the WCJ for further proceedings.

In response to this court’s inquiry as to whether this court should grant peremptory relief in light of the WCAB’s letter brief, the CDCR contends the matter should not be remanded because “[i]t is well established that an appellant cannot complain about an error that he or she created.” The CDCR asserts any lack of an adequate record is invited error of Singh’s own making by not further developing the record. (Mesecher v. County of San Diego (1992) 9 Cal.App.4th 1677, 1685.)

The court granted the WCAB request in the unpublished case of Sing v WCAB, and the California Department of Corrections and Rehabilitation, “Given the WCAB’s admission it did not consider all available legal theories that might have entitled Singh to benefits, we conclude the WCAB’s decision fails to “state the evidence relied upon and specify in detail the reasons for the decision” as required under section 5908.5. The WCAB’s failure to set forth its reasoning in adequate detail constitutes a sufficient basis to annul the decision and remand for a statement of reasons.”

Scientists in the UK and Sweden previously developed a new surgical technique to reconnect sensory neurons to the spinal cord after traumatic spinal injuries. Now, they have gained new insight into how the technique works at a cellular level by recreating it in rats with implications for designing new therapies for injuries where the spinal cord itself is severed.

The brain and the neurons (nerve cells) in the rest of our body are connected in the spine. Here, motor neurons, which control muscle movement, and sensory neurons, which relay sensory information such as pain, temperature and touch, connect with the spinal cord.

Where the neurons connect with the cord, motor neurons bundle together to form a structure called the motor root, while sensory neurons form a sensory root. In patients with traumatic injuries, these roots can be torn, causing areas of the body to lose neural control.

Surgeons can implant motor roots at the area from which they are torn, and they will usually successfully reconnect, as motor neurons can regrow out of the spinal cord and into the motor root. However, this does not apply to the more troublesome sensory root, which surgeons couldn’t reconnect properly until recently. “Doctors previously considered this type of spinal cord injury impossible to repair,” says Nicholas James, a researcher at King’s College London. “These torn root injuries can cause serious disability and excruciating pain.”

Happily, Thomas Carlstedt, also at King’s College London, recently helped to develop a new surgical technique to reconnect the sensory root. It involves cutting the original sensory nerve cells out of the root and implanting the remaining root directly into a deeper structure in the spinal cord. This area is called the dorsal horn, and it contains secondary sensory neurons that don’t normally directly connect to sensory roots. When the team tried the technique in patients, certain spinal reflexes returned, indicating that the implanted neuron had integrated with the spine to form a functional neural circuit.

In a new study recently published in Frontiers in Neurology, James, Carlstedt and other collaborators set out to understand how the implanted sensory root was connecting with the spinal cord in the dorsal horn. By understanding the mechanism, they hope to develop new treatments for patients with other types of spinal injuries.

The scientists used a rat model of spinal injury to study the process at a cellular level. During surgery, they produced a similar spinal injury in the rats and then reattached the sensory root using the new technique. At 12-16 weeks after surgery, the researchers assessed the spinal repair by passing electricity along the neurons to see if they formed a complete neural circuit. They then analyzed the neural tissue under a microscope.

The electrical tests showed that the neural circuit was complete, and that the root had successfully integrated with the spinal cord. When they examined the tissue, they found that small neural offshoots had grown from structures called dendrites (branched projections at the end of neurons) in the dorsal horn. These thin offshoots had extended all the way into the implanted sensory root to create a functional neural circuit.

So, what does this teach us about spinal cord repair? The researchers hope that this type of neural growth could also be used to repair other types of spinal cord injury. “The strategy of encouraging new growth from spinal neurons could potentially be of use in other injuries of the nervous system,” says Carlstedt. For example, scientists could capitalize on this mechanism when designing new therapies for injuries where the spinal cord itself is severed, by implanting grafts that encourage or facilitate this type of nerve growth.

Reuters reports that specialty pharmacy firm US Bioservices Corp has agreed to pay $13.4 million to settle U.S. government claims that it pushed patients to refill prescriptions of Novartis AG’s iron overload drug Exjade in exchange for referrals from the Swiss drugmaker.

US Bioservices, a unit of drug wholesaler AmerisourceBergen, agreed to pay $10.6 million to the federal government and $2.8 million to states, according to a filing on Tuesday in Manhattan federal court by Acting U.S. Attorney Joon Kim.

The deal, which must be approved by the court, would resolve a civil lawsuit filed by Kim earlier on Tuesday claiming that U.S. federal and state insurance programs were illegally billed for Exjade prescriptions that stemmed from kickbacks.

AmerisourceBergen said in a previous filing with U.S. securities regulators that it was not admitting wrongdoing as part of the settlement.

According to the lawsuit, from August 2010 to March 2012, US Bioservices encouraged patients to refill Exjade prescriptions by having its nurses call them with “one-sided advice,” emphasizing the dangers of not treating iron overload and downplaying the drug’s side effects.

Exjade had been linked to severe side effects including kidney and liver failure and gastrointestinal bleeding, which have resulted in deaths, according to the lawsuit.

US Bioservices also assigned a group of employees known as patient care coordinators to call patients and urge them to refill their prescriptions, the lawsuit said.

US Bioservices competed with two other pharmacy companies that distributed the drug – BioScrip Inc and Express Scripts unit Accredo Health Group Inc – for patient referrals from Novartis. Novartis would dole out the referrals according to how many refills each pharmacy achieved, according to the lawsuit.

As a result of the scheme, the government-run Medicare and Medicaid programs were billed for prescriptions “tainted” by kickbacks, violating federal law, according to the lawsuit.

Novartispreviously settled claims that it paid kickbacks to promote Exjade and other drugs for $390 million in 2015. BioScrip and Accredo also previously settled claims, collectively paying $75 million.

The case is United States v. US Bioservices Corp, U.S. District Court, Southern District of New York, No. 17-cv-06353.