Author: WorkCompAcademy

It seems as though some doctors may be milking their better-insured patients. In fact, a recent study published in JAMA Internal Medicine suggests that more than $750 billion of U.S. health care spending annually represents waste, including approximately $200 billion in overtreatment. Keep in mind, that a person treating under the California workers’ compensation system is a “better-insured” patient since they do not have any policy limit and no deductible.

This study examines low-value health care spending among US adults ages 18 to 64 years using data from Optum Clinformatics Datamart of UnitedHealthcare commercial claims for 2011 to 2013.

Data from 2013 insurance claims, which included nearly 1.5 million adults with commercial insurance, showed that just under eight percent of people had received “low-value services,” meaning they provided little value to patients given all the costs and alternatives.

The most commonly received low value services included: triiodothyronine measurement in hypothyroidism (1.5%), imaging for nonspecific low back pain (1.3%), and imaging for uncomplicated headache (1.0%). The greatest proportion of spending was for spinal injection for lower-back pain at $12.l million (37.0%), head imaging for uncomplicated headache at $3.6 million (11.0%), and imaging for nonspecific low back pain at $3.1 million (9.4%)

“The important caveat to highlight is, we’re only looking at 28 services. We’re looking at a very small slice, but it can give you a lens on the larger problem,” said Rachel Reid, lead author and a policy researcher at RAND Corporation to CNN.

In a previous report published in The National Academies of Sciences – Engineering – Medicine, a study found that the U.S. spends more on healthcare than any other nation. In 2009, health care costs reached $2.5 trillion, nearly 17 percent of the GDP. Yet, despite this spending, health outcomes in the U.S. are considerably below those in other countries.

It was also discovered that low-value spending was less among patients who were older, male, black or Asian, lower income, or enrolled in a Consumer-Directed Health Plan. Regionally, the Southern, Middle Atlantic, and Mountain regions had greater proportionate low-value spending

What happens when a patient asks for a specific test? Should a doctor refuse? “What are you supposed to say – no?” says Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons, to CNN. “Failure to diagnose is one of the most common reasons for filing a lawsuit, so there is a lot of pressure [on doctors], if you think of something, to do it,” according to Dr. Orient.

Ideally, the California workers’ compensation Utilization Review and Independent Medical Review process will screen for and refuse authorization for low value care. And current and future amendments to the Medical Treatment Utilization Schedule will continue to identify what is considered by evidence based medicine to be low value care.

In October 2015, Governor Brown signed Assembly Bill 1124 mandating that the California Division of Workers’ Compensation (DWC) adopt a prescription drug formulary for the California workers’ compensation system. The draft regulations published last week reflect a broad effort by the Division to streamline the delivery of effective care to injured workers by implementing the formulary and the 30-day pass-through utilization review (UR) provisions proposed under Senate Bill 1160 (Mendoza).

Studies by the California Workers’ Compensation Institute (CWCI) and the Workers Compensation Research Institute (WCRI) published before the new law estimated that depending on how it was structured and implemented, a state-mandated workers’ compensation formulary could save 8 to 42 percent of total drug spend,

At this point it remains to be seen what savings will actually materialize.

But, a new California Workers’ Compensation Institute (CWCI) study uses data from 1.2 million drug prescriptions dispensed to California injured workers in 2014 to model the impact of the draft Medical Treatment Utilization Schedule (MTUS) Drug Formulary released by the Division of Workers’ Compensation last week.

The draft MTUS Drug Formulary List classifies listed drugs as either “Preferred” or “Non-Preferred.” If prescribed in accordance with the state’s Medical Treatment Utilization Schedule for outpatient use, Preferred drugs would not have to be authorized through prospective review, while authorization via prospective review would be required before Non-Preferred drugs could be prescribed or dispensed. Drugs not on the formulary’s Preferred or Non-Preferred list, (“Not Listed” drugs), also would require authorization through prospective review prior to prescribing or dispensing. All opioids would be Non-Preferred, but the regulations would allow a limited “first fill” of 7 specific opioids if prescribed or dispensed at an initial visit within 7 days of the injury date and the prescription meets MTUS standards.

To test the impact of the draft MTUS Drug Formulary, the authors determined the percentage of the 1.2 million prescriptions and prescription dollars in the study sample that would fall into the Preferred, Non-Preferred, and Not Listed categories; identified the drug groups that would be most affected; and estimated the effect of the “first-fill” provision.

The model found that Preferred drugs comprise 26.6% of currently prescribed drugs and 22.0% of total drug spend; Non-Preferred drugs make up 57.0% of the prescriptions and 53.1% of the drug spend, while Not Listed drugs made up 16.4% of the prescriptions and 24.9% of the drug spend. The most-prescribed drugs that would be subject to prior review include opioids and certain bulk chemicals found in compound drugs. The model also found that the First Fill policy for the 7 opioids would affect fewer than 5% of current prescriptions.

Based on the preliminary analysis summarized in this report, the proposed formulary represents a significant step forward in achieving the legislative intent of AB 1124. In a follow-up report, the authors will provide a more in-depth analysis of the potential system-wide impact of the proposed formulary on UR and IMR expenses by comparing the specific drugs currently subject to UR and IMR, as well as dispute resolution outcomes, against the MTUS drug list.

CWCI plans a follow-up analysis that will examine the proposed formulary’s impact on system-wide utilization review and independent medical review (IMR) expenses by comparing specific drugs currently subject to UR and IMR and the outcomes of disputes involving those drugs against the formulary drug list. In the meantime, the initial study has been issued as a CWCI Spotlight Report, “California’s Proposed Workers’ Compensation Formulary, Part 1: A Review of Preferred and Non-Preferred Drugs,” and is available for free in the Research section at www.cwci.org.

Two doctors who each operated medical offices in Lynwood have been arrested on federal drug charges that allege they issued prescriptions for narcotics and sedatives without a medical purpose. The two doctors were charged by the United States Attorney’s Office in conjunction with an operation conducted by the Torrance Police Department and the Los Angeles District Attorney’s Office that targeted members and associates of the East Coast Crips criminal street gang.

The two doctors – Sonny Oparah, 75, of Long Beach, and Edward Ridgill, 64, of Ventura – surrendered to federal authorities on Friday and were released on bond that afternoon after making their first appearances in United States District Court. Both men were ordered to again appear in federal court for arraignments on September 15.

Two criminal complaints unsealed on Friday charge Oparah and Ridgill with illegally prescribing the powerful painkillers hydrocodone (best known as Vicodin or Norco) and codeine (for example, promethazine with codeine cough syrup, which is known on the street as purple drank), alprazolam (commonly known as Xanax), and carisoprodol (a muscle relaxer best known as Soma). According to the affidavit filed in the cases, Oparah issued nearly 13,000 prescriptions for those drugs in a one-year period between July 2014 and July 2015, and Ridgill issued more than 21,000 such prescriptions in a three-year period between July 2011 and July 2014. All of the prescribed drugs were at or near maximum strength.

The affidavit describes 12 undercover operations during which Oparah or Ridgill sold prescriptions in exchange for cash fees. In most instances, the doctors sold the prescriptions without ever examining the undercover officer or cooperating witness. A medical expert’s independent review of the undercover recordings and seized patient files confirmed that there was no legitimate medical basis for the prescriptions. The expert, writing about Oparah, said his “actions are very alarming” and the evidence reflects “extreme departures from the standard of care,” according to the affidavit.

The federal investigation into Oparah and Ridgill showed that they operated cash businesses. Federal authorities made cash seizures from both doctors, and bank records showing that Ridgill deposited $500,000 in cash into his bank accounts over a period of less than three years.

The arrests of Oparah and Ridgill occurred jointly with a sweep that targeted the East Coast Crips street gang in “Operation Money Bags.” The charges against gang members and their associates are being unsealed. As described in the federal affidavit, the investigation into Oparah and Ridgill originated when the investigation into the East Coast Crips revealed evidence that “Oparah and Ridgill served as large-scale sources of supply to [gang] members and associates via their issuance of medically unnecessary controlled drug prescriptions.”

“These arrests demonstrate DEA’s resolve to target all drug traffickers regardless of their standing in the community,” said Anthony A. Chrysanthis, Assistant Special Agent in Charge of the DEA’s Los Angeles Field Division. “With our law enforcement partners, we will continue our pursuit of those that contribute to the opioid addiction crisis and poison our society under the guise of the medical profession.”

Sergius Apostolos Orloff is a seriously injured worker and is confined to a wheelchair. As a result of a work-related spinal cord injury, Orloff suffers from chronic back pain, anxiety disorder, and personality disorder. He was awarded a permanent disability rating of 100 percent on his worker’s compensation claim,

He also seemed to have an “attitude” when dealing with others, and has a history of threatening physical harm to those involved in his case.

In this current (fourth) criminal case he was prosecuted (again!) and convicted for threatening Police Officer David Kelley who made contact with him while investigating a citizens complaint that he had made “threats of bodily harm or death.” The underlying investigation was triggered by his threats to a CVS pharmacy employee. He appealed this conviction. The Court of Appeal affirmed the trial court this month in the published case of People v Sergius Apostolos Orloff.

But – this was not Orloff’s first criminal case for making threats to those involved in his workers compensation claim. in 2003, he suffered a misdemeanor conviction for violating PC section 653m, subdivision (c), after he made annoying or threatening phone calls to his neighbors. In 2008, he was again convicted of the same offense after he placed several increasingly hostile phone calls and sent fax transmissions to representatives of Health Quest Home Care due to his dissatisfaction with their service. He was again placed on probation and ordered to serve 180 days in jail. (The jail sentence was apparently stayed.)

He was on probation for less than one year when he committed the third offenses which involved his threats to Workers’ Compensation Judges involved in his case and was an unpublished Court of Appeal decision reported in the Workers’ Compensation literature as People v. Orloff (2nd–B211573), 74 Cal. Comp. Cases 1330

Facts of his prior misconduct in the third case, unrelated to the current prosecution, were allowed into evidence and heard by the jury in his fourth case. In the third criminal case Orloff made the threats between 2006 and 2008 while litigating his workers’ compensation claim at the Oxnard WCAB. He telephoned Judge Carrero’s secretary, Belinda Doleman, and left a message “that he was going to get the fxxxxxx judge, that [the judge] better have a policeman available.” Later, Orloff left a message for Judge Carrero that “if he didn’t get what he wanted, he was going to jump out of his [wheel]chair and confront Judge Carrero, . . . [and] make Judge Carrero feel what it was like to be him and have a cervical discectomy . . . .” Appellant also said “something to [the] effect” that he was going “to break Judge Carrero’s legs.” A few days later, appellant left a message that Judge Carrero, Doleman, and David Brotman, another judge, “were going to meet members of the Russian Mafia” who “were going to make sure [they] did what [appellant] wanted.” Appellant said “that he wasn’t going to call anymore because [the judges and the secretary] weren’t going to hear from him and that no one was going to hear from [them] either.”

In July of 2008, Orloff pleaded guilty in the third criminal case to one count of making a criminal threat (PC 422), and one count of making annoying telephone calls (PC 653m, subd. (a)).

This fourth prosecution pertained to a 2014 complaint by Dennis Masino worked as a store manager for CVS Pharmacy. His store filled Orloff’s prescriptions for pain medication. After several episodes of disruptive behavior, Masino told Orloff that he was no longer welcome at the store and that his prescription would be transferred “to any pharmacist that he wants.” But Orloff insisted that Masino had “to give him his medications.” Later Masino received two telephone calls from Orloff. In the first call, Orloff said to “expect something when you least expect it.” About 90 minutes later, Masino received the second call. Masino said, “This is Dennis. How may I help you?” Orloff replied, “You’re dead,” and hung up. Masino understood the threat to mean that his “life [was] at risk.” Masino knew that Orloff was in a wheelchair. But he considered appellant’s death threat credible because “[a]nybody could carry a gun.”

Officer David Kelley had prior police contacts with appellant and was aware of his disability. He was investigating a citizen’s complaint that Orloff had made “threats of bodily harm or death.” He telephonically spoke with Orloff. During that conversation, Orloff uttered racial epithets while responding to Kelly’s comments, which concluded with a threat “Hey, you’re a fxxxxx’ dead nxxxxx if you keep this sxxx up.”

Orloff appeals from the judgment entered after a jury had convicted him in this fourth case of making a criminal threat arising out of the 2014 incidents (Pen. Code, § 422) and attempting, by means of a threat, to deter an executive officer from performing his duties. (§ 69.) The Court of Appeal sustained the fourth conviction in the case of People v Orloff.

The Court of Appeal explained its decision by saying a “person confined to a wheelchair is capable of making a criminal threat. Here the threats were directed to a peace officer and a pharmacy manager. Similar prior threats were directed to workers’ compensation judges. We have compassion for a person confined to a wheelchair. However, pain and suffering does not give license to threaten people.”

“The law does not countenance threats of bodily harm against citizens, peace officers, or judges. This is true whether the threats are clear or veiled. Threats against peace officers or judges are directed not only to the individual but also to the public office that the individual occupies. Such threats strike at the heart of government and will not be tolerated. The judgment is affirmed.”

This case now sets a precedent for proper conduct of an injured worker while working with claims, physicians, and others who are involved in administering the claim.

A study published this month in BMJ offers additional evidence of a correlation between payments by drug manufacturers to doctors and increased prescriptions for drugs developed by the latter.

The analysis of Medicare’s Open Payments program offers a statistical demonstration of a phenomenon supported by more than 20 years of suggestive data, though the study’s authors point out that most previous studies have relied upon self-reporting to obtain payment and prescribing data. Where a recent study published in JAMA established a link between the free meals pharmaceutical companies offer and increased prescriptions, this new study expands that purview to include payments for speaking and consulting fees, as well as indirect payments for education, or for food and entertainment.

Moreover, the authors see a potential connection between payments made to physicians and “substantial differences in regional prescribing.” They conclude that “one additional payment in a region [median value $13] was associated with approximately 80 additional days filled of the marketed drug in the region.” As damning as that sounds, the authors caution that their study doesn’t prove the payments actually led to the increased prescribing, and say that their findings should not be interpreted beyond a regional level.

Even absent clear evidence of causation, pharmaceutical companies continue to make payments to doctors, most of whom don’t believe they can be influenced, according to the study.

Reporting by ProPublica undermines this claim, showing the industry’s efforts seem to specifically target physicians already under sanction for unnecessary prescribing. The preponderance of the evidence suggests pharmaceutical companies have a profit motive behind their actions, according to Charles Rosen, co-founder of the Association for Medical Ethics, who told ProPublica, “I think it’s crystal clear that their fiduciary duty is not to educate physicians and make public welfare better. It’s to sell a product.”

Pharmaceutical and medical device companies are continuing to pay doctors as promotional speakers and expert advisers even after they’ve been disciplined for serious misconduct, according to an analysis by ProPublica.

One such company is medical device maker Stryker Corp.

In June 2015, New York’s Board for Professional Medical Conduct accused orthopedic surgeon Alexios Apazidis of improperly prescribing pain medications to 28 of his patients. The board fined him $50,000 and placed him on three years’ probation, requiring that a monitor keep an eye on his practice.

Despite this, Stryker paid Apazidis more than $14,000 in consulting fees, plus travel expenses, in the last half of 2015.

Stryker also paid another orthopedic surgeon, Mohammad Diab of San Francisco, more than $16,000 for consulting and travel, even though California’s medical board had disciplined him for having a two-year-long inappropriate sexual relationship with a patient, whose two children he also treated. He was suspended from practice for 60 days, required to seek psychological treatment and given seven years’ probation. He is still required to have a third party present while seeing female patients.

According to the ProPublica investigation Stryker is one of more than at least 400 pharmaceutical and medical device makers that have made payments to doctors after they were disciplined by their state medical boards. ProPublica reviewed disciplinary records for doctors in five states, California, Texas, New York, Florida and New Jersey, and checked them against data released by the Centers for Medicare and Medicaid Services on company payments to doctors. The analysis identified at least 2,300 doctors who received industry payments between August 2013 and December 2015 despite histories of misconduct.