Author: WorkCompAcademy

According to a report by The American Prospect, the big three Group Purchasing Organizations (GPOs) – Premier, Vizent and HealthTrust use sole-source contracts to require hospitals to purchase virtually the same amount from suppliers every year. If a supplier cannot snag one of these contracts, they cannot sell to nearly all hospitals, and they cannot go forward as a business. This dramatically shrinks the manufacturers available for particular sterile injectable drugs, any of which can be thrown offline by the slightest imperfection.

The GPO structure therefore limits competition for these drugs, and exacerbates resiliency challenges. It also can increase prices, because the determining factor of getting a contract is often the highest fee a manufacturer can provide. These fees cut into supplier margins and induce them to take shortcuts to ramp up production, making the system even more vulnerable to supply shocks.

Hospitals have favored the scheme because they get paid too, through “share-backs” from the GPOs. This secures their participation and keeps the system stuck with supply challenges.

Ending the anti-kickback safe harbor would shift the GPO compensation model. They would be paid by hospitals as co-op purchasers, for finding the cheapest prices for medical supplies, rather than being paid by suppliers as for-profit operators, hunting the biggest fees for access. A market with suppliers competing for business rather than paying GPOs to get into hospitals would reduce what hospitals pay, studies have shown.

The Senate Finance Committee is releasing a bipartisan discussion draft this month that aims to tackle the epidemic of drug shortages, mostly in low-margin generic injectables used in hospitals. It attempts to reckon with the broken market structure that has created the most drug shortages in America on record.

The discussion draft uses Medicare and Medicaid payments to incentivize reform of contracting practices that put generic injectables and other drugs at heightened risk for shortages. In particular, Senate Finance Committee chair Ron Wyden (D-OR) has taken aim at group purchasing organizations (GPOs), three of which handle bulk purchasing for 90 percent of all hospitals. Sole-source contracts and profit-skimming by GPOs (and large wholesalers, which also have extreme concentration, with three controlling 90 percent of purchases) have been blamed for creating the conditions where low-margin drugs are no longer profitable to most manufacturers, thinning out the supply chain and opening it up to regular disruptions.

Yet the bill does not take what some have identified as the easiest path to breaking the power of GPOs: removing the safe harbor from anti-kickback laws that allows the companies to maintain their dominance by taking fees from hospital suppliers in exchange for inclusion in their guaranteed sale contracts.

Instead, it creates a new framework starting in 2027 called the Medicare Drug Shortage Prevention and Mitigation Program. Hospitals and other providers would be eligible for incentive payments under the program, but only if they commit to a variety of contracting reforms to ensure that certain generic drugs are no longer chronically in shortage. This includes injectables like saline, and chemotherapy drugs that have recently gone into short supply.

Some critics see that as a missed opportunity. “This draft is a convoluted, unworkable, nonsensical, overly complex mess,” said Phillip Zweig, co-founder and executive director of Physicians Against Drug Shortages, which has highlighted anti-competitive contracting practices and kickbacks as the source of the problem.

That there’s a draft at all reflects renewed attention to the problematic function of middlemen in the health care system, both on prices and the timely dispensation of treatment. Pharmacy benefit managers (PBMs), which play a similar role for prescription drugs purchased at pharmacies, have also come under scrutiny in Washington. Federal regulators are currently examining both GPOs and PBMs.

But solutions have been elusive, and while the committee is optimistic that they could really get something done, critics argue that there are much simpler alternatives available: in this case, making pay-to-play GPO schemes illegal again.

The Malibu Times as well as a story in the Conejo Valley Acorn, reports that Malibu/Lost Hills Sheriff’s Capt. Jennifer Seetoo has won her lawsuit against Los Angeles County implicating former Sheriff Alex Villanueva. Villanueva was accused of discrediting Seetoo by spreading false rumors about her and denying her the opportunity to interview for a promotion. In just under two hours of deliberations, a jury awarded Seetoo just over $971,000 in damages.

The trial unfolded over nine days of testimony from April 8 to 19 at the Stanley Mosk Courthouse in downtown L.A. Among the witnesses were Seetoo herself and former L.A. County Sheriff Alex Villanueva, under whose administration the alleged mistreatment occurred. Villanueva himself was not named as a defendant in the lawsuit.

Seetoo started with LASD as a custody assistant in 1997 at age 20. She was first in her class at the academy and rose through the ranks, arriving at Malibu/Lost Hills sheriff station as operations lieutenant, or second-in-command, in November 2018.

On her first day the captain, Josh Thai, suffered a medical emergency, making her acting captain. That same week saw the Borderline mass shooting and the Woolsey fire, with Seetoo leading the station’s response to that historic disaster.

In early December Villanueva was sworn in as sheriff, having campaigned on a promise to let local communities choose their captains.

According to Seetoo’s original complaint, filed in January 2020, she soon began to face accusations from higher-ups that she was jockeying for the absent captain’s job. These included false comments about an “inappropriate relationship” with the city manager in one of the municipalities in her jurisdiction, insinuations which Seetoo believed came from the office of the sheriff himself.

Seetoo was removed as acting captain and told she owed additional time as watch commander to be eligible for promotion. But this policy of Villanueva’s was not consistently applied to male officers, her suit alleged. She was also prevented from transferring to the detective bureau for a similar reason.

When the captain position at Lost Hills opened in June 2019, Seetoo applied but did not get an interview. The 10 candidates selected to interview were all male.

City officials told Seetoo they had sent a letter to LASD demanding that she be considered, which made her concerned about the potential repercussions. After Agoura Hills honored her Woolsey fire work by asking her to ride in the Reyes Adobe Parade, new Lost Hills Capt. Matt Vander Horck was allegedly directed to remove Seetoo from the operations lieutenant position he had asked her to fill, as well as her role as Malibu liaison.

At that point, in October, Seetoo complained about the unfounded rumors and retaliation in an email to a commander. Shortly thereafter Vander Horck told her the decision had been made to transfer her to West Hollywood. Sending employees to work at stations far from their homes as punishment is a familiar tactic in the sheriff’s department, known as “freeway therapy.” Vander Horck himself was abruptly removed as captain and transferred in Feb. 2020.

Although Villanueva was not named as a party in the lawsuit, he was accused of spreading an unfounded rumor that the married Seetoo, then the Malibu Sheriff’s liaison, was having an affair with a city manager in Agoura Hills, a city in her jurisdiction. Villanueva did testify at the trial, but so did a Villanueva colleague, an assistant sheriff who contradicted Villanueva’s testimony. That witness testified that he heard the rumor directly from Villanueva, who stated it as if it was a fact. The former Agoura Hills city official, who now works for another nearby municipality, testified in support of Seetoo, a mother of two, that the rumor was completely baseless and unsubstantiated.

Seetoo did not allege discrimination by her direct superiors, but rather from the very top of the department. Her complaint mentioned “spies” planted by the sheriff to watch her work. It also spoke of a larger pattern of discrimination against female sworn officers in the LASD under Villanueva.

In May 2022 Seetoo finally became the first female captain at Lost Hills.

Jurors found in Seetoo’s favor after deliberating for just over one and a half hours. The bulk of the jury award – $750,000 – was for non-economic losses including harm to her reputation and emotional distress. An additional $221,369 was awarded for lost earnings and benefits, bringing the total to $971,369. Seetoo also won legal fees.

Seetoo’s attorney, Kathleen Erskine, said, “It has been a highlight of my career to represent Jennifer Seetoo. She led the Malibu/Lost Hills Station with bravery and skill during the Woolsey Fire, one of the most devastating events in its history. Rather than allowing her to compete for the promotion she deserved, former Sheriff Alex Villanueva and his high-ranking executives discriminated and retaliated against her.”

The ongoing case is Jennifer Seetoo v County of Los Angeles et. al assigned to Hon. Rupert A. Byrdsong in Department 28 Stanley Mosk Courthouse.

Palm Care Pharmacy, a San Diego County pharmacy chain with a storefront in El Cajon, has paid $350,000 to resolve allegations that it diverted controlled substances, failed to keep necessary accounting records for controlled substances, and improperly sold pseudoephedrine chemical products.

The settlement arises from a U.S. Drug Enforcement Administration investigation into suspected illegal activity at Talimi International, Inc. d/b/a Palm Care Pharmacy. Based on an inventory audit conducted by the DEA and other investigative activities, the government concluded that Palm Care Pharmacy’s El Cajon location committed multiple violations of the Controlled Substances Act and the Combat Methamphetamine Epidemic Act from 2018 through 2022.

The government alleged that Palm Care Pharmacy failed to control its inventory of controlled substances, failed to maintain a complete record of controlled substances and the transactions, and sold listed chemical products (e.g., pseudoephedrine) without the necessary training and certification.

Palm Care Pharmacy’s failure to control inventory resulted in unaccounted-for pills, including: opioids (oxycodone, hydrocodone, and tramadol), benzodiazepines (Xanax), and muscle relaxants (Soma).

In addition to paying $350,000 to resolve the government’s claims, Palm Care Pharmacy entered into a Memorandum of Agreement with the DEA requiring Palm Care Pharmacy to undertake additional measures to handle controlled substances properly and safely.

“Accurate record keeping prevents controlled substances from ending up in the wrong hands,” said DEA Diversion Program Manager Rostant Farfan. “DEA will continue to hold registrants accountable to ensure they are operating within the closed system of distribution.”

This settlement was the result of a coordinated effort by the U.S. Attorney’s Office for the Southern District of California and the Drug Enforcement Administration.  This case was prosecuted by Assistant U.S. Attorney Dylan M. Aste. The claims resolved by the settlement are allegations only, and there has been no determination of liability.

Sedgwick, announced several new updates to its artificial intelligence-powered (AI) technology program, ahead of the upcoming RISKWORLD 2024, the annual conference of RIMS, Sedgwick also said it “remains at the vanguard of technological innovation in the industry with its pioneering generative AI technologies and claims management applications.”

The latest enhancements are significant milestones on Sedgwick’s journey of technology evolution and have been supported by dedicated research and development in predictive modeling, machine learning and now, generative AI. This work has been propelled by the company’s vast global dataset and expert in-house data science and technology teams.

Their goal is to expedite the claims process by predicting, addressing, and automating steps in the claim lifecycle, thereby enhancing consumer experiences, and streamlining claim resolutions. Claim resolution times are expected to decrease, early adopters will swiftly benefit from the technological advancements, and the overall experience for Sedgwick’s consumers and clients will be significantly elevated.

Sedgwick’s technology stack is built around several AI-enhanced tools that comprise a scalable, rapidly deployable platform. Recent enhancements to Sedgwick technologies include:

1- Sidekick+: In April, Sedgwick achieved integration of generative AI tools into its proprietary technology program with a best-in-class claims workflow. New updates to Sidekick+, an industry-first application that integrates Microsoft/OpenAI’s ChatGPT technology with Sedgwick’s established claims management tools, leverage API integration so that claim professionals automatically receive medical document summarizations directly into their claim files.

Sidekick+ has processed 50,000 documents in the initial pilot with greater than 98% accuracy in its summarizations. Sidekick is bundled with Sedgwick’s digital intelligence suite, including predictive models and decision engines, so that AI can prescribe optimal workflows, leading to genuine process transformation. Sedgwick was named by Foundry’s CIO as a 2024 CIO 100 Award winner for Sidekick+, which is a first-of-its-kind application developed by the company’s technology team. Foundry’s CIO 100 award recognizes enterprise excellence and innovation in IT.

2- AI care guidance: Sedgwick has expanded its offerings with the launch of an AI-powered care guidance application to identify claims on workers’ compensation programs with integrated managed care whose progression could benefit from early clinical intervention. The proprietary model uses modern AI, machine learning and natural language processing to rapidly review unstructured data – such as claim notes, correspondence, medical bills, and clinical documentation – and collect meaningful, actionable information for review. By identifying subtle patterns that might otherwise be overlooked,

AI care guidance detects the warning signs of claim severity early in the process and facilitates prompt referrals to appropriate clinical resources.

3-  mySedgwick: With an eye toward continued innovation addressing communication gaps in the claims process, mySedgwick – Sedgwick’s customer-centric self-service tool and virtual guide through the claims journey – has been refreshed with a simplified, mobile- first user experience for U.S. casualty and workforce absence clients and their employees/customers. Today, nearly 70% of claimants use mobile devices to check on their claims and ask questions – up from 30% just three years ago.

AI-backed chat capabilities can address many claims questions in real time or direct claimants to their assigned examiners for more complex queries. This update simplifies the claims experience and meets claimants where they are in the digital realm.

May 1st, 2024, marked a turning point for Walmart’s healthcare ambitions. All 51 Walmart Health clinics in six states will be closed, and the giant retailer will end virtual health care services, the company said Tuesday.

The company had opened these clinics next to its superstores, and offered primary and urgent care, labs, X-rays, behavioral health and dental work. It had expected that it could use its massive financial scale and store base to offer convenient, low-cost services to patients in rural and underserved areas that lacked primary care options.

The decision, came as a shock to many. Just five years ago, Walmart had entered the healthcare scene with a bold promise: to disrupt the system and provide high-quality, low-cost care as an alternative to traditional doctor’s offices. Their clinics offered primary care, urgent care, x-rays, and even dental work, all conveniently located next door to the familiar blue vestibules.

“Health care looks like a big opportunity,” Walmart CEO Doug McMillion said in 2020, shortly after the first clinics opened.

However, the dream of revolutionizing healthcare proved elusive. Walmart cited “challenging reimbursement environments and escalating operating costs” as reasons for the closure. In simpler terms, the clinics just weren’t profitable enough. This echoed a wider trend – Walgreens had recently shuttered a significant number of their own in-store clinics, suggesting that the retail healthcare model might not be sustainable in the current climate.

Ateev Mehrotra, a professor of health care policy and medicine at Harvard Medical School who researches retail health clinics said Walmart’s closures reflect the challenges for primary care providers in the United States.

The closure leaves many patients scrambling for alternatives. Walmart has assured them that existing appointments will still be honored, and they’re working to connect patients with other providers within their insurance networks. However, finding a new doctor, especially in underserved areas, can be a daunting task.

The impact goes beyond patients. Hundreds of healthcare workers, from doctors and nurses to administrative staff, now face an uncertain future. Walmart has offered them the opportunity to transfer to other positions within the company, but for many, this may not be a viable option.

The story of Walmart’s healthcare experiment serves as a cautionary tale. While the goal of affordable, accessible care was noble, the execution proved difficult. The complex landscape of healthcare reimbursement and the high cost of operation ultimately proved insurmountable.

However, Walmart’s exit doesn’t necessarily negate the potential of retail healthcare entirely. It simply underscores the need for a more sustainable model. The future of affordable healthcare access remains an open question, and Walmart’s story serves as a reminder of the ongoing struggle to find a solution that works for everyone.