A new retrospective cohort study – Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic – confirmed that some common general surgeries had the biggest migrations to the outpatient setting during the first year of the COVID-19 pandemic. And this is likely a favorable trend perhaps reducing the costs of worker’s compensation medical claims.

Compared with the previous few years, calendar year 2020 saw disproportionately more outpatient cases of mastectomy for cancer, minimally invasive adrenalectomy, thyroid lobectomy, breast lumpectomy, minimally invasive ventral hernia repair, minimally invasive sleeve gastrectomy, parathyroidectomy, and total thyroidectomy.

For the present retrospective cohort study, Thiels and colleagues analyzed case volumes for the 16 most common general surgeries in the ACS National Surgical Quality Improvement Program (NSQIP). Outpatient procedures were defined as those that had patients discharged the same day as their procedure.

Patients were split between the 823,746 who received surgery prior to the COVID-19 pandemic (January 2016 through December 2019) and the 164,690 patients who had surgery during the pandemic (January through December 2020). The study population had an average age of 54.5 years and 58.1% were women.

According to a report on this study published by MedPage Today, the increase in outpatient volumes from 2016 to 2020 was deemed clinically significant for the following four procedures:

– – Mastectomy for cancer: 9.2% to 28.6%
– – Thyroid lobectomy: 43.2% to 57.9%
– – Minimally invasive ventral hernia repair: 58.8% to 69.4%
– – Parathyroidectomy: 51.8% to 61.8%

Driving the accelerated transition to outpatient surgeries was the need to simultaneously meet the needs of the massive influx in patients, a result of the COVID-19 pandemic, while still accepting and treating patients in need of non-urgent surgery, according to Cornelius Thiels, DO, MBA, surgical oncologist at the Mayo Clinic in Rochester, Minnesota, and coauthors, writing in JAMA Network Open.

As U.S. hospitals were beginning to buckle under limited resources and the need to mitigate SARS-CoV-2 exposure, the American College of Surgeons (ACS) and other organizations published elective case triage guidelinesopens in a new tab or window in early 2020.

“These guidelines recognize that postoperative inpatient admission uses key hospital resources that need to be allocated toward the care of acutely unwell patients with COVID-19 and exposes patients undergoing routine surgery to the risk of nosocomial COVID-19 infection,” Thiels and colleagues noted.

Adrian Diaz, MD, general surgery resident at The Ohio State University in Columbus, said the study’s findings are consistent with his group’s reported experience before and since the pandemic, and that the trends may continue for years.

Diaz suggested that outpatient surgery may be the preference for many patients. “Often times outpatient surgery is logistically more convenient and patients can return home and to normalcy much faster. Finally, outpatient surgery is often less resource intensive and thereby less expensive, leading to less cost to patients.”

“I believe this study is further evidence that more and more surgery is moving to an outpatient setting. Although this study did not assess safety or outcomes, the trends in the study demonstrate that most providers feel comfortable performing these operations in an outpatient setting,” he told MedPage Today.

The pandemic-era rise of outpatient procedures reportedly also extends to minimally invasive procedures like percutaneous coronary intervention and transcatheter aortic valve replacement, other groups have shown.

Data from the ACS-NSQIP-participating hospitals may not be fully representative of the entire U.S. population, the investigators acknowledged. Another limitation was the possibility of confounding due to surgical patients during the pandemic being sicker overall.

Walmart Health announced that it is expanding into two new states and opening 28 centers in 2024. This will expand Walmart Health’s footprint into two new states – Missouri and Arizona – and deepen its presence in Texas. By the end of 2024, it will have more than 75 Walmart Health centers across the United States.

The company also says it i changing the physical footprint and layout of the center so patients spend less time in the waiting room and more time with their doctor. It also integrated modern equipment and technology to enable our providers and patients alike to experience what it claims is best-in-class healthcare technology. This includes integrating Epic’s electronic health record system across Walmart Health locations.

With 90% of the U.S. population located within 10 miles of a Walmart, Walmart Health is in a unique position to provide health and wellness services where its neighbors already live and shop.

The new state-of-the-art facilities will be approximately 5,750 square feet, located inside Walmart Supercenters, and will feature Walmart Health’s full suite of health services. The range of services include primary care, dental care, behavioral health, labs and X-ray, audiology and Walmart Health Virtual Care telehealth services.

Electronics retailer Best Buy recently kicked off a partnership with Atrium Health, part of Advocate Health, one of the country’s largest nonprofit hospital systems, Best Buy Chief Executive Officer Corie Sue Barry announced Thursday on a call with analysts. The partnership combines Atrium’s hospital-at-home program with Best Buy’s technological services, she said.

The partnership combines Atrium’s hospital-at-home program with Best Buy’s technological services, she said.

Best Buy has been investing heavily in health care services over the last few years as an alternative revenue stream to electronics sales, and has made several acquisitions in the sector, the most notable being its $800 million purchase of senior-citizen focused GreatCall Inc in 2018.

In 2021, the company also bought Current Health, a home-care technology platform that offers monitoring through wearable devices. “The role of technology within health care is becoming more important than ever, and our strategy is to enable care at home for everyone,” Barry said.

Dollar General is expanding into healthcare services in what could be a competitive shot across the bow for drugstores and other retailers. The company is piloting mobile health clinics at three stores in Tennessee to provide customers with basic, preventive and urgent care services along with lab testing.

The discount retailer teamed up with DocGo, a provider of mobile health and transportation services, to provide the medical services, which are set up in large vans in store parking lots.

The two companies plan to evaluate customer response and determine the feasibility of expanding the mobile health clinic offering to additional stores, executives said in a press release. Customers can schedule appointments online or walk in without an appointment. The retailer noted at the time that 75% of the U.S. population lives within about five miles from a Dollar General store, providing unique access to rural and other communities often underserved in the current health care ecosystem.

Health spending – projected to reach $5.2 trillion nationally by 2025, according to the U.S. Centers for Medicare and Medicaid Services – has become an alluring growth avenue for some retailers.

Heath Fulkerson, At Home Electric, and Heath V. Fulkerson LLC sued Albert & Mackenzie LLP, a law firm, Jeremiah Brasher, an attorney, and Hartford Accident & Indemnity Company, a workers’ compensation insurer, for intentional infliction of emotional distress, slander, and fraud.

The workers’ compensation case involved an alleged injury that occurred on August 22, 2020. Albert & Mackenzie LLP was the attorney of record for Hartford in that case. Brasher investigated Fulkerson’s claim, communicated with Fulkerson regarding possible settlement, developed Hartford’s defenses, conducted discovery, and filed documents in the case.

Fulkerson filed another application for adjudication of claim with the Workers’ Compensation Appeals Board in relation to an alleged injury that occurred on February 6, 2020.

The complaint alleged that as a result of defendants’ actions, Heath Fulkerson was forced to represent himself in Workers’ Compensation Appeals Board case No. ADJ13747725 and incur costs. The complaint did not specify the conduct or statements by defendants upon which plaintiffs’ claims for relief were based.

Defendants filed special motions to strike the complaint pursuant to Code of Civil Procedure section 425.16, asserting that plaintiffs’ claims arose from counsel’s conduct in representing Hartford before the Workers’ Compensation Appeals Board and that plaintiffs could not establish a prima facie case supporting their claims.

The trial court denied the motions, concluding the complaint was too vague to support a finding that it arose from protected activity.

Hartford and Albert & Mackenzie LLP contend on appeal that the trial court should have considered the declarations defendants submitted with their motions, which they claim allowed them to meet their threshold burden of showing that plaintiffs’ claims arose from protected conduct under section 425.16, subdivision (e).

Finding no error, the court of appeal affirmed the trial court’s order in the unpublished case of Fulkerson v Albert & Mackenzie LLP – C095168 (February 2023).

Section 425.16 sets out a procedure for striking what are commonly called strategic lawsuits against public participation or SLAPPs, which are lawsuits brought primarily to chill the valid exercise of the constitutional rights of freedom of speech and petition for the redress of grievances.

Section 425.16, subdivision (b)(1) provides, “A cause of action against a person arising from any act of that person in furtherance of the person’s right of petition or free speech under the United States Constitution or the California Constitution in connection with a public issue shall be subject to a special motion to strike, unless the court determines that the plaintiff has established that there is a probability that the plaintiff will prevail on the claim.”

A motion brought under section 425.16 is called an anti-SLAPP motion. Consideration of such a motion involves a two-step process. Only a cause of action that satisfies both steps is subject to being stricken under the statute.

At the first step of the anti-SLAPP analysis, the moving defendant must make a prima facie showing that the plaintiff’s cause of action arises from an act by the defendant taken in furtherance of the defendant’s right of petition or free speech under the United States or the California Constitution in connection with a public issue. A defendant meets his or her threshold burden by demonstrating that the conduct by the defendant underlying the plaintiff’s claim fits one of the categories described in section 425.16, subdivision (e). Those categories include statements or writings in connection with matters before the Workers’ Compensation Appeals Board.

Here the complaint did not identify liability-producing conduct or statements by defendants. Defendants do not cite authority for the proposition that they can satisfy their threshold burden with declarations articulating possible bases for the plaintiffs’ claims when the challenged pleading does not contain such allegations.

The court of appeal cannot assume that Hartford’s attorneys must have engaged in protected activity. The trial court properly denied the anti-SLAPP motions. The court need not address the second step, whether plaintiffs could demonstrate a probability of prevailing on the merits.

Part I of a new California Workers’ Compensation Institute (CWCI) research series on low-volume/high-cost drugs used to treat injured workers in California spotlights a handful of Anti-Inflammatory and Anticonvulsant medications that account for a relatively small share of the prescriptions within their therapeutic drug groups, but that have become significant cost drivers by consuming a disproportionately large share of the payments.

CWCI’s analysis of Anti-Inflammatory and Anticonvulsant drugs used in California workers’ compensation is the first of a three-part series that uses data from the Institute’s Prescription Drug Application to track changes in the distribution of California workers’ compensation prescriptions and prescription payments over the past decade, and to identify medications with high average reimbursements that have an outsized impact on the total payments within their drug group.

The authors of the study note the changes in the average amounts paid per prescription for each of the highlighted drugs over the 10-year study period (service years 2012 through 2021), as well as changes in the percent of the prescriptions dispensed as a brand rather than a generic drug, and review factors that contribute to the high cost of the medications.

Among the key findings for the Anti-Inflammatory and Anticonvulsant drugs:

– – Ibuprofen and naproxen represented 2/3 of the Anti-Inflammatories dispensed in 2021, but with average payments of $12 and $49 respectively, they were relatively cheap, so it was low-volume, high-cost fenoprofen calcium (with an average payment of $1,479), and ketoprofen (with an average payment of $1,073) that kept Anti-Inflammatories at the top of the list in terms of total drug spend.
– – Fenoprofen calcium represented 1.4% of the 2021 Anti-Inflammatory prescriptions but 33.2% of the payments, while ketoprofen represented 0.6% of the prescriptions but 9.8% of the payments.
– – Fenoprofen calcium represented just 0.5% of all workers’ compensation prescriptions in 2021, but 8.1% of the total drug spend within the system, by far the largest percentage of any single drug.
– – The biologic etanercept (Enbrel) accounted for less than 0.1% of the Anti-Inflammatory prescriptions in 2021 but was only available as a brand drug with an average payment of $7,716, so it consumed 4.3% of the Anti-Inflammatory payments. On the other hand, none of the fenoprofen calcium or ketoprofen dispensed in 2021 was brand, which shows that generics are not always inexpensive.
– – Fenoprofen calcium, ketoprofen, and etanercept are not in the national Medicaid database, so they have no Federal Upper Limit (FUL) – the maximum fee allowed under Medicaid, which also serves as a price control in the Medi-Cal and California workers’ compensation pharmacy fee schedules. Instead, these drugs are paid at 83% of their average wholesale price, which is based on manufacturer pricing.
– – Four Anticonvulsant drugs (lacosamide, levetiracetam, lamotrigine, and pregabalin) accounted for 24.2% of the 2021 Anticonvulsant prescriptions, but 72.5% of the Anticonvulsant drug spend.
– – Pregabalin, which is subject to prospective utilization review (UR) under the California Workers’ Compensation Formulary, was the second most common Anticonvulsant prescribed in 2021, but its 20.7% share of the Anticonvulsant prescriptions was far below its 55.5% share of the payments.
– – Pregabalin’s share of the Anticonvulsant prescriptions increased after the Formulary and the Pain Management and Opioid Treatment Guidelines took effect in 2018, but the average payment peaked at $557 that year, and in 2019 so too did pregabalin’s share of the Anticonvulsant drug spend (77.5%) as the FDA approved nine generic versions of the drug, which quickly hit the market at a fraction of the cost of the brand version.
– – By 2021, the payment differential between brand and generic pregabalin had widened, as the average payment for generics fell to $152 per prescription while the average payment for brand versions rose to $714. By that point, however, generics accounted for 92% of the pregabalin prescriptions, so the overall average payment for pregabalin declined to $197 in 2021.
– – The 3 other Anticonvulsants highlighted in the study accounted for much smaller shares of the prescriptions within their drug group in 2021 (0.7%, 1.7%, and 1.0% respectively), but their high average payments made them significant cost drivers.
– – Lacosamide, which is Not Listed in the formulary but can be used if the prescriber presents an evidenced-based rationale for its use was only available as a brand drug at an average payment of $832. It accounted for just 0.7% of the Anticonvulsant prescriptions, but 8.3% of the payments.
– – Levetiracetam, which is subject to prospective UR, accounted for 1.7% of the 2021 Anticonvulsant prescriptions. Available as a brand and generic drug, in recent years levetiracetam has been increasingly dispensed as a brand drug (with an average reimbursement of $1,880 in 2021), which drove the overall average payment per prescription up to $274, so it consumed 6.3% of the Anticonvulsant dollars.
– – Lamotrigine, which is also subject to prospective UR, accounted for 1.1% of the Anticonvulsant prescriptions in 2021. While 95% of the 2021 prescriptions were generics, with an average payment of $62, the average amounts paid for various brand versions, including an extended-release version, were much higher, which pushed the overall average payment for Lamotrigine up to $174 per prescription, so it accounted for 2.4% of the Anticonvulsant drug spend.

CWCI has published the first part of its study in a Spotlight Report, Cost-Driver Medications in the Top California Workers’ Comp Drug Groups: Part 1, Anti-Inflammatories & Anticonvulsants. Institute members and subscribers can log on to the Institute’s website at www.cwci.org to access the report under in the Research section, others can purchase a copy from the Institute’s online store.

CWCI research on low-volume/high-cost medications will continue with Part II in the series, which will focus on medications found in the Dermatological, Opioid, and Antidepressant drug categories, while Part III will highlight low-volume/high-cost Musculoskeletal and Ulcer Drugs.