Tag: 2015 News

Under SB 899, apportionment can now be based upon causation. Apportionment can be used to divide a specific injury case into two cases, the original specific injury, and then a continuous trauma case if continuous trauma played a causation role in the current medical problem. This strategy can take a life pension specific injury claim and reduce it to two smaller cases neither of which triggers a life pension. For this reason, it becomes significant to follow medical literature as elements of causation are developed in the medical literature. Here is a current example.

New research reveals the physical and psychosocial factors that significantly increase the risk of low back pain onset. In fact, according to the article in Science Daily, results published in Arthritis Care and Research, a journal of the American College of Rheumatology (ACR), show that being engaged in manual tasks involving awkward positions will increase the risk of low back pain by eight times. Those who are distracted during activities or fatigued also significantly increase their risk of acute low back pain.

At some point, nearly 10% of the world’s population experience back pain, which is the leading cause of disability according to the World Health Organization (WHO) Global Burden of Disease report (2010). WHO reports that low back pain has a greater impact on global health than malaria, diabetes, or lung cancer; yet little progress has been made to identify effective prevention strategies.

“Understanding which risk factors contribute to back pain and controlling exposure to these risks is an important first step in prevention,” explains Associate Professor Manuela Ferreira, Ph.D., with The George Institute for Global Health and Sydney Medical School at The University of Sydney in New South Wales, Australia. “Our study is the first to examine brief exposure to a range of modifiable triggers for an acute episode of low back pain.”

For this case-crossover study, researchers recruited 999 participants from 300 primary care clinics in Sydney, Australia, who had an acute low back pain episode between October 2011 and November 2012. Study subjects were asked to report exposure to 12 physical or psychosocial factors in the 96 hours prior to the onset of back pain.

The risk of a new episode of low back pain significantly increased due to a range of triggers, from an odds ratio of 2.7 for moderate to vigorous physical activity to 25.0 for distraction during an activity. Researchers found that age moderated the effect of exposure to heavy loads, with odds ratio for individuals 20, 40, or 60 years of age at 13.6, 6.0, and 2.7, respectively. A new finding not reported previously was that back pain risk was highest between 7:00 a.m. and noon.

“Understanding which modifiable risk factors lead to low back pain is an important step toward controlling a condition that affects so many worldwide,” concludes A/Prof Ferreira. “Our findings enhance knowledge of low back pain triggers and will assist the development of new prevention programs that can reduce suffering from this potentially disabling condition.”

The citation to this study is: Daniel Steffens, Manuela L Ferreira, Jane Latimer, Paulo H Ferreira, Bart W Koes, Fiona Blyth, Qiang Li, Christopher G Maher. What triggers an episode of acute low back pain? A case-crossover study. Arthritis Care Research, 2014; DOI: 10.1002/acr.22533

Security experts are warning healthcare and insurance companies that 2015 will be the “Year of the Healthcare Hack,” as cybercriminals are increasingly attracted to troves of personal information held by U.S. insurers and hospitals that command high prices on the underground market according to the story in Reuters Health.

Anthem Inc, the No. 2 U.S. health insurer, last week disclosed a massive breach of its database containing nearly 80 million records, prompting investigations by state and federal authorities. That hack followed a breach last year at hospital operator Community Health Systems, which compromised some 4.5 million records.

“People feel that this will be the year of medical industry breaches,” said Dave Kennedy, chief executive of TrustedSEC LLC. In the past decade, cybercriminals focused their efforts on attacking banks and retailers to steal financial data including online banking credentials and payment card numbers. But as those companies boost security, using stolen credit card numbers has become more difficult. Their prices on criminal exchanges have also dropped, prompting hackers to turn to the less-secure medical sector, just as the amount of digital healthcare data is growing dramatically, Kennedy said.

Stolen healthcare data can be used to fraudulently obtain medical services and prescriptions as well as to commit identity theft and other financial crimes, according to security experts. Criminals can also use stolen data to build more convincing profiles of users, boosting the success of scams. “All of these factors are making healthcare information more attractive to criminals,” said Rob Sadowski, marketing director at RSA, the security division of EMC Corp.

RSA Executive Chairman Art Coviello recently wrote in a letter to customers that he expected well-organized cybercriminals to turn their attention to stealing personal information from healthcare providers. “A name, address, social and a medical identity … That’s incredibly easy to monetize fairly quickly,” said Bob Gregg, CEO of ID Experts, which sells identity protection software and services. Identities can sell for $20 apiece, or more, he said. Insurers, medical equipment makers and other companies say they have been preparing for breaches after seeing the waves of attacks on other industries.

Cigna Corp has looked to financial and defense companies for best practices, including hiring hackers to break into its systems, said Chief Executive David Cordani. Attempts to break into corporate systems to probe for information are a constant, he said in an interview.

St Jude Medical Inc CEO Daniel Starks said the company increased investment in cybersecurity significantly over the last few years, to protect both patient data and the medical devices it manufactures. “You may see from time to time law enforcement briefings on nation-based (intellectual property) issues, espionage,” he said. “Those are things that we take very seriously and have been briefed on and that we work to guard against.”

The insurers UnitedHealth Group Inc and Aetna Inc have warned investors about the risks of cyber crime in their annual reports since 2011. UnitedHealth has said the costs to eliminate or address the threats could be significant and that remediation may not be successful, resulting in lost customers. In response to the Anthem attack, UnitedHealth spokesman Tyler Mason said in an emailed statement: “We are in close contact with our peers in … the industry cybersecurity organization, and are monitoring our systems and the situation closely.”

Aetna has cited the automated attempts to gain access to public-facing networks, denial of service attacks that seek to disrupt websites, attempted virus infections, phishing and efforts to infect websites with malicious content. Aetna spokeswoman Cynthia Michener said in a statement: “We closely follow the technical details of every breach that’s reported to look for opportunities to continually improve our own IT security program and the health sector’s information protection practices broadly.”

Arguments will be presented to the California Supreme Court next month in the case of an injured worker whose death from a prescription drug overdose was ruled noncompensable by the 4th District Court of Appeal in December 2013. The high court is scheduled to hear arguments in South Coast Framing v. Workers’ Compensation Appeals Board on March 3 in San Francisco. The court agreed last March to consider the case.

Brandon Clark, a South Coast employee, suffered back, head, neck and chest injuries when he fell off a roof while working for South Coast in 2008. His workers comp doctor prescribed an antidepressant, Vicodin and Neurontin, a drug used to treat neuropathic pain. Mr. Clark also was prescribed Xanax and Ambien by his personal physician in January 2009 for anxiety and sleep problems. He died the following July allegedly from the combined effects of the antidepressant, Neurontin, Xanax, Ambien and associated early pneumonia.

Mr. Clark’s wife and children filed for workers comp death benefits, contending that his death was a result of his work injury and related medications. She supported her claim with the report of Dr. Bressler who concluded that “[Brandon’s] death was secondary to an accidental overdose.” In reaching this conclusion, Dr. Bressler stated, “[t]he specific combination of medicines [Brandon] was on, which included Xanax, Ambien, Flexeril, Neurontin, amitriptyline, and hydrocodone, all separately and in combination had the capacity to induce respiratory depression, and even respiratory arrest.” Thus there was a mixed cause of both industrial and non-industrially prescribed medications. However the agreed medical examiner, Dr. Thomas C. Bruff, had a more detailed analysis of the interaction of the industrial and non-industrial drugs and came to the opposite conclusion.

A workers’ compensation judge concluded that Brandon Clark died as a result of medications he took after suffering an industrial injury. South Coast and its insurance carrier, Redwood Fire and Casualty Company administered by Berkshire Hathaway Homestate Companies petitioned for writ of review after the Workers’ Compensation Appeals Board denied reconsideration of the WCJ’s decision in favor of Brandon’s wife and children.

The Court of Appeal in the unpublished case of South Coast Framing v WCAB (Clark) concluded that the Board erred in denying reconsideration because the WCJ’s decision was not supported by substantial evidence. A physician’s report and testimony must demonstrate his opinion is based on “reasonable medical probability.”

The dispute will now be resolved by the California Supreme Court after oral arguments are heard next month.

Medications such as Abilify and Actiq are being used off-label to treat injured workers, prompting the workers comp sector to focus on curbing inappropriate prescribing that may be pricey and dangerous. Research shows that about one in five of all prescriptions are written for off-label use, or uses outside those approved by the U.S. Food and Drug Administration. According to the article in Business Insurance, experts say the practice has popped up in workers comp with drugs such as Abilify, an anti-psychotic that’s FDA-approved as an add-on treatment for adults with depression, but inappropriately used as a lone treatment of injured workers’ depression or anxiety.

“We’re starting to see more Abilify being added to problematic claims, and Abilify really doesn’t have a place in work comp,” said Brian Carpenter, Atlanta-based senior vice president of pharmacy product development and clinical management for Healthcare Solutions. “It’s a very expensive medication.” About $6.5 billion was spent on Abilify in the United States in 2013, according to the IMS Institute for Healthcare Informatics. “Certainly because of the cost and the fact that … we believe there are other drugs that are therapeutically effective to do what it does, we would certainly try to have a conversation with a physician to not use the drug to treat an injured worker”, said Rita Wilson, Delray Beach, Florida-based CEO of Tower MSA Partners L.L.C., a Medicare secondary payer compliance company.

The impact of off-label drugs is difficult to quantify in workers comp since it’s not always clear why a medication is prescribed, said Brigette Nelson, Cave Creek, Arizona-based senior vice president of workers compensation clinical management at St. Louis-based pharmacy benefit manager Express Scripts Inc. However, sources said off-label use in comp is seen primarily in pain management.

Opioids make up a large percentage of off-label prescriptions, said Michael Gavin, Duluth, Georgia-based president of medical cost management company PRIUM. “It has serious implications for injured worker health because the FDA is signaling to the physician community that these drugs should be used in really limited circumstances, and yet we see our work comp payer community spending $1.5 billion a year on them,” Mr. Gavin said. It’s important for PBMs and third-party administrators to be familiar with medications commonly prescribed off-label so they can appropriately flag and monitor claims, sources said.

State rules also can come into play. For example, a recent update proposed for the California Medical Treatment Utilization Schedule could limit off-label use by requiring physicians to prove with a study or alternate guideline that that treatment contrary to the state’s schedule is appropriate. Off-label prescribing becomes a problem when physicians prescribe potentially dangerous and expensive drugs, such as “Actiq instead of Vicodin or Norco,” said David Cooper, director of orthopedic surgery at The Knee Center in Wilkes-Barre, Pennsylvania. Actiq, which is FDA-approved for breakthrough, chronic cancer pain, is a drug that sources agree has no place in workers comp. “We’ve seen (Actiq) used in workers compensation for nonspecific low back pain,” Mr. Gavin said. “That’s incredibly damaging. That’s a very powerful narcotic.” He said use of Actiq has declined in recent years as “we’ve gotten smarter as a payer community.”

One of the most important things a TPA can do is partner with the right doctors to avoid off-labeling from the onset, said Debbie Michel, Chicago-based president of TPA Helmsman Management Services L.L.C. And in states that allow it, conducting utilization reviews is considered a best practice to decide whether off-label use is appropriate, experts said.

Anthem is the nation’s second-largest health insurer, operating Blue Cross and Blue Shield plans in 14 states including California. Company officials report that Anthem was the target of a very sophisticated external cyber attack. These attackers gained unauthorized access to Anthem’s IT system and have obtained personal information from up to 80 million current and former members such as their names, birthdays, medical IDs/social security numbers, street addresses, email addresses and employment information, including income data. No information is available about the status of any information in its database arising out of Workers’ Compensation MPN services.

Anthem officials became aware of the breach when one of their senior administrators noticed someone was using his identity to request information from the database. Once the attack was discovered, Anthem said it immediately made every effort to close the security vulnerability, contacted the FBI and began fully cooperating with their investigation. Anthem has also retained Mandiant, one of the world’s leading cybersecurity firms, to evaluate our systems and identify solutions based on the evolving landscape.

Anthem will individually notify current and former members whose information has been accessed. It will provide credit monitoring and identity protection services free of charge. Anthem created a dedicated website – www.AnthemFacts.com – where members can access information such as frequent questions and answers. It has also established a dedicated toll-free number that both current and former members can call if they have questions related to this incident. That number is: 1-877-263-7995.

The hackers are thought to have infiltrated Anthem’s networks by using a sophisticated malicious software program that gave them access to the login credential of an Anthem employee. “This is one of the worst breaches I have ever seen,” said Paul Stephens, director of policy and advocacy for the Privacy Rights Clearinghouse, a nonprofit consumer education and advocacy group. “These people knew what they were doing and recognized there was a treasure trove here, and I think they are going to use it to engage in very sophisticated kinds of identity theft.”

The decision by Anthem to bring in the Federal Bureau of Investigation and go public with the breach is the kind of move that law enforcement officials have been encouraging for the last several months. F.B.I. officials have appeared at a number of industry conferences urging corporate executives to promptly report breaches and, when possible, share information about the breach with competitors.

The cyberattack points to the vulnerability of health care companies, which security specialists say are behind other industries in protecting sensitive personal information. Experts said the information was vulnerable because Anthem did not take steps, like protecting the data in its computers though encryption, in the same way it protected medical information that was sent or shared outside of the database. While the health industry has not previously experienced the large-scale breaches that have plagued retailers like Target and Home Depot, there have been smaller attacks. Statistics maintained by the federal government’s Office for Civil Rights at the Department of Human Services say there have been 740 major health care breaches affecting 29 million people over the last five years. But the information that health providers maintain about consumers tended to be more valuable on the black market than the credit card information that is often stolen from on a retailer.

Katherine Keefe, global focus group leader for breach response services at Beazley, which underwrites cyberliability policies, said “The value to a criminal of having a full set of medical information on a person can go for $40 to $50 on the street. By contrast, a credit card number is often worth $4 or $5,” The information can be used to impersonate hacking victims to obtain medical care or to purchase expensive medical equipment such as motorized wheelchairs. It often takes health-care providers longer to detect this type of fraud than credit card companies or banks, which are constantly looking for inconsistencies that could signal a problem. That also means it can be more time consuming and costly for victims to correct, experts say. Criminal attacks on health-care organizations increased 100 percent between 2009 and 2013, according to a report on patient privacy by think tank the Ponemon Institute. About 40 percent of health organizations reported facing criminal cyberattacks in 2013, the report said.